Simultaneous Tricuspid Valve Replacement and Left Bundle Branch Area Pacing With Surgical Lead Refixation

The importance of managing tricuspid regurgitation (TR) has been increasingly recognized, and tricuspid valve replacement (TVR) is now performed more frequently. Conduction system pacing (CSP), including left bundle branch area pacing (LBBAP), offers substantial benefits by improving left ventricular (LV) electrical synchrony. However, combining these two strategies is challenging.

A 58-year-old man underwent dual-chamber pacemaker implantation for complete atrioventricular block. Five years later, he developed severe LV dysfunction due to right ventricular (RV) apical pacing-induced cardiomyopathy. Upgrade to conventional cardiac resynchronization therapy resulted in a persistently prolonged QRS duration (150 msec) and modest improvement in LV ejection fraction (LVEF, 35%). RV lead-related TR progressively worsened, leading to biventricular heart failure. Although tricuspid valve repair was performed, severe TR recurred. Following heart team discussion, both CSP upgrade and TVR were deemed necessary without delay. An LBBAP lead was implanted the day before surgery as an "electrophysiological anchor." During TVR, the lead was dislodged; however, the surgeon identified the insertion ("anchor") site, reinserted the lead, and secured it by jailing it outside the prosthetic valve in a protective position. Postoperatively, the pacing threshold improved (1.5 V@0.4 ms to 0.75V@0.4 ms) with QRS narrowing (135 to 125 ms). At three months, heart failure symptoms were markedly relieved, LVEF improved to 50%, and lead parameters remained stable.

Although jailing a lead with a prosthetic valve requires great caution to ensure long-term lead survival, we successfully combined LBBAP and surgical TVR with intraoperative refixation.