Leadless Pacemakers in the Setting of Surgical and Transcatheter Tricuspid Valve Procedures

Transvenous pacing is increasingly recognized as problematic in patients with prior or concomitant tricuspid valve intervention, owing to risks of leaflet interference, prosthetic dysfunction, and progression of tricuspid regurgitation. Leadless pacemakers offer a valve-sparing alternative; however, their safety and performance in structurally altered right heart anatomy remain incompletely defined. We conducted a systematic review to evaluate procedural feasibility, electrical performance, device-valve interaction, and clinical outcomes of leadless pacemaker implantation in patients undergoing surgical or transcatheter tricuspid valve interventions. Thirty-four studies comprising 272 patients were included, encompassing surgical repair, bioprosthetic replacement, valve-in-valve procedures, transcatheter edge-to-edge repair, and transcatheter tricuspid valve replacement. Leadless pacemakers were implanted via transfemoral, transjugular, or direct surgical approaches, achieving a procedural success rate of 99.3%. Electrical performance was consistently favorable, with stable capture thresholds, sensing amplitudes, and impedance during follow-up. Device-valve interaction was infrequent and generally manageable. Leadless pacemaker-related complications were rare (1.1%), with no device-related mortality. Within the included studies of patients undergoing surgical or transcatheter tricuspid valve interventions, no study demonstrated worsening tricuspid regurgitation attributable to the leadless pacemaker or its delivery system. Across a broad spectrum of complex tricuspid anatomies, leadless pacemakers demonstrated excellent feasibility, durable electrical performance, and a low complication profile, supporting their role as a valve-sparing pacing strategy in this population. These findings support leadless pacing in patients with prior tricuspid intervention, although prospective comparative data are required to define its role relative to alternative pacing modalities.