First Report of Left-Sided Transvenous Pacemaker Implantation Through a Bicaval TricValve Prosthesis

The transcatheter bicaval system is a heterotopic therapy option for patients with torrential tricuspid regurgitation (TR) at prohibitive surgical risk. Experience with permanent pacing in patients with bicaval prostheses remains extremely limited.

An 83-year-old woman with chronic obstructive pulmonary disease, permanent atrial fibrillation, transfusion-dependent anemia, prior non-ST elevation myocardial infarction, and previous MitraClip implantation for severe mitral regurgitation presented with advanced right-sided heart failure and massive functional TR due to a 17 mm coaptation gap. Transcatheter tricuspid edge-to-edge repair was not feasible, and she underwent transcatheter bicaval system implantation with two nitinol stent-mounted bioprostheses in the superior and inferior vena cava, resulting in marked symptomatic improvement. Ten months later, she developed symptomatic bradycardia requiring permanent pacing. A single-chamber pacemaker was successfully implanted via the left subclavian vein after venography confirmed safe drainage of the left brachiocephalic vein into the superior vena cava, allowing safe passage of the pacing lead through the prosthetic stent struts. Electrical parameters were excellent, and 10-month follow-up confirmed stable function without lead or valve damage.

This is, to our knowledge, the first published report of successful left-sided pacemaker implantation through a tricuspid bicaval prosthesis. Alternative pacing strategies, including conduction system pacing and leadless pacemakers, were carefully considered but deemed unsuitable because of anatomical and clinical constraints. Our case demonstrates that left-sided implantation can be performed safely when venographic anatomy allows. Careful pre-procedural imaging and meticulous lead navigation are essential to ensure prosthesis integrity and durable pacing performance.