Device-Sparing Posteroseptal Trans-Tricuspid Lead Implantation After Tricuspid TEER: A Three-Case Device Rounds Report

Transvenous right ventricular lead implantation after tricuspid transcatheter edge-to-edge repair (T-TEER) may be challenging because of potential interaction with implanted repair devices, grasped leaflets, or the repaired coaptation zone. We describe three patients requiring transvenous pacemaker or implantable cardioverter-defibrillator implantation after T-TEER with TriClip or PASCAL systems. In each case, the posterior-most T-TEER device was used as a fluoroscopic landmark to guide lead passage inferior and posterior to the device toward an unobstructed posteroseptal residual orifice. Pacemaker leads were delivered using catheter-and-wire crossing followed by advancement of a long slittable sheath, whereas the defibrillator lead required direct shaping and fluoroscopic manipulation because of sheathlead incompatibility. Implantation was successful in all three patients. During 612 months of follow-up, tricuspid regurgitation remained mild or trace, mean transtricuspid gradients ranged from 1.8 to 2.1 mmHg, and no echocardiographic leadleaflet or leaddevice interaction or lead-related complications were observed. This fluoroscopy-guided, device-sparing strategy may represent a practical option when transvenous right ventricular lead implantation is clinically necessary after T-TEER.