Cardiac Rhythm Management
Articles Articles 2012 December

Right Ventricular Lead Preclusion by Mechanical Tricuspid Valve

DOI: 10.19102/icrm.2012.031203


1Department of Internal Medicine, Division of Cardiology, University of New Mexico, Albuquerque, NM
2 New Mexico Veterans Affairs Health Care System, Albuquerque, NM

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ABSTRACT.Objective: To use safe alternative methods to accomplish effective dual-chamber permanent pacemaker (PPM) implantation in the presence of mechanical tricuspid valve replacement (TVR). Background: Right ventricular endocardial lead placement is contraindicated in the presence of mechanical TVR. Alternative approaches are warranted in such cases where dual-chamber pacing is indicated. Methods: A 69-year-old female with a mechanical TVR and bradycardia elected to undergo implantation of a dual-chamber PPM. Epicardial left ventricular lead positioning in the coronary sinus (CS) tributary was performed under fluoroscopic guidance. Results: The LV lead was successfully placed into the CS without traversing the prosthesis. The lead was further advanced and positioned in an anterolateral coronary vein, yielding excellent threshold data. Conclusion: Investing effort and creativity to find alternative approaches to dual chamber PPM implantation in the presence of mechanical TVR is indeed worthwhile. As the population ages, patients with mechanical TVRs requiring PPM implantation may become more common.

KEYWORDS.bradycardia, epicardial lead, mechanical prosthetic valve, pacemaker implantation, tricuspid valve replacement.

The authors report no conflicts of interest for the published content.
Manuscript received September 4, 2012, final version accepted October 11, 2012.

Address correspondence to: Allon Rafael, MD, University of New Mexico, Division of Cardiology, Department of Internal Medicine, MSC 10-5550, 1 University of New Mexico, Albuquerque, New Mexico, 87131. E-mail:


A 69-year-old female with a history of rheumatic heart disease and a St. Jude Medical (St. Paul, MN) tricuspid valve replacement (TVR) presented with symptomatic, severe bradycardia with atrioventricular block. During her TVR surgery 9 years prior, a single ventricular epicardial lead permanent pacemaker (PPM) was implanted with an abdominally placed pulse generator. Interrogation of her PPM revealed non-capture and increasing output producing diaphragmatic and chest wall contractions. She was referred for a new, dual-chamber pacing system. A pectoral device was recommended with implantation of an active fixation atrial lead and a ventricular lead via the coronary sinus (CS). The presence of a mechanical TVR precluded placement of a right ventricular (RV) endocardial pacing electrode.

The patient elected to receive a new pacing system as described. Vitamin K angtagonist therapy was held on the evening prior to the procedure and restarted on the evening of device implantation; she was otherwise maintained on full therapeutic anticoagulation throughout the periprocedure timeframe. The active fixation was performed and a-J CapSureFix-5568 atrial lead (7.2 Fr, Medtronic, Minneapolis, Inc.) was successfully positioned in the region of the right atrial appendage; efforts were then directed toward left ventricular (LV) lead placement.

Our technique developed for accessing the CS does not involve crossing into the right ventricle. We exploit the irregular 2–5–2 spacing of the Viking CS decapolar catheter (65 cm, Bard, Inc., Murray Hill, NJ) to align the electrodes with counterclockwise (CCW) rotation while imaging from a 30-degree left anterior oblique projection. This provides an essential three-dimensional perspective of a two-dimensional image. When the electrodes on the catheter are aligned, indicating alignment with the CS os, the catheter is advanced into the CS. If entry is not immediate, the catheter is gently probed along the posterior septum near the os until entry is achieved. The catheter typically enters the CS with minimal difficulty in seconds.

In cases of occlusive or webbed Thebesian valves preventing direct catheter insertion, the catheter is prolapsed along the septum and slowly withdrawn back while applying a small amount of CCW torque. This allows entry into the CS from above usually within seconds. Occasionally, the Thebesian valve may provide resistance to railing the sheath (Attain Command 6250-AM delivery guide catheter;Medtronic, St. Paul, MN) into the CS and consequently requires “push and pull” of the sheath and catheter pair, respectively; rarely, forward pressure applied to the sheath may require some dottering of the sheath to afford further advancement into the CS.

This technique, utilized and refined for over 12 years, provides access to the CS in less than 10 s in most cases, with little or no risk of entering the RV; it has helped avoid complications such as mechanical heart block; and in this case was quite useful to avoid entrapment of the catheter within the mechanical valve. Nonetheless, great caution was exercised while achieving CS access in this patient.

CS angiography identified a well-positioned target vein over the anterolateral surface of the left ventricle (Figure 1). The sheath was advanced and the target vein was subselected. A subselected angiogram was then performed and used to guide the Ability-4296 LV lead (Medtronic) through the sheath and into the vein. A 0.014 Whisper EDS guide wire (Boston Scientific, Natick, Inc.) was used to further advance the lead into what was felt to be an ideal pacing sight yielding excellent threshold data and no phrenic nerve stimulation (Figure 2). We elected to implant a bipolar pacing lead (rather than an active fixation unipolar lead) to provide optimal pacing thresholds and to afford more pacing options in avoidance of potential diaphragmatic pacing and flexibility with possible future devices. The stability of the bipolar lead against dislodgement was maintained both by considerable distal advancement into the coronary vein and by providing a significant degree of slack in the resting position.

After demonstrating stable lead position and continued good thresholds on both leads they were secured and attached to a dual-chamber Adapta L ADDRL1 pulse generator (Medtronic). The entire apparatus was then inserted into the preformed pocket (Figure 3). Lastly, the abdominally located PPM device was removed; the corresponding lead was detached, capped and buried.


Figure 1: Coronary sinus angiography, 30 degree LAO. White arrow: mechanical tricuspid valve. White chevron: epicardial lead from abdominal pacemaker. Black arrow: anterolateral coronary vein.


Figure 2: Left ventricular (LV) lead advanced over wire to anterolateral position. White arrow: mechanical tricuspid valve. White chevron: epicardial lead from abdominal pacemaker. Black chevron: LV lead.


Figure 3: Final resting position White arrow: mechanical tricuspid valve. Black chevron: LV lead.

In the era of cardiac resynchronization therapy (CRT), biventricular (BiV) versus univentricular pacing of the left ventricle is a general consideration in patients who are (anticipated to become) pacemaker dependent. An endocardial RV lead could not be placed in this case, however, and there are data to suggest that LV-only pacing is non-inferior to BiV pacing in CRT.13 This supports hypotheses that intraventricular synchronization of the left ventricle rather than interventricular synchronization may be responsible for clinical benefits of CRT.

LV lead placement in dual-chamber PPM implantation is uncommon. To our knowledge, only one other case has been reported in the United States describing LV lead placement in the coronary sinus tributary in the absence of a RV lead during dual chamber PPM implantation.4 One earlier case from Yale in 1970 by Anagnostopoulos et al5 describes LV lead placement in a coronary vein during implantation of a single lead PPM system. Lastly, there are two reports from the American literature of coronary vein placement of a LV lead during implantation of a dual chamber implantable cardioverter defibrillator when the right ventricle was not accessible.6,7 In each of these four cases the patient presented with a tricuspid valve prosthesis.

As our population continues to grow older, unique and challenging situations will continue to present more frequently warranting creative techniques and alternative methods. Our case emphasizes the value of improvisation and encourages innovation.


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