Leadless pacemaker implantation via right jugular approach in a patient with a bicaval valve system: a case report

Tricuspid regurgitation in elderly patients with multiple comorbidities presents unique challenges, especially after prior valve interventions and when advanced heart failure symptoms persist. New device-based therapies such as bicaval valve stents (TricValve®) can offer alternatives for patients not suitable for surgery but may complicate pacemaker implantation.

We report an 85-year-old woman with a history of coronary artery disease, prior valve-in-valve transcatheter aortic valve implantation (TAVI) for a degenerated aortic prosthesis, and permanent atrial fibrillation. She presented with decompensated right heart failure due to severe secondary tricuspid regurgitation, despite optimal medical treatment. After the heart team discussion, surgical repair and transcatheter tricuspid valve replacement were denied for prohibitive risk. A TricValve® system was successfully implanted to treat symptomatic caval reflux.

Several days later, she developed complete atrioventricular block with recurrent syncope. A leadless pacemaker (Aveir VR™) was implanted via the right internal jugular vein and navigated safely through the superior cava prosthesis. Device deployment was successful, with no acute procedural complications; however, the patient died shortly thereafter due to pneumonia.

This case demonstrates the feasibility of leadless pacemaker implantation in the presence of a bicaval valve system and complex, high-risk anatomy. While transvenous pacemaker implantation may still be feasible with a superior vena cava valve prosthesis in place, it can cause unwanted interference, potentially impairing valvular function and increasing the risk of endocarditis compared with leadless pacemaker solutions. However, the findings are limited to acute procedural success.