Quadripolar left ventricle only single lead pacing in a patient with a tricuspid mechanical valve: A less invasive approach

In the presence of prosthetic tricuspid valve, the inaccessibility to the right ventricle makes permanent pacing challenging. The placement of a left ventricle (LV) single lead in the coronary sinus (CS) is a well-accepted alternative, with some limitations regarding sensing and threshold. We describe a clinical case of a patient who had a previous LV only lead in the CS due to the presence of a prosthetic tricuspid valve and, after a surgical valvular intervention, presented with recurrent syncope episodes due to lead malfunction with lack of pacing capture and significant ventricular pauses. A quadripolar lead was chosen to be placed in the CS connected to a cardiac resynchronization therapy pacemaker device, programmed at biventricular VVI and using a specific manufacturer T-wave protection algorithm to prevent pacemaker-induced arrhythmias and to use the patient's own rhythm. This approach prevented a fourth surgical intervention to place an epicardial lead and resulted in reasonable LV sensing and pacing threshold. LEARNING OBJECTIVES: This paper reports an alternative and atypical approach that could solve some of the limitations associated with ventricular pacing in patients with tricuspid prosthetic valves and multiple previous surgeries.