Implantable Defibrillator in a Patient with a Tricuspid Valve Bioprosthesis

Author Affiliations: From the Electrophysiology Department, Winthrop University Hospital, Mineola, New York. The authors report no conflicts of interest regarding the content herein. Manuscript submitted May 30, 2008, provisional acceptance given July 17, 2008, and final version accepted August 7, 2008. Address for correspondence: Todd Cohen, MD, Electrophysiology Department, Winthrop University Hospital, 120 Mineola Blvd., Suite 500, Mineola, NY 11501. E-mail: jillcohen49@hotmail.com

_______________________________________________ ABSTRACT: In the case presented here, we were able to achieve an adequate defibrillation configuration with acceptable thresholds in a patient with a tricuspid valve bioprosthesis.

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J INVASIVE CARDIOL 2008;20:E341–E342 Case Report. A 47-year-old female with a history of ventricular tachycardia, syncope, permanent pacemaker and a tricuspid valve bioprosthesis (Medtronic Hancock porcine bioprosthesis, Medtronic Inc., Minneapolis, Minnesota) implanted 11 years ago was referred for an electrophysiology (EP) study. The EP study demonstrated inducible sustained ventricular tachycardia and the patient was referred for an upgrade of the pacemaker to an implantable defibrillator. The patient had a permanent pacemaker implanted at the time of initial surgery in the left abdomen with a tunneled right atrial endocardial lead and 2 epicardial screw-in leads. A decision was made to implant a defibrillator lead in the coronary sinus in order to avoid crossing the tricuspid valve bioprosthesis. Figure 1 shows ventricular tachycardia induced in this patient. Figure 2 shows placement of a coronary sinus/left ventricular coil via a guide catheter. The new lead was eventually tunneled into the abdomen, and defibrillation thresholds were performed. At implantation, ventricular electrogram recordings using the old epicardial leads were acceptable in quality and no significant oversensing was observed. The defibrillation thresholds with the coil serving as cathode and the pulse generator as anode failed at 25 joules. Subsequently, with the coil serving as the anode and the generator as the cathode, defibrillation thresholds were acceptable at both 25 joules and 20 joules. Discussion. There have been limited reports in which pacing leads have been placed across a tricuspid valve prosthesis.1,2 In a larger series, transvalvular pacing was an increased risk for worsening tricuspid valvular regurgitation.3 One may conclude from this study that the presence of a tricuspid valve bioprosthesis is a relative contraindication for placement of a lead across the valve. This is due to the wear and tear of the lead and its potential interaction with the valve. Additionally, if lead extraction were ever required, this procedure might jeopardize the structure and function of the prosthetic valve, potentially resulting in the need for premature valvular replacement. In order to access ventricular tissue, the coronary sinus/left ventricular access method has been described.4 Wedekind and colleagues described placing a defibrillation lead in the coronary sinus vein in a 25-year-old male with a prosthetic tricuspid valve.5 Defibrillation thresholds tested at 25 joules were successful. In fact, other investigators have demonstrated improved defibrillation utilizing the coronary sinus/left ventricular shocking-coil approach.6–9 In this case, we were able to achieve an adequate defibrillation configuration with acceptable thresholds in a patient with a tricuspid valve bioprosthesis. For simplicity, the patient’s older epicardial pace-sense leads were utilized, although a theoretical potential for extracardiac oversensing did exist. Alternatively, it may have been feasible to place an entire implantable cardioverter defibrillator lead in a left ventricular branch via the coronary sinus route similar to that reported in Wedekind.5

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