
==== Front
9918506088006676
52148
Ann Thorac Surg Short Rep
Ann Thorac Surg Short Rep
Annals of thoracic surgery short reports
2772-9931

39238544
10.1016/j.atssr.2023.11.034
nihpa1999138
Article
Surgical Repair After Leadless Pacemaker–Induced Avulsion of Tricuspid Valve
Wang Yoyo MD 1
Ailawadi Gorav MD, MBA 1
Brescia Alexander A. MD, MSc 1
Duggal Neal M. MD 2
1 Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
2 Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
Address correspondence to Dr Ailawadi, Department of Cardiac Surgery, 1425 E Ann St, Ann Arbor, MI 48109; ailawadi@med.umich.edu.
4 7 2024
6 2024
03 1 2024
05 9 2024
2 2 262265
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
The use of the leadless pacemaker system (Micra; Medtronic) has grown in popularity with a lower risk of postimplantation complications associated with traditional pacemakers. We describe the case of a 78-year-old woman who presented with torrential tricuspid regurgitation due to avulsion of the anterior papillary muscle and entire chordal apparatus of the tricuspid valve after Micra pacemaker placement at an outside hospital. After she was deemed ineligible for transcatheter approaches, she underwent a minimally invasive tricuspid valve operation. Although her planned operation was valve replacement, she underwent a successful repair with postoperative echocardiography demonstrating no residual torrential tricuspid regurgitation.
==== Body
pmcCompared with traditional pacemaker systems, leadless pacemakers (Micra; Medtronic) have been associated with a 25% to 50% lower risk of complications, including incisional hematoma, infection, pneumothorax, hemothorax, venous stenosis, and late tricuspid regurgitation.1,2 However, improper implantation can still lead to damage of surrounding structures. We present the case of a patient who underwent tricuspid valve repair after development of torrential tricuspid regurgitation caused by a flail septal leaflet after Micra pacemaker placement.

A 78-year-old woman with a 10-year history of persistent atrial fibrillation who failed to respond to multiple catheter ablations and intolerant of antiarrhythmic medications underwent atrioventricular node ablation and Micra pacemaker implantation at an outside hospital. Afterward, a transient ischemic attack and pericarditis developed, both of which resolved. During the ensuing weeks, she had New York Heart Association class III symptoms. A transthoracic echocardiogram obtained at the outside hospital demonstrated severe tricuspid regurgitation with a flail tricuspid valve and a left ventricular ejection fraction of 35%. Transesophageal echocardiography demonstrated avulsion of the anterior papillary muscle and chordal apparatus with a completely flail anterior leaflet, torrential tricuspid regurgitation, and a tricuspid valve annulus of 48 mm (Figure 1). Right ventricular function was mildly depressed with moderate dilation. She was referred to our multidisciplinary advanced valve center. Because of her large flail gap/complex anatomy and known nickel allergy, she was not a candidate for transcatheter tricuspid repair or replacement trials, respectively. Moreover, her recent transient ischemic attack required a prolonged waiting period before eligibility. Given her ongoing and worsening symptoms, we offered isolated tricuspid valve replacement. To minimize the insult to the right ventricle, we planned a beating heart bioprosthetic tricuspid valve replacement through a right mini-thoracotomy approach.

A standard 4-cm right anterior thoracotomy approach was used with femoral arterial and venous cannulation and an additional superior vena cava cannula through the right internal jugular vein. With endoscopic assistance, the right atrium was opened, and an atrial lift retractor was placed to expose the tricuspid valve. Examination of the tricuspid valve demonstrated an enlarged tricuspid annulus with ruptured chordae tendineae to most of the anterior leaflet (Figure 2A). The Micra pacemaker was visualized beneath the tricuspid valve in the right ventricle septal wall through a papillary muscle, explaining the multiple torn cords (Figure 2B). At this point, it was decided that the valve was potentially salvageable, and a repair was attempted. In addition, the decision was made to leave the Micra leadless pacemaker in to reduce further trauma to the right ventricle septal wall with removal of the device.

Annular 2–0 braided Ethibond (Johnson & Johnson) sutures were placed in the tricuspid annulus for exposure. The valve was tested with warm saline and the area of tricuspid regurgitation identified, beginning in the anteroseptal commissure and extending along most of the anterior leaflet (Video). Interrupted 4–0 Ethibond edge-to-edge repair was performed along the anteriorseptal coaptation surface (Figure 2C). With more than one-third of the valve orifice eliminated through the edge-to-edge repair, we wished to confirm that the remaining orifice would be large enough to avoid tricuspid stenosis. The residual orifice would accommodate a 29-mm mitral bioprosthesis, which was deemed adequate to avoid tricuspid stenosis in a patient of this size.

The annulus was true sized and measured to a 36-mm Tri-Ad (Medtronic) annuloplasty ring. The sutures were anchored with Cor-Knot (LSI Solutions) titanium fasteners. Final saline test demonstrated good coaptation and no tricuspid regurgitation (Figure 2D). Postoperative transesophageal echocardiography revealed preserved biventricular function with no residual tricuspid regurgitation and a mean transvalvular gradient of 1 mm Hg (Figure 3).

The patient did well and was discharged on postoperative day 3 with no complications. She remains well 4 months after her procedure.

COMMENT

Leadless pacemaker requires the use of a 27F transfemoral venous delivery system to affix the pacemaker to the myocardium of the right ventricle with 4 nitinol tines and no indwelling lead or generator.2 Micra leadless pacemakers have been associated with a 25% to 45% reduction in short-term postimplantation complications compared with transvenous pacemakers.1,3 On the contrary, leadless pacemakers have been limited to single-chamber pacing, although trials are ongoing with new dual-chamber leadless devices. Major complications from these leadless implants include pericardial effusion, cardiac perforation, device dislodgement, and tricuspid valve dysfunction.2,4 Specifically, the large delivery system and common implantation performed without echocardiographic guidance allow the possibility of damage to the tricuspid valve or subvalvular apparatus, especially for cases in which multiple attempts are made at device deployment.4,5 However, it is believed that the force generated during implantation and retrieval of the Micra pacemaker is insufficient to rupture the chordae tendineae.4 Unfortunately, in this case, there was no outside hospital procedural report available for the placement of the Micra leadless pacemaker. As such, it is difficult to discern the role that the delivery system or the device deployment had on avulsion of the tricuspid valve.

Although the incidence of new tricuspid regurgitation after Micra pacemaker implantation is not well reported, the anatomic location can significantly affect the odds for development of valvular dysfunction.4,6 Specifically, placement of the device along the septum is associated with higher rates of tricuspid regurgitation and required lower tensile forces to induce rupture of the chordae tendineae compared with pacemakers placed anteriorly or posteriorly.4,7 However, placement of the pacemaker anteriorly or posteriorly should be weighed against the inherent risk of perforation or cardiac tamponade. Currently, there is only 1 other reported case of a Micra pacemaker implantation complicated by flail tricuspid valve in a young patient.8

We demonstrate a unique case of tricuspid valve repair due to suboptimal placement of the Micra leadless pacemaker along the right ventricular septum. This was suspected to be the main cause of the chordae tendineae rupture and subsequent severe tricuspid regurgitation. Judicious and careful placement of leadless pacemakers, potentially under echocardiographic guidance, may prevent serious postimplantation complications. Although transcatheter approaches are appealing, this case demonstrates how surgical repair remains a viable option in isolated tricuspid disease. Importantly, tricuspid repair is feasible in cases in which there is no underlying tricuspid or right ventricular disease.

Supplementary Material

1

FUNDING SOURCES

Research funding was provided by the NIH (grant number is: 5T35HL007690–38).

FIGURE 1 (A) Preoperative transesophageal echocardiography demonstrating flail tricuspid valve. (B) Preoperative transesophageal echocardiography demonstrating torrential tricuspid regurgitation.

FIGURE 2 (A) Examination of flail tricuspid valve. (B) Micra pacemaker implanted in right ventricular septum. (C) Saline testing during tricuspid valve repair. (D) Saline testing after complete repair of tricuspid valve.

FIGURE 3 (A) Postoperative transesophageal echocardiography demonstrating no tricuspid regurgitation. (B) Postoperative transvalvular mean gradient of 1 mm Hg. (max PG, maximal pressure gradient; mean PG, mean pressure gradient; Vmax, maximum velocity; Vmean, mean velocity; VTI, velocity–time integral.)

The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.atssr.2023.11.034] on http://www.annalsthoracicsurgery.org.

DISCLOSURES

Gorav Ailawadi reports a relationship with Medtronic Inc that includes: consulting or advisory; with Abbott, Edwards, Gore, Anteris that includes: consulting or advisory; with AtriCure Inc, CryoLife, Philips, Johnson & Johnson, JenaValve Technology Inc, MediaSphere, Arthrex Inc that includes: consulting or advisory.

PATIENT CONSENT

Obtained.
==== Refs
REFERENCES

1. Duray GZ , Ritter P , El-Chami M , Long-term performance of a transcatheter pacing system: 12-month results from the Micra Transcatheter Pacing Study. Heart Rhythm. 2017;14 :702–709.28192207
2. Reynolds D , Duray GZ , Omar R , A leadless intracardiac transcatheter pacing system. N Engl J Med. 2016;374 :533–541.26551877
3. Piccini JP , El-Chami M , Wherry K , Contemporaneous comparison of outcomes among patients implanted with a leadless vs transvenous single-chamber ventricular pacemaker. JAMA Cardiol. 2021;6 :1187–1195.34319383
4. Mattson AR , Zhingre Sanchez JD , Iaizzo PA . The fixation tines of the Micra leadless pacemaker are atraumatic to the tricuspid valve. Pacing Clin Electrophysiol. 2018;41 :1606–1610.30341813
5. Berdaoui B , Pintea Bentea G , Samyn S , Morissens M , Castro Rodriguez J . Leadless pacemaker implantation: an unexpected complication. Pacing Clin Electrophysiol. 2022;45 :289–291.34743338
6. Haeberlin A , Bartkowiak J , Brugger N , Evolution of tricuspid valve regurgitation after implantation of a leadless pacemaker: a single center experience, systematic review, and meta-analysis. J Cardiovasc Electrophysiol. 2022;33 :1617–1627.35614867
7. Beurskens NE , Tjong FV , de Bruin-Bon RH , Impact of leadless pacemaker therapy on cardiac and atrioventricular valve function through 12 months of follow-up. Circ Arrhythm Electrophysiol. 2019;12 :e007124.
8. Pingitore A , Calcagno S , Salvador L , Mennuni S , Cavarretta E . Tricuspid leaflet flail after Micra leadless pacemaker implantation: a case report. Eur Heart J Case Rep. 2022;6:ytac154.
