Case Presentations:
The first patient is a 78 y.o. woman with persistent atrial
fibrillation, hypertension, breast cancer, ischemic heart disease
status-post coronary bypass, near-normal systolic function and mitral
valve replacement with severe TR. She was not a surgical candidate and
underwent TTVR with a 52mm EVOQUE. She developed complete heart block
with a ventricular escape at 30 bpm immediately following valve
deployment. A temporary pacemaker was placed via the right internal
jugular vein. Heart block persisted and a MICRA VR was placed two days
later. At the time of leadless placement implant both of the femoral
sites were unacceptable due to cutaneous infections and the right
internal jugular vein was used for a temporary pacemaker. We therefore
used the left internal jugular vein was used for Micra placement using
techniques that have been previously described[16].
The second patient is an 82 y.o. woman with hypertension,
hyperlipidemia, prior pacemaker for sinus node dysfunction and now
permanent atrial fibrillation who had undergone system extraction for
MRSA bacteremia. After completion of antibiotic therapy she was found to
have severe TR. She was not a surgical candidate and underwent TTVR with
a 52mm EVOQUE. She developed complete heart block with a junctional
escape at 59 bpm immediately following valve deployment. Given her
stable rhythm, conservative management was initially employed. Although
the patient recovered some degree of AV conduction (ventricular rates in
the 40s) she had several ventricular pauses and multiple episodes of
Torsades de Pointes. She underwent MICRA VR placement via a RFV approach
seven days after TTVR.
The third patient is an 87 y.o. man with ischemic heart disease
status-post coronary bypass with preserved left ventricular function,
Parkinson’s disease with modest dementia, chronic kidney disease stage
III, and right sided heart failure with severe TR. He was not a surgical
candidate and underwent TTVR with a 52mm EVOQUE. He developed complete
heart block with a junctional escape at 50 bpm immediately following
valve deployment. Notably, prior to TTVR implantation, he had first
degree AVB with a PR of 395ms. Due to very low likelihood of conduction
recovery, he underwent immediate MICRA AV placement via a left femoral
vein approach. With optimization of his device he demonstrated
> 90% AV synchrony 12 hours after device implantation and
was able to discharged from the hospital the day after his combined
procedure.