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.