Hostile tricuspid valve overcome by selecting the middle cardiac vein: An alternative for the standard right ventricular lead placement of biventricular ICD

Background: Right ventricular (RV) lead placement can be contraindicated or impossible in patients after tricuspid valve (TV) surgery. Placement of the ICD lead in the middle cardiac vein (MCV) can be a viable option in such population with indication for Biventricular (BiV) ICD. Case: A 76-year-old male has a history of paroxysmal atrial fibrillation, prior CABG, bioprosthetic mitral and tricuspid valve replacements. He had several admissions for worsening biventricular function (EF of 25%). His course was also complicated by severe valvular and peri-valvular regurgitation of his bioprosthetic TV (Figure 1). He has significant first-degree AV block with a wide RBBB (Figure 3). Heart catheterization revealed patent grafts and no need for revascularization. Decision-making: Given the TV pathology, TV replacement and epicardial BiV ICD system was discussed. He was found to be a poor candidate for repeat thoracotomy. Implantation of a transvenous BiV ICD system was thought to be the best management option. Given the significant pathology of TV, there was concern that placement of the lead in the RV would worsen his valvular or perivalvular regurgitation. We elected to place the RV lead in the MCV (Figure 2 and 4). He had remarkable improvement in his NYHA Class III-IV to Class II symptoms, and no heart failure admissions with BiV pacing at his 1 year follow up. Conclusion: RV lead placement, of BiV ICD, in the MCV can be excellent alternative in patients with significant TV pathology and poor surgical candidacy. [Figure presented