Case History
A 21-year-old male, known case of pulmonary valve atresia, large ASD and PDA who underwent pulmonary valvotomy and PDA closure shortly after his birth, presented with exacerbation of dyspnea and peripheral edema. Right heart catheterization and transesophageal echocardiography revealed moderate RV enlargement, severe pulmonary insufficiency, severe secondary tricuspid regurgitation (due to large ASD and RV enlargement), and large secondum atrial septal defect (ASD) with significant bidirectional shunt. He underwent simultaneous bioprosthetic replacement of pulmonary valve (Perimount 25) and tricuspid valves (Magna Ease 31) and ASD closure.
One week after surgery, he became bradycardic, and electrocardiogram showed complete AVB . Considering the persistence of AVB for more than a week, it was decided to implant a permanent pacemaker. As he had undergone recent BTV replacement, insertion of conventional transvenous pacemaker was not preferred. So, the options were placement of epicardial pacemaker, coronary sinus (CS) lead, or a leadless pacemaker. As the patient has undergone multiple cardiac surgery with resultant pericardial adhesion, cardiac surgeon refused to implant an epicardial lead. Implantation of a CS lead was impossible due to absence of proper cardiac vein. Finally, it was decided to implant a leadless pacemaker (Micra, Medtronic Inc).