In the setting of tricuspid valve repair or replacement, should epicardial pacing leads be favoured over transvenous leads?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed "In patients undergoing tricuspid valve repair or replacement, should epicardial pacing leads be favored over transvenous leads?" A total of 46 papers were identified, of which 9 represented the best available evidence, including observational cohort studies and registry analyses. Key outcomes included tricuspid regurgitation (TR) severity, lead failure, prosthetic dysfunction, need for reintervention, mortality and long-term device reliability, with TR severity and valve-related reinterventions considered the primary clinically meaningful endpoints. In patients undergoing tricuspid valve replacement, there was a trend towards increased prosthetic valve dysfunction with transvenous leads. Epicardial lead placement, despite lower long-term durability and higher lead thresholds, avoids direct leaflet interaction and therefore represents a potential strategy in selected patients undergoing tricuspid valve replacement, although current evidence is insufficient to support formal recommendations. Larger prospective studies are required to establish guideline-level recommendations.