A 25 year old man with a history of intravenous drug abuse presented with a large tricuspid vegetation and evidence of uncontrolled infection. He underwent excision of the infected material and tricuspid valve replacement with a 33 mm bileaflet prosthesis.

After his operation he developed complete heart block requiring temporary epicardial pacing and a pericardial effusion. The effusion was drained and a dual chamber pacemaker inserted using a lead in a posterior branch of the coronary sinus to pace the left ventricle.

Six months later he is well on warfarin with excellent pacing thresholds in the right atrium and left ventricle (both less than 0.65 V at 0.4 ms).

The figure shows the relationship of the pacing lead (Medtronic 4193) to the tricuspid ring and to the posterior pericardial space delineated by the pericardial catheter.