Introduction Precautions for implanting cardiac implantable electronic devices (CIED) into patients with end-stage kidney disease (ESKD) are more prevalent nowadays. However, concerns about haemodialysis in patients with CIED are rare.

Case Presentation A 45-year-old woman with underlying type 2 diabetes mellitus hypertension. She was diagnosed with a complete heart block, which required a permanent pacemaker in 2007, and underwent a box change in 2017. She was further complicated with ESKD, requiring regular peritoneal dialysis since 2019. Unfortunately, she had to convert to haemodialysis in May 2024 due to recurrent peritonitis. The nephrology team referred us as the patient had been oxygen-dependent since starting haemodialysis through internal jugular catheter insertion. Upon review, she had right ventricular failure: oedematous over her lower extremities and had sacral oedema and ascites; a chest drain was inserted for persistent pleural effusion. A loud systolic murmur was heard over the left sternal edge with loud P2. Electrocardiogram shows RV strain pattern. Echocardiography revealed severe tricuspid regurgitation (TR) with a systolic pressure gradient of 80mmHg. 3D echocardiography showed pacemaker wire impinging septal leaflet, causing mechanical TR. Pacemaker interrogation found 99.9% ventricular pacing. Consensus between managing teams and patients was made, and volume control was decided through fluid restriction and haemodialysis to maintain ideal dry weight as guided by a body composition monitor. She eventually developed a hospital-acquired infection, worsening pulmonary hypertension, leading to her demise within 3 months of haemodialysis.

Discussion Patients with ESKD have shorter lives compared to the healthy population. A study found higher mortality in the first 5 months for those with peritoneal dialysis switching over to haemodialysis. Our patient developed severe TR and right ventricular failure after starting with haemodialysis through the internal jugular catheter, with echocardiography evidence of pacemaker wire causing mechanical free flow TR. She was, unfortunately, pacemaker dependent. Transvenous lead retraction and any form of tricuspid valve intervention (surgery / transcatheter edge-to-edge repair / transcatheter tricuspid valve transplant) were too invasive or expensive treatment for her.

Conclusion Haemodialysis in ESRD patients may worsen underlying CIED-related TR and is expensive to treat. Serial TR assessment in CIED patients is essential.