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Case Reports
. 2023 Nov 9:10:1287506.
doi: 10.3389/fcvm.2023.1287506. eCollection 2023.

Case Report: A leadless and endovascular pacemaker teamwork

Sarah Zeriouh  1 , Vasileios Sousonis  1 , Roberto Menè  1 , Serge Boveda  1 , Quentin Voglimacci-Stephanopoli  1 , Stéphane Combes  1
Affiliations
Case Reports

Case Report: A leadless and endovascular pacemaker teamwork

Sarah Zeriouh et al. Front Cardiovasc Med. .

Abstract

Background: Cardiac Implantable Electronic Device infections increase short- and long-term mortality, along with healthcare costs. Leadless pacemakers (PM) were developed to overcome pocket- and minimize lead-related complications in selected high-risk patients. Recent advancements enable leadless devices to mechanically detect atrial activity, facilitating atrioventricular (AV) synchronous stimulation.

Case summary: A 90-year-old woman, implanted with a dual-chamber pacemaker eight years ago due to sinus node dysfunction, presented with syncope. A diagnosis of complete AV block, in the setting of ventricular lead dysfunction was made. Due to a high risk of infection, the patient was implanted with a leadless PM capable of maintaining AV synchrony in VDD mode (MICRA™ model MC1AVR1). The transvenous PM was programmed to AAI-R mode to drive the atria, which, in turn, triggered the leadless PM to stimulate the ventricles. At six month follow-up, the AV synchrony rate was 85%.

Conclusion: The combination of classic atrial pacing with leadless ventricular stimulation can be used in high-risk patients to reduce the risk of complications, in the setting of ventricular lead dysfunction. In this manner, AV synchrony can be maintained, improving hemodynamic parameters and quality of life. Low sinus rate variability at rest is essential to achieve a high AV synchrony rate in such cases.

Keywords: atrioventricular synchrony; device infection; endovascular pacemaker; lead dysfunction; leadless pacemaker.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Electrocardiogram showing spontaneous P wave activity followed by unipolar ventricular stimulation spikes that most of the times are ineffective (blue arrows) and rarely result in ventricular capture (green arrows).
Figure 2
Figure 2
Procedural fluoroscopy images showing leadless PM's position at the level of the lower interventricular septum, just before device deployment. RAO, right anterior oblique; LAO, left anterior oblique.
Figure 3
Figure 3
Electrocardiogram showing unipolar atrial stimulation by the transvenous pacemaker followed by a ventricular spike generated by the leadless pacemaker that leads to ventricular capture with a fixed atrioventricular delay, resulting in atrioventricular synchrony. One ventricular and one atrial ectopic beat are also present.
Figure 4
Figure 4
Post-procedural chest x-Ray showing a dual chamber transvenous pacemaker and a MICRA™ AV leadless pacemaker implanted at the interventricular septum.
Figure 5
Figure 5
MICRA™ AV window. Lead DI shows a sharp and high-amplitude signal that corresponds to the atrial pacing stimulus. An atrial mechanical event is sensed during the A3 (passive ventricular filling phase)/A4 (active ventricular filling) window, marked as AM on the stip. After the predefined atrioventricular delay, the pacing stimulus is delivered (VP). The amplitude of the recorded atrial signal has been automatically decreased to adapt to the sensing of the high amplitude far-field atrial pacing stimulus. Nevertheless, the atrial activity is well recognized by the accelerometer and the resulting atrioventricular synchrony is effective. VE, defines the end of the A3 window; AM, presumed atrial mechanical contraction (A4 signal/A-wave); VP, ventricular pacing.
See this image and copyright information in PMC

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