Leadless pacing: a comprehensive review

Abstract

Over the past decade, leadless pacing has undergone a rapid evolution, resulting in multiple leadless pacemaker (LPM) devices that offer advancements such as atrioventricular synchronized pacing in VDD mode, atrial stimulation, dual-chamber pacing, and longer battery longevity. Studies comparing LPMs with transvenous pacemakers (TVPMs) show a lower rate of device-related complications with LPMs. In the near future, LPMs could be combined with other devices such as non-transvenous implantable cardioverter-defibrillators to provide anti-tachycardia pacing or bradycardia pacing. Future prospectives for leadless cardiac resynchronization therapy and leadless conduction system pacing are being investigated. As LPMs continue to improve, their applications are anticipated to expand further improving patient outcome, promising a bright future for leadless pacing. In this review, the past, present, and future of leadless pacing are discussed with a focus on cutting-edge implantation techniques, clinical outcomes, and modern advancements of LPMs.

Keywords: AVEIR; CRT; CSP; Leadless pacemaker; Micra.

Graphical Abstract

An overview of the past, present, and future of leadless pacing: comparison of different leadless pacemakers (LPMs) and their size in millimetre, with the Nanostim in the past, the Micra VR/AV and AVEIR with atrial module in the present. Furthermore, an overview of the different pacing modes: single-chamber pacing VVI/VDD mode, dual-chamber pacing DDD mode, cardiac resynchronization therapy (CRT) (it is not clear how this will be implemented, a LPM in the left ventricle is not desirable), conduction system pacing with a LPM in the interventricular septum activating the conduction system, and a LPM combined with a subcutaneous implantable cardioverter-defibrillator (S-ICD), which can deliver shock therapy. Different pacing locations with the right ventricular (RV) apex in the past, given the higher risk of pericardial effusion and the broader paced QRS complex. The vascular access with the femoral vein (FV) in the past, given more vascular complications, and the internal jugular vein (IJV) in the future with less vascular complications and easier access to the RV septum. Different pacing indications in the very young and the very old. Long-term complications in LPMs vs. transvenous pacemakers (TVPMs), showing lower overall complications, lower infection rate, lower device revision rate, and a lower heart failure (HF) hospitalization rate for LPMs. On the other hand, more cardiac perforations and a higher all-cause mortality rate for LPMs. AVB, atrioventricular block; RVOT, RV outflow tract.

Figure 1

Comparison of the size and volume of the different leadless pacemakers. The Nanostim leadless pacemaker, the Micra leadless pacemaker, and the AVEIR leadless pacemaker with device characteristics

Figure 2

(A) Left anterior fluoroscopic image of the device positioned on the apical septum in the right ventricle with contrast injection approached through the internal jugular vein. (B) Right anterior fluoroscopic image of the device positioned on the apical septum in the right ventricle with contrast injection approached through the internal jugular vein. (C) Depiction of the flamingo neck confirming the right amount of push, with the jugular approach the force applied is transmitted 1:1