Leadless Pacing: Where We Currently Stand and What the Future Holds

Procedural and long-term outcomes of tunneled transvenous leads

BACKGROUND

Lead-related venous stenosis and occlusion can complicate the insertion or replacement of transvenous leads in patients with cardiac implantable electronic devices (CIEDs). A possible solution is to tunnel the lead from the contralateral vasculature to the ipsilateral generator. Procedural complications and long-term outcomes remain unclear with this technique.

OBJECTIVE

We sought to assess outcomes of tunneled transvenous leads.

METHODS

We retrospectively identified all patients who underwent transvenous CIED lead tunneling to a contralateral pocket at our institution between 2014 and 2024. Clinical characteristics, indications for lead implantation, postoperative complications, and long-term outcomes were collected.

RESULTS

We identified that 27 patients underwent transvenous lead tunneling at our institution. Most patients were men (20, 74%) with a mean age of 68.8 ± 18.3 years. Most patients had nonischemic cardiomyopathy (16, 59%) with a mean ejection fraction of 29.3% ± 11.3%. The tunneled leads were coronary sinus leads (20, 74%), followed by defibrillator leads (5, 18.5%) and right ventricular pacing leads (2, 7.4%). Implantation procedures were primarily for device upgrade (18), lead revisions (8), or de novo lead placement (1). No postoperative complications were seen. Patients were followed for a mean of 2.2 ± 1.4 years. One tunneled defibrillator lead (3.7%) had low shock impedance 3 years after implantation, which was monitored and did not require an intervention.

CONCLUSION

In patients with ipsilateral venous occlusion, contralateral lead tunneling appears to be an effective and safe approach to manage patients with CIEDs and occluded ipsilateral subclavian veins.

Leadless Pacing: Current Status and Ongoing Developments

Although significant strides have been made in cardiac pacing, the field is still evolving. While transvenous permanent pacing is highly effective in the management of bradyarrhythmias, it is not risk free and may result in significant morbidity and, rarely, mortality. Transvenous leads are often the weakest link in a pacing system. They may dislodge, fracture, or suffer breaches in their insulation. This review was undertaken to clarify leadless risks, benefits, and alternatives to transvenous cardiac pacing for bradyarrhythmias and heart failure management. In order to clarify the role(s) of leadless pacing, this narrative review was undertaken by searching MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and review articles, as well as other clinically relevant reports and studies. The search was limited to English-language reports published between 1932 and 2024. Leadless pacing was searched using the terms Micra™, Nanostim™, AVEIR™, single-chamber leadless pacemaker, dual-chamber leadless pacemaker, cardiac resynchronization therapy (CRT), cardiac physiological pacing (CPP) and biventricular pacing (BiV). Google and Google Scholar, as well as bibliographies of identified articles were also reviewed for additional references. The advantages and limitations of leadless pacing as well as options that are under investigation are discussed in detail.

A Primer on Pacemakers and Defibrillators for Nurses

Although the concepts of pacing have been around for more than half a century, technological advances in cardiac implantable electronic devices (CIEDs) have changed the landscape for patients in need of pacing support or sudden death prevention. Nurses encounter patients with CIEDs in all aspects of the health care setting. Because exciting CIED therapies are on the horizon, nurses must stay up-to-date to promote optimal outcomes for CIED patients. This essential guide provides nurses with a comprehensive overview of the principles of pacing and implantable cardioverter defibrillators (ICDs), as well as innovative technologies such as leadless cardiac pacemakers and subcutaneous ICDs.

Leadless Cardiac Pacing: New Horizons

Since the introduction of transvenous cardiac pacing leads, pacemaker system design has remained similar for several decades. Progressive miniaturisation of electronic circuitry and batteries has enabled a smaller, single pacing unit comprising the intracardiac electrodes, generator and computer. This review explores the development of leadless pacing, the clinical trials comparing leadless to transvenous pacing in addition to the future developments of multi-chamber leadless pacing.

Leadless Pacemaker Implantation in the Emergency Bradyarrhythmia Setting: Results from a Multicenter European Registry

Background. Data on leadless pacemaker (LPM) implantation in an emergency setting are currently lacking. Objective. We aimed to investigate the feasibility of LPM implantation for emergency bradyarrhythmia, in patients referred for urgent PM implantation, in a large, multicenter, real-world cohort of LPM recipients. Methods. Two cohorts of LPM patients, stratified according to the LPM implantation scenario (patients admitted from the emergency department (ED+) vs. elective patients (ED−)) were retrieved from the iLEAPER registry. The primary outcome of the study was a comparison of the peri-procedural complications between the groups. The rates of peri-procedural characteristics (overall procedural and fluoroscopic duration) were deemed secondary outcomes. Results. A total of 1154 patients were enrolled in this project, with patients implanted due to an urgent bradyarrhythmia (ED+) representing 6.2% of the entire cohort. Slow atrial fibrillation and complete + advanced atrioventricular blocks were more frequent in the ED+ cohort (76.3% for ED+ vs. 49.7% for ED−, p = 0.025; 37.5% vs. 27.3%, p = 0.027, respectively). The overall procedural times were longer in the ED+ cohort (60 (45−80) mins vs. 50 (40−65) mins, p < 0.001), showing higher rates of temporary pacing (94.4% for ED+ vs. 28.9% for ED−, p < 0.001). Emergency LPM implantation was not correlated with an increase in the rate of major complications compared to the control group (6.9% ED+ vs. 4.2% ED−, p = 0.244). Conclusion. LPM implantation is a feasible procedure for the treatment of severe bradyarrhythmia in an urgent setting. Urgent LPM implantation was not correlated with an increase in the rate of major complications compared to the control group, but it was associated with longer procedural times.

Clinical Updates in Cardiac Pacing—The Future Is Bright

The history of cardiac pacing has been defined by many innovation milestones starting in the early 1960s [...]