Leadless Pacing: Therapy, Challenges and Novelties

Anesthesia and EMI: Ensuring Safe CIED Management During Surgical Procedures

When planning surgical procedures for patients with conventional pacemakers, leadless pacemakers, cardiac resynchronization therapy devices, or implantable cardioverter-defibrillators, it is imperative to assess the risk of electromagnetic interference to ensure the safe functioning of these cardiac implantable electronic devices (CIEDs) during surgery. This paper explores the strategies for managing both conventional CIEDs and leadless devices during such procedures, emphasizing the importance of the preoperative evaluation, appropriate device programming, intraoperative monitoring, and postoperative evaluation. This report highlights the critical role of collaboration with cardiology and the CIED team in ensuring patient safety during surgical procedures. Ultimately, diligent intraoperative management, adherence to guidelines when available, and preparedness to address any complications are essential for protecting CIED function during surgical procedures.

Pacemakers in Modern Cardiology and Their Transition From Traditional to Leadless Models

Cardiac rhythm disorders are a major subset of cardiovascular diseases and continue to pose significant global health challenges. Pacemakers remain central to their management, with evolving technologies offering improved therapeutic outcomes. This narrative review traces the progression of pacemaker technology from traditional cardiac pacemakers (TCPs) to leadless cardiac pacemakers (LCPs), emphasizing key differentiators such as implantation techniques, complication profiles, and long-term clinical performance. While TCPs have proven effective, they are associated with issues like lead-related complications, infections, and mechanical failures. In contrast, LCPs, which are implanted via minimally invasive transcatheter approaches and lack transvenous leads, significantly reduce these risks, resulting in improved patient satisfaction and fewer hospitalizations. Although limited to single-chamber pacing and higher initial costs, LCPs may prove cost-effective over time due to lower complication-related expenses. This review synthesizes current evidence on safety, efficacy, and patient outcomes and explores recent advancements, including multicomponent systems, energy-harvesting mechanisms, and biocompatible materials. Many of these innovations are in preclinical or early clinical stages but hold promise for broader applicability and long-term sustainability. Despite challenges, the trajectory of pacemaker technology underscores its potential to revolutionize cardiac care, driven by increasing clinical adoption of leadless systems, evolving regulatory approvals, and a growing emphasis on equitable access and personalized management.

Leadless Pacemakers: The "Leading Edge" of Quality of Life in Cardic Electrophysiology

PURPOSE OF THE REVIEW

Permanent pacemakers (PPMs) are common cardiac implantable devices indicated for patients with bradycardia or tachycardia. Currently, PPMs include both transvenous pacemakers (TV-PM) and leadless pacemakers (L-PM). This paper reviews the existing data on L-PM technology including: a) medical aspects and indications, b) patient experience and quality of life (QOL) outcome studies, and c) recommendations for optimizing patient QOL through enhanced knowledge and shared decision-making.

RECENT FINDINGS

This review includes the seven papers that report on patient-reported outcomes (PRO) in leadless pacemakers and indicate that QOL is as good, if not better, than TV-PM. Existing evidence from descriptive statistics suggests that patients with L-PM report high levels of patient acceptance and satisfaction with esthetic appearance (96%), recovery (91%), and level of physical activity (74%). Leadless pacemakers provide an attractive alternative for the indicated potential patient. The evidence demonstrates the benefits of L-PM such as a minimal implant and lack of leads. Recommendations for future research indicate that electrophysiology-specific metrics are essential and control for the common co-morbidities in the PM population are needed.

Left internal jugular vein approach to right atrial appendage base implantation of the Aveir AR leadless pacemaker

INTRODUCTION

There is no prior report of an Aveir leadless pacemaker implantation into the atrial appendage via the internal jugular vein.

CASE

A 44-year-old female patient with history of multiple ablations for sinus node dysfunction presented with symptomatic bradycardia. The patient had femoral veins <9mm, chronic pain at the femoral vein insertion sites, as well as a recent car accident with persistent leg pain due to femoral fractures. Placement of a leadless pacemaker was decided based on patient discretion. An Abbott Aveir AR leadless pacemaker was implanted via left internal jugular vein access without complication. Post device implantation showed threshold of 0.75V @0.4 ms, impedance of 340 Ω, Pwave of 4.4 mV. Six-month follow-up demonstrated a threshold of 0.5 V @0.2 milliseconds, impedance of 300 Ω and Pwave of 7.2 mV with 92 % pacing and predicted longevity of 12.7 years.

DISCUSSION

The follow-up showed no complications in the patient. A similar approach may be feasible for other patients needing atrial leadless pacing, in which the transfemoral approach is not preferred.

CONCLUSION

Implantation of the Aveir AR leadless pacemaker into the right atrial appendage is feasible via the left internal jugular vein.

Perioperative Considerations for Modern Leadless Pacemakers

Since their initial approval by the Food and Drug Administration in 2016, leadless pacemakers have become increasingly prevalent. This growth has been driven by an improved adverse effect profile when compared to traditional pacemakers, including lower rates of infection, as well as eliminated risk of pocket hematoma and lead complications. More recently, technology enabling leadless synchronized atrioventricular pacing in patients with atrioventricular block has vastly expanded the indications for these devices. Anesthesiologists will increasingly be relied upon to safely care for patients with leadless pacemakers undergoing non-electrophysiology procedures and surgery. This article provides an overview of the technology, evidence base, current indications, and unique perioperative considerations for leadless pacemakers.