Transcatheter/leadless pacing

Trans-oesophageal echocardiography-guided implantation of a cardiac resynchronization therapy pacemaker and successful ablation of the atrioventricular node after TriClip: case report

Background

Edge-to-edge intervention is the most common trans-catheter procedure performed for isolated severe tricuspid regurgitation in high-surgical-risk patients. However, it creates an obstacle for future right ventricular (RV) procedures such as implantation of cardiac implantable electronic devices (CIEDs). Reports of the management of CIED implantation after tricuspid edge-to-edge therapy are scarce.

Case summary

A 76-year-old woman suffered from severe tricuspid regurgitation with New York Heart Association three symptoms despite optimal medical therapy. After a thorough evaluation, the heart team recommended the TriClip procedure as the treatment of choice. However, 12 months after a successful TriClip procedure, rapid atrial fibrillation needed to be addressed with CIED implantation and atrioventricular (AV) node ablation. Pre-procedural planning included the intended posterior location of the CIED to avoid interference with the implanted clip and future AV node ablation. With an additional left ventricular lead positioned anteriorly to the RV lead, the posterior position of the RV lead was secured. Under peri-procedural trans-oesophageal echocardiography (TEE), the planned procedures were performed successfully.

Discussion

A blind manoeuvring of the RV lead may damage the edge-to-edge tricuspid device. In addition, friction due to an overly close contract between the RV lead and the edge-to-edge device may damage the RV lead. A successful and safe CIED implantation and atrioventricular node ablation can be performed after tricuspid edge-to-edge therapy with careful planning and its precise execution under TEE surveillance.

Strategies for Safe Implantation and Effective Performance of Single-Chamber and Dual-Chamber Leadless Pacemakers

Leadless pacemakers (LPMs) have emerged as an alternative to conventional transvenous pacemakers to eliminate the complications associated with leads and subcutaneous pockets. However, LPMs still present with complications, such as cardiac perforation, dislodgment, vascular complications, infection, and tricuspid valve regurgitation. Furthermore, the efficacy of the leadless VDD LPMs is influenced by the unachievable 100% atrioventricular synchrony. In this article, we review the available data on the strategy selection, including appropriate patient selection, procedure techniques, device design, and post-implant programming, to minimize the complication rate and maximize the efficacy, and we summarize the clinical settings in which a choice must be made between VVI LPMs, VDD LPMs, or conventional transvenous pacemakers. In addition, we provide an outlook for the technology for the realization of true dual-chamber leadless and battery-less pacemakers.

Leadless cardiac ventricular pacing using helix fixation: Step-by-step guide to implantation

INTRODUCTION

Leadless cardiac pacemakers are an alternative modality to traditional transvenous pacemaker systems. Recently receiving Food and Drug Administration approval, the AVEIR VR leadless pacemaker system provides a helix based active fixation leadless pacemaker system. This step-by-step review will cover patient selection, preprocedural planning, device implantation technique, implant site evaluation, troubleshooting, short- and long-term complications as well as future directions for leadless pacing.

METHODS

We collected and reviewed cases from primary operators to provide a step-by-step review for implanters.

RESULTS

Our paper provides a guide to patient selection, pre-procedural planning, device im plantation technique, implant site evaluation, troubleshooting, short- and long-term complications as well as future directions for leadless pacing.

CONCLUSION

The helix based active fixation leadless pacemaker system is a safe and efficacious way to provide pacing support to patients and provides an alternative to transvenous pacing systems. Our review provides a step-by-step guide to implantation.

A leadless pacemaker in the real-world setting: Patient profile and performance over time

Background

While prior Micra trials demonstrated a high implant success rate and favorable safety and efficacy results, changes in implant populations and safety over time is not well studied. The objective of this analysis was to report the performance of Micra in European and Middle Eastern patients and compare to the Micra Investigational Device Exemption (IDE) and Micra Post Approval Registry (PAR) studies.

Methods

The prospective, single-arm Micra Acute Performance European and Middle Eastern (MAP EMEA) registry was designed to further study the performance of Micra in patients from EMEA. The primary endpoint was to characterize acute (30-day) major complications. Electrical performance was analyzed. The major complication rate through 12 months was compared with the IDE and PAR studies.

Results

The MAP EMEA cohort (n = 928 patients) had an implant success rate of 99.9% and were followed for an average of 9.7 ± 6.5 months. Compared to prior studies, MAP EMEA patients were more likely to have undergone dialysis and have a condition which precluded the use of a transvenous pacemaker (p < .001). Within 30 days of implantation, the MAP EMEA cohort had a major complication rate of 2.59%. Mean pacing thresholds were low and stable through 12 months (0.61 ± 0.40 V at 0.24 ms at implant and 12 months). Through 12 months post-implantation, the major complication rate for MAP EMEA was not significantly different from IDE (p = .56) or PAR (p = .79).

Conclusion

Despite patient differences over time, the Micra leadless pacemaker was implanted with a high success rate and low complication rate, in-line with prior reports.

Micra implantation in a patient with transposition of great arteries

We describe a 56-year-old male with transposition of the great arteries and Mustard repair, superior vena cava obstruction, atrial fibrillation, and progressive deterioration of his epicardial lead performance. We were successful in deploying of Micra (Medtronic, Minneapolis, MN, USA) at the septo-apical area of his nonsystemic ventricle in a stable position with satisfactory pacing and sensing thresholds.

Updated performance of the Micra transcatheter pacemaker in the real-world setting: A comparison to the investigational study and a transvenous historical control

BACKGROUND

Early results of the Micra Investigational Device Exemption (IDE) study and Micra Post-Approval Registry (PAR) demonstrated excellent safety and efficacy performance; however, intermediate-term results across a large patient population in the real-world setting have not been evaluated.

OBJECTIVES

We report updated performance of the Micra transcatheter pacemaker from a worldwide PAR and compare it with the IDE study as well as a transvenous historical control.

METHODS

The safety objective of the analysis was system- or procedure-related major complications through 12 months postimplantation. We compared the major complication rate with that of the 726 patients from the IDE and with a reference data set of 2667 patients with transvenous pacemakers by using a Fine-Gray competing risk model.

RESULTS

The Micra device was successfully implanted in 1801 of 1817 patients (99.1%). The mean follow-up period was 6.8 ± 6.9 months. Through 12 months, the major complication rate was 2.7% (95% confidence interval [CI] 2.0%-3.7%). The risk of major complications for Micra PAR patients was 63% lower than that for patients with transvenous pacemakers through 12 months postimplantation (hazard ratio 0.37; 95% CI 0.27-0.52; P < .001). The major complication rate trended lower in the PAR than in the IDE study (hazard ratio 0.71; 95% CI 0.44-1.1; P = .160), driven by the lower pericardial effusion rate in the PAR. There were 3 cases of infection associated with the procedure, but none required device removal and there were no battery or telemetry issues. Pacing thresholds were low and stable through 12 months postimplantation.

CONCLUSION

Performance of the Micra transcatheter pacemaker in international clinical practice remains consistent with previously reported data. Major complications were infrequent and occurred 63% less often compared to transvenous systems.

CLINICAL TRIAL REGISTRATION

Micra Transcatheter Pacing System Post-Approval Registry ClinicalTrials.gov identifier: NCT02536118; Micra Transcatheter Pacing Study ClinicalTrials.gov identifier: NCT02004873.