Leadless Pacing: Therapy, Challenges and Novelties

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.