(261) The Great Escape of a Leadless Pacemaker

Introduction: Implantable leadless pacemakers offer a less invasive alternative to traditional devices. Despite their innovative design and minimally invasive implantation, complications, including device migration, can occur. We present a case of a leadless pacemaker embolizing into the right pulmonary artery in a 78-year-old male.

Description: A 78-year-old male with coronary artery disease, congestive heart failure, diabetes mellitus, hypertension, and end-stage renal disease on hemodialysis (HD) presented to the ED with dizziness and confusion. He was bradycardic with a heart rate in the 20s. Initial electrocardiogram (EKG) showed a complete (3rd-degree) heart block. He underwent emergent transcutaneous pacing followed by transvenous pacing (TVP). Ultimately, an implantable leadless pacemaker was placed in the distal right ventricular septum via right femoral transcatheter approach. Unfortunately, later that day, telemetry monitoring revealed the pacemaker was not capturing, necessitating another emergent TVP insertion. A subsequent chest x-ray revealed the leadless pacemaker had migrated to the right pulmonary artery. Interventional radiology removed it using a snare removal technique, and a new leadless pacemaker was implanted. The TVP was then removed after the EKG confirmed the paced rhythm.

Discussion: Leadless pacemakers are new to the field, and complications are uncommon. Pacer migration is rare. Risk factors for migration include improper placement, trauma, abnormal heart contractility, high right ventricular pressures, and patient movement. Symptoms include chest pain, shortness of breath, palpitations, and syncope. Diagnosis involves CXR, CT scans, echocardiogram, and EKG. Management entails urgent removal and potential reimplantation.
In an observational study by Roberts PR et al., device dislodgement occurred in 1 of 792 patients receiving a leadless pacemaker [1]. Overall, leadless pacers had a 51% lower odds ratio of complications compared to TVP in 5 trials over one year (3.30% vs. 7.43%; OR 0.49; 95% CI, 0.34–0.70) [2]. Dislocated pacer devices primarily embolize into pulmonary arteries, affecting the left and right sides similarly [3].
Timely diagnosis and intervention of complications of leadless pacers while being aware of them improve outcomes.