1 1 Arrhythmias Section, Cardiology Service - Hospital Universitario de Girona Doctor Josep Trueta, Institut Català de la Salut Girona. Universitat de Girona. Institut d`Investigació Biomèdica de Girona (IDBGI), Girona. Spain.
Corresponding author’s address
Dra. Emilce Trucco
Sección de Arritmias, Servicio de Cardiología; Hospital Universitario de Girona Doctor Josep Trueta.
Postal address: Avinguda de França, s/n CP 17007, Girona (España).
E-mail
Received on September 20, 2022 Accepted after review on September 21, 2022 www.revistafac.org.ar
There are no conflicts of interest to disclose.
Keywords:
Cardiac pacing
Leadless pacemakers
Indications
First implantations
Leadless pacemakers have revolutionized the field of cardiac pacing through smaller generators that are completely intracardiac, which are implanted within the right ventricle through femoral venous access, using a release system specific to the device, and therefore, reducing the complications related to the generator pocket and the transvenous electrodes of the conventional cardiac pacing systems[1].
For devices in VVI mode, the fundamental indication is focused on patients with permanent atrial fibrillation or infrequent pacing, due to the potential deleterious effects in patients in sinus rhythm and high percentage of pacing, in agreement with recommendations for conventional pacing. Technology has advanced fast, and the new generation of leadless pacemakers is capable of maintaining atrioventricular synchrony by VDD pacing mode. The recommendation for this type of pacemaker is level IIa, when there is no venous access in the upper limbs or there is high risk of infection. As an alternative to lead pacing, the level of recommendation is IIb, taking into consideration life expectancy and the preferences of patients[1,2].
Several prospective studies have published a very high success during implantation with proper and stable electrical parameters, both acutely and during device monitoring, which entails an extended longevity for the battery. There are few major complications; mainly cardiac perforation and pericardial effusion, which decrease with the learning curve, modification of implant area to more septal regions within the ventricular chamber, and a proper selection of patients. Besides, benefits have been proven in comparison to conventional systems in terms of complications within the first 12 months after the implantation[3,4,5]. Other studies with a higher number of patients and more extended follow-up have observed a 38% reduction in re-interventions and a 31% reduction in chronic complications, but with no differences in adjusted mortality when compared to transvenous systems[6,7]. However, it is very important to take into account that all these data are drawn from observational studies, and therefore, their results should be confirmed in controlled and randomized studies.
The prevalence of infection in leadless systems is extremely low, since the most frequent source of infection is absent. On the other hand, the device has factors that grant it resistance to infections, such as the size and location of the generator, the lining material, the little contact with the physician’s gloves or the skin of the patient[8]. Observational studies have shown that leadless pacemakers are a safe option in patients with previous infections in cardiac devices, even when implanting them during acute infection and in patients with high risk of infection, such as people in hemodialysis[9,10]. This important aspect makes it an attractive alternative in patients who depend on pacing, in whom temporary pacing may be dismissed after extracting the infected pacing system, reducing hospital stay time until bacteriemia resolution.
I have read with interest the article by Aguinaga et al, which concludes that cardiac pacing has taken a promising step forward with the advent of leadless pacing, obtaining in expert hands, more safety and less complications in the implantation[11].
In the study by Aguinaga et al, the initial experience is presented on the first four implants of MICRA AV performed in Argentina. They start from the basis of the current recommendations of leadless pacemaker implantation and the need for this new type of cardiac pacing based on the vulnerability of conventional pacing electrodes. The technological advancement generated by VDD pacing mode is commented, as well as the studies supporting it.
We should highlight the great success of implants made in short procedure times, with the appropriate electrical parameters measured acutely and 24 hours after the implant, and the absence of acute complications observed in the communication of cases. The remarkable high percentage of success reinforces the concept that leadless pacing is a simpler procedure, with a faster learning curve than conventional pacing, and which in expert hands, allows to decrease the complications proper of traditional cardiac pacing systems.
We should not forget that during the initial experience with a new technique, a higher incidence of certain complications may occur, which underscores the importance of proper training and supervision. Additionally, physicians who make implantations should have the same competencies and credits as those required for conventional cardiac pacing[12]. The implantation should be made in the appropriate center, with access to heart surgery due to the risk of perforation that could be more complex to treat than during the implantation of a pacemaker with electrodes[13].
The revolution of cardiac pacing is already here; its positioning in the future will depend on the technological improvements that will enable minimizing complications and improving battery longevity. Pacing in other cardiac chambers and the chance of physiological pacing is currently being developed[14,15].
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