THE FIRST successful implantation of a helical-fixation leadless pacemaker (LP) in the subpulmonic morphologic left atrium has been performed in a patient with prior atrial switch for dextro-transposition of the great arteries. This case highlights an alternative pacing approach in patients with complex congenital heart disease where transvenous systems pose significant challenges.
The atrial switch procedure for dextro-transposition of the great arteries is frequently associated with sinus node dysfunction, necessitating long-term pacing solutions. However, transvenous pacemaker leads in this population often lead to complications such as baffle stenosis, lead malfunction, and the need for extraction, particularly in young patients. Conventional pacing approaches may be limited due to venous baffle occlusion or stenosis, necessitating alternative strategies. Leadless pacemakers have emerged as a potential solution, but prior experience with helical-fixation LPs in the subpulmonic left atrium has not been reported. This case describes a patient with superior baffle occlusion, multiple abandoned leads, and failed lead extraction, requiring a novel approach to atrial pacing.
A helical-fixation LP (Aveir, Abbott) was successfully implanted in the left atrium via a transfemoral approach across the atrial baffle. The procedure encountered challenges, including higher impedances and increased force requirements for adequate fixation due to the altered anatomy. The initial deployment likely engaged the venous baffle material and was repositioned for optimal function. The patient’s conduction through the atrioventricular node remained intact, eliminating the need for a ventricular LP. Given the complexity of the case, this approach was intended as a bridge to a future surgical baffle revision and open lead extraction. Despite the challenges, the procedure demonstrated the feasibility of helical-fixation LP placement in this unique anatomic setting, offering a potential alternative to traditional pacing strategies.
This case highlights the importance of innovation in pacing strategies for adult congenital heart disease patients with complex anatomy. Helical-fixation LPs provide a viable alternative to transvenous systems, mitigating complications such as baffle stenosis and lead-related failures. Future considerations include long-term outcomes of this approach and further development of LP technology to optimize implantation techniques. As dual-chamber leadless systems continue to evolve, they may offer broader applications for this population.
Katrina Thornber, EMJ
Reference
Staloch DA et al. First-in-human helical-fixation leadless pacemaker in the left atrium for D-transposition with atrial switch procedure. Case Reports. 2025;30(2):102792.
