Long-term management of leadless pacemakers

Leadless pacemakers (LPs) are increasingly being used to treat bradyarrhythmias, and end of service (EOS) management decisions are becoming increasingly important given finite battery lifespans. Two strategies have been adopted for device EOS: LP abandonment and LP removal. Certain scenarios including high degree of LP encapsulation and 'last expected' pacing devices favour LP abandonment, while other LP complications may necessitate device removal. When abandoning LP, clinicians must understand design, performance, and safety considerations for devices left in place. When removing LP, specialized tools and techniques have been developed, each varying by device manufacturer and model. Case reports and series on LP removal have elucidated how to overcome challenges that may arise during removal. Despite best practice techniques, complications can arise before and after removal. Current studies on LP EOS management are limited, and further studies are needed to help understand predictors of successful device removal and long-term sequelae of both strategies. The aim of this state-of-the-art review is to help clinicians understand current strategies and considerations for both LP abandonment and removal.