Step-by-step approach to ultrasound-guided leadless pacemaker implantation

Leadless pacemakers (LPs) have emerged as an alternative therapy to the transvenous system for patients who require a permanent pacemaker. Despite the reduced risks of lead-related complications, devastated complications with LP can occur, including access site bleeding and cardiac perforation. Traditionally, ventricular LP implantation requires fluoroscopy and contrast/ventriculogram to guide septal placement, with the use of transesophageal echocardiogram or intracardiac echocardiogram in certain complex cases. We previously reported a novel technique of using a transthoracic echocardiogram implemented with fluoroscopy to guide LP implantation with minimal/no contrast utilization, which has been the primary imaging modality during ventricular LP implantation at our institution. This article provides a technical overview and step-by-step instructions on using ultrasound to guide LP implantation.