Era of Synchronized Physiologic Leadless Pacing: A Novel Approach to Cardiac Pacing and Ongoing Development

Cardiac pacing has undergone a significant transformation in the last decade. Leadless pacing (LP), once only a conceptual idea stemming from the early interest in eliminating lead-related complications of transvenous pacemakers, has now become a reality in clinical practice. Since the introduction of the first human single-chamber asynchronous leadless ventricular pacing in 2012, atrioventricular-synchronized single- or dual-chamber leadless pacing systems have been approved for clinical use since 2020. Leadless cardiac resynchronization therapy (CRT) has shown optimistic results in case series and awaits its full utility in real-world clinical practice. With the successful feasibility study of leadless conduction system pacing, we are eagerly awaiting long-term safety and efficacy data on a large scale. Another important frontier is the development of self-rechargeable LP, which may be an ideal pacemaker for the future and may reduce the burden of multiple device replacements as batteries near the end-of-service. Totally extravascular percutaneous leadless pericardial micro-pacemaker system implantation is under development. In this state-of-the-art review, we examine the evolution of cardiac pacing, emphasizing the development and utility of LP to meet maximum physiological pacing needs, optimize atrioventricular synchrony and cardiac resynchronization, and broaden its indications.