Comparative Analysis of Extraction Complications in Transvenous Versus Leadless Pacemakers

Pacemakers are cardiac implantable electronic devices (CIEDs) that deliver electrical impulses to regulate heart rhythm and manage conditions such as cardiac arrhythmias. While transvenous pacemakers (TP) have a generator with pacing leads, leadless pacemakers (LPs) are anchored within the right ventricular endocardium via tined or helical fixation. Device extractions may occur due to infection, dysfunction, or device upgrade. This study aims to analyze the incidence and severity of extraction complications between TPs and LPs.    A comprehensive narrative review was performed through the PubMed database. The following key search terms and synonyms were incorporated into the search algorithm: "transvenous pacemaker," "leadless pacemaker," "pacemaker extraction," "device infection," and "bacterial complications". This yielded 788 entries. After uploading the search results, articles that focused on pacemaker extractions were included, while animal studies, pediatric studies, and studies that were not peer-reviewed were excluded. After excluding 691 studies, 97 original articles on pacemaker extractions underwent full-text analysis.    Both TP and LP extractions had high procedural success and low mortality rates. TPs were found to have procedural risks absent from leadless, namely, the development of arteriovenous fistula through subclavian access, tricuspid dysfunction, and atrial tearing. Examples of some differences between these studies include one LP study, which reported no change in mortality at a follow-up period of 18 months, and one TP study showed little change in mortality up to 24 months. Patients with TP and bacteremia have an increased risk of infection in the pocket and along the pacing leads. Infection of pacing leads has been shown to increase mortality and long-term complications. LPs are favored in many cases, for they minimize the incidence of these complications, have shorter extraction times, and have better recovery post-op in comparison to TPs.    LPs are associated with fewer extraction complications due to their smaller size and minimally invasive procedural approach, eliminating the use of a generator pocket and transvenous leads. Due to the incorporation of case studies, this review's limited sample size may decrease external validity. Future studies should collect large-scale data to further analyze the extraction complications between TP and LP patients.  .