Novel technique for leadless pacemaker implantation in the small right atrial appendage: a case report

An atrial leadless pacemaker (Aveir AR [Abbott]) has recently become available, enabling atrial pacing and maintaining strict atrioventricular synchronization. Although the efficacy and safety of leadless pacemakers have already been reported, some cases present challenges during implantation due to anatomical variations.

A 66-year-old man visited our hospital complaining of dizziness. A 12-lead electrocardiogram exhibited junctional rhythm with a heart rate of 40 beats/min. A leadless pacemaker was implanted instead of a transvenous pacemaker because of daily oral steroid administration and the risk of a pocket infection.The Aveir AR delivery catheter was guided to the base of the right atrial appendage (RAA) using deflection manoeuvres. However, upon deflection release, the catheter tip slipped towards the superior vena cava because of the significantly small RAA. To avoid catheter tip slip, the catheter lever was turned clockwise to rotate the chevron marker one-quarter from its initial position while maintaining deflection. Mapping measurements obtained while maintaining catheter deflection were favourable. Even after releasing the deflection, the catheter tip position remained stable at the RAA base without slippage. Subsequently, the delivery catheter deflection was released, and the chevron marker 1 1/2 was rotated under fluoroscopy. The Aveir AR position and each final parameter were favourable. No adverse events, including cardiac tamponade and dislodgement, were recorded.

This case highlights the specific bailout technique using partial rotation while maintaining deflection for Aveir AR implantation in a markedly small RAA; however, it should not replace standard implantation technique.