Lose the Hardware: The Rise of Leadless Modular Cardiac Pacing

Leadless pacemakers have reshaped the approach to cardiac pacing by eliminating transvenous leads and subcutaneous pockets. Since the introduction of the first leadless pacemakers, leadless pacing has advanced from single-chamber ventricular systems to atrioventricular synchronous pacing, standalone atrial pacing, and fully leadless dual-chamber platforms, enabling patient-tailored pacing therapy. The modular leadless pacing concept allows a standalone leadless pacing device to be implanted initially, with additional leadless devices added sequentially as pacing requirements evolve, minimizing unnecessary hardware while preserving the option for future pacing upgrades. This modular approach has expanded to include integration with subcutaneous implantable cardioverter-defibrillators and leadless cardiac resynchronization therapy, moving towards a fully leadless cardiac rhythm management ecosystem. This review summarizes the evolution of leadless pacing, compares currently available devices and their clinical applications, explains leadless pacemaker implantation and end-of-life management, and explores the modular leadless pacing concept as the foundation for future fully leadless cardiac rhythm management.