Internal jugular vein approach facilitating second leadless pacemaker implantation after battery depletion

Leadless pacemakers (LLPMs) have become an established treatment for bradyarrhythmias because they are associated with fewer lead-related complications and infections than transvenous pacemakers. However, when battery depletion occurs, implantation of a second device may be technically more challenging than the initial procedure because the available right ventricular (RV) implantation sites are limited by the existing device. We report a case of second LLPM implantation using the internal jugular vein (IJV) approach. A 92-year-old man with atrioventricular block had undergone Micra implantation 10 years earlier. The device battery was approaching depletion and implantation of a second LLPM was planned. Computed tomography revealed a narrow tricuspid valve and clockwise rotation of the RV. Because these anatomical features and the existing device could limit catheter maneuverability with the conventional femoral approach, the IJV approach was selected. The delivery catheter was advanced smoothly across the tricuspid valve and positioned superior to the existing device. The second Micra device was successfully deployed without mechanical interference with the initial device. No procedure-related complications occurred. The internal jugular approach may represent a useful alternative strategy for second LLPM implantation, particularly in patients with anatomical features or a previously implanted device limiting the available RV implantation site.

Implantation of a second leadless pacemaker (LLPM) may be more challenging than the initial procedure because of limited available implantation sites. LLPM implantation via the internal jugular vein (IJV) allows firm contact with the right ventricular septum and is associated with a lower risk of venous complications. The IJV approach represents a feasible alternative strategy for second Micra implantation.