Novel Use of an Atrial Aveir AR Pacemaker Implanted in the Right Ventricle for a Pediatric Patient with Prolonged Sinus Pause

Leadless pacemakers offer an attractive alternative to transvenous systems in children but are limited by vascular size, cardiac chamber dimensions, and device-specific characteristics. We describe the first implantation of an atrial Aveir AR leadless pacemaker in the right ventricle of a pediatric patient using a superior venous approach. A 7-year-old, 23.7-kg girl presented with recurrent syncope and was found to have an 8.7-second sinus pause on ambulatory monitoring consistent with sinus node dysfunction. Pre-procedural echocardiography and ultrasound assessment demonstrated relatively small atrial dimensions and identified the right internal jugular vein (1 cm) as the largest available central vessel compared with the femoral and left internal jugular veins. To optimize catheter maneuverability and accommodate the 27-Fr delivery sheath, a right internal jugular approach was selected. The Aveir AR device was advanced across the tricuspid valve and fixed to the mid–right ventricular septum on the first attempt, with stable sensing and capture parameters and no periprocedural complications (threshold 0.5 V at 0.2 ms, impedance 400 ohms, R-wave 5.9 mV). The patient was discharged within 24 hours and remained asymptomatic with preserved device function on one month follow-up, with threshold 0.75 V at 0.2 ms, impedance 410 ohms, R-wave 8.3 mV, and with <1% pacing, predicted longevity at 15.9 years. This case illustrates that superior venous access can facilitate safe ventricular deployment of an Aveir AR leadless pacemaker in select pediatric patients with sinus pauses.