Jugular approach for implantation of helix-based leadless pacemakers: first clinical experience in 30 patients

Scientific background and purpose Leadless pacemakers, both helix- and tine-based, offer a modern alternative to conventional transvenous systems by reducing lead- and pocket-related complications. Implantation is usually performed via the femoral vein, however in patients with limited femoral access (e.g. due to vascular disease, anatomical variations, or infections), the jugular approach is gaining clinical importance as an alternative route of access. In complex anatomies, such as after tricuspid valve interventions or vertical heart axis, achieving optimal septal placement can be easier from the right jugular vein. Some studies suggest that the jugular access may also allow shorter procedure times, fewer vascular complications and improved patient comfort, as individuals can remain upright postoperatively and do not have to confine to supine bedrest. However, clinical time-series data on its efficacy and safety are still limited. Methods Thirty patients received a helix-based leadless pacemaker via the right jugular vein at our University Hospital between May 2024 and September 2025. Access choice was made individually, particularly in patients with increased infection risk or previous tricuspid valve interventions. Periprocedural parameters such as procedure duration and electrical measurements (sensing, pacing threshold, impedance) were recorded intraoperatively, on the first postoperative day, and after one month. Results Mean age was 73.96 ± 12.86 years. Indications included immunosuppression (n = 7, 23.3%), prior tricuspid valve interventions (n = 6, 20%), ongoing oncologic therapy (n = 8, 26.7%), and increased infection risk or prior endocarditis (n = 9, 30%). Mean implantation time was 51.97 ± 30.81 minutes. The pacing threshold averaged 1.03 ± 0.72 V intraoperatively, decreased to 0.75 ± 0.52 V on day 1, and was 0.80 ± 0.87 V at one month. Impedance declined significantly from implantation to day 1 (785.09 Ω vs. 690.29 Ω, p = 0.013) and to month 1 (785.09 Ω vs. 661.25 Ω, p < 0.001), with no significant change after day 1 (690.29 Ω vs. 661.25 Ω, p = 0.051). Sensing remained stable over the course of one month (7.35 ± 3.44 mV intraoperatively, 6.97 ± 4.25 mV on day 1, 8.54 ± 6.09 mV after one month; p = 0.035). No intra- or postprocedural complications occurred. Conclusion This registry study demonstrates that jugular access for helix-based leadless pacemaker implantation yields reliable electrical parameters and excellent safety. The absence of complications and stable follow-up data support the jugular route as a viable alternative, especially in patients with complex anatomy or contraindications to femoral access. Limitations include the retrospective design and small sample size. Larger, prospective, randomized and multicenter studies are warranted to confirm these findings.