AVEIR leadless pacemaker implantation in a patient with a small right ventricle

Objective: To describe a reproducible "hockey-stick" modification of the Aveir VR (Abbott, USA) delivery technique enabling safe leadless pacing in a patient with an exceptionally small adult right ventricle.Case presentation: A 64-year-old woman with sick sinus syndrome, tachycardia-bradycardia syndrome, and intermittent Mobitz II AV block presented with symptoms requiring permanent pacing.Echocardiography revealed an extremely small right ventricle (RV) (basal diameter 20 mm, length 48 mm, both <1st percentile).Conventional transvenous pacing was considered high-risk due to the patient's exceptionally small right ventricle.The challenge was not related to the final positioning of the device within the RV, but rather to the passage of the delivery system across the tricuspid valve.Because the Aveir VR (Abbott, USA) has a length of 38 mm, in asthenic patients with a "drop-like heart" the catheter, when introduced from the inferior approach, abuts the anterior RV wall and creates an acute angle, making safe advancement difficult.To overcome this, our team developed and applied for the first time a modified acute "hockeystick configuration of the delivery catheter.By introducing additional curvature from the superior vena cava, with this newly developed and first-time applied technique by our team, we successfully overcame the restricted ventricular cavity and implanted the device in the apical-septal region without complications.Importantly, no description of such a technique has been identified in the available literature.Follow-up at 6 and 12 months confirmed stable electrical parameters and sustained symptomatic improvement. Conclusion:In anatomically constrained ventricles, a controlled, mapping-first, helix-fixation approach with an acute delivery curve may expand candidacy for leadless pacing while maintaining safety.