A hybrid approach combining a transvenous atrial pacemaker and a leadless ventricular pacemaker can successfully maintain AV synchrony in patients with RV lead failure who are poor candidates for lead extraction.
Micra AV may be considered for RV lead fracture in frail elderly patients; single case leaves open need for prospective data.
An elderly gentleman with a dual-chamber pacemaker presented to our institution with symptoms of symptomatic bradycardia and high-grade atrioventricular (AV) block. Device interrogation revealed failure to capture in the right ventricle (RV) lead with bipolar pacing, high RV pacing threshold with unipolar pacing, and high impedance suggesting lead fracture. The atrial lead function was normal. Given his advanced age, gait instability, and dementia, the decision was made to proceed with Micra AV pacemaker implantation, while programming his dual-chamber pacemaker to AAIR mode, thus maintaining AV synchrony by tracking paced atrial impulses and providing ventricular pacing.
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Nona et al. (2021) studied this question.
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