National adoption of leadless pacemakers for bradyarrhythmia indications in the United States (2018–2022): a NIS analysis

Background Leadless pacemakers (LPM) offer an alternative to traditional transvenous pacemakers (TVP) by eliminating pocket- and lead-related complications. However, contemporary national patterns of LPM adoption and subgroup-specific uptake remain inadequately characterized. Methods We conducted a serial cross-sectional analysis of the HCUP National Inpatient Sample (NIS) from 2018 to 2022, including adult hospitalizations with new pacemaker implantation for bradyarrhythmia. New implants were identified via ICD-10-PCS codes and classified as LPM or TVP. Admissions with both device types or generator revisions were excluded to focus on index implants. Bradyarrhythmia indications were defined by diagnosis codes for sick sinus syndrome, atrioventricular block, or symptomatic bradycardia. Results Among 641,598 new bradycardia pacemaker implantations, LPM utilization increased from 3.14% in 2018 to 9.75% in 2022. Uptake was higher in patients aged ≥80 years (3.36% to 11.79%) compared to those <80 years (2.98% to 8.35%). Patients with end-stage renal disease (ESRD) showed markedly greater adoption, rising from 13.60% to 31.03%, versus 2.74% to 8.95% in non-ESRD patients. LPM use increased most in urban teaching hospitals (3.49% to 10.24%), followed by urban non-teaching (2.33% to 8.67%) and rural hospitals (1.23% to 4.85%). Uptake trends were similar between men and women. Conclusions Leadless pacemaker use in U.S. inpatient settings more than tripled from 2018 to 2022, with disproportionately higher adoption among older adults, ESRD patients, and urban teaching hospitals. These findings highlight the rapid diffusion of LPM technology and identify key populations and healthcare settings driving contemporary adoption.