Effective and Potentially Retrievable: Will Leadless Pacemakers Become Gold Standard for Pause Prevention Pacing?

Abstract Leadless pacemakers (LPMs) constitute a significant advancement in the management of bradyarrhythmias by eliminating complications associated with transvenous leads and subcutaneous pockets. Accumulating evidence demonstrates substantial clinical benefits, including a marked reduction in complications, particularly infections, and fewer system revisions as compared with transvenous pacemakers (TVPMs). However, several limitations preclude their widespread adoption. Cardiac tamponade occurs in up to 2% of cases, requiring sternotomy in approximately one third. Management of devices at elective replacement interval (ERI) through intracardiac abandonment raises concerns, particularly in younger patients; experience with extraction remains limited and entails substantial risks, with severe complications occurring in up to 3% of cases. Limitations in atrioventricular synchronization persist despite technological advances, and cardiac resynchronization therapy remains unavailable. LPMs are emerging as the preferred option for selected populations at high risk of infection, whereas TVPMs maintain a predominant role owing to their versatility and capacity to deliver advanced therapies. LPMs are gaining traction in specific high-risk subgroups and may expand their indications as technology evolves; however, they are likely to coexist with TVPMs rather than supplant them entirely in the medium term.