We report the case of a 76-year-old man with a complex cardiac history including previous transvenous pacemaker infections, biological tricuspid valve replacement, and epicardial pacemaker implantation, who underwent successful implantation of a leadless pacemaker (Micra AV). This approach offered a minimally invasive solution in the context of venous occlusions and prior device-related endocarditis. The case highlights the increasing relevance of leadless systems in patients with limited vascular access or high infection risk or pre existing biological tricuspid valve prosthesis.
Introduction
Conventional transvenous pacemaker systems remain an established standard of care, however, are associated with complications such as device-related infections and tricuspid valve dysfunction due to chronic lead placement [1]. These risks are hightened in patients who have undergone multiple device revisions or previous valve surgeries. In such contents – particularly in the context of bioprosthetic tricuspid valve, where transvalvular leads may interfere with leaflet motion or compromise valve function - leadless pacemakers offer a compelling alternative [2]. We report the case of patient with a history of recurrent device infections, bilateral venous occlusions, and a tricuspid valve prosthesis, in whom a Micra AV leadless pacemaker was successfully implanted as a minimally invasive and functionally effective solution.
Case Presentation
A 76-year-old man with a long history of cardiac pacing first received a VVI pacemaker in 1986 for sick sinus syndrome. Over the following decades, several interventions were required: an upgrade to a DDD system in 1996, lead revision and generator relocation in 2018, and ultimately epicardial DDD pacemaker implantation during biological tricuspid valve replacement in 2023, which was necessitated by severe tricuspid stenosis secondary to chronic lead adherence.
In early 2025, the patient presented with fever and was diagnosed with Staphylococcus aureus device-endocarditis. Blood cultures grew Staphylococcus aureus, consistent with device-related endocarditis. Empiric intravenous antibiotics (Meropenem) were started and later de-escalated to Cotrimoxazole based on sensitivity testing. Device reading revealed progressively increasing capture thresholds of the epicardial RV lead, despite complete pacing dependency. Phlebography and CT angiography demonstrated bilateral subclavian vein occlusion, excluding further transvenous access.
Given the patient’s complete pacing dependency and lack of transvenous access, a leadless Micra AV pacemaker was successfully implanted in March 2025 in a hybrid operating suite under 3-D-transesophageal echocardiographic guidance. The existing epicardial generator was reprogrammed to AAIR mode with a prolonged AV delay, allowing atrial pacing to be tracked by the Micra AV system. The procedure was uncomplicated, and postoperative follow-up demonstrated stable device parameters with clinical improvement of dyspnea from class III to class I.
Postoperative follow-up demonstrated stable device function, satisfactory pacing parameters, and no complications. The patient’s symptoms improved notably, and he was discharged in good condition on continued oral antibiotics and scheduled follow-up.
Discussion
This case exemplifies several key challenges in cardiac device management, especially in patients with structural valve interventions and device infections. The Micra AV system enables atrioventricular (AV)-synchronous ventricular pacing through atrial tracking. Despite being entirely intracardiac and leadless, it avoids the need for transvenous lead and subcutaneous pocket, thereby significantly reducing the risk of infection [3]. This in concordance of present data from studies like the Micra CED Study and the MAUDE registry suggest fewer major complications and lower infection rates compared with conventional transvenous systems [4][5].
In patients with a bioprosthetic tricuspid valve, avoiding transvalvular leads is particularly advantageous, as it eliminates the risk of leaflet trauma or impaired prosthetic motion [6].
In this case, the combination of an existing epicardial atrial lead with a leadless ventricular pacing system proved especially useful. This hybrid approach maintained effective AV synchrony and supported stable hemodynamics in a patient who was fully pacing-dependent and without viable venous access. Maintaining AV synchrony was critical for optimizing cardiac output in this pacing-dependent patient, and which was achieved by combining atrial pacing from the existing epicardial lead with atrial tracking by the Micra system [7].
Comorbidities such as coronary artery disease and atrial arrhythmias further complicate management but do not contraindicate the use of leadless devices.
Conclusion
This case underscores the expanding role of leadless pacemakers in complex patients, particularly those with restricted venous access, prior device-related infections, prosthetic tricuspid valves, or dysfunctional epicardial systems. In this patient, the micra AV system offered a safe, effective and minimally invasive alternative, emphasizing the importance of individualized pacing strategies in high-risk populations.
References
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- Mediratta A, Addetia K, Yamat M, et al. 3D echocardiographic evaluation of device-induced tricuspid regurgitation. JACC Cardiovasc Imaging. 2014;7(3):252–261.
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