Leadless Pacemakers & Conduction System Pacing: The Next Generation of Rhythm Care

Leadless Pacemakers & Conduction System Pacing: The Next Generation of Rhythm Care

Introduction — why pacing is changing

Pacemakers have transformed lives by preventing slow heart rates and fainting. But the last decade has seen two major innovations that are reshaping rhythm care: Leadless Pacemakers and Conduction System Pacing. Together they offer less invasive options, more physiological heart activation, and new choices for patients who were poor candidates for traditional devices. This article explains what these technologies are, who may benefit, their real-world advantages and limitations, and what the future might hold.

What are Leadless Pacemakers?

Leadless Pacemakers are self-contained pacing devices implanted directly into the heart (usually the right ventricle) through a small catheter inserted via the femoral vein — there’s no chest incision, pocket, or transvenous leads. Modern models are about the size of a large capsule and contain the battery, electronics, and electrodes in a single unit. Compared with traditional transvenous systems they reduce lead-related complications (infection, lead fracture, venous occlusion) and often allow faster recovery.

Important device examples you may see in practice:

• Micra™ AV2 — a leadless pacemaker that adds atrioventricular (AV) synchrony algorithms to provide coordinated atrial-ventricular timing in selected patients
• Micra™ AV2 expands the indications of leadless pacing beyond simple single-chamber ventricular pacing.
• AVEIR DR Dual-Chamber Leadless System — one of the first dual-chamber leadless systems reported in clinical use, enabling communication between two leadless modules to give coordinated atrial and ventricular pacing without leads.

What is Conduction System Pacing (CSP)?

Conduction System Pacing aims to stimulate the heart’s natural electrical conduction fibers (the His-Purkinje system) rather than pacing the ventricular muscle directly. Two common CSP strategies are His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP / LBBP). By engaging the native conduction system, CSP can produce narrower QRS complexes and more physiological ventricular activation — this may preserve or even improve cardiac function compared with conventional right ventricular apical pacing.

Who are the best candidates for each approach?

Leadless Pacemakers — good candidates

• Patients at high risk of pocket or lead infection (prior device infection or immunocompromised).
• Limited or occluded venous access where leads can’t be advanced.
• Elderly or frail patients where a minimally invasive option with faster recovery is attractive.

Conduction System Pacing — good candidates

• Patients needing ventricular pacing where preserving physiological activation is important (e.g., high expected pacing burden, heart failure risk).
• Patients referred for cardiac resynchronization alternatives when CRT is not feasible — CSP can sometimes serve as a physiologic alternative.

When combined approaches matter: Emerging systems (research-stage and early clinical implants) are exploring leadless devices that can provide conduction-system–like activation or multi-module coordination. Clinical trials and early human studies show feasibility but require longer follow-up for durability and extraction strategies.

Advantages — what patients and clinicians gain

• Lower infection and lead complication risk — because there’s no subcutaneous pocket or transvenous lead.
• Smaller procedural footprint & faster recovery — percutaneous femoral access vs chest surgery.
• More physiological ventricular activation (CSP) — narrower QRS, better ventricular synchrony, potential to prevent pacing-induced cardiomyopathy.
• Novel options for complex patients — e.g., those with prior device infection, vascular access issues, or need for AV synchrony without leads. Micra™ AV2 and dual-leadless systems illustrate progress here.

Limitations and open questions

• Extraction and device longevity: Leadless devices are retrievable in many cases but long-term extraction practice is evolving. Battery replacement strategies (implant another device vs extraction) remain a practical consideration.
• Pacing modalities: Traditional leadless systems historically provided single-chamber ventricular pacing; although Micra AV2 and dual-leadless systems expand functionality, not all patients needing complex multi-chamber therapy are yet ideal candidates.
• Skill & training: CSP (HBP/LBBP) requires specialized implantation technique and equipment; outcomes improve with operator experience and appropriate mapping tools.
• Long-term outcomes vs randomized data: While registry and observational data are promising, randomized long-term trials comparing CSP or leadless strategies directly with conventional systems for hard endpoints (mortality, HF hospitalization) are still emerging. Guidelines are evolving to reflect current evidence.

Practical patient pathway — what to expect

• Assessment: Detailed history, ECG, echocardiogram, and discussion of pacing indication (symptoms, pauses, AV block, expected pacing burden).
• Shared decision-making: Discuss pros/cons of transvenous vs leadless vs CSP — infection risk, need for AV synchrony, vascular anatomy, long-term plans.
• Procedure: Leadless pacemaker via femoral venous puncture under fluoroscopic guidance; CSP via transvenous lead placed at His or left bundle region using mapping and fixation techniques. Sedation/anesthesia choices vary.
• Follow-up: Device clinic checks, remote monitoring when available, and periodic imaging or ECGs to confirm lead/device function.

Real-world examples (short)

• Hospitals around India and globally are increasingly performing Micra AV and other leadless implants with successful short-term outcomes and early discharge in many patients.
• Early human studies and case reports demonstrate feasibility of leadless systems working in tandem and of leadless devices interfacing with conduction-system targets — an exciting area of active research

The future — where the technology is heading

Expect:

• Smarter leadless devices with improved AV algorithms and inter-device communication for dual-chamber coordination.
• Hybrid approaches that combine leadless hardware with conduction-system targeting to deliver physiological pacing without transvenous leads.
• Bigger evidence base — randomized trials and longer follow-up registries that will refine guidelines and patient selection.

who should consider these options?

• Consider a leadless pacemaker if you’re at high infection risk, have problematic venous access, or prefer a minimally invasive option and your pacing needs fit available leadless features (e.g., ventricular pacing or AV-sensing Micra AV algorithms).
• Consider Conduction System Pacing if you need frequent ventricular pacing and preserving physiological ventricular activation is a priority (to reduce the risk of pacing-induced heart dysfunction).

Want to discuss whether this is right for you?

If you or a family member are considering a pacemaker, schedule a consultation with Dr. Ashish Agarwal — best cardiologist in Dwarka — to review your ECG, echo, and individual risks/benefits so we can choose the pacing strategy that fits your heart and lifestyle .