Background: Endocardial pacemaker leads and right ventricular (RV) pacing are well-known causes of tricuspid valve, mitral valve, and cardiac dysfunction. Lead-related adverse consequences can potentially be mitigated by leadless pacemaker (LP) therapy by eliminating the presence of a transvalvular lead. This study assessed the impact of LP placement on cardiac and valvular structure and function. Methods: Echocardiographic studies before and 12±1 months after LP implantation were performed between January 2013 and May 2018 at our center and compared with age- and sex-matched controls of dual-chamber transvenous pacemaker recipients. Results: A total of 53 patients receiving an LP were included, of whom 28 were implanted with a Nanostim and 25 with a Micra LP device. Tricuspid valve regurgitation was graded as being more severe in 23 (43%) patients at 12±1 months compared with baseline ( P <0.001). Compared with an apical position, an RV septal position of the LP was associated with increased tricuspid valve incompetence (odds ratio, 5.20; P =0.03). An increase in mitral valve regurgitation was observed in 38% of patients ( P =0.006). LP implantation resulted in a reduction of RV function, according to a lower tricuspid annular plane systolic excursion ( P =0.003) and RV tricuspid lateral annular systolic velocity ( P =0.02), and a higher RV Tei index ( P =0.04). LP implantation was further associated with a reduction of left ventricular ejection fraction ( P =0.03) and elevated left ventricular Tei index ( P =0.003). The changes in tricuspid valve regurgitation in the LP group were similar to the changes in the dual-chamber transvenous pacemaker control group (43% versus 38%, respectively; P =0.39). Conclusions: LP therapy is associated with an increase in tricuspid valve dysfunction through 12 months of follow-up; yet it was comparable to dual-chamber transvenous pacemaker systems. Furthermore, LP therapy seems to adversely impact mitral valve and biventricular function.

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Introduction: Permanent transvenous pacemaker therapy is an essential management option in patients with symptomatic bradyarrhythmias, but harbors a concomitant risk of serious complications. As most complications are lead-or pocket-related, intracardiac leadless pacemaker therapy has the potential to positively impact patient outcome. Since the first leadless pacemaker implant in 2012, many studies have been conducted to evaluate the effectiveness, safety, and applicability of this novel pacing approach.Areas covered: This review will cover the current status of leadless pacemaker technology. Available safety and efficacy outcomes, current area of indication, and end-of-life management will be evaluated. Furthermore, future perspectives for clinical practice and new pacing modalities are discussed. Expert opinion: The first-generation leadless pacemakers are a promising innovation that provide safe and efficient single-chamber pacing therapy without the use of transvenous pacemaker leads. Yet, broad implementation of this technology is hampered by limitations of the current leadless devices, such as end-of-life management and its single-chamber pacing indication. Further innovations such as leadless dual-chamber pacing therapy, leadless cardiac synchronization therapy, energy-harvesting leadless pacemakers, communicating leadless pacemakers with subcutaneous implantable cardiac defibrillators, and minimally invasive completely extracardiac pacemakers are currently being developed that have the potential to become major game changers in pacing therapy.