Delivery of a Leadless Transcatheter Pacing System as First-line Therapy in a 28-kg Pediatric Patient Through Proximal Right Internal Jugular Surgical Cutdown

Abstract

The Micra™ transcatheter pacing system (TPS) (Medtronic, Minneapolis, MN, USA) is the only leadless pacemaker currently approved by the United States Food and Drug Administration. A limitation to the use of this device in the pediatric population is the large size of the delivery sheath. We present a 28-kg, nine-year-old male with symptomatic asystolic pauses who underwent successful placement of a Micra™ TPS via right internal jugular vein surgical cutdown as a first-line option. Current reports in the literature using the right internal jugular vein due to small patient size are limited to those involving patients with concurrent medical conditions that render the use of traditional systems unfavorable or contraindicated. Given the potential benefits of a leadless pacemaker system, its use in the pediatric population will likely continue to increase with time. This case describes technical strategies and procedural caveats that could aid in continued successful implantations of the Micra™ TPS in smaller patients as first-line therapy. In this report, room setup, the use of preprocedure vascular duplex studies, sheath manipulation, and a multidisciplinary approach are reviewed.

Percutaneous jugular leadless pacemaker implantation in a pediatric patient

“…Most adult patients generally only require 1–3 devices over their remaining lifetimes, so devices are abandoned and replacements are added into the RV. However, in younger patients, the volume of the RV is smaller and may not tolerate additional devices 8 . While extractions of Micra™ pacemakers have been performed in adult patients as late as 4 years after implant, pediatric extraction has only been reported once, in a device that was retrieved only 3 weeks after implantation 13,14 .…”

“…Leadless pacemakers pose an interesting and novel solution for many pediatric patients. However, other than a handful of case reports and case series' the majority of cases have been performed in adults 2,3,6–9 . A major disadvantage of the leadless pacing approach is the large size of the delivery sheath (27‐French outer diameter), which can be prohibitive in small patients.…”

“…However, other than a handful of case reports and case series' the majority of cases have been performed in adults. 2,3,[6][7][8][9] A major disadvantage of the leadless pacing approach is the large size of the delivery sheath (27-French outer diameter), which can be prohibitive in small patients. While a jugular vein approach has been previously used in adults and with a surgical cut down in some pediatric cases, a percutaneous jugular approach in pediatrics has not yet been described.…”

“…While a jugular vein approach has been previously used in adults and with a surgical cut down in some pediatric cases, a percutaneous jugular approach in pediatrics has not yet been described. 7,8,10 We present the case of an 8-year-old male (28.5 kg, 123.0 cm) who underwent transcatheter delivery of a Micra™ AV leadless pacemaker via percutaneous jugular access without a surgical cutdown.…”

The Year in Pediatric Electrophysiology: 2021

“…Hackett et al described the implantation of a Micra™ VR LTP system in a 28-kg, 9-year-old patient by surgical cutdown of the right internal jugular vein. 7 This hybrid approach, with their systematic approach to vessel assessment with preprocedural ultrasound imaging nicely described in the article, is contrasted with the femoral vein approach, which has been used in patients as small as 16 kg. 8 It has been suggested that a minimum vessel diameter of 9 mm is required for the 27-French (Fr) delivery sheath, though the distensibility of the femoral vasculature has been demonstrated by proponents of the traditional femoral approach in even the smallest patients (Figure 1).…”