Research Insights

Leadless Pacemakers: Advancing Cardiac Care with Promising Results

Pacemakers are essential devices for maintaining a steady heartbeat, particularly in bradycardia cases. They typically consist of a skin-implanted generator connected to the heart via leads, which regulate its rhythm through electrical signals. Innovations like leadless pacemakers, directly implanted in the heart, minimize lead-related complications. While limitations remain, these advancements promise an exciting future for cardiac pacing.


Traditional Pacemakers with Leads

Modern cardiac pacing often employs pacemakers containing a generator and one or more leads. These leads thread through the heart, transmitting electrical signals for rhythm regulation, mainly in the right atrium and right ventricle.

Recent progress highlights the effectiveness of leadless pacemakers, displaying promising outcomes. In this article, we’ll explore the pros and cons of leadless pacemakers versus traditional generator-and-leads methods. This underscores the substantial potential of leadless pacemakers in shaping cardiac care’s future landscape.

Leadless Pacemakers: Advancing Cardiac Care with Promising Results Heart Matters

Figure 1: Conventional Pacemaker Setup Conventional pacemakers comprise a generator can and leads. The leads establish a connection with the generator and are routed through the veins to the right side of the heart. This configuration enables the transmission of electrical signals to regulate the heart’s rhythm in cases of slow heart rate or related conditions.


Leadless Pacemakers

Leadless pacemakers are small, self-contained devices that are implanted directly into the heart. Unlike traditional pacemakers, which require leads to be threaded through veins into the heart, leadless pacemakers are placed directly in the right ventricle or atrium. This innovative design offers several advantages over their traditional counterparts.

Leadless Pacemakers: Advancing Cardiac Care with Promising Results Heart Matters

Figure 2: Illustrates the configuration of a typical leadless pacemaker. Unlike conventional pacemakers that involve leads threading through the heart, leadless pacemakers are designed to be self-contained units implanted directly within the heart. This compact design eliminates the need for leads and simplifies the overall pacing setup. The figure showcases how leadless pacemakers represent a streamlined and minimally invasive option for cardiac pacing


Configuration, Advantages, and Limitations

As a cardiologist, I find the leadless pacemaker technology undeniably intriguing, albeit in a phase of ongoing evolution. Until fairly recently, these pacemakers have found their primary utility in cases where a single lead from a conventional pacemaker suffices – typically among patients with underlying atrial fibrillation. It’s worth noting that adopting this technology involves a learning curve to accumulate experience, and the upfront cost is comparatively higher than that of conventional options. Despite these considerations, the prospects offered by leadless pacemakers are indeed noteworthy and warrant continued exploration.

Reduced Risk of Lead-Related Complications: One of the primary benefits of leadless pacemakers is the elimination of pacing leads. Traditional pacemakers with leads carry a small risk of lead fracture, dislodgement, or infection. Leadless pacemakers mitigate these risks, reducing the need for lead-related interventions.

Minimally Invasive Procedure: The implantation of leadless pacemakers involves a minimally invasive procedure compared to traditional pacemakers. This results in shorter hospital stays, faster recovery times, and decreased discomfort for patients.

Improved Aesthetics and Comfort: The smaller size and lack of visible leads make leadless pacemakers more discreet and comfortable for patients. They eliminate the need for a visible pocket under the skin, reducing self-consciousness and improving overall quality of life.

Longevity and Battery Life: Leadless pacemakers have demonstrated impressive battery longevity, with some models designed to last over a decade. This eliminates the need for frequent battery replacements and reduces the long-term maintenance burden on patients.

Limited Functionality: Currently, leadless pacemakers are primarily single-chamber devices, providing pacing only to the ventricles or atria. This limits their application to patients who require single-chamber pacing. However, the recent study on dual chamber leadless pacemakers suggests potential advancements in this area and offers a very exciting future for cardiac pacing.

Higher Cost: Leadless pacemakers tend to be more expensive than traditional pacemakers due to their advanced technology and specialized design. While the long-term benefits may outweigh the initial cost, this aspect should be considered during treatment planning.

Availability: Leadless pacemakers are still relatively new in the market and may not be widely available in all healthcare facilities. However, as their efficacy becomes more established, their accessibility is expected to increase.


New Research Insights

The recent study titled “Safety, Performance, and Synchrony With Dual-Chamber Leadless Cardiac Pacing,” published in the New England Journal of Medicine on May 20, 2023, assesses the safety and effectiveness of a percutaneously implanted dual-chamber leadless pacemaker system in the right atrium and right ventricle of patients who conventionally require dual-chamber pacing. Conducted by the Aveir DR i2i Study Investigators and supported by Abbott Medical, this study examines a novel pacemaker system comprising two heart-implanted devices.

The study focused on evaluating the safety and functionality of this new pacemaker system designed for dual-chamber pacing, addressing both the atrium and ventricle. The findings revealed that the pacemaker system exhibited safety and reliable pacing capabilities for a three-month period post-implantation. However, it’s important to acknowledge the study’s limitation of short-term follow-up, emphasizing the need for extended observation to comprehensively assess the safety and efficacy of this innovative pacemaker system. According to the study, a dual-chamber leadless pacemaker system might surpass lead-based counterparts due to various considerations.

The authors conclude that leadless pacemakers eliminate the need for transvenous leads and the generator pocket, which reduces the long-term risk of infection and lead malfunction that affects one in six patients during 3 years of follow-up. 

In contrast to single-chamber ventricular leadless pacemakers, the dual-chamber system offers atrial pacing and consistent atrioventricular synchrony. This broadens the scope of leadless pacemaker therapy. In the study, the dual-chamber system successfully achieved the primary safety goal and sustained atrial pacing along with reliable atrioventricular synchrony for three months post-implantation. The investigator suggests that this dual-chamber leadless pacemaker system could present a safer, more dependable, and adaptable alternative to conventional lead-based pacemakers.



The recent study highlighting the positive outcomes of dual chamber leadless pacemakers marks a significant milestone in cardiac care. While these pacemakers offer various benefits like reduced risk of lead-related complications, minimally invasive procedures, enhanced aesthetics, and longer battery life, they also present limitations, including restricted functionality and higher costs. Evaluating these pros and cons is essential for healthcare providers and patients when choosing the appropriate pacemaker option. With technology’s continuous advancement, leadless pacemakers hold considerable promise in enhancing patient outcomes and revolutionizing cardiac care. Ongoing research and technological advancement should alleviate limitations, expanding leadless pacemaker potential for a wider patient population.

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other anti-anginals

When first-line therapies for angina, such as beta blockers, calcium channel blockers, and nitrates, prove inadequate or are not well-tolerated, second-line therapies may be considered.
Perhexiline is a unique medication that enhances the heart's ability to utilize fatty acids for energy, reducing its reliance on oxygen and lowering oxygen demand. This action helps improve blood flow and alleviates chest pain in some patients with refractory angina.
Nicorandil is another second-line option with a dual mechanism of action. It opens potassium channels in smooth muscle cells, causing vasodilation and enhancing coronary blood flow. Additionally, nicorandil also stimulates nitric oxide release, further dilating blood vessels and reducing heart workload.
Trimetazidine is an anti-ischemic agent that improves cardiac efficiency by enhancing glucose metabolism and shifting the heart's energy production to a more oxygen-efficient process. As second-line therapies, these medications offer alternative approaches for managing angina in individuals who do not respond adequately to first-line treatments or those experiencing side effects from other medications.

lipid lowering therapies

Lipid-lowering therapies play a critical role in managing coronary artery disease (CAD), a condition characterized by the narrowing of blood vessels that supply the heart. Among the most commonly discussed and debated classes of medications are statins, which effectively reduce cholesterol levels and are widely prescribed to lower the risk of cardiovascular events. Alongside statins, other medications like ezetimibe, fibrates, and niacin are also utilized to target specific aspects of lipid metabolism, such as cholesterol absorption, triglyceride levels, and raising high-density lipoprotein (HDL) cholesterol. Additionally, the introduction of medications that inhibit PCSK9, an enzyme involved in cholesterol metabolism, has provided a promising new approach to further lower LDL cholesterol levels. These PCSK9 inhibitors, such as Repatha (evolocumab), have shown significant efficacy in reducing LDL cholesterol levels in patients with CAD, especially for those who may not respond well to traditional therapies.


Nitrates are widely used to treat angina and provide quick relief for chest pain. Commonly available in the form of sublingual sprays or tablets, patches, and long-acting tablets, nitrates work by dilating blood vessels, allowing for increased blood flow and reduced resistance. This dilation eases the heart's workload, leading to a decreased demand for oxygen and prompt alleviation of angina symptoms. Sublingual nitrates act rapidly and are often used to provide immediate relief during angina attacks, while patches and long-acting tablets are employed for preventive purposes. However, nitrates may cause side effects such as headaches, dizziness, and flushing, which usually subside over time.

calcium channel blockers

Calcium channel blockers, including amlodipine, felodipine, cardizem (diltiazem), and verapamil, are commonly prescribed for the treatment of angina. These medications work by inhibiting the influx of calcium into the muscle cells of the heart and blood vessels, leading to their relaxation. As a result, blood vessels widen, promoting improved blood flow and reduced blood pressure. In the context of angina, this relaxation decreases the heart's workload, lowering the demand for oxygen and alleviating chest pain. Calcium channel blockers offer a valuable treatment option for individuals with angina, but it is essential to be aware of potential side effects, which may include headaches, dizziness, flushing, and ankle swelling.

Beta blockers

Beta blockers, such as metoprolol, propranolol, atenolol, carvedilol, and bisoprolol, play a crucial role in treating angina. By blocking certain receptors in the heart, they effectively reduce heart rate and the force of contraction, thereby easing the heart's workload. This mechanism of action leads to a decreased demand for oxygen, making beta blockers highly effective in relieving chest pain associated with angina. As with any medication, it's important to consider potential side effects, including tiredness, worsened asthma, erectile dysfunction in some males, and more vivid dreams during sleep. Consult your healthcare provider to determine the suitability of beta blockers for managing your angina and overall heart health.

Anti-platelet Medications

Anti-platelet medications play a crucial role in preventing blood clot formation, reducing the risk of serious cardiovascular events such as heart attacks and strokes. Among the widely used anti-platelet drugs are aspirin, clopidogrel, and ticagrelor.

Aspirin: This well-known medication inhibits platelet activation, making it less likely for platelets to stick together and form clots. Aspirin is commonly used for primary and secondary prevention of heart attacks and strokes.

Clopidogrel: As a potent anti-platelet agent, clopidogrel works by blocking specific receptors on platelets, preventing them from aggregating. It is often prescribed to patients with acute coronary syndrome, those undergoing stent procedures, and for some cases of peripheral arterial disease.

Ticagrelor: Ticagrelor is another effective anti-platelet drug that works by inhibiting platelet activation. It is used in acute coronary syndrome, often given alongside aspirin to reduce the risk of heart-related events.