Kojodjojo P, Chow J. Leadless pacing in pre-adolescent patients weighing 30 kg or less: case report and systematic review. Cardiology in the Young. 2026;36:606-609. doi:10.1017/S1047951126112104.
PubMed: https://pubmed.ncbi.nlm.nih.gov/41940515/
Take-Home Points
- Leadless pacemaker implantation appears technically feasible in carefully selected children weighing ≤30 kg, addressing many of the long-term challenges associated with transvenous and epicardial pacing systems.
- The authors report successful implantation of an Aveir VR leadless pacemaker through the internal jugular vein in an 8-year-old child weighing 24 kg with congenital complete heart block.
- Systematic review identified 22 pediatric patients (<13 years and <30 kg) who underwent leadless pacemaker implantation, with 100% procedural success and no procedural mortality.
- The internal jugular approach was used in 86% of reported cases, emerging as the preferred access strategy in smaller children.
- Serious complications were uncommon, occurring in only two patients (9%): one pericardial effusion requiring drainage and one femoral venous thrombosis requiring anticoagulation.
- Long-term concerns remain regarding pacing-induced cardiomyopathy, loss of AV synchrony, future extraction, and durability of leadless systems in young patients expected to require decades of pacing support.
Commentary from Dr. Varun Aggarwal (Wilmington, DE, USA), editor-in-chief of Congenital Heart Disease Journal Watch:
Leadless pacing may represent the most important advance in cardiac rhythm management since the introduction of transvenous pacing itself. Yet despite its rapid adoption in adults, pediatric electrophysiologists have understandably proceeded with caution. Children are not simply small adults. A pacing system implanted in childhood must function not for years but for decades, while accommodating somatic growth, changing anatomy, and multiple future device replacements.
The report by Kojodjojo and Chow highlights an area of growing interest within pediatric electrophysiology: the use of leadless pacemakers in children too large for traditional epicardial pacing yet still small enough that transvenous leads carry important long-term disadvantages.
Historically, pediatric pacing has involved a difficult tradeoff. Epicardial systems avoid intravascular hardware but suffer from relatively high lead failure rates and often require surgical implantation. Transvenous systems offer superior pacing performance but introduce lifelong concerns regarding venous occlusion, tricuspid valve dysfunction, lead fracture, infection, extraction challenges, and the cumulative burden of multiple lead revisions over a patient’s lifetime.
The emergence of leadless pacing offers an intriguing alternative.
The authors present an illustrative case of an 8-year-old child weighing 24 kg who developed symptomatic congenital complete heart block. After discussion of epicardial, transvenous, and leadless options, the family selected implantation of a retrievable Aveir VR leadless pacemaker. The procedure was successfully performed through the internal jugular vein, with excellent pacing parameters and an anticipated battery longevity exceeding 18 years.
More important than the individual case, however, is the accompanying systematic review. By identifying all published leadless pacing experiences in children younger than 13 years and weighing less than 30 kg, the authors provide the most focused assessment to date of this particularly challenging patient population.
The results are encouraging.
Across 22 patients reported worldwide, procedural success was universal, with no procedural mortality. Most patients underwent implantation for congenital or acquired atrioventricular block, the patient group in whom the benefits of pacing are clear and long-term support is typically required. Serious complications were rare, and access-related issues were generally manageable.
One of the most interesting observations is the dominance of the internal jugular venous approach.
In adults, femoral access is the standard route for leadless pacemaker implantation. Yet among smaller children, the internal jugular vein was used in more than 85% of reported procedures. This reflects several important anatomical realities. Internal jugular veins are often larger than femoral veins in small children and may better accommodate the large delivery sheaths required for leadless systems. Moreover, the superior approach provides a more direct path across the tricuspid valve and into the right ventricle, reducing catheter manipulation within a relatively small right atrium.
For pediatric electrophysiologists, these findings may influence procedural planning as leadless pacing becomes more widely adopted.
Nevertheless, substantial unanswered questions remain.
The greatest concern is not implantation but long-term physiology. Nearly all children identified in the review received single-chamber right ventricular pacing. While this approach is technically straightforward, it is also the least physiologic pacing modality. Chronic right ventricular pacing may lead to ventricular dys-synchrony, pacing-induced cardiomyopathy, and pacemaker syndrome, particularly in patients expected to be paced continuously for many decades.
This issue is especially relevant in congenital complete heart block, where pacing burden often approaches 100%.
Modern pacing philosophy increasingly emphasizes physiologic pacing through conduction system pacing, cardiac resynchronization, or AV-synchronous technologies. Current leadless pacing systems in small children generally cannot provide these advanced strategies. Although Micra AV devices can achieve limited AV synchrony through accelerometer-based sensing and dual-chamber leadless systems are beginning to emerge, long-term pediatric experience remains extremely limited.
The question of extraction also looms large.
Leadless pacemakers are frequently described as retrievable, yet most retrieval data come from relatively short implant durations in adults. Pediatric patients may require device management 20, 30, or even 40 years after implantation. Whether current systems can be consistently extracted after such prolonged dwell times remains unknown. The possibility that some devices ultimately become permanent intracardiac implants must be considered during shared decision-making.
Battery longevity represents a similarly important issue. While projected longevity exceeding 15 to 20 years is impressive, pediatric patients will likely outlive multiple device generations. Future strategies for managing sequential leadless implants, extraction, and device replacement remain incompletely defined.
It is also important to recognize the limitations of the available evidence. The entire literature consists primarily of case reports and small series. Publication bias almost certainly exists because successful and innovative procedures are more likely to be reported than unsuccessful attempts. Consequently, the observed 100% procedural success rate should be interpreted cautiously.
Despite these limitations, this review provides compelling early evidence that leadless pacing can be performed safely in carefully selected young children.
For ACHD specialists, the implications extend beyond pediatrics. The current generation of children receiving leadless pacing will eventually transition into adult congenital care. Understanding the strengths and limitations of these devices will become increasingly important as this population grows. Future ACHD practitioners may encounter patients who have lived with leadless systems since childhood and require decisions regarding revision, replacement, extraction, or physiologic pacing upgrades decades later.
Ultimately, this paper represents an important step in the evolution of pediatric pacing. While leadless systems cannot yet fully replace conventional pacing approaches, they are beginning to fill an important niche between epicardial and transvenous systems. The challenge now is to determine which children will derive the greatest long-term benefit while minimizing the risks of decades of nonphysiological pacing.
Clinical Perspective
Leadless pacemaker implantation appears feasible and safe in selected children weighing ≤30 kg, with excellent short-term procedural success and low complication rates. The internal jugular approach has emerged as the preferred access route in smaller patients. However, long-term concerns regarding pacing-induced cardiomyopathy, AV synchrony, device retrieval, and lifetime pacing management remain unresolved and warrant continued surveillance as pediatric leadless pacing expands.
