Leadless Pacemaker Implantation in an 11 y.o. Patient with Recurrent Vasovagal Syncope

We present a case of an 11 y.o. boy with recurrent syncope, documented sinus pauses & family history of sudden death who underwent a leadless PM implantation.

OA was presented at the age of 9 y.o. after his 14 y.o. brother passed away while playing a video game. OA`s ECG, Holter monitor & stress test were normal. An Epinephrine challenge test showed bidirectional VT after a 0.01 mcg/kg bolus. It shortly organized into a uniform monofocal VT & resolved spontaneously. A genetic consultation showed no arrhythmic predisposition. Treatment with beta blockers was initiated & repeated Holter monitors & stress tests were normal. One year later OA had a syncope event during school & a subcutaneous Reveal LinQ was implanted. Six months later, while asymptomatic, a 9 sec. sinus pause was documented during sleep, his treatment was unchanged. Lately OA experienced syncope during class, & an 18 sec. sinus pause was documented. In view of the family history, with no arrhythmia ever recorded, the beta blockers were stopped & PM implantation was recommended & performed. Height of 160 cm & weight of 65 kg allowed a leadless Medtronic Micra implantation.

During implantation, initial contrast fluoroscopy estimated the IVC diameter 11 mm, compatible with the 27F delivery system. Under fluoroscopic guidance the PM was placed in the RV apex. After showing 3 tines attached, good sensing & pacing thresholds the device was released. Pacing set at VVI 40. AO was discharged a day after in good condition.

Discussion: PM implantation due to vasovagal syncope is controversial. Lead fracture & pocket infections are the major complications in children. Its small size enables the leadless PM to be implanted in the young. This procedure spares the veins during puberty & allows normal physical activity without restrictions, avoiding the above complications and assisting psychologically.