Clinical Decision Based on Aveir VR LP Patient History
Question:
Given the historical data from the AVEIR HISTORICO.xlsx spreadsheet showing the performance of an Aveir VR LP (leadless pacemaker), which of the following decisions would you make?
- Wait and Watch
- Implant a new unicameral LP
- Upgrade to a bicameral system by removing the existing device
- Remove the LP and place a transvenous Conduction System Pacing (CSP) pacemaker
Patient Data Summary (from AVEIR HISTORICO.xlsx)
| Date |
Diurnal SpO₂/PI/HR |
Nocturnal SpO₂/PI/HR |
Capture/Output |
Sense (mV) |
Impedance (Ω) |
Battery Life |
Weekly Aerobic Exercise (min) |
| 5/7/24 | 97/3/30 | 87/3/27 | | | | | 540 |
| 5/8/24 | 97/3/50 | 87/3/50 | 1.5V @0.4ms | 2.7 | 340 | 8 years | |
| 5/19/24 | 97/11/50 | 97/11/50 | | | | | 475 |
| 8/27/24 | 97/3/50 | 92/14/50 | | | | | 510 |
| 12/1/24 | 97/3/50 | 97/5/50 | | | | | 660 |
| 1/30/25 | 97/3/50 | 93/8/50 | | | | | |
| 3/26/25 | 97/14/34 | 96/11/26 | | | | | |
| 3/29/25 | 99/4/50 | 97/14/30 | | | | | |
| 3/30/25 | 97/5/50 | 97/4/27 | | | | | 470 |
| 3/31/25 | | 97/18/27 | | | | | |
| 4/1/25 | | | 3.0V @0.4ms | 4.0 | 550 | 4.5 years | |
| 4/2/25 | 98/8/50 | 98/5/50 | | | | | |
| 5/4/25 | | 98/8/35 | | | | | |
| 5/10/25 | | 97/8/30 | | | | | |
| 5/14/25 | | 96/20/27 | | | | | 660 |
| 5/24/25 | 98/6/50 | 96/11/26 | | | | | |
| 6/15/25 | | 97/20/27 | | | | | |
| 6/17/25 | | 97/20/25 | | | | | 710 |
| 6/25/25 | | 96/20/24 | | | | | |
| 7/25/25 | 98/8/50 | | | | | | |
| 8/4/25 | | 97/13/50 | | | | | |
| 8/9/25 | | 97/15/28 | | | | | 550 |
Key Clinical Observations
- Pacemaker Dependence: Nocturnal heart rates as low as 24–27 bpm, indicating significant bradycardia and likely pacemaker dependence.
- Increased Output: Output increased from 1.5V to 3.0V @ 0.4ms on 4/1/25 — suggests rising capture threshold or precautionary adjustment.
- Battery Life: Projected battery life dropped from 8 years to 4.5 years, likely due to higher output settings.
- Impedance Rise: Increased from 340 Ω to 550 Ω — within normal range but may indicate fibrotic encapsulation.
- Sensing: Improved from 2.7 mV to 4.0 mV — excellent and stable.
- High Activity Level: Weekly aerobic exercise ranges from 470–710 minutes — patient is highly active and will benefit from physiologic pacing.
Evaluation of Options
1. Wait and Watch
Risk: High. Battery life is halved, output increased, and patient is pacemaker-dependent. Not safe long-term.
2. Implant a New Unicameral LP
Not feasible. Cannot safely implant a second ventricular leadless device. Dual-chamber requires Aveir atrial LP, not just another VR unit.
3. Upgrade to Bicameral (Remove Existing)
Possible. Aveir VR LP is retrievable. Could implant Aveir atrial LP + new VR LP for VDD pacing. Good option if leadless preferred.
4. Remove LP and Place Transvenous CSP Pacemaker
Best long-term solution. Enables His bundle or left bundle branch pacing (LBBP), preserving cardiac synchrony — ideal for active, dependent patients.
✅ Recommended Decision: Option 4 — Remove the existing Aveir VR LP and implant a transvenous Conduction System Pacing (CSP) pacemaker.
Rationale
This patient is young, highly active, and pacemaker-dependent. The current device shows signs of progressive threshold rise and reduced battery longevity. While the Aveir system is innovative and retrievable, long-term ventricular pacing (even leadless) risks ventricular dyssynchrony and heart failure.
Conduction System Pacing (CSP) offers physiologic pacing, preserves cardiac function, and allows future upgrades (e.g., ICD, CRT). Given the retrievability of the Aveir LP, transitioning to a transvenous CSP system is both safe and optimal.
Conclusion
The best decision is to remove the current Aveir VR LP and implant a transvenous CSP pacemaker to ensure long-term cardiac health, activity tolerance, and pacing efficacy.