Managing Symptomatic Bradycardia in a Patient on Long-Term Antithrombotic Therapy: A Case Report of Leadless Pacemaker Implantation

Managing symptomatic bradycardia in a patient on long-term antithrombotic therapy: A case report of leadless pacemaker implantation

Sakthivel^*

Senior Cathlab Technician, Kauvery Hospital, Hosur, Tamil Nadu

*Correspondence

Abstract

Patient had history of Double Valve Replacement (DVR) and recent TIA (Transient Ischemic Attack). She was on long-term antithrombotic therapy, which presented a challenge when permanent pacemaker implantation was required as she also had bleeding and pocket-related complications. Leadless pacemakers eliminate the need for a subcutaneous generator pocket and trans venous leads, making them a potential alternative in selected patients with high-bleeding-risk.

Key words: Leadless pacemaker; Double valve replacement; Rheumatic heart disease; TIA Trans ischemic Attack Atrial fibrillation; Slow ventricular response; Antithrombotic therapy; Anticoagulation; Bleeding risk; Permanent pacing; Pocket-related complications.

Introduction

Permanent pacemaker implantation is essential in patients with symptomatic bradycardia or significant conduction abnormalities to maintain an adequate heart rate and prevent symptoms such as giddiness, syncope, and hemodynamic compromise. In patients receiving long-term antithrombotic therapy, such as those with previous double valve replacement & present TIA, conventional pacemaker implantation may be associated with an increased risk of pocket hematoma and bleeding. Leadless pacemakers, which eliminate the need for a subcutaneous generator pocket and trans venous leads, provide an alternative pacing strategy in appropriately selected patients where minimizing bleeding and pocket-related complications is important.

Case presentation

A 59-year-old female, a known case of rheumatic heart disease, hypertension, and chronic atrial fibrillation, underwent double valve replacement in 2004 with a mechanical aortic and mitral valve prosthesis. She subsequently underwent redo aortic valve replacement in 2022 for a stuck aortic valve with severe aortic stenosis. She presented with marked tiredness, poor appetite, and grade II dyspnea on exertion and was found to have atrial fibrillation with a slow ventricular rate of approximately 35 bpm. Despite withdrawal of rate-controlling medications, the bradycardia and symptoms persisted, indicating the need for permanent pacemaker implantation. Following an acute Transient Ischemic Attack (TIA), continued antiplatelet and anticoagulation therapy was considered necessary; therefore, a leadless pacemaker was preferred to avoid interruption of antithrombotic therapy and minimize pocket-related bleeding risk.

Clinical Findings

ECG: Atrial fibrillation with a slow ventricular response, ventricular rate approximately 35 beats/min.

Echocardiography: Rheumatic heart disease with dilated right & left atrium and preserved LV systolic function.
Valvular history: Status post double valve replacement (2004) and redo aortic valve replacement (2022).
Coronary angiography: Minimal coronary artery disease (06/09/2026)

Lab investigation

Lab Test	Result
Hb	11.6g/dl
TC	10010/cumm
Platelet Count	241000/cumm
Urea	44.9 mg/dl
Creatinine	1.1 mg/dl
Sodium	137 mmol/L
Potassium	4.6 mmol/L
PTT	19.3 sec
PT	11.3 sec
INR	1.75

Pulse generator details

Manufacture	Medtronic/ micravr2
Serial No	MVR637049E
Model	MC2VR01
Mode	VVIR
Rate	60 bpm
MRI Compatible	MRI Compatible

Pacing parameters

Site	RV
Amplitude	2.5v
Sensitivity	2.0mv
Refractory period	250ms
Pulse width	0.24ms
Polarity	Bipolar

Intra-procedural mmnagement

Sedation and monitoring:
The procedure was performed under local anaesthesia at the femoral access site with conscious sedation. Continuous electrocardiographic (ECG), pulse oximetry, and blood pressure monitoring were maintained throughout the procedure.

Vascular access:
Femoral venous access was obtained using standard technique. The vascular tract was sequentially dilated using 12–16 Fr dilators to accommodate the 23-Fr long delivery sheath required for leadless pacemaker implantation.

Device deployment and fixation:
Under fluoroscopic guidance, the Medtronic Micra VR2 leadless single-chamber pacemaker was advanced through the delivery sheath into the right ventricle. The device was appropriately positioned and successfully deployed and fixed within the right ventricular myocardium.

Electrical testing:
Before releasing the device from the delivery sheath, electrical parameters were assessed and found to be satisfactory. The right ventricular pacing parameters were as follows:

Pacing threshold: 1.25 V
R-wave sensing: 20 mV
Impedance: 670 ohms
Pulse width: 0.24 ms

Haemostasis management
As the patient was receiving regular antithrombotic therapy and a large-bore delivery sheath had been used, meticulous haemostasis was essential. Following withdrawal of the sheath, a figure-of-eight suture was applied at the femoral venous access site to achieve effective haemostasis and minimize the risk of bleeding and hematoma formation.

Post-procedural management

Following the leadless pacemaker implantation, the patient was closely monitored for hemodynamic stability, cardiac rhythm, and complications related to the femoral venous access site. The puncture site was regularly assessed for bleeding, swelling, hematoma, or other vascular complications. The patient was maintained on bed rest for 4-8 hours following sheath removal, as per the procedural protocol. The femoral access site was kept clean and dry, and the patient was monitored for any signs of bleeding or infection. The patient’s activity was gradually advanced according to her clinical condition and institutional protocol. Antithrombotic therapy was resumed/continued as prescribed by the treating team, considering her mechanical valve prostheses, atrial fibrillation, and recent TIA. The patient’s cardiac rhythm and heart rate were monitored, and no significant post-procedural complications were observed. Routine pacemaker interrogation and cardiology follow-up were planned to assess device function and ensure appropriate long-term pacing support.

Outcome

Symptom Resolution: Corrected her heart rate from 35 bpm to a stable 60 bpm, completely resolving her giddiness and Dyspnea On Exertion (DOE).
Minimized Bleeding Risk: Avoided a traditional chest pocket incision, eliminating the high risk of pocket hematoma associated with her lifelong antithrombotic therapy.
Secure Access Site: Achieved complete, uncomplicated haemostasis at the large-bore femoral puncture site.
Thromboembolic Safety: Successfully protected the patient against valve thrombosis and recurrent TIA by allowing safe, continuous antithrombotic management.
Excellent Device Performance: Obtained excellent intra-procedural pacing thresholds and sensing parameters, ensuring safe, long-term rate support.
Successful Discharge: Patient met all recovery criteria and was discharged home safely in stable condition.

Discussion – Medical Aspects

This case highlights the challenges associated with permanent pacing in a patient with multiple thromboembolic risk factors and a high requirement for long-term antithrombotic therapy. The patient had mechanical prosthetic valves, chronic atrial fibrillation, and a recent TIA, making interruption or inappropriate management of anticoagulation potentially hazardous. The presence of symptomatic bradycardia despite withdrawal of rate-controlling medications established the need for permanent pacing. A conventional transvenous pacemaker would require the creation of a subcutaneous generator pocket and placement of transvenous leads. In a patient requiring long-term antithrombotic therapy, pocket hematoma and bleeding are important concerns. Pocket hematoma may also increase the risk of wound complications and infection. The leadless pacemaker provided an alternative approach by eliminating the subcutaneous generator pocket and transvenous lead. The Micra VR2 system was delivered through femoral venous access and implanted directly within the right ventricle. In this patient, the approach allowed permanent pacing while avoiding the creation of a conventional chest pocket. The intra-procedural pacing threshold, sensing amplitude, and impedance were satisfactory, demonstrating effective electrical performance. The improvement in ventricular rate from approximately 35 beats/min to 60 beats/min was associated with resolution of the patient’s symptoms. However, leadless pacemaker implantation is not completely free from complications. Large-bore femoral venous access may result in vascular bleeding, hematoma, or other access-related complications. Therefore, meticulous vascular access management and post-procedure monitoring are essential, particularly in patients receiving antithrombotic therapy.

Discussion – Nursing Aspects

Nursing management plays an important role in achieving a safe outcome in patients undergoing leadless pacemaker implantation. Particular attention is required because these patients may have an increased risk of bleeding due to anticoagulant or antiplatelet therapy. Pre-procedural nursing assessment should include evaluation of cardiovascular status, heart rate, rhythm, bleeding risk, medication history, laboratory values, and baseline neurological status. Accurate documentation of anticoagulant and antiplatelet therapy is essential. During the procedure, continuous monitoring of ECG, blood pressure, oxygen saturation, and clinical status enables early identification of hemodynamic instability or arrhythmias. Strict aseptic technique is necessary to reduce the risk of infection.

Following the procedure, assessment of the femoral access site is a major nursing responsibility. Regular monitoring for bleeding, hematoma, swelling, pain, distal limb perfusion, and neurovascular changes is essential. Appropriate bed rest and activity restrictions should be maintained according to institutional protocol. Another important aspect is medication management. Because the patient has mechanical prosthetic valves and a history of TIA, careful coordination with the treating team is required regarding continuation or resumption of antithrombotic therapy.

Patient and family education is also essential. The patient should understand the importance of medication adherence, follow-up device interrogation, access-site care, recognition of bleeding, and prompt reporting of symptoms suggestive of recurrent arrhythmia, TIA, stroke, or infection. Thus, comprehensive nursing care contributes significantly to early identification of complications, safe recovery, medication adherence, and long-term management following leadless pacemaker implantation.

Discharge

The patient was discharged in a hemodynamically stable condition after meeting the required clinical recovery criteria. Her ventricular rate remained adequately controlled, and the femoral venous access site was clean and dry without significant bleeding, swelling, or hematoma. The patient and her family were educated regarding proper care of the femoral access site and were advised to observe for signs of bleeding, swelling, pain, or hematoma. They were instructed to report any dizziness, syncope, palpitations, chest discomfort, or breathlessness immediately. The importance of strict adherence to the prescribed anticoagulant and other medications was emphasized, considering her mechanical valve replacement, atrial fibrillation, and recent TIA. The patient was advised to avoid strenuous activities as instructed by the treating team and to attend scheduled cardiology follow-up and routine pacemaker interrogation. She and her family were also educated to seek immediate medical attention if any neurological symptoms suggestive of recurrent TIA or stroke developed. Regular follow-up and continued monitoring were emphasized to ensure optimal long-term pacemaker function and cardiovascular care.

Conclusion

The successful implantation of a leadless pacemaker in this 59-year-old female patient effectively addresses her symptomatic chronic Atrial Fibrillation with a slow ventricular rate of 35 bpm. By utilizing a leadless system, we successfully bypassed the high risk of pocket hematoma and device-related infections associated with traditional transvenous pacemakers-a critical consideration given her mandatory, lifelong antithrombotic therapy for a Double Valve Replacement (DVR) and history of Transient Ischemic Attack (TIA).

This procedure resulted in the immediate resolution of her giddiness and Dyspnea On Exertion (DOE), achieved excellent local hemostasis at the femoral puncture site, and allowed for the safe resumption of her vital antithrombotic regimen. The patient demonstrated an uneventful recovery and was successfully discharged in stable clinical condition with a favorable long-term cardiovascular prognosis.

Managing Symptomatic Bradycardia in a Patient on Long-Term Antithrombotic Therapy: A Case Report of Leadless Pacemaker Implantation

Managing symptomatic bradycardia in a patient on long-term antithrombotic therapy: A case report of leadless pacemaker implantation

Sakthivel*

Nightingale Journals

Sakthivel^*