LP implantation in octogenarians
A previous report from Micra post-approval registry proposed
octogenarians with an age of more than 85 years old as a risk factor for
a perforation during LP implantation. 12 They proposed
that most patients who developed perforations had more than 1 risk
factor including an older age, low BMI, female sex, congestive heart
failure, non-AF indication, and chronic lung disease. However, although
the number is small, our experience suggested a safety profile of LP
implantations even in octogenarians. Furthermore, all patients could
achieve successful deployment with only 1 or 2 device deployment
attempts. There might be one explanation supporting this favorable
outcome. In this cohort, 4 of 8 patients (50%) had AF including 3 with
permanent AF and all these patients had a giant left atrium with a left
atrial dimension of more than 50mm. Furthermore, 5 of 8 patients (63%)
had moderate or severe tricuspid valve regurgitation (TR), suggesting an
right atrial volume overload. The previous transvenous leads might help
worsening the severity of the TR owing to the mechanical interferences
with the tricuspid valve closure. 23 These anatomical
remodeling in the right atrium might allow for a safer manipulation of
the LP catheter system. 12
The LP may have several advantages in considering it as a
re-implantation strategy in octogenarians. First, the small surface
area, occurrence of LP encapsulation, and location completely within the
intracardiac space, could lead to a potential benefit in preventing a
relapse of an infection. 24 Second, patients with
dementia may have the risk of self-manipulation of the pacemaker pulse
generator within the pocket resulting in pocket trouble.25 Furthermore, patients with severe frailty might
have the risk of skin thinning that could cause a generator exposure.
The use of a small intracardiac LP eliminates all risks of pocket
trouble and infections and the necessity of infection-prone pectoral
generator replacements. 11, 12 Third, in our cohort, 6
of 8 patients (75%) had ipsilateral subclavian vein occlusions in the
preprocedural venography. Re-implantation of a PM without using the
collateral subclavian vein may have been of benefit, especially in
patients who had a risk of future hemodialysis considering a patent
vascular access.