Immediate retrieval of an astray leadless Micra pacemaker with double-snare in single sheath

Immediate retrieval of an astray leadless Micra pacemaker with double-snare in single sheath | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 25 April 2025 V1 Latest version Share on Immediate retrieval of an astray leadless Micra pacemaker with double-snare in single sheath Authors : Jie Tan 0000-0003-2478-3647 , Yang-zhen Liu , Fang Tong , and Peng Yan 0000-0002-6108-6982 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174555022.26111299/v1 Published Indian Journal of Thoracic and Cardiovascular Surgery Version of record Peer review timeline 188 views 91 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background The leadless Micra pacemaker has emerged as a safe and minimally invasive alternative for selected patients with arrhythmias. However, as the technology is still relatively new, clinical experience with urgent device retrieval—particularly in critical care settings—remains limited. Case Summary An 85-year-old female with chronic atrial fibrillation and complete heart block underwent Micra pacemaker implantation. Within minutes of tether removal, the device became dislodged and migrated between the tricuspid valve and the right ventricular apex, resulting in nonsustained ventricular tachycardia. Immediate retrieval was performed using a double-snare technique through a single 23-French delivery sheath. The pacemaker was successfully extracted within 40 minutes, with no complications. Discussion This case highlights a rare but critical complication of leadless pacemaker dislodgement, requiring urgent recognition and rapid procedural response. The double-snare technique enabled safe and efficient retrieval through a single access site, minimizing procedural time and trauma—key considerations in high-risk and elderly patients. As leadless pacing becomes more widespread, familiarity with emergency retrieval strategies and procedural adaptability will be essential, particularly in intensive care and interventional cardiology settings. Title: Immediate retrieval of an astray leadless Micra pacemaker with double-snare in single sheath [1]¿p#1 Brief introduction of the authors 1. The first author, Jie Tan, Department of Interventional Vascular Surgery, Hunan Provincial People’s Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, 410002, China. (E-mail: [email protected] ), ORCID: 0000-0003-2478-3647 2. The second author, Yang-zhen Liu, Department of hepatology, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University (The First Hospital of Changsha), Changsha, 410005, China. (E-mail: [email protected] ) 3. The third author, Fang Tong, Department of interventional vascular surgery, Li County People’s Hospital, Changde, 415500, China. (E-mail: [email protected] ) 4. The fourth author, Peng Yan, Department of Interventional Vascular Surgery, Hunan Provincial People’s Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, 410002, China. (E-mail: [email protected] ), ORCID: 0000-0002-6108-6982 Correspondence to Prof. Peng Yan, Department of Interventional Vascular Surgery, Hunan Provincial People’s Hospital (The First Affiliated Hospital of Hunan Normal University), No. 89, Guhan Road, Furong District, Changsha City, Hunan Province, 410002, China. (Fax: +86 0731-84731703; Tel: +86 18673150432; E-mail: [email protected] ) Funding : This project was supported by the Hunan Provincial Health Commission Scientific Research Program Project (D202304017483), and Chen Xiaoping Foundation for the Development of Science and Technology of Hubei Province (H2023-11) [1]¿p#1 Background The leadless Micra pacemaker has emerged as a safe and minimally invasive alternative for selected patients with arrhythmias. However, as the technology is still relatively new, clinical experience with urgent device retrieval—particularly in critical care settings—remains limited. Case Summary An 85-year-old female with chronic atrial fibrillation and complete heart block underwent Micra pacemaker implantation. Within minutes of tether removal, the device became dislodged and migrated between the tricuspid valve and the right ventricular apex, resulting in nonsustained ventricular tachycardia. Immediate retrieval was performed using a double-snare technique through a single 23-French delivery sheath. The pacemaker was successfully extracted within 40 minutes, with no complications. Discussion This case highlights a rare but critical complication of leadless pacemaker dislodgement, requiring urgent recognition and rapid procedural response. The double-snare technique enabled safe and efficient retrieval through a single access site, minimizing procedural time and trauma—key considerations in high-risk and elderly patients. As leadless pacing becomes more widespread, familiarity with emergency retrieval strategies and procedural adaptability will be essential, particularly in intensive care and interventional cardiology settings. Key word Leadless pacemaker, Micra, Retrieval, Astray, Snare Introduction The implantable leadless Micra pacemaker (Micra, Medtronic, Minneapolis, USA) is a novel device developed for selected patients with arrhythmias, particularly those with occluded subclavian or superior vena cava veins, or in cases where minimizing lead-related complications—such as lead dislodgement, injury, or infection—is critical. Since its clinical introduction in 2015, more than ten thousand Micra devices have been implanted worldwide. Following its approval by the Chinese National Medical Products Administration (NMPA) in 2019, implantation rates have steadily increased in China. According to published studies, the success rate of Micra implantation is approximately 99.6%, with major complications occurring in only 1.51% of cases [1]. Given the device’s projected battery lifespan of over 10 years, retrieval due to battery depletion is rare, and standardized retrieval protocols remain largely undeveloped. Nevertheless, in rare cases, retrieval becomes necessary due to complications such as device dislodgement or malfunction. Here, we report a case of immediate dislodgement of a leadless Micra pacemaker following tether removal, and describe its successful retrieval using a double-snare technique via a single vascular access point. Case presentation An 85-year-old female was admitted to our hospital due to a syncopal episode. The patient had a history of chronic atrial fibrillation and complete heart block. Given these findings, the cardiology team scheduled implantation of a leadless Micra pacemaker. The procedure was performed under fluoroscopic and echocardiographic guidance, following the manufacturer’s recommended protocol. The pacemaker was successfully implanted near the right ventricular apex, with satisfactory sensing and pacing thresholds. A tilt test confirmed stable fixation with at least three deployments. However, within minutes of tether removal, the ECG monitor unexpectedly showed loss of pacemaker signals. Fluoroscopy revealed that the device had become dislodged and was floating between the tricuspid valve and the right ventricular apex (Video 1). Intermittent ventricular tachycardia was also observed. In response, the team decided to proceed with immediate retrieval of the pacemaker. With the original Micra delivery sheath still in place, we inserted a 20 mm steerable Günther Tulip® snare (Cook Medical, USA) through the 23-French sheath to capture the mobile device within the right ventricle. The body of the pacemaker was successfully snared and secured. As we attempted to withdraw the device into the inferior vena cava, resistance was encountered due to entanglement of the FlexFix tines with the tricuspid chordae tendineae and the hepatic vein. Nevertheless, the device was pulled back into the right atrium without major difficulty. At this stage, the primary challenge was how to align the device with the sheath for successful reinsertion. Snaring the body alone caused misalignment, as its axial orientation did not match that of the introducer sheath (Figure. 1). Similarly, attempting to retrieve the device by capturing only the proximal retrieval feature did not correct the angle, making sheath insertion difficult. Therefore, we introduced a second snare through the same sheath to grasp the proximal retrieval knob. This double-snare technique allowed precise control of the device’s orientation, guiding the proximal end into the sheath first (Figure. 2, Video 2). Shortly after successful coaxial alignment, the proximal snare loosened. Fortunately, the first snare remained securely locked around the device body, preventing further displacement (Figure. 3, Video 3). Ultimately, both the pacemaker and the delivery sheath were withdrawn together, and the entire retrieval procedure was completed within approximately 40 minutes. Discussion The implantable leadless Micra pacemaker offers a minimally invasive alternative for selected arrhythmia patients, particularly those at increased risk for complications from traditional transvenous systems. While its overall safety profile is well-established, rare but potentially life-threatening complications—such as device dislodgement—require rapid recognition and expert intervention, especially in critical care settings [1,2]. In our case, the patient developed immediate device dislodgement following tether removal, accompanied by intermittent ventricular tachycardia. This unexpected deterioration required urgent decision-making and procedural response, underscoring the importance of procedural preparedness and multidisciplinary coordination in managing high-acuity cardiac patients. Prompt identification of device migration and hemodynamic instability was crucial, and retrieval was initiated without delay [3]. Using the retained 23-French delivery sheath, we employed a double-snare retrieval technique via a single vascular access. This approach allowed for precise control and alignment of the dislodged pacemaker, enabling safe and efficient extraction in a time-sensitive situation. Compared with previously reported cases requiring multiple access sites [4,5], our method minimized procedural complexity and reduced potential vascular trauma—critical considerations in elderly or hemodynamically unstable patients. A significant concern during the extraction process was the potential for further injury to cardiac structures, such as the tricuspid valve or hepatic veins, due to entanglement of the FlexFix tines. Additionally, the presence of ventricular arrhythmias heightened the risk of deterioration during manipulation. Fortunately, with careful snare placement and real-time imaging guidance, we avoided further complications and stabilized the patient promptly. From a critical care perspective, this case highlights the need for rapid procedural adaptability and the availability of appropriate retrieval tools in emergency scenarios. Although the Micra pacemaker is designed to be retrievable within the acute phase, there are limited standardized retrieval protocols, particularly for unstable patients. Our experience supports the double-snare technique as a feasible and effective option in such scenarios. Design challenges of the device—including its slippery surface and cylindrical shape—pose additional difficulties for rapid retrieval. Structural modifications such as a central groove or enhanced proximal hooks could improve handling and safety, particularly in high-stakes environments where time and stability are critical. Emerging literature describes various retrieval strategies, including the use of tri-loop snares, gooseneck snares, and steerable sheaths, as well as alternative systems like the INARI FlowTriever and ONO retrieval system in more complex or delayed retrievals [6,7]. In critical care, where time-sensitive decisions are essential, tools that combine control, flexibility, and minimal invasiveness—such as the Aveir retrieval system or the use of intracardiac echocardiography (ICE)—can significantly improve outcomes and reduce the risk of complications [8]. To date, large-scale data on leadless pacemaker dislodgement in clinical practice remain lacking. It is hypothesized that in some patients—particularly those with anatomical variation or poor myocardial fixation—tine slippage may occur. Pre-procedural imaging and cardiac anatomical assessment may be essential in high-risk patients, especially in critical care populations where complications carry higher morbidity and mortality. In summary, this case underscores the importance of rapid response and procedural versatility in managing acute leadless pacemaker dislodgement. The double-snare technique provides a reliable retrieval strategy that is both time-efficient and minimally invasive—crucial qualities in the critical care setting. As the use of leadless pacing technology continues to grow, critical care teams must be equipped not only to recognize complications early but also to intervene decisively using evolving interventional techniques. References 1. Roberts PR, Clementy N, Al Samadi F, Garweg C, Martinez-Sande JL, Iacopino S, Johansen JB, Vinolas Prat X, Kowal RC, Klug D, Mont L, Steffel J, Li S, Van Osch D, El-Chami MF. A leadless pacemaker in the real-world setting: the Micra transcath- eter pacing system post-approval registry. Heart Rhythm 2017;14:1375–1379. 2. Medtronic. MicraTM Implants: Increasing at a Fast Rate. 2017. https://www.med tronic.com/us-en/about/news/Micra-10k-patients.html. 3. Muhammad R Afzal, Emile G Daoud, Ryan Cunnane, etc. Techniques for successful early retrieval of the Micra transcatheter pacing system: A worldwide experience. HeartRhythm. 2018 Jun;15(6):841-846. 4. Stephanie Fichtner, Heidi L. Estner, Michael Näbauer, and Jörg Hausleiter. Percutaneous extraction of a leadless Micra pacemaker after dislocation: a case report European Heart Journal - Case Reports (2019) 3, 1–4. 5. Saki Hasegawa-Tamba, Yoshifumi Ikeda, Kenta Tsutsui, Ritsushi Kato, Toshihiro Muramatsu, and Kazuo Matsumoto. Two-directional snare technique to rescue detaching leadless pacemaker. HeartRhythm Case Rep. 2020 Oct; 6(10): 711–714. 6. Golzarian H, Rashid W, Patel SM, Shaikh M, Hakim FA. Using Coronary Guide Catheters with the Sheath-in-sheath Technique to Retrieve a Micra™ Leadless Pacemaker. J Innov Card Rhythm Manag. 2024 May 15;15(5):5867-5870. doi: 10.19102/icrm.2024.15052. 7. Funasako M, Hála P, Janotka M, Šorf J, Machová L, Petrů J, Chovanec M, Škoda J, Šedivá L, Šimon J, Dujka L, Reddy VY, Neužil P. Transcatheter non-acute retrieval of the tine-based leadless ventricular pacemaker. Europace. 2024 Oct 3;26(10):euae256. doi: 10.1093/europace/euae256. 8. Gabrah K, Mahtani AU, Nair DG. Micra Extraction Out To 4.5 Years. Card Electrophysiol Clin. 2024;16(2):149-155. doi:10.1016/j.ccep.2023.10.015. Figure Caption Figure 1. (A) FlexFix tines entangled with tricuspid chordae tendineae; the device body was misaligned with the introducer sheath. (B) FlexFix tines twisted with the hepatic vein. Figure 2. (A) Double-snare technique used via a single access to adjust the capsule orientation. (B) Proper alignment achieved, allowing the proximal end to enter the sheath first. Figure 3. Final retrieval step. The pacemaker was successfully aligned and withdrawn into the sheath using the remaining snare after proximal snare loosening. Video Caption Video 1. Fluoroscopic view showing the dislodged Micra pacemaker freely floating between the tricuspid valve and the right ventricular apex shortly after tether removal. Video 2. Fluoroscopic view showing the double-snare technique used to retrieve the dislodged Micra pacemaker within the inferior vena cava. Video 3. Fluoroscopic view showing the pacemaker was successfully aligned and withdrawn into the sheath. Information & Authors Information Version history V1 Version 1 25 April 2025 Peer review timeline Published Indian Journal of Thoracic and Cardiovascular Surgery Version of Record 18 Nov 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Jie Tan 0000-0003-2478-3647 Hunan Provincial People's Hospital View all articles by this author Yang-zhen Liu First Hospital of Changsha View all articles by this author Fang Tong Changde First Hospital of Traditional Chinese Medicine View all articles by this author Peng Yan 0000-0002-6108-6982 [email protected] Hunan Provincial People's Hospital View all articles by this author Metrics & Citations Metrics Article Usage 188 views 91 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Jie Tan, Yang-zhen Liu, Fang Tong, et al. Immediate retrieval of an astray leadless Micra pacemaker with double-snare in single sheath. Authorea . 25 April 2025. DOI: https://doi.org/10.22541/au.174555022.26111299/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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