Micra Pacemaker: Underutilized in High Risk Patients?

Background Micra transcatheter pacing systems were first brought onto the market in 2016. Currently the Micra pacemaker is indicated for VVIR mode in patients that experience symptomatic high-grade AV block, tachy-brady syndrome and individuals considered high risk for right atrial lead dislodgement. Our institution has utilized Micra pacing successfully in various clinical applications: limited transvenous access due to superior vena cava syndrome, right ventricular pacemaker lead induced tricuspid regurgitation, pacemaker infection and as described below, atrial fibrillation ablation shortly after pacemaker insertion. Case We report a case of a 72-year-old male with a history of symptomatic paroxysmal atrial fibrillation, mechanical aortic valve and morbid obesity who presented to our outpatient clinic for evaluation of his symptomatic atrial fibrillation. Despite increased Sotalol dosing, the patient continued to have symptomatic paroxysmal atrial fibrillation with symptoms of dizziness and near syncope. Outpatient monitoring revealed greater than 5-6 second pauses during atrial fibrillation episodes and greater than 1 second pauses during sinus rhythm. Clinical Decision Making Due to the patient's need for both a pacemaker and an atrial fibrillation ablation, the electrophysiologist felt the patient would be high risk for atrial lead dislodgment. Another concern was the patient's long-term anticoagulation secondary to his mechanical aortic valve. After a multidisciplinary discussion, the consensus was for a Micra pacemaker to be inserted with atrial fibrillation ablation to be performed shortly after. This was performed successfully and in outpatient follow up, the patient has been free of any further syncope, dizziness or atrial fibrillation. Conclusions This case focuses on creating awareness that Micra transcatheter pacing can be utilized in high risk patients with excellent results in an ever-expanding list of clinical indications.