High Output Heart Failure Following Leadless Pacemaker Implantation

BACKGROUND: Leadless pacemakers have a significantly higher risk of vascular complications than traditional transvenous devices. CASE SUMMARY: An 85-year-old man with permanent atrial fibrillation presented with symptomatic bradycardia. A leadless pacemaker was implanted, and the procedure was complicated by a right common femoral vein pseudoaneurysm which was treated with thrombin injection. Months later, he presented with worsening volume overload related to high output heart failure from an arteriovenous fistula at the access site. After surgical repair of his fistula, the patient had resolution of heart failure. DISCUSSION: Arteriovenous fistula is a relatively rare complication of cardiac catheterization, but its risk is increased with procedures like leadless pacemaker insertion. Such procedures require a larger caliber sheath, which is associated with a significantly higher risk of vascular complications. TAKE-HOME MESSAGES: Leadless pacemakers have a unique set of associated vascular complications that could lead to significant adverse outcomes.