Double-Snare Retrieval and Mapping-Guided Reimplantation of a Dislodged Atrial Leadless Pacemaker

BACKGROUND: Atrial leadless pacemaker (LP) dislodgement is an uncommon but serious complication, more frequent than ventricular LP dislodgement. CASE SUMMARY: A 64-year-old man with tachycardia-bradycardia syndrome and end-stage renal disease on long-term hemodialysis underwent a dual-chamber LP implantation. The atrial LP initially demonstrated acceptable electrical parameters, but the capture threshold progressively increased, leading to early battery depletion; repeat implantation again showed high thresholds (4.25 V at 0.4 ms). One week later, imaging revealed atrial LP dislodgement with inversion into the right ventricle. Fixation helix capture was unreliable, and device slippage occurred during withdrawal. A double-snare technique stabilized the LP, enabling secure docking and extraction. Given suspected uremic atrial myopathy, 3-dimensional electroanatomic mapping guided reimplantation, achieving excellent electrical performance. DISCUSSION: Double-snare retrieval improves procedural control during complex retrievals, while mapping-guided implantation may reduce fixation failure in diseased atria. TAKE-HOME MESSAGES: Double-snare retrieval enhances safety in inverted atrial LP dislodgement. Preimplant 3-dimensional mapping optimizes atrial LP outcomes.