Clinical Guidance for Cardiac Electrophysiologists | Advanced Cardiac Pacing
The Aveir VR (Abbott) is a single-chamber leadless pacemaker implanted in the right ventricle via transcatheter delivery. Left Bundle Branch Area Pacing (LBBAP) is an emerging physiologic pacing strategy that captures the left bundle branch or left bundle fascicles through deep septal screw fixation, providing more synchronous ventricular activation. When a patient with an existing Aveir VR requires upgrading to LBBAP — due to pacemaker syndrome, dyssynchrony, or device-related complications — the question of what to do with the leadless device becomes critical.
Retrieval is preferred when feasible (typically within 6–12 months of implant). However, when the device is left in place and simply deactivated, the following risk categories must be carefully considered.
Even in a deactivated state, the Aveir VR remains a conductive metallic body within the right ventricular cavity. It can act as a passive antenna, potentially generating sensing artifacts that may be misinterpreted by the LBBAP system, leading to:
If the Aveir VR reactivates due to electromagnetic noise, device reset, or programming error, true crosstalk between two ventricular devices becomes possible — a scenario not covered by any current safety testing protocol.
This is often the most clinically decisive risk. The Aveir VR carries its own MRI conditional labeling under specific parameters (1.5T and 3T with defined SAR limits). An LBBAP system with a conventional lead has its own separate MRI conditionality. When two CIEDs with independent MRI labeling coexist in the same patient:
For many implanters, loss of MRI access alone is sufficient reason to pursue Aveir VR retrieval rather than leaving it deactivated.
An electrically inactive leadless device may behave differently from an active one in terms of endothelialization dynamics and fibrin deposition. Key considerations include:
Patients with a deactivated Aveir VR in situ should have anticoagulation need assessed and documented explicitly.
The Aveir VR is anchored via helical fixation to the right ventricular trabeculae. Even when deactivated, the physical presence of the device may contribute to:
Serial echocardiographic monitoring of tricuspid valve function is advisable in patients with a retained deactivated Aveir VR.
While uncommon, CIED programming resets due to electromagnetic interference, strong magnetic fields, or device-specific firmware behavior have been documented across multiple platforms. A deactivated Aveir VR retains its battery and internal circuitry in a functional state. If it inadvertently reactivates in a patient already being paced by an LBBAP device:
A deactivated Aveir VR may still respond to Abbott Merlin or bedside telemetry interrogation, creating:
Patient device identification cards and the electronic health record must clearly document the presence and deactivated status of the retained Aveir VR.
There is currently no formal published protocol from Abbott, HRS, ACC/AHA, or ESC specifically addressing management of a deactivated Aveir VR after LBBAP implantation. Decision-making must be individualized. The following framework may guide the discussion:
| Factor | Favors Retrieval | Favors Retention |
|---|---|---|
| Time since Aveir VR implant | < 6–12 months | > 12–18 months |
| MRI likelihood in patient's future | High (young patient, oncology, neurology) | Low |
| Tricuspid valve status | Pre-existing TR or borderline function | Normal tricuspid valve |
| Pacemaker dependency | 100% pacemaker dependent | Intermittent pacing need |
| Retrieval risk | Low (experienced operator, early device) | High (fibrosis, complex anatomy) |
Leaving an Aveir VR leadless pacemaker deactivated after LBBAP implantation is a manageable but clinically meaningful decision carrying several layers of risk:
When retrieval is feasible — particularly within the first year of implant — it is the preferred strategy. When retention is chosen, it must be a deliberate, documented, and closely monitored decision made in collaboration with the Abbott clinical team and with full informed consent from the patient.