How should a patient prepare for an LBBAP procedure in the days beforehand?

Preparation spans approximately 7 to 10 days and covers medication and anticoagulation planning, current labs and imaging, reduction of training intensity in athletes, skin and site preparation with chlorhexidine washes, completion of any pending dental work, hydration and fasting logistics, and confirmation of procedural details including sheath choice, lead type, mapping approach, and contingency plans for when true LBB capture is not achievable.

What are the key questions to ask an electrophysiologist before an LBBAP upgrade?

Core questions address retrieval of any existing leadless pacemaker including operator volume and bailout plans, LBBAP technique and capture confirmation criteria such as V6 R-wave peak time and selective versus non-selective capture transition, the fallback hierarchy if true LBB capture cannot be achieved, post-upgrade device configuration and AV delay programming, echocardiographic surveillance for pacing-induced cardiomyopathy reversal, and athlete-specific return-to-training considerations.

Why is retrieval of a leadless pacemaker the highest-variance part of an LBBAP upgrade procedure?

Retrieval is higher variance than the LBBAP implant itself because outcomes depend heavily on dwell time, tine encapsulation, and myocardial adherence, which can result in snare failure, right ventricular perforation, tamponade, or tricuspid valve injury. An experienced operator will have documented personal volume at the relevant dwell time and a clear threshold at which retrieval is abandoned in favor of leaving the device in place.

Top 10 Questions to Ask Before an LBBAP Upgrade After a Leadless Pacemaker

A focused consultation framework for patients and clinicians preparing for Left Bundle Branch Area Pacing after Aveir VR implantation.

Clinical scenario. A patient with a previously implanted Aveir VR leadless pacemaker develops evidence suggestive of pacing-induced cardiomyopathy (PICM) — eccentric left ventricular remodeling, left atrial dilation, elevated E/E′, and chronically elevated high-sensitivity troponin T — together with nocturnal capture threshold variability. The implanting electrophysiologist recommends upgrade to Left Bundle Branch Area Pacing (LBBAP) with retrieval of the existing leadless device. The questions below are organized to stress-test the retrieval plan first, then address LBBAP technique, post-upgrade configuration, and athlete-specific recovery considerations.

How to prepare in the days before the procedure

7 to 10 days before

Medication and anticoagulation planning is the most consequential decision point. Aspirin is typically continued when indicated for secondary prevention. Direct oral anticoagulants are commonly held 24 to 48 hours preoperatively depending on renal function and bleeding risk, although uninterrupted strategies are acceptable in selected low-risk patients. Warfarin is generally continued with a target INR of 2.0 to 2.5, as uninterrupted warfarin has better evidence than bridging for cardiac implantable electronic device procedures. NSAIDs, fish oil, vitamin E, ginkgo, and turmeric supplements should be held when feasible.

When a leadless pacemaker is already in place, upgrade planning must address whether the existing device will be retrieved at the time of LBBAP implant or abandoned. This decision affects procedure duration, fluoroscopy and contrast exposure, and venous access strategy. A venogram or venous ultrasound of the planned access extremity can be useful to confirm patency before the implant day.

Laboratory and imaging data to have current within two to four weeks includes a complete blood count, comprehensive metabolic panel, coagulation studies, a recent echocardiogram, a baseline 12-lead electrocardiogram documenting native and paced QRS morphology and duration, current device interrogation data with capture thresholds, sensing values, lead impedance, and ventricular pacing percentage, and a chest radiograph for venous anatomy reference.

3 to 5 days before

Athletes should reduce training intensity to avoid arriving in a depleted state with elevated baseline troponin or inflammatory markers. Zone 2 aerobic work is acceptable; race-pace efforts and maximal heart rate testing should be avoided. Sleep of at least eight hours per night meaningfully affects perioperative recovery. Skin preparation includes avoiding new tattoos, shaving, or irritation at the planned incision site, and beginning chlorhexidine washes of the chest and axilla two to three days preoperatively as an evidence-based measure against CIED infection. Any pending dental work should be completed before implantation rather than after.

1 to 2 days before

Standard NPO guidelines apply, typically six to eight hours for solids and up to two hours for clear liquids. Adequate hydration supports venous access and reduces the risk of contrast-associated acute kidney injury if venography is used. Alcohol should be avoided for 48 hours. Procedural details worth confirming with the implanting team include the specific delivery sheath planned, whether a stylet-driven or lumenless lead will be used, the mapping approach, and the contingency hierarchy if true LBB capture is not achievable.

The Top 10 Consultation Questions

Aveir VR retrieval — the highest-variance element

When an operator is committed to retrieval of an existing leadless pacemaker, the retrieval itself becomes the highest-variance part of the procedure — more so than the LBBAP implant, which is typically a routine operation for high-volume electrophysiologists. The first four questions are designed to pressure-test the retrieval plan.

1. What is your personal Aveir retrieval volume and acute success rate at this dwell time? How many retrievals have you performed beyond one year of implant?

2. What is your escalation plan if the device does not release cleanly — snare failure, tine encapsulation, or evidence of myocardial adherence? At what point do you abandon retrieval and leave the device in place?

3. What is the quoted risk profile for right ventricular perforation, tamponade, tricuspid valve injury, and need for surgical backup during retrieval at this dwell time?

4. Will retrieval and LBBAP implant be performed in the same procedure, or staged? What drives that decision?

LBBAP implant technique and capture confirmation

5. What is your annual LBBAP volume and acute true LBB capture rate, distinguished from LV septal pacing? What intraprocedural criteria will you use — V6 R-wave peak time cutoff, selective versus non-selective capture transition, programmed stimulation at varying outputs?

6. What is your fallback hierarchy if true LBB capture is not achievable (LV septal pacing, deep septal pacing, His-bundle pacing), and what final QRS duration would you consider acceptable?

Post-upgrade configuration and PICM reversal surveillance

7. Single-chamber LBBAP versus dual-chamber configuration with an added atrial lead — what is your recommendation for a patient in sinus rhythm with high athletic demand? How will AV delay and rate response be programmed for athletic physiology?

8. What echocardiographic surveillance timeline and parameters will you track for PICM reversal — left ventricular ejection fraction, chamber dimensions, global longitudinal strain, left atrial volume, E/E′? If reverse remodeling has not occurred by 6 to 12 months, what is the next step?

Athlete-specific and strategic

9. For a competitive rower, when is it safe to resume ergometer training, on-water rowing, and maximal-effort racing after implant? Are there rate-response or programming considerations specific to the rowing stroke and its heart rate profile?

10. If this were your case, would you proceed now or wait? Is there another electrophysiologist — at Cleveland Clinic main campus or elsewhere — whose opinion you would value on the retrieve-versus-abandon decision before committing?

Strategic framing and a reserve question

Opening line to set the frame: “I have 10 questions I would like to cover. Would it be more efficient for me to walk through them, or for you to give me your overall assessment first and then fill in gaps?”

Reserve question worth holding for Question 3: Ask about tricuspid valve assessment before and after retrieval. Tine-based leadless device extraction can injure the tricuspid apparatus, and new tricuspid regurgitation after retrieval alters the hemodynamic picture on top of any existing PICM physiology. A well-prepared operator will already have this in the pre-procedural imaging plan.

Why retrieval — not implantation — is the pressure point

In a high-volume LBBAP practice, the implant is mechanically reproducible: sheath selection, septal targeting, confirmation of LBB capture via V6 R-wave peak time, and programming for optimal AV timing. What varies substantially from case to case is the retrieval of a leadless device with meaningful dwell time. Tine encapsulation, fibrotic adherence to the right ventricular septum, and proximity to the tricuspid apparatus introduce variables that are not present in a de novo implant. The questions prioritized in this framework reflect that asymmetry.

Equally important is the behavioral signal in Question 10. A confident, experienced operator welcomes the suggestion of a second opinion and typically responds without defensiveness. The reaction itself carries information.

Educational disclaimer. This content is intended for educational purposes for healthcare professionals and informed patients. It does not constitute individual medical advice. All clinical decisions regarding device therapy, including retrieval of leadless pacemakers and upgrade to conduction system pacing, should be made in consultation with a qualified cardiac electrophysiologist familiar with the patient’s complete clinical picture.