Abstract
Background Leadless pacemakers offer an important alternative for patients with recurrent cardiac implantable electronic device infections. However, clinical data on long-term management and sequential implantation strategies after battery depletion remain limited. We aimed to evaluate the feasibility and safety of a sequential leadless-only pacing strategy in a patient with a multi-decade history of pacing-related complications. Case Presentation We report the long-term clinical course of a patient with a 26-year history of cardiac pacing (2000–2026). Following multiple transvenous system failures and recurrent infections, the patient transitioned to a leadless platform in 2017. We describe the clinical rationale and procedural outcome of upgrading from a depleted first-generation leadless pacemaker (Micra VR, implanted 2017, left in situ at the right ventricular septum) to an AV-synchronous leadless pacemaker (Micra AV, implanted 2025 because of battery depletion of the prior device, not infection) using a leave-in-situ approach. Results Sequential implantation was successfully performed in 2025, with the new device implanted at the right ventricular mid-septum while the previously implanted device was left in situ . Acute electrical parameters were satisfactory (pacing threshold 0.63 V, R-wave amplitude 9.8 mV, impedance 720 Ω ), with no evidence of inappropriate sensing. At follow-up, electrical parameters remained stable (pacing threshold 0.50 V, impedance 670–650 Ω ), with atrioventricular synchrony of 80% at 1 month and 84–85% at 3–6 months. No clinical or device-telemetry evidence of mechanical interaction or electrical interference between the devices was observed during follow-up. No device-related complications occurred during follow-up. Conclusion A sequential leadless-only pacing strategy, including a leave-in-situ approach, may represent a feasible and safe long-term option in selected high-risk patients with device-related infections and a history of transvenous system extraction.