Anatomic, histologic, and mechanical features of the right atrium: implications for leadless atrial pacemaker implantation

Abstract Background Leadless pacemakers (LPs) may mitigate the risk of lead failure and pocket infection related to conventional transvenous pacemakers. Atrial LPs are currently being investigated. However, the optimal and safest implant site is not known. Objectives We aimed to evaluate the right atrial (RA) anatomy and the adjacent structures using complementary analytic models [gross anatomy, cardiac magnetic resonance imaging (MRI), and computer simulation], to identify the optimal safest location to implant an atrial LP human. Methods and results Wall thickness and anatomic relationships of the RA were studied in 45 formalin-preserved human hearts. In vivo RA anatomy was assessed in 100 cardiac MRI scans. Finally, 3D collision modelling was undertaken assessing for mechanical device interaction. Three potential locations for an atrial LP were identified; the right atrial appendage (RAA) base, apex, and RA lateral wall. The RAA base had a wall thickness of 2.7 ± 1.6 mm, with a low incidence of collision in virtual implants. The anteromedial recess of the RAA apex had a wall thickness of only 1.3 ± 0.4 mm and minimal interaction in the collision modelling. The RA lateral wall thickness was 2.6 ± 0.9 mm but is in close proximity to the phrenic nerve and sinoatrial artery. Conclusions Based on anatomical review and 3D modelling, the best compromise for an atrial LP implantation may be the RAA base (low incidence of collision, relatively thick myocardial tissue, and without proximity to relevant epicardial structures); the anteromedial recess of the RAA apex and lateral wall are alternate sites. The mid-RAA, RA/superior vena cava junction, and septum appear to be sub-optimal fixation locations. Graphical Abstract Graphical Abstract Attitudinal view of the right atrium demonstrating the three proposed optimal locations for the implantation of an atrial leadless pacemaker; (1) anteromedial RAA apex, (2) base of the RAA, (3) right atrial lateral wall. AM, anteromedial (aspect of the RAA); CS, coronary sinus; CT, crista terminalis; EV, eustachian valve; IVC, inferior vena cava; PL, posterolateral (aspect of the RAA); RAA, right atrial appendage; RCA, right coronary artery; RVOT, right ventricular outflow tract; SB, septal bundle; SC, supraventricular crest; SVC, superior vena cava; TV, tricuspid valve.