TTE-guided leadless pacemaker implantation shows feasibility and comparable duration to fluoroscopy in small cohort

Background and objectiveConventional leadless pacemaker (LP) implantation relies on fluoroscopy, exposing patients and operators to ionizing radiation and contrast-related risks. Transthoracic echocardiography (TTE) is a radiation-free alternative, but complete TTE-guided LP implantation remains challenging due to poor ultrasound visibility of interventional devices. This study evaluated the short-term safety, technical feasibility, and procedural efficiency of completely TTE-guided LP implantation assisted by the ultrasound-optimized Panna guidewire.MethodsThis study utilized a prospectively protocolized, single-arm design for the TTE-guided cohort, with a retrospective comparative analysis against a historical fluoroscopy-guided control group. All safety and efficacy endpoints were formally predefined prior to patient enrollment. A total of 32 consecutive patients with LP implantation indications were screened during the study period (July 2024–July 2025), and 10 eligible patients underwent fluoroscopy/contrast-free, TTE-guided LP implantation using the Panna guidewire. Preoperative TTE acoustic window grading was performed, and standardized protocols (semi-quantitative “gooseneck” sign assessment, TTE-guided tug test) were applied during the procedure. A historical control group of 44 fluoroscopy-guided LP patients (January 2020–December 2023) was included, with propensity score overlap weighting-based comparative statistical analyses performed to balance baseline covariates and assess between-group differences. Procedural feasibility, short-term safety, pacing parameters, and skin-to-skin procedural duration were evaluated intraoperatively and during follow-up.ResultsAll 10 patients had optimal TTE acoustic windows (Grade 1). Procedural success was 100%, with no adverse events (median follow-up: 4.7 months) and stable device performance. Sensitivity analysis showed the TTE technique's effectiveness was not affected by operator experience. Compared with 44 propensity score-weighted controls, TTE-guided implantation had slightly longer but comparable procedural duration (62.78 ± 13.05 vs. 60.5 ± 19.1 min, P > 0.05) and comparable efficiency, eliminating radiation/contrast-related risks for high-risk patients (e.g., CKD, radiation sensitivity). Long-term follow-up (12/24 months) is ongoing per schedule.ConclusionsThis preliminary experience demonstrates the short-term safety and technical feasibility of completely TTE-guided LP implantation assisted by the Panna guidewire, which eliminates radiation/contrast risks while matching fluoroscopy-guided efficiency. As a hypothesis-generating proof-of-concept study (small sample, incomplete long-term follow-up), these findings require validation in larger multicenter registries (n ≥ 50) with ≥24-month follow-up to confirm long-term safety and generalizability.