Intraprocedural tail-first pulmonary artery migration of a leadless pacemaker: a protective sleeve-assisted helix-side retrieval strategy-a case report.

Background: Leadless pacemaker migration into the pulmonary artery is an exceptionally rare but potentially serious complication. Tail-first (proximal helix-oriented) migration poses additional risk, as traction on the exposed helix may cause vascular injury. Case summary: A 72-year-old woman with bradycardic atrial fibrillation underwent implantation of an Aveir™ VR leadless pacemaker. Immediately after device release, fluoroscopy revealed a tail-down shift suggesting inadequate mechanical engagement, accompanied by frequent premature ventricular contractions and non-sustained ventricular tachycardia, prompting immediate retrieval. During the retrieval procedure, the device became completely dislodged and migrated into the left pulmonary artery with the helix oriented proximally.In this orientation, standard docking button retrieval was not feasible. The Aveir™ retrieval catheter was advanced into the pulmonary artery, the helix was captured, and the device was enclosed within the protective sleeve before successful extraction.The new device was subsequently re-implanted at a more apical septal site, and stable fixation was achieved. Discussion: In previously reported cases of pulmonary artery migration of the Aveir™ pacemaker, retrieval was performed using non-dedicated flexible sheaths and snare catheters. In contrast, this case demonstrates that advancing the dedicated retrieval system to enclose the grasped helix enabled controlled retrieval while minimizing direct contact between the exposed helix and the pulmonary arterial wall. This case also highlights that satisfactory electrical parameters alone may not guarantee adequate mechanical fixation. Although this technique may represent a practical bailout strategy when engagement of the docking button is not feasible, further clinical experience is required to establish its safety and reproducibility.