Contrast-Free Dual-Chamber Leadless Pacemaker Implantation Using Intracardiac Echocardiography and 3-Dimensional Electroanatomical Mapping.

OBJECTIVE: The authors aim to describe contrast-free dual-chamber leadless pacemaker implantation using combined intracardiac echocardiography (ICE) and CARTO three-dimensional electroanatomical mapping in near-dialysis-stage chronic kidney disease cases. KEY STEPS: 1) Noncontrast computed tomography reconstruction imported into CARTO as an anatomical roadmap; 2) ICE-guided 3D right-heart geometry reconstruction with color-tagged targets; 3) Aveir VR implantation at the mid-interventricular septum under ICE/CARTO co-registration with echo-fan-guided advancement; 4) Aveir AR implantation at the right atrial appendage base using pectinate muscles as landmarks; 5) sequential impedance monitoring as a tissue-contact surrogate. POTENTIAL PITFALLS: The echo fan must be directed toward the septum, not the right ventricular apex, before advancing the catheter; misalignment may cause apical fixation. Accurate right atrial appendage base identification via pectinate muscles is essential to avoid fixation at insufficiently thick myocardium. TAKE-HOME MESSAGE: Combined ICE and CARTO 3-dimensional electroanatomical mapping enables safe, contrast-free dual-chamber leadless pacemaker implantation in chronic kidney disease cases, potentially expanding this therapy to patients in whom contrast is contraindicated.