# Navigating the Lead Paradox: Successful Co‐Implantation of Cardiac Contractility Modulation Device and a Micra Leadless Pacemaker

## TL;DR

A new approach allows combining two heart devices in patients with a specific heart condition, improving their quality of life.

## Contribution

The first successful co-implantation of a lead-based CCM device and a leadless Micra pacemaker in a patient with wild-type transthyretin cardiac amyloidosis.

## Key findings

- A multi-view fluoroscopic technique ensured safe spatial separation of the devices.
- Device programming successfully mitigated electrical crosstalk post-implantation.
- The patient's heart failure improved from NYHA III to NYHA II with no further hospitalizations after one year.

## Abstract

Wild‐type transthyretin cardiac amyloidosis (ATTRwt‐CA) can lead to refractory heart failure. A “lead paradox” occurs when patients with a Micra leadless pacemaker require lead‐based Cardiac Contractility Modulation (CCM) therapy.

We detail the first co‐implantation of CCM and Micra devices in a 78‐year‐old male with ATTRwt‐CA and NYHA III heart failure. A multi‐view fluoroscopic technique ensured spatial separation, while specific device programming mitigated electrical crosstalk post‐procedure.

At 1 year, the patient stabilized to NYHA Class II without further hospitalizations. This dual‐device strategy is a feasible and safe technical roadmap for this complex clinical problem.

This central illustration visually summarizes the first co‐implantation of a Cardiac Contractility Modulation (CCM) system and a Micra leadless pacemaker in a 78‐year‐old male with wild‐type transthyretin cardiac amyloidosis and NYHA Class III heart failure. The patient's case presented a “lead paradox”—a need for a lead‐based therapy (CCM) in an individual with a pre‐existing leadless solution (Micra). The procedural strategy emphasized a multi‐view fluoroscopic technique to ensure spatial separation and post‐implant device programming to mitigate interaction. At 1‐year follow‐up, the patient's condition improved to NYHA Class II with no further heart failure hospitalizations. The case establishes a feasible and safe technical roadmap for this dual‐device strategy.