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Kouranloo K, Lawson J, Goode A, Goode G, Abozguia K. Improving outcomes in single chamber leadless pacemakers: strategies for minimizing vascular complications. BMC Cardiovasc Disord 2023; 23:601. [PMID: 38066488 PMCID: PMC10704690 DOI: 10.1186/s12872-023-03634-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Leadless pacemaker therapy is associated with a significant reduction in lead-related complication rate compared to conventional transvenous single chamber pacemaker therapy. However, a significant complication rate of 1.2% was observed in vascular access due to the use of large delivery femoral sheath (27Fr). The aim of this study was to evaluate the effectiveness of real-time ultrasound guidance and Z suture technique in reducing total and major vascular complications in leadless pacemaker therapy. METHOD In this study, we performed a retrospective and prospective analysis of all adverse events associated with leadless pacemaker (Micra) implantation by two operators at a single tertiary center from December 2016 to December 2018. To mitigate the risk of vascular complications, all patients underwent real-time ultrasound-guided venipuncture for vascular access, as well as the application of a Z-suture technique for hemostasis at the end of the procedure. Data were collected on implant indications, implant procedure details, complications, and follow-up information. RESULTS In this study, 45 patients with an age range of 24 to 94 years (mean 76 ± 14 years) were recruited, with 21 (46.6%) being female. The pacing indications for the patients included atrial fibrillation (24, 53.3%), vascular (7, 15.5%), infection (9, 20%), cognitive/frailty (3, 6.6%), and occupational (2, 4.4%). The implant procedures were performed under general anesthesia in 6 (13.3%) of the cases, and under local anesthesia and sedation in 39 (86.6%) of the cases. A single deployment was achieved in 43 (95.5%) of the patients, while 2 deployments were required in 2 (4.4%) of the patients. Notably, no vascular or major complications were reported in our cohort of patients. CONCLUSIONS The results of this observational study indicate that incorporating real-time ultrasound guidance during venipuncture and the use of a Z-suture technique significantly reduce the occurrence of both total and major vascular complications associated with the implantation of leadless pacemaker. However, more robust and larger studies are required in order to confirm these results and implications for clinical practice.
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Affiliation(s)
- Koushan Kouranloo
- University of Liverpool School of Medicine, Ashton St, Liverpool, UK.
- Royal Liverpool University Hospitals Mount Vernon St, Liverpool, UK.
| | - Joanne Lawson
- Blackpool Victoria Hospital, NHS Foundation Trust, Blackpool, UK
| | - Angelic Goode
- Blackpool Victoria Hospital, NHS Foundation Trust, Blackpool, UK
| | - Grahame Goode
- Blackpool Victoria Hospital, NHS Foundation Trust, Blackpool, UK
| | - Khalid Abozguia
- Marshall Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, WV, USA
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Wijesuriya N, De Vere F, Mehta V, Niederer S, Rinaldi CA, Behar JM. Leadless Pacing: Therapy, Challenges and Novelties. Arrhythm Electrophysiol Rev 2023; 12:e09. [PMID: 37427300 PMCID: PMC10326662 DOI: 10.15420/aer.2022.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/15/2023] [Indexed: 07/11/2023] Open
Abstract
Leadless pacing is a rapidly growing field. Initially designed to provide right ventricular pacing for those who were contraindicated for conventional devices, the technology is growing to explore the potential benefit of avoiding long-term transvenous leads in any patient who requires pacing. In this review, we first examine the safety and performance of leadless pacing devices. We then review the evidence for their use in special populations, such as patients with high risk of device infection, patients on haemodialysis, and patients with vasovagal syncope who represent a younger population who may wish to avoid transvenous pacing. We also summarise the evidence for leadless cardiac resynchronisation therapy and conduction system pacing and discuss the challenges of managing issues, such as system revisions, end of battery life and extractions. Finally, we discuss future directions in the field, such as completely leadless cardiac resynchronisation therapy-defibrillator devices and whether leadless pacing has the potential to become a first-line therapy in the near future.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Felicity De Vere
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Jonathan M Behar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Buchan S, Kar R, John M, Post A, Razavi M. Electrical Stimulation for Low-Energy Termination of Cardiac Arrhythmias: a Review. Cardiovasc Drugs Ther 2023; 37:323-340. [PMID: 34363570 DOI: 10.1007/s10557-021-07236-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/24/2022]
Abstract
Cardiac arrhythmias are a leading cause of morbidity and mortality in the developed world, estimated to be responsible for hundreds of thousands of deaths annually. Our understanding of the electrophysiological mechanisms of such arrhythmias has grown since they were formally characterized in the late nineteenth century, and this has led to the development of numerous devices and therapies that have markedly improved outcomes for patients affected by such conditions. Despite these advancements, the application of a single large shock remains the clinical standard for treating deadly tachyarrhythmias. Such defibrillating shocks are undoubtedly effective in terminating such arrhythmias; however, they are applied without forewarning, contributing to the patient's stress and anxiety; they can be intensely painful; and they can have adverse psychological and physiological effects on patients. In recent years, there has been interest in developing defibrillation protocols that can terminate arrhythmias without crossing the human pain threshold for energy delivery, generally estimated to be between 0.1 and 1 J. In this article, we review existing literature on the development of such low-energy defibrillation methods and their underlying mechanisms, in an attempt to broadly describe the current landscape of these technologies.
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Affiliation(s)
- Skylar Buchan
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Ronit Kar
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA.,Department of Biomedical Engineering, The University of Texas At Austin, Austin, TX, 78712, USA
| | - Mathews John
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Allison Post
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA. .,Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA.
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Habibagahi I, Mathews RP, Ray A, Babakhani A. Design and Implementation of Multisite Stimulation System Using a Double-Tuned Transmitter Coil and Miniaturized Implants. IEEE MICROWAVE AND WIRELESS TECHNOLOGY LETTERS 2023; 33:351-354. [PMID: 37025623 PMCID: PMC10070160 DOI: 10.1109/lmwc.2022.3217519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
This letter presents a double-tuned dual input transmitter coil operating at 13.56 MHz and 40.68 MHz industrial, scientific, and medical (ISM) bands for multisite biomedical applications. The proposed system removes the need for two separate coils, which reduces system size and unwanted couplings. The design and analysis of the double-tuned transmitter coil using a lumped element frequency trap are discussed in this letter. The transmitter achieves measured matching of -26.2 dB and -21.5 dB and isolation of -17.7 dB and -11.7dB at 13.56 MHz and 40.68 MHz, respectively. A 3 mm × 15 mm flexible coil is used as an implantable receiver. This letter shows synchronized multisite stimulation of two flexible implants at a distance of 2 cm while covered with 1 cm chicken breast.
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Affiliation(s)
- Iman Habibagahi
- Department of Electrical Engineering, University of California, Los Angeles, CA 90095 USA
| | - Roshan P Mathews
- Department of Electrical Engineering, University of California, Los Angeles, CA 90095 USA
| | - Arkaprova Ray
- Department of Electrical Engineering, University of California, Los Angeles, CA 90095 USA
| | - Aydin Babakhani
- Department of Electrical Engineering, University of California, Los Angeles, CA 90095 USA
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Agarwal S, Shinde RK. Smart Pacemaker: A Review. Cureus 2022; 14:e30027. [PMID: 36348845 PMCID: PMC9637326 DOI: 10.7759/cureus.30027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
Since the first pacemaker was implanted, nearly 60 years have passed. Since then, pacemaker technology has made major advancements that have increased both its safety and effectiveness in treating people with bradyarrhythmias. The repeated stimulation of cells in specialized "pacemaker" regions of the mammalian heart and the transmission of stimulus via the ventricles serve as evidence that the electrical function of the mammalian heart is necessary for a regular mechanical (pump) role. The development of action potentials in individual cardiac cells is linked to myocardial electrical activity and the heart's regular cooperative electrical functioning. A container or pulse initiator that houses the battery and electronics, as well as lines that connect to the myocardium to deliver a depolarizing pulse and detect intrinsic cardiac stimulation, are all parts of a pacemaker. Defibrillators could be used with artificial hearts that have electrical pacemakers integrated into them in order to treat arrhythmia, heart failure, and cardiac arrest. Modern pacemakers have units for supporting patients with other disorders like "heart failure," which happens when the heart does not pump as forcefully as it should. While many pacemakers are effective in treating different types of arrhythmias (irregular heartbeats), they also have units for treating them.
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R Roberts P, ElRefai M, Foley P, Rao A, Sharman D, Somani R, Sporton S, Wright G, Zaidi A, Pepper C. UK Expert Consensus Statement for the Optimal Use and Clinical Utility of Leadless Pacing Systems on Behalf of the British Heart Rhythm Society. Arrhythm Electrophysiol Rev 2022; 11:e19. [PMID: 36304202 PMCID: PMC9585647 DOI: 10.15420/aer.2022.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/08/2022] [Indexed: 11/25/2022] Open
Abstract
Pacemakers are a key technology in the treatment of bradyarrhythmias. Leadless pacemakers (LP) were introduced to address limitations of transvenous devices. However, guidelines and other restrictions have led to LPs becoming niche products. The aim of this consensus statement was to determine the strength of opinion of UK implantation experts as to how LPs can be more optimally used. Using a modified Delphi approach, a panel of LP experts developed 36 statements that were used to form a survey that was distributed to LP implanters in the UK. Stopping criteria included a 3-month window for response, a minimum 25% response rate and at least 75% of statements achieving the threshold for consensus (agreed at 66%). In all, 31 of 36 statements reached consensus, and 23 of these achieved ≥90% agreement. Five statements did not achieve consensus. On the basis of these results, seven recommendations were proposed. The implementation of these recommendations may increase the use of LPs, with the aim of improving patient outcomes.
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Affiliation(s)
- Paul R Roberts
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK
| | - Mohamed ElRefai
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Trust, Southampton, UK
| | - Paul Foley
- Department of Cardiology, Great Western Hospital NHS Foundation Trust, Swindon, UK
| | - Archana Rao
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - David Sharman
- Department of Cardiology, Northampton General Hospital NHS Trust, Northampton, UK
| | - Riyaz Somani
- Department of Cardiology, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Simon Sporton
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Gary Wright
- Department of Cardiology, NHS Golden Jubilee, Glasgow, UK
| | - Amir Zaidi
- Department of Cardiology, Manchester University NHS Trust, Manchester, UK
| | - Chris Pepper
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Anwar U, Ajijola OA, Shivkumar K, Markovic D. Towards a Leadless Wirelessly Controlled Intravenous Cardiac Pacemaker. IEEE Trans Biomed Eng 2022; 69:3074-3086. [PMID: 35320081 DOI: 10.1109/tbme.2022.3161415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Traditional lead-based cardiac pacemakers suffer from lead-related complications including lead fracture, lead dislodgement, and venous obstruction. Modern leadless pacemakers mitigate the complications, but since they are implanted inside the heart with a small battery, their limited battery lifetime necessities device replacement within the patient's lifetime. This paper presents a leadless and batteryless, wirelessly powered intravenous cardiac pacemaker that can potentially mitigate both problems. METHODS Wireless power is transferred at 13.56 MHz in bursts between the pacemaker modules to achieve sufficient power over the required distance for wireless pacing. The pacemaker stimulation module is designed to fit within the anatomical constraints of a cardiac vein, consume low power, apply greater than 5V stimulation and comply with FCC SAR regulations. The module is primarily implemented in CMOS technology to achieve extreme system miniaturization. RESULTS Ex-vivo pacing capability was demonstrated with a system that can apply 5V stimulation, consume 1mW power, and operate up to 2.5cm TX and RX separation. An in-vivo experiment verified the pacemaker functionality by increasing the heartbeat of Yorkshire pig from 64bpm to 100bpm. CONCLUSION This work establishes that intravascular cardiac pacing can be achieved that can mitigate lead and battery-related complications. SIGNIFICANCE This study has a potential to advance leadless and wirelessly powered pacemaker technology.
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Kotalczyk A, Kalarus Z, Wright DJ, Boriani G, Lip GYH. Cardiac Electronic Devices: Future Directions and Challenges. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2020; 13:325-338. [PMID: 33061681 PMCID: PMC7526741 DOI: 10.2147/mder.s245625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/02/2020] [Indexed: 12/26/2022] Open
Abstract
Cardiovascular implantable electronic devices (CIEDs) are essential management options for patients with brady- and tachyarrhythmias or heart failure with concomitant optimal pharmacotherapy. Despite increasing technological advances, there are still gaps in the management of CIED patients, eg, the growing number of lead- and pocket-related long-term complications, including cardiac device–related infective endocarditis, requires the greatest care. Likewise, patients with CIEDs should be monitored remotely as a part of a comprehensive, holistic management approach. In addition, novel technologies used in smartwatches may be a convenient tool for long-term atrial fibrillation (AF) screening, especially in high-risk populations. Early detection of AF may reduce the risk of stroke and other AF-related complications. The objective of this review article was to provide an overview of novel technologies in cardiac rhythm–management devices and future challenges related to CIEDs.
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Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - David Justin Wright
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
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