Effect of varying pacing waveform shapes on propagation and hemodynamics in the rabbit heart

A transient, closed-loop network of wireless, body-integrated devices for autonomous electrotherapy

Temporary postoperative cardiac pacing requires devices with percutaneous leads and external wired power and control systems. This hardware introduces risks for infection, limitations on patient mobility, and requirements for surgical extraction procedures. Bioresorbable pacemakers mitigate some of these disadvantages, but they demand pairing with external, wired systems and secondary mechanisms for control. We present a transient closed-loop system that combines a time-synchronized, wireless network of skin-integrated devices with an advanced bioresorbable pacemaker to control cardiac rhythms, track cardiopulmonary status, provide multihaptic feedback, and enable transient operation with minimal patient burden. The result provides a range of autonomous, rate-adaptive cardiac pacing capabilities, as demonstrated in rat, canine, and human heart studies. This work establishes an engineering framework for closed-loop temporary electrotherapy using wirelessly linked, body-integrated bioelectronic devices.

Electrogram analysis to detect cathodal and anodal capture in left ventricular cardiac resynchronization pacing leads

AIMS

Our study analyzed cardiac electrograms (EGMs) to identify characteristics for detecting cathodal, anodal, or cathodal-anodal (simultaneous) capture in left ventricular (LV) quadripolar pacing leads of cardiac resynchronization therapy (CRT) patients. The relationship between these EGM characteristics and the electrocardiogram (ECG) was also examined.

METHODS

We performed a retrospective analysis of 54 bipolar pacing configurations across 9 patients with implanted CRT devices and quadripolar leads who had undergone a 12 lead ECG optimization. Three pacing tests (cathode unipolar, anode unipolar, and bipolar) per bipolar pair were performed, examining ECG and EGM morphology changes accompanying each test and any transitions of morphology or amplitude during voltage stepdown.

RESULTS

During the cathode and anode unipolar pacing tests, the EGM was biphasic (negative/positive) or monophasic (positive) in 52/53 (98%), and biphasic (positive/negative) or monophasic (negative) in 50/51 (98%) respectively. During bipolar LV capture threshold testing, 30 bipolar pairs displayed a sudden increase in EGM amplitude (median 9.4mV, interquartile range [7 to 14mV]) when transitioning from cathodal-anodal capture to cathodal or anodal capture. 90% of these EGM transitions had a corresponding simultaneous change in ECG, while 10% had no ECG changes. Two patients demonstrated "quad-site" capture on their quadripolar lead with multipoint pacing enabled and cathodal-anodal capture from each stimulus.

CONCLUSION

EGM characteristics during LV pacing tests can reliably detect cathodal, anodal, or cathodal-anodal capture, with greater sensitivity than 12 lead ECG changes. Integration of EGM analysis into routine CRT device follow up can be performed easily and may have implications for CRT efficacy. This article is protected by copyright. All rights reserved.

Left Ventricular Stimulation With Electrical Latency Predicts Mortality in Patients Undergoing Cardiac Resynchronization Therapy

OBJECTIVES

This study sought to evaluate the prognostic value of the time interval from left ventricular (LV) pacing to the earliest onset of QRS complex (S-QRS) for long-term clinical outcomes in patients who underwent cardiac resynchronization therapy (CRT).

BACKGROUND

The electrical latency during LV pacing evaluated by S-QRS is associated with local tissue property, and the S-QRS ≥37 ms has been previously proposed as an independent predictor of mechanical response to CRT.

METHODS

This study included 82 consecutive patients with heart failure with reduced LV ejection fraction (≤35%) and a wide QRS complex (≥120 ms) who underwent CRT. Patients were divided into a short S-QRS group (SS-QRS; <37 ms) and a long S-QRS group (LS-QRS; ≥37 ms). The primary endpoint was total mortality, including LV assist device implantation or heart transplantation, whereas the secondary endpoint was total mortality or HF hospitalization.

RESULTS

S-QRS was 25.9 ± 5.3 ms in SS-QRS and 51.5 ± 13.7 ms in LS-QRS (p < 0.01), and baseline QRS duration and electrical activation at the LV pacing site (i.e., Q-LV) were similar. During mean follow-up of 44.5 ± 21.1 months, 24 patients (29%) reached the primary endpoint, whereas the secondary endpoints were observed in 47 patients (57%). LS-QRS had significantly worse event-free survival for both endpoints. LS-QRS was an independent predictor of total mortality (hazard ratio: 2.6; 95% confidence interval: 1.11 to 6.12; p = 0.03) and the secondary composite events (hazard ratio: 2.4; 95% confidence interval: 1.31 to 4.33; p < 0.01).

CONCLUSIONS

The S-QRS ≥37 ms at the LV pacing site was a significant predictor of total mortality and HF hospitalization. S-QRS-guided optimal LV lead placement is critical in patients who receive CRT.

The effect of anodal/cathodal biphasic electrical stimulation on insulin release

We studied the effects of electrical stimulation on insulin release from rat insulinoma (INS-1) cells. The anodal/cathodal biphasic stimulation (ACBPS) electrical waveform resulted in a voltage- and stimulation duration-dependent increase in insulin release. ACBPS elicited insulin release both in the presence and absence of glucose. Basal and ACBPS-induced insulin secretion could be inhibited by mitochondrial poisons and calcium channel blockers, indicating that insulin release was dependent on adenosine triphosphate (ATP) and the influx of calcium. ACBPS parameters that released insulin caused no detectable plasma membrane damage or cytotoxicity, although temporary morphological changes could be observed immediately after ACBPS. ACBPS did not alter the plasma membrane transmembrane potential but did cause pronounced uptake of MitoTracker Red into the mitochondrial membrane, indicating an increased mitochondrial membrane potential. While the ATP:ADP ratio after ACBPS did not change, the guanosine triphosphate (GTP) levels increased and increased GTP levels have previously been associated with insulin release in INS-1 cells. These results provide evidence that ACBPS can have significant biological effects on cells. In the case of INS-1 cells, ACBPS promotes insulin release without causing cytotoxicity.

Non-selective His bundle pacing with a biphasic waveform: enhancing septal resynchronization

Aims

His bundle pacing has shown to prevent detrimental effects from right ventricular apical pacing (RVA) and proved to resynchronize many conduction disturbances cases. However, the extent of His bundle pacing resynchronization is limited. An optimized stimulation waveform could expand this limit when implemented in His bundle pacing sets. In this work, we temporarily implemented RVA and Non-selective His bundle pacing with a biphasic anodal-first waveform (AF-nHB) and compared their effects against sinus rhythm (SR).

Methods and results

Fifteen patients referred for electrophysiologic study with conduction disturbances, cardiomyopathy and ejection fraction below 35% were enrolled for the study. The following acute parameters were measured: QRS duration, left ventricular activation (RLVT), time of isovolumic contraction (IVCT), ejection fraction (EF), and dP/dtmax. QRS duration and RLVT decreased markedly under AF-nHB (SR: 169 ± 34 ms vs. nHB: 116 ± 31 ms, P < 0.0005) while RVA significantly increased QRS duration (SR: 169 ms vs. RVA: 198 ms, P < 0.05) and did not change RLVT (P = NS). Consistently, IVCT moderately decreased under AF-nHB (SR: 238 ms vs. RVA: 184 ms, P < 0.05 vs. SR) and dP/dtmax showed a 93.35 [mmHg] average increase under AF-nHB against SR. Also, T-wave inversions were observed during AF-nHB immediately after SR and RVA pacing suggesting the occurrence of cardiac memory.

Conclusions

AF-nHB corrected bundle branch blocks in patients with severe conduction disturbances, even in those with dilated cardiomiopathy, outstanding from RVA. Also, the occurrence of cardiac memory during AF-nHB turned up as an observational finding of this study.

Paced monophasic and biphasic waveforms alter transmembrane potentials and metabolism of human fibroblasts

Resting transmembrane potential (TMP) of primary human fibroblast cells was altered in predictable directions by subjecting cell cultures to specific monophasic and biphasic waveforms. Cells electrically stimulated with an anodal pulse resulted in hyperpolarization while a cathodal waveform depolarized the TMP to below that of non-paced control cells. The biphasic waveform, consisting of an anodal pulse followed immediately by an inverse symmetric cathodal pulse, also lessened the TMP similar to that of the cathodal pulse. The effect of short-term pacing on the TMP can last up to 4 h before the potentials equilibrate back to baseline. While subjecting the cells to this electrical field stimulation did not appear to damage the integrity of the cells, the three paced electrical stimulation waves inhibited expansion of the cultures when compared to non-paced control cells. With longer pacing treatments, elongation of the cells and electrotaxis towards the anodal polarity were observed. Pacing the fibroblasts also resulted in modest, yet very statistically significant (and likely underestimated) changes to cellular adenosine-5'-triphosphate (ATP) levels, and cells undergoing anodal and biphasic (anodal/cathodal) stimulation also exhibited altered mitochondrial morphology. These observations indicate an active role of electrical currents, especially with anodal content, in affecting cellular metabolism and function, and help explain accumulating evidence of cellular alterations and clinical outcomes in pacing of the heart and other tissues in general.

Stimulus intensity in left ventricular leads and response to cardiac resynchronization therapy

Background

Increased left ventricular (LV) stimulus intensity has been shown to improve conduction velocity and cardiac output. However, high-output pacing would shorten device battery life. Our prospective trial analyzed the clinical effects of high- versus low-output LV pacing.

Methods and Results

Thirty-nine patients undergoing initial cardiac resynchronization therapy device implantation with bipolar LV leads were assigned to 3 months of either high-output LV pacing (Hi) or low-output LV pacing (Lo) in a randomized, blinded crossover fashion. Hi and Lo settings were determined with a rigorous intraoperative protocol specific to each patient. Clinical and echocardiographic data were obtained at randomization, at 3 months, and a subsequent 3 months after crossover. Mean age was 66.4±9.8 years, and mean QRS duration was 159.3±23.1 ms. Compared to baseline, both arms had significant improvements in Minnesota Living With Heart Failure score (given as mean [95% confidence interval]) (baseline versus Lo: 43.3 [35.5 to 51.1] versus 21.3 [14.6 to 28.0], P<0.01; baseline versus Hi: 43.3 [35.5 to 51.1] versus 23.6 [16.1 to 31.1], P<0.01) and 6-minute walk distance (baseline versus Lo: 692 ft [581 to 804] versus 995 ft [876 to 1114], P<0.01; baseline versus Hi: 699 ft [585 to 813] versus 982 ft [857 to 1106], P<0.01). Although both Hi and Lo arms had some echocardiographic parameters that significantly improved compared to baseline (baseline end-diastolic diameter 5.7 cm [5.5 to 6.0] versus Lo 5.5 cm [5.1 to 5.8], P<0.01; baseline end-systolic diameter 4.9 cm [4.6 to 5.3] versus Hi 4.7 cm [4.3 to 5.0], P<0.05), there were no significant differences observed when comparing the Hi- versus Lo-output arms.

Conclusions

Low-output LV pacing with a relatively narrow safety margin above capture threshold affords significant improvement from baseline and is clinically equivalent to high-output LV pacing. These data support a strategy of minimizing the programmed LV safety margin to increase battery life in cardiac resynchronization therapy devices.

Clinical Trial Registration Information

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01060449

Atrial burst pacing with biphasic and monophasic waveforms for atrial fibrillation

BACKGROUND

Biphasic pacing is a novel mode of pacing that was suggested to increase cardiac conduction velocity as compared with cathodal monophasic pacing. We aimed to evaluate the safety and efficacy of rapid atrial pacing to convert atrial fibrillation (AF) to normal sinus rhythm.

METHODS

Multiple biphasic (anodal/cathodal), reverse biphasic (cathodal/anodal), and monophasic (cathodal) atrial pacing therapies were performed among 12 patients undergoing left atrial catheter ablation for AF. The efficacy end point was successful conversion of AF to sinus rhythm, and safety end point no induction of ventricular arrhythmias. Patients were paced at three cycle lengths (100, 200, and 333 msec) for 60 seconds at three locations (right and left atrial appendages and coronary sinus).

RESULTS

Among the 66 biphasic (anodal/cathodal) pacing procedures one procedure in a patient with chronic AF, which involved pacing at the left atrial appendage with a cycle length of 200 msec, led to conversion of AF to sinus rhythm. None of the 66 monophasic pacing procedures or the 66 reverse biphasic (cathodal/anodal) pacing procedures was associated with AF termination. None of the biphasic pacing procedures was associated with induction of ventricular arrhythmias.

CONCLUSIONS

Rapid atrial pacing using a variety of waveforms at the cycle length and output used in the current study was found to be safe. There was a single success in converting a chronic AF to sinus rhythm.

Comparison of chronic biphasic pacing versus cathodal pacing of the right ventricle on left ventricular function in sheep after myocardial infarction

BACKGROUND

The physiological effects of biphasic pacing have not been studied in compromised hearts.

METHODS

Myocardial infarction was induced in 12 sheep by high coronary artery ligation. Perioperative mortality was 33%. The surviving eight animals exhibited increased left ventricular volume and reduced percent fractional shortening. Two weeks after the infarction, sheep were implanted with atrial-triggered, right ventricular pacemaker systems capable of pacing with cathodal (cathodal pulse) and biphasic (anodal pulse followed by cathodal pulse) waveforms, and randomly assigned to an initial mode. At 3-month intervals, or whenever pacing was lost for any reason, the pacing system was switched to the alternative mode. Cardiac function was assessed at 2- to 3-week intervals through the use of echocardiograms. Successful pacing was confirmed over an average of 8 weeks in each mode.

RESULTS

Cathodal pulsing had neither beneficial nor deleterious effect on the diminished cardiac performance induced by myocardial infarction. When compared to the cathodal mode, biphasic pulsing improved cardiac performance as reflected by decrease of diastolic and systolic ventricular volumes, reduction in left ventricular systolic diameter, and increases in percent fractional shortening. When compared to the unpaced state after the myocardial infarction, the percent fractional shortening was significantly increased by biphasic pacing. Concordant trends in improvement in the other cardiac parameters were also observed for the biphasic mode. No ventricular tachyarrhythmias or mortality was associated with biphasic stimulation.

CONCLUSION

When compared to cathodal pacing, myocardial biphasic pacing has no safety issues in sheep that have undergone a large myocardial infarction. Importantly, biphasic pulsing elicited significant benefits in cardiac performance.

Reverse Polarity Pacing:The Hemodynamic Benefit of Anodal Currents at Lead Tips forCardiac Resynchronization Therapy

BACKGROUND

Myocardial depolarization can be achieved with currents of either anodal or cathodal polarity. In contrast to conventional cathodal pacing, anodal pacing initially hyperpolarizes tissue and improves myocardial contractility in animal models.

METHODS AND RESULTS

In 13 patients undergoing cardiac resynchronization therapy (CRT) device implantation, we compared the mean left ventricular outflow velocity-time integral (LV-VTI) for anodal and cathodal polarities in three different pacing configurations. Intraoperative continuous-wave Doppler measurements were taken at a fixed interrogation angle, while polarities were switched during unipolar left ventricular, unipolar biventricular, and shared-coil biventricular pacing. Comparisons used identical pacing rates, intervals, and stimulus strengths. Patients had a mean ejection fraction of 0.18 +/- 0.08 and a mean QRS duration of 140 +/- 34 ms. All capture thresholds were less than 4.5 volts at a pulse width of 0.4 ms. Data were suitable for analysis in 37 of the 39 pairs of Doppler measurements. Anodal polarity significantly increased average LV-VTI in 36 of these 37 comparisons. The mean increase in LV-VTI for each configuration with anodal versus cathodal polarity was 2.8 +/- 2.6 cm (P < 0.001). The combined mean LV-VTI for all configurations was similarly higher for anodal polarity (24.4 +/- 11.7 cm) versus cathodal polarity (21.7 +/- 10.9 cm; P < 0.001).

CONCLUSION

Anodal pacing polarity significantly improves a measure of LV function compared to traditional cathodal currents. Anodal pacing, which can be achieved by a simple reversal of pacing circuit polarity, may represent an important therapeutic addition to future resynchronization devices.

[Cardiac resynchronization therapy (CRT) and anodal stimulation]

We describe a biventricular stimulation mode to pace both ventricles with a single electrical stimulus between the tip of the left ventricular electrode and the tip of the right ventricular electrode: one ventricle is stimulated cathodal the other anodal.

Anode-break excitation during end-diastolic stimulation is explained by half-cell double layer discharge

The phenomenon of anodal-break excitation during end-diastolic stimulation of the heart was discovered many years ago by B. Hoffman. Yet, the existence and mechanistic explanation of this effect remain controversial. We sought to confirm its existence and to determine a possible role of half-cell potential. We used isolated Langendorff-perfused rabbit hearts (n = 6) which were stained with di-4-ANEPPS and perfused with 15-mM butanedione monoxime (BDM). Transmembrane potentials were optically recorded at the left ventricular epicardium with a high spatial and temporal resolution (200 microm/343 micros) near the tip of a 120-microm platinum-iridium Teflon-coated unipolar pacing electrode to detect virtual electrode polarization and to reconstruct an activation pattern. Hearts were paced at a cycle length of 300 ms by anodal square pulses with an amplitude of 0.1-10 mA and a duration of 5-60 ms. Data revealed that the anodal-break excitation does exists and is accompanied by an overshoot in the recordings of the pacing current. Addition of a diode in the stimulation circuit eliminated both the overshoot and the break excitation. The findings suggest that a half-cell surface potential at the pacing electrode metal-saline interface may influence the pacing currents during unipolar anodal cardiac stimulation providing "break"-like activation. We also confirmed that the threshold of "break"-like excitation is lower than make-excitation. We suggest that further exploration of this effect is needed in order to design improved multiphasic pacing waveforms.

Effects of anodal vs. cathodal pacing on the mechanical performance of the isolated rabbit heart

Previous studies have suggested that anodal pacing enhances electrical conduction in the heart near the pacing site. It was hypothesized that enhanced conduction by anodal pacing would also enhance ventricular pressure in the heart. Left ventricular pressure measurements were made in isolated, Langendorff-perfused rabbit hearts by means of a Millar pressure transducer with the use of a balloon catheter fixed in the left ventricle. The pressure wave was analyzed for maximum pressure (Pmax) generated in the left ventricle and the work done by the left ventricle (Parea). Eight hearts were paced with monophasic square-wave pulses of varying amplitudes (2, 4, 6, and 8 V) with 100 pulses of each waveform delivered to the epicardium. Anodal stimulation pulses showed statistically significant improvement in mechanical response at 2, 4, and 8 V. Relative to unipolar cathodal pacing, unipolar anodal pacing improved Pmax by 4.4 +/- 2.3 (SD), 5.3 +/- 3.1, 3.5 +/- 4.9, and 4.8 +/- 1.9% at 2, 4, 6, and 8 V, respectively. Unipolar anodal stimulation also improved Parea by 9.0 +/- 3.0, 12.0 +/- 6.0, 10.1 +/- 7.7, and 11.9 +/- 6.0% at 2, 4, 6, and 8 V, respectively. Improvements in Pmax and Parea indicate that an anodally paced heart has a stronger mechanical response than does a cathodally paced heart. Anodal pacing might be useful as a novel therapeutic technology to treat mechanically impaired or failed hearts.

Reduction in energy pacing thresholds by overlapping biphasic stimulation versus conventional bipolar pacing

Overlapping biphasic (OLBI) stimulation is a new pacing waveform consisting of two simultaneous monophasic pulses of opposite polarities applied to a bipolar electrode. The goal of this prospective study was to compare, using conventional pacing leads, the acute energy pacing thresholds, measured at 0.5-ms pulse duration, associated with bipolar versus OLBI (mode 7 and mode 8) pulse delivery.

RESULTS

Thirty one leads were tested in 20 patients. Of these leads, 7 (23%) were implanted chronically, 12 (39%) were in atrial positions, and 19 (61%) in ventricular positions. Energy pacing thresholds were significantly lower (-25.6 +/- 25.6%, P = 0.005) in OLBI mode 8 (1.30 +/- 3.96 microJ) compared to bipolar (1.55 +/- 4.37 microJ) pacing, regardless of the pacing site or length of service of the leads. In contrast, OLBI mode 7, which has an anodal component, at the tip electrode was associated with higher energy pacing thresholds (3.65 +/- 6.48 microJ; +358.3 +/- 219.4%, P = 0.002).

CONCLUSIONS

Mode 8 OLBI pacing is associated with lower acute energy pacing thresholds when used with bipolar leads in contact with the myocardium. OLBI pacing may increase pacemaker longevity by reducing long-term energy consumption.