Cardiovascular alterations induced by chronic transvenous implantation of an automatic defibrillator electrode catheter in dogs

Quantitative and Qualitative Assessment of Adhesive Thrombo-Fibrotic Lead Encapsulations (TFLE) of Pacemaker and ICD Leads in Arrhythmia Patients-A Post Mortem Study

The demand for cardiac implantable electronic devices for arrhythmia therapy is still unabated and rising. Despite onward optimizations, lead-related problems such as infections or fractures often necessitate lead extraction. Due to adhesive thrombo-fibrotic lead encapsulations (TFLE) transvenous lead extraction is challenging and risky. However, knowledge on TFLEs and possible correlations with technical lead parameters and dwelling time (DT) were hitherto insufficiently studied. Therefore, we analyzed TFLEs of 62 lead from 35 body donor corpses to gain information for a potential lead design optimization. We examined both TFLE topography on the basis on anatomical landmarks and histo-morphological TFLE characteristics by means of histological paraffin sections and scanning electron microscopy of decellularized samples. The macroscopic analysis revealed that all leads were affected by TFLEs, mainly in the lead bearing veins. Half (47.2%) of the right-ventricular leads possessed adhesions to the tricuspid valve. On average, 49.9 ± 21.8% of the intravascular lead length was covered by TFLE of which 82.8 ± 16.2% were adhesive wall bindings (WB). The discrete TFLEs with at least one WB portion had a mean length of 95.0 ± 64.3 mm and a maximum of 200 mm. Neither sex, DT nor certain technical lead parameters showed distinct tendencies to promote or prevent TFLE. TFLE formation seems to start early in the first 1-2 weeks after implantation. The degree of fibrotization of the TFLE, starting with a thrombus, was reflected by the amount of compacted collagenous fibers and likewise largely independent from DT. TFLE thickness often reached several hundred micrometers. Calcifications were occasionally seen and appeared irregularly along the TFLE sheath. Leadless pacemaker systems have the advantage to overcome the problem with TFLEs but hold their own specific risks and limitations which are not fully known yet.

Neointimal fibrotic lead encapsulation - Clinical challenges and demands for implantable cardiac electronic devices

Every tenth patient with a cardiac pacemaker or implantable cardioverter-defibrillator implanted is expected to have at least one lead problem in his lifetime. However, transvenous leads are often difficult to remove due to thrombotic obstruction or extensive neointimal fibrotic ingrowth. Despite its clinical significance, knowledge on lead-induced vascular fibrosis and neointimal lead encapsulation is sparse. Although leadless pacemakers are already available, their clinical operating range is limited. Therefore, lead/tissue interactions must be further improved in order to improve lead removals in particular. The published data on the coherences and issues related to lead associated vascular fibrosis and neointimal lead encapsulation are reviewed and discussed in this paper.

Gross and microscopic pathological changes associated with nonthoracotomy implantable defibrillator leads

BACKGROUND

Although the effects of epicardial implantable cardioverter-defibrillator (ICD) leads on underlying cardiac tissue have been reported, the gross and microscopic changes associated with endocardial ICD leads are less well described. This study describes the gross and microscopic changes associated with endocardial ICD leads in humans.

METHODS AND RESULTS

The hearts from 8 patients were examined. At the time of ICD implantation, the patients' mean age was 47+/-11 years, and the left ventricular ejection fraction was 0.24+/-0.10. Four patients had ischemic heart disease, and 4 had dilated cardiomyopathy. Five hearts were examined after transplantation; 3, after death. The electrode-myocardial interfaces were characterized by intense endocardial fibrosis and were remarkably consistent. Each lead was encased by a ring of fibroelastic tissue, and there was fibrosis of the right ventricular myocardium adjacent to the leads. Fibrosis involved the tricuspid valve in 5 patients, and 1 had perforation of the valve by the lead. Microscopically, interstitial fibrosis was adjacent to each lead in the current path of ICD shocks. Acute cell injury was present only in the hearts that had received recent shocks.

CONCLUSIONS

The ICD electrode-myocardial interface is characterized by intense fibrosis. The fibrosis associated with endocardial ICD leads and the cumulative acute damage produced by defibrillation discharges may explain changes in the defibrillation and pacing thresholds and the difficulty of lead extraction that can be encountered with transvenous ICD systems.

Internal cardiac defibrillation: histopathology and temporal stability of defibrillation energy requirements

The automatic implantable cardioverter/defibrillator is tested intraoperatively to ensure effectiveness by performing a number of induced fibrillation-defibrillation trials. The temporal stability of defibrillation energy requirements and the histopathologic effects of multiple defibrillating shocks were studied in 12 dogs chronically instrumented with an internal spring-patch lead system identical to that used in humans. Dogs were studied on days 1, 11, 18, 25 and 32. Data were analyzed by logistic regression and the energy required for 50% (E50) and 80% (E80) success was compared. On day 32 the dogs were killed and the heart was removed for gross and microscopic pathologic examination. There was a significant decrease in energy requirements from day 1 to day 11, as the E50 decreased from 6.9 +/- 4.5 to 4.9 +/- 2.5 J (p less than 0.02) and the E80 decreased from 8.5 +/- 5.2 to 6.1 +/- 3.4 J (p less than 0.02). The energy requirements then remained stable over the remainder of the experiment. The dogs were administered 209 +/- 18 shocks (range 1 to 24 J) for a total cumulative dose of 1,524 +/- 571 J. In all cases, both grossly and microscopically, there was no evidence of pathologic changes in the myocardium or coronary vessels. In all cases there was a fibrous plaque beneath the patch electrodes, at times containing an area of patchy hemorrhage; in a single specimen a mixed inflammatory infiltrate accompanied the hemorrhage. Endothelialization of the spring electrode with mild right atrial endocardial fibrosis was also observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Catheter electrode defibrillation in dogs: threshold dependence on implant time and catheter stability

A catheter-mounted electrode system designed for intracavitary ventricular defibrillation was implanted in the right ventricular apex of 12 dogs. Defibrillation thresholds were obtained in all dogs at the time of implant using an external defibrillator. Roentgenograms obtained 3 weeks after catheter implantation revealed that six dogs had catheters intact at the site of implant (group A) and six dogs had catheters that had dislodged from the original implant site (group B). There were no statistically significant differences (p less than 0.05) in mean body weight or mean defibrillation threshold between group A and group B dogs, respectively, at implant. Defibrillation thresholds were obtained for both groups of animals at 5, 12, and 26 weeks after catheter implantation. At all post implant monitors mean threshold for group B was significantly higher (p less than 0.05) than mean threshold for group A. Moreover, mean defibrillation threshold for both groups had increased by week 5 and remained stable through week 26. Catheter dislodgement increases defibrillation threshold, but does not prevent successful defibrillation. Also, defibrillation threshold increases to a stable value by 5 weeks post implant.

Potential hazards of implanted devices for the electrical control of tachyarrhythmias

Sensing difficulties are more common with antitachycardia devices employing atrial rather than ventricular leads, but the consequences are potentially more disastrous with ventricular leads. The problem may be magnified in that the spurious discharge from poor sensing is likely to be asynchronous. Worsening of arrhythmias during termination attempts cannot be totally avoided, but may be minimized if caution and expertise are applied to selection and testing. A device which can reliably terminate a tachyarrhythmia accelerated by a termination attempt is the safest.

Formation of cartilage in bioprosthetic cardiac valves implanted in sheep: a morphologic study

Foci of cartilage were found in 12 of 120 bioprostheses implanted in young sheep for 13 to 24 weeks, but in none of 47 bioprostheses implanted for less than 13 weeks. Cartilage was found more frequently (p less than 0.01) in bioprotheses implanted in the tricuspid position than in those implanted in the mitral position. In porcine aortic valvular bioprostheses, the cartilage was preferentially localized in the region of the muscle shelf; in pericardial bioprostheses, it occurred in the fibrous sheaths covering the cusps. In both instances, the cartilage was found to undergo calcification and was considered to be formed by metaplasia of connective tissue cells of host origin.

Cardiac damage in dogs with chronically implanted automatic defibrillator electrode catheters and given four episodes of multiple shocks

In 14 dogs, a newly designed automatic defibrillator electrode catheter with paired ventricular and superior vena caval electrodes was implanted transvenously into the right ventricular (RV) apex for 26 weeks. Twelve dogs were given multiple (mean total = 21.3) near-threshold (mean delivered energy = 17.6 joules) shocks via the lead at 0, 5, 12, and 26 weeks after implantation. Two days after the last shocks, the dogs were killed and the cardiac alterations were evaluated at necropsy and by histopathology. The lead induced mild to moderate cardiac alterations of (1) endocardial fibrosis, either as flat or papillary lesions, and of (2) segments of smooth thin fibrous sheath formation over the lead with adhesions to the adjacent endocardium. Mild cardiac alterations were induced by the shocks including myocardial necrosis and calcification, concentrated in the ventricular septum and RV free wall adjacent to the ventricular electrodes, and foci of postnecrotic fibrosis. The chronically implanted lead was determined to be safe and effective in dogs.

Alterations induced by a single defibrillating shock applied through a chronically implanted catheter electrode

In ten beagles ranging in weight from 7.4 to 13.0 kg, a defibrillating shock of 10 A (three dogs), 20 A (four dogs), or 30 A (three dogs) intensity was applied through a chronically implanted right ventricular catheter electrode. Ten-lead ECG, right ventricular electrogram, and right ventricular impedance were recorded prior to, immediately following, and 48 hours post-shock. A single shock of 10 A, 20 A, and 30 A intensity succeeded in defibrillating nine of ten dogs. One dog required two 20 A shocks to defibrillate. No shock was fatal. Post-shock arrhythmias increased in duration and severity as the shock strength increased. ECG vector analysis suggested damage to the right ventricle in eight of ten dogs. The impedance signal amplitude increased directly after the shock, but dropped below control level by 200 seconds post-shock and remained below control by 48 hours post-shock. Pale areas of shock-induced myocardial necrosis were concentrated in the right ventricular walls adjacent to the distal electrode. The mean weight of necrotic myocardium was 0.043 + 0.006 grams at 10 A, 1.203 + 0.268 grams at 20 A, and 1.397 + 1.218 grams at 30 A (mean + sd). Defibrillation was effective after long-term implantation. The alterations sustained from defibrillation were minimized by using a low intensity shock.