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Soejima K, Hilpisch K, Samec ML, Temple RL, Bonner MD. Jugular Approach for the Transcatheter Pacemaker Implant - Better Access for Smaller Hearts? Circ J 2024:CJ-24-0083. [PMID: 38658350 DOI: 10.1253/circj.cj-24-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND The Micra leadless pacemaker was developed to fit inside the right ventricle, thereby reducing overall complications by 48% compared with a historical control group. The current labeling restricts implants to the femoral approach. In this article we used 3-dimensional computer models of human hearts to demonstrate why implants can be difficult in small patients and how using the jugular approach reduces these difficulties.Methods and Results: Cardiac computed tomography scans were made of 45 pacemaker patients, 26 in the US and 19 from a single center in Japan. Dimensional measurements were taken in all 45 hearts, and these dimensions were compared between patient cohorts and between the Micra delivery tool dimension and patient heart dimensions. Hearts were smaller among patients in the Japanese than US cohort. In addition, the tool dimension exceeded heart dimensions in a larger percentage of hearts from Japanese patients. Three dimensions were identified that most likely limit navigating across the tricuspid valve to the right ventricle in smaller hearts and for which the jugular approach improved navigation. CONCLUSIONS Although the femoral procedure today maintains an excellent safety profile and procedure experience for most global implants, this study provides the rationale as to why the jugular approach may improve the ease of the Micra implant in small hearts, namely by reducing the tortuosity of the navigation across the tricuspid valve.
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Affiliation(s)
- Kyoko Soejima
- Department of Cardiology, Kyorin University Hospital
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Hulsmans M, Aguirre AD, Bonner MD, Bapat A, Cremer S, Iwamoto Y, King KR, Swirski FK, Milan DJ, Weissleder R, Nahrendorf M. A Miniaturized, Programmable Pacemaker for Long-Term Studies in the Mouse. Circ Res 2019; 123:1208-1219. [PMID: 30571465 DOI: 10.1161/circresaha.118.313429] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
RATIONALE Cardiac pacing is a critical technology for the treatment of arrhythmia and heart failure. The impact of specific pacing strategies on myocardial function is an area of intense research and high clinical significance. Mouse models have proven extremely useful for probing mechanisms of heart disease, but there is currently no reliable technology for long-term pacing in the mouse. OBJECTIVE We sought to develop a device for long-term pacing studies in mice. We evaluated the device for (1) treating third-degree atrioventricular block after macrophage depletion, (2) ventricular pacing-induced cardiomyopathy, and (3) high-rate atrial pacing. METHODS AND RESULTS We developed a mouse pacemaker by refashioning a 26 mm×6.7 mm clinical device powered by a miniaturized, highly efficient battery. The electrode was fitted with a single flexible lead, and custom software extended the pacing rate to up to 1200 bpm. The wirelessly programmable device was implanted in the dorsal subcutaneous space of 39 mice. The tunneled lead was passed through a left thoracotomy incision and attached to the epicardial surface of the apex (for ventricular pacing) or the left atrium (for atrial pacing). Mice tolerated the implantation and both long-term atrial and ventricular pacing over weeks. We then validated the pacemaker's suitability for the treatment of atrioventricular block after macrophage depletion in Cd11b DTR mice. Ventricular pacing increased the heart rate from 313±59 to 550 bpm ( P<0.05). In addition, we characterized tachypacing-induced cardiomyopathy in mice. Four weeks of ventricular pacing resulted in reduced left ventricular function, fibrosis, and an increased number of cardiac leukocytes and endothelial activation. Finally, we demonstrated the feasibility of chronic atrial pacing at 1200 bpm. CONCLUSIONS Long-term pacing with a fully implantable, programmable, and battery-powered device enables previously impossible investigations of arrhythmia and heart failure in the mouse.
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Affiliation(s)
- Maarten Hulsmans
- From the Department of Radiology, Center for Systems Biology (M.H., A.D.A., S.C., Y.I., K.R.K., F.K.S., R.W., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Aaron D Aguirre
- From the Department of Radiology, Center for Systems Biology (M.H., A.D.A., S.C., Y.I., K.R.K., F.K.S., R.W., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston.,Cardiology Division (A.D.A., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Matthew D Bonner
- Cardiac Rhythm and Heart Failure, Medtronic PLC, Mounds View, MN (M.D.B.)
| | - Aneesh Bapat
- Cardiovascular Research Center (A.B., D.J.M., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston.,Cardiology Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (A.B.)
| | - Sebastian Cremer
- From the Department of Radiology, Center for Systems Biology (M.H., A.D.A., S.C., Y.I., K.R.K., F.K.S., R.W., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Yoshiko Iwamoto
- From the Department of Radiology, Center for Systems Biology (M.H., A.D.A., S.C., Y.I., K.R.K., F.K.S., R.W., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Kevin R King
- From the Department of Radiology, Center for Systems Biology (M.H., A.D.A., S.C., Y.I., K.R.K., F.K.S., R.W., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston.,Department of Bioengineering, Jacobs School of Engineering (K.R.K.), University of California San Diego, La Jolla.,Department of Medicine, Cardiology Division (K.R.K.), University of California San Diego, La Jolla
| | - Filip K Swirski
- From the Department of Radiology, Center for Systems Biology (M.H., A.D.A., S.C., Y.I., K.R.K., F.K.S., R.W., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - David J Milan
- Cardiology Division (A.D.A., D.J.M.), Massachusetts General Hospital and Harvard Medical School, Boston.,Cardiovascular Research Center (A.B., D.J.M., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston.,Program in Population and Medical Genetics, The Broad Institute of Harvard and MIT, Cambridge, MA (D.J.M.)
| | - Ralph Weissleder
- From the Department of Radiology, Center for Systems Biology (M.H., A.D.A., S.C., Y.I., K.R.K., F.K.S., R.W., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston.,Department of Systems Biology, Harvard Medical School, Boston, MA (R.W.)
| | - Matthias Nahrendorf
- From the Department of Radiology, Center for Systems Biology (M.H., A.D.A., S.C., Y.I., K.R.K., F.K.S., R.W., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston.,Cardiovascular Research Center (A.B., D.J.M., M.N.), Massachusetts General Hospital and Harvard Medical School, Boston
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Omdahl P, Eggen MD, Bonner MD, Iaizzo PA, Wika K. Right Ventricular Anatomy Can Accommodate Multiple Micra Transcatheter Pacemakers. Pacing Clin Electrophysiol 2016; 39:393-7. [PMID: 26710918 PMCID: PMC4834726 DOI: 10.1111/pace.12804] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 11/24/2015] [Accepted: 12/23/2015] [Indexed: 12/02/2022]
Abstract
BACKGROUND The introduction of transcatheter pacemaker technology has the potential to significantly reduce if not eliminate a number of complications associated with a traditional leaded pacing system. However, this technology raises new questions regarding how to manage the device at end of service, the number of devices the right ventricle (RV) can accommodate, and what patient age is appropriate for this therapy. In this study, six human cadaver hearts and one reanimated human heart (not deemed viable for transplant) were each implanted with three Micra devices in traditional pacing locations via fluoroscopic imaging. METHODS A total of six human cadaver hearts were obtained from the University of Minnesota Anatomy Bequest Program; the seventh heart was a heart not deemed viable for transplant obtained from LifeSource and then reanimated using Visible Heart(®) methodologies. Each heart was implanted with multiple Micras using imaging and proper delivery tools; in these, the right ventricular volumes were measured and recorded. The hearts were subsequently dissected to view the right ventricular anatomies and the positions and spacing between devices. RESULTS Multiple Micra devices could be placed in each heart in traditional, clinically accepted pacing implant locations within the RV and in each case without physical device interactions. This was true even in a human heart considered to be relatively small. CONCLUSIONS Although this technology is new, it was demonstrated here that within the human heart's RV, three Micra devices could be accommodated within traditional pacing locations: with the potential in some, for even more.
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Affiliation(s)
| | | | | | - Paul A Iaizzo
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Kent Wika
- Medtronic, PLC., Mounds View, Minnesota
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Ritter P, Duray GZ, Steinwender C, Soejima K, Omar R, Mont L, Boersma LVA, Knops RE, Chinitz L, Zhang S, Narasimhan C, Hummel J, Lloyd M, Simmers TA, Voigt A, Laager V, Stromberg K, Bonner MD, Sheldon TJ, Reynolds D. Early performance of a miniaturized leadless cardiac pacemaker: the Micra Transcatheter Pacing Study. Eur Heart J 2015; 36:2510-9. [PMID: 26045305 PMCID: PMC4589655 DOI: 10.1093/eurheartj/ehv214] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/04/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Permanent cardiac pacing is the only effective treatment for symptomatic bradycardia, but complications associated with conventional transvenous pacing systems are commonly related to the pacing lead and pocket. We describe the early performance of a novel self-contained miniaturized pacemaker. METHODS AND RESULTS Patients having Class I or II indication for VVI pacing underwent implantation of a Micra transcatheter pacing system, from the femoral vein and fixated in the right ventricle using four protractible nitinol tines. Prespecified objectives were >85% freedom from unanticipated serious adverse device events (safety) and <2 V 3-month mean pacing capture threshold at 0.24 ms pulse width (efficacy). Patients were implanted (n = 140) from 23 centres in 11 countries (61% male, age 77.0 ± 10.2 years) for atrioventricular block (66%) or sinus node dysfunction (29%) indications. During mean follow-up of 1.9 ± 1.8 months, the safety endpoint was met with no unanticipated serious adverse device events. Thirty adverse events related to the system or procedure occurred, mostly due to transient dysrhythmias or femoral access complications. One pericardial effusion without tamponade occurred after 18 device deployments. In 60 patients followed to 3 months, mean pacing threshold was 0.51 ± 0.22 V, and no threshold was ≥2 V, meeting the efficacy endpoint (P < 0.001). Average R-wave was 16.1 ± 5.2 mV and impedance was 650.7 ± 130 ohms. CONCLUSION Early assessment shows the transcatheter pacemaker can safely and effectively be applied. Long-term safety and benefit of the pacemaker will further be evaluated in the trial. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov ID NCT02004873.
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Affiliation(s)
- Philippe Ritter
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Bordeaux, IHU LIRYC, Bordeaux, France
| | - Gabor Z Duray
- Clinical Electrophysiology Department of Cardiology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - Clemens Steinwender
- Department of Cardiology, Linz General Hospital, Johannes Kepler University School of Medicine Linz, Linz, Austria
| | - Kyoko Soejima
- Department of Cardiology, Kyorin University Hospital, Tokyo, Japan
| | - Razali Omar
- Electrophysiology and Pacing Unit, National Heart Institute, Kuala Lumpur, Malaysia
| | - Lluís Mont
- Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | | | - Reinoud E Knops
- Academisch Medisch Centrum (AMC), Amsterdam, the Netherlands
| | | | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Calambur Narasimhan
- Division of Electrophysiology, Department of Cardiology, CARE Hospitals and CARE Foundation, Hyderabad, India
| | - John Hummel
- The Ohio State University, Columbus, OH, USA
| | | | | | - Andrew Voigt
- University of Pittsburgh Medical Center UPMC Presbyterian, Pittsburgh, PA, USA
| | | | | | | | | | - Dwight Reynolds
- Cardiovascular Section, University of Oklahoma Health Sciences Center, OU Medical Center, Oklahoma City, OK, USA
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