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Unexpected loss of bipolar lead function associated with lead connection design in dual chamber pacemakers.

Unexpected loss of bipolar pacing function can occur in Guidant VIGOR dual chamber pacemakers with QC2 (Quick Connect) headers. In a retrospective review of 305 implanted patients, 23 exhibited unexpected loss of bipolar pacing lead function from < 1 to 51 months postimplant. Atrial lead problems were seen in 17 patients and ventricular lead problems in 6 (P < 0.05 atrial vs ventricular). Significant symptoms developed in six patients including two with syncope as a result of noncapture. No significant change in bipolar sensing function was seen. Reprogramming devices to the unipolar mode restored appropriate pacing thresholds and lead impedance. The changes in bipolar lead function are likely caused by failure of the QC2 header lead connection system over time.

Cardiac Pacing, Artificial↗

Mechanism of decrease in the atrial potential after implantation of a single-lead VDD pacemaker: atrial histological changes after implantation of a VDD pacemaker lead in dogs.

The single-lead VDD pacemaker system (VDDPS) enables atrial synchronous ventricular pacing with only one lead in patients with an atrioventricular block. There are some cases in which the atrial potential decreases after implantation of a VDDPS, making physiological pacing difficult. The mechanism of this decrease has not been elucidated yet. To elucidate the possible relationship between the decrease of the atrial potential after implantation of a VDDPS and histopathological changes of the atrium. We implanted a VDDPS from the jugular vein under anesthesia in 10 adult dogs. The tip of the pacing lead was fixed in the right ventricular apex of the heart under fluoroscopic guidance. Then, the lead was ligated and fixed to the jugular vein at a point where a favorable atrial potential was obtained. The end of the lead was passed from the neck to the back subcutaneously; then pulled outside and fixed there to measure the atrial potential. The atrial potential was measured using a pacing system analyzer under anesthesia on days 3 (n = 9) and 7 (n = 8), as well as on weeks 2 (n = 6), 3 (n = 4), and 4 (n = 3), after the implantation. The heart was removed from the dogs on day 3 (n = 2), day 7 (n = 2), week 2 (n = 2), and week 4 (n = 4) to examine the atrial histological findings. The atrial potential was 2.7 +/- 0.7 mV at the time of the implantation, 1.7 +/- 1.1 mV (P < 0.05) on day 3, and 1.7 +/- 0.7 mV on week 4 after the implantation. Macroscopically, the pacemaker lead was covered with thrombus, and adhered to the atrial wall in 80% of animals. Microscopically, the endocardium was hypertrophic due to fibrous tissue; besides RBC extravasation, inflammatory cells infiltration and degeneration of myocardial cells, were observed under the endocardium. Inflammatory changes developed in the atrial wall after implantation of the VDDPS, and this seemed to be one of the mechanisms for the decrease of the atrial potential of the VDDPS.

Animals↗

Novel brugada SCN5A mutation leading to ST segment elevation in the inferior or the right precordial leads.

Mutations in the SCN5A gene can lead to the Brugada syndrome, a genetically inherited form of idiopathic ventricular fibrillation that has a characteristic ECG phenotype usually restricted to precordial leads V1-V3. We identified a novel G752R SCN5A missense mutation leading to various degrees of the Brugada ECG phenotype in members of a French family. In the proband, the G752R mutation produced ST segment elevation and prominent J wave in leads II, III, and aVF. In four other relatives, ST segment elevation in the right precordial but not in the inferior leads was observed either spontaneously or under flecainide challenge. Recombinant G752R mutant exhibited a markedly reduced Na+ current amplitude and a voltage shift in both activation and inactivation curves. The mutant was found in all affected but not in nonaffected family members. One additional gene-carrier had an almost normal ECG (silent gene-carrier). We provide genetic demonstration that Brugada ECG anomalies related to a unique SCN5A mutation can be observed either in the inferior or the right precordial leads.

Adult↗

Use of the sinus P wave in diagnosing electrocardiographic limb lead misplacement not involving the right leg (ground) lead.

No general approach has been established for the diagnoses of the various types of electrocardiograms of limb lead misplacement not involving the right leg (ground) lead. We have developed a 3-step algorithm for such differential diagnosis that can be applied without having to rely on the comparison with a reference electrocardiogram. It is based on the observation that the frontal plane sinus P vector loop is almost invariably inscribed counterclockwise. The 5 types of electrocardiograms of limb lead misplacement can be differentiated according to the P wave axis, the location of the lead aVR in the electrocardiogram, and specifically any apparent reversal of the direction of inscription of the frontal plane P vector loop due to lead misplacement. Characteristic limb lead P wave patterns provide 6 signs capable of inferring from the electrocardiogram alone the direction of inscription about 94% of the time. P wave axis itself is diagnostic in an additional 4%.

Algorithms↗

Observation of the lead carbonyls, PbnCO(n=1-4): reactions of lead atoms and small clusters with carbon monoxide in solid argon.

Reactions of laser-ablated Pb atoms with CO molecules in solid argon lead to the formation of the lead carbonyls, PbnCO (n=1-4), using matrix-isolation infrared spectroscopy. Absorption at 2027.7 cm(-1) is assigned to C-O stretching mode of the PbCO product, which appears and increases on annealing, disappears on broadband irradiation, and recovers on further annealing. Small lead cluster mono-carbonyls PbnCO (n=2-4) are also observed in the present infrared spectra. Based on the results of stepwise annealing and the comparison with theoretical predictions, the absorptions at 1915.5, 1923.8, and 2042.8 cm(-1) are assigned to Pb2CO, Pb3CO, and Pb4CO, respectively. Bridging CO is found in Pb2CO or Pb3CO, whereas terminal CO in Pb4CO. The density functional theory calculations have been performed on these molecules and small naked lead clusters. The good agreement between experimental and calculated vibrational frequencies, relative absorption intensities, and isotopic shifts provides strong support for the identifications of these lead mono-carbonyls PbnCO (n=1-4). Furthermore, energetic analysis for the possible reactions of lead atoms with CO molecules is also given.

Journal Article↗

Removal of the protruding retention wire via a femoral approach while leaving the active-fixation atrial "J" lead in situ: a technique for the management of class III atrial "J" leads.

The Telectronics Accufix Atrial "J" pacing lead poses a mechanical risk to patients of retention wire fracture and protrusion. Standard lead extraction techniques include percutaneous approaches, which are associated with significant risk of morbidity and mortality, and open procedures, which necessitate thoracotomy. In nine patients referred with Class III retention wire fractures, attempts were made to snare the protruding retention wire from a femoral approach using snare devices and bioptomes. In six cases, the retention wire was successfully removed, leaving the lead body in place. In four patients with lead function that was able to be evaluated, the atrial lead remained functional after the procedure. There were no complications. Snare removal of the protruding retention wire via a femoral approach should be considered as an option in the management of patients with Class III Accufix leads.

Aged↗

Lead noise with an active-fixation defibrillation lead.

Inappropriate detection and therapy is the most common adverse effect of implantable cardioverter defibrillator therapy. One mechanism is lead artifact, which usually presents late and is due to stress and fatigue of the lead components. Our experience with a defibrillator lead (Endotak Endurance EZ leads, Models 0154/0155/0156) and its method of active fixation is described. Of 20 implants with this lead, four patients were found to have noise that resulted in inappropriate detections in three. No patient received therapy as a consequence of these detections. The artifact appeared soon after implant and resolved in three of four cases by 4 weeks. None of the 16 remaining patients developed noise after this time. This is a unique lead problem that resolves with time, but it may result in inappropriate therapies and difficult management decisions in high risk patients with ventricular arrhythmias.

Aged↗

Left ventricular lead performance in cardiac resynchronization therapy: impact of lead localization and complications.

INTRODUCTION: Cardiac resynchronization therapy (CRT) using left ventricular (LV) pacing from the coronary sinus tributary is increasingly and frequently used in patients with severe congestive heart failure. The present study investigates LV lead performance in different anatomic locations. METHODS: The LV pacing site was defined by bi-plane fluoroscopy. In the left anterior oblique view, the coronary sinus is encircling the mitral ring with the tributaries radiating out like the hands of a watch. Using this clockwise method, Group A had an LV pacing site before 3 o'clock and Group B at or after 3 o'clock. In right anterior oblique view, the LV was divided into three segments: basal, mid-ventricular, and apical. RESULTS: LV lead implantation was successful in all of 120 consecutive patients. Mean follow-up was 16.7 months. Implantation time decreased from mean 190 to 80 minutes during the period (P = 0.01). The mean LV lead stimulation threshold increased initially and stabilized afterwards. The threshold measured at last follow-up was higher than at implantation (2.3 vs 2.7 microJ, P = 0.04). Useful venograms were obtained in 94 patients. No significant difference in thresholds was observed between Groups A and B. Phrenic nerve stimulation was most commonly seen in Group B (8/70 vs 1/24, P = 0.001). CONCLUSION: Implantation of an LV lead for CRT is possible in patients with congestive heart failure and associated with an acceptable low complication rate. LV lead implantation is associated with a learning curve. At mid-term follow-up, LV lead performance is stable and unrelated to the LV implantation site.

Adolescent↗

Age, size, and lead factors alone do not predict venous obstruction in children and young adults with transvenous lead systems.

BACKGROUND: Venous occlusion is a recognized complication of transvenous pacing, and lead cross-sectional area indexed to body surface area (BSA) has been used to predict venous obstruction in children. OBJECTIVE: The aim of this study was to identify the risk factors and incidence of angiographic venous obstruction after transvenous lead implantation in both children and young adults. METHODS: Contrast venography was obtained in 85 of 90 consecutive patients undergoing repeat pacemaker or ICD procedures from 2002 to 2004 at a single cardiac center. Venograms were graded as complete venous obstruction, significant partial obstruction (>70% with collaterals), or patent. RESULTS: The cohort had a median age of 15.0 years at implant and was divided into two age groups: 3-12 years (n = 35) and 13 years and over (n = 50). After a median interval of 6.5 years, complete obstruction was seen in 11 of 85 patients (13%) and partial obstruction in another 10 patients (12%). No significant differences were seen in the incidence of obstruction between the two age groups although younger patients had a larger lead indexed to BSA ratio (6.82 vs 5.05, P = 0.005). There were no significant differences between obstructed and nonobstructed patients in relation to age, size, growth, or lead factors. CONCLUSION: Transvenous lead systems implanted in young children have a similar incidence of venous occlusion compared to older patients. Furthermore, patient age, body size, and lead characteristics at implant do not clearly predict venous occlusion.

Adolescent↗

The "lead tug" sign for the diagnosis of early and inapparent lead fracture.

The cause of pacemaker malfunction in a patient having intermittent pacing failure associated with diminished pacer stimuli was not determined during conventional intraoperative electrical testing. A modest manual pull on the lead, termed the "lead tug" sign, induced an inordinately high lead impedance and established lead fracture as the etiology. The "lead tug" maneuver is proposed as a useful procedure during stimulation studies for the detection of early lead fracture, not apparent from the x-ray film or usual testing protocol.

Aged↗

Differential activation of MAPK and ICE/Ced-3 protease in chemical-induced apoptosis. The role of oxidative stress in the regulation of mitogen-activated protein kinases (MAPKs) leading to gene expression and survival or activation of caspases leading to apoptosis.

Chemical-induced oxidative stress to a cell can signal many cellular responses which include proliferation, differentiation, hemeostasis, apoptosis or necrosis. To better understand the underlying molecular mechanisms after exposure to chemicals, we investigated the signal transduction pathways, in particular the mitogen-activated protein kinase (MAPK) pathway and the ICE/Ced-3 protease (caspase) pathway, activated by different agents. Butylated hydroxyanisol (BHA) and its metabolite, t-butyl-hydroquinone (tBHQ), both are well known phenolic antioxidants used in food preservatives, strongly activated c-Jun N-terminal kinase 1 (JNK1) and/or extracellular signal-regulated protein kinase 2 (ERK2) in a dose- and time-dependent fashion. Pretreatment with free radical scavengers N-acetyl-L-cysteine (NAC), glutathione (GSH), or vitamin E, inhibited ERK2 activation and, to a much lesser extent, JNK 1 activation by BHA and tBHQ, implicating the role of oxidative stress. Under conditions where JNK1 and ERK2 were activated, BHA also activated transcription factors nuclear factor kappa B (NF-kappaB), activated-protein-1 (AP-1), and anti-oxidant response element (ARE), leading to induction of genes such as c-jun, and c-fos. At relatively high concentrations, BHA and tBHQ stimulated proteolytic activity of ICE/Ced3 cysteine proteases, and caused apoptosis, which was blocked by pretreatment with NAC. Further increase in concentrations lead to rapid cell death predominantly occurred via necrosis. Some naturally occurring phytochemicals, such as phenylethyl isothiocyanate (PEITC), green tea polyphenols (GTP), and sulfarophane, which have been shown to be potent inducers of Phase II enzymes, also differentially regulated the activities of JNK, ERK, or CPP-32, in a time- and dose-dependent manner. Our data, together with the work of others, enable us to propose a model in which low concentrations of these chemicals (e.g., BHA, PEITC) activate MAPKs leading to induction of gene expression (e.g., c-jun, c-fos, GSI) which may protect the cells against toxic insults and enhance cell survival. At relatively high concentrations, these agents activated both MAPKS, and the ICE/Ced-3 caspase pathway, leading to apoptosis. The exact mechanisms by which MAPK and caspases are activated by these agents are currently unknown, but may involve oxidative modification of glutathione (GSH) and/or protein thiols, and/or generation of secondary messengers, ceramide and calcium, which further activate downstream events. Taken together, our results suggest that chemicals including phenolic antioxidants activate MAPK pathways which may lead to the induction of genes producing protection and survival mechanisms, as well as the ICE/Ced-3 protease pathway, leading to apoptosis. The balancing amongst these pathways may dictate the fate of the cells upon exposure to chemicals.

Journal Article↗

QT dispersion estimated from 80 body surface potential map leads and from standard 12-leads ECG in psychiatric patients treated with dosulepin.

The aim of the study was to detect changes of the QT dispersion (QTd) due to cardiotoxicity of tricyclic antidepressant dosulepin. Electrocardiographic and body surface potential mapping (BSPM) recordings were obtained using Cardiag 112.2 diagnostic system from 27 psychiatric outpatients treated with prophylactic doses of dosulepin and compared to those obtained from 37 healthy volunteers. From these recordings the QTd and the dispersion of heart rate-corrected QT interval QTc were evaluated. These parameters were estimated both from 80 BSPM leads and from 12 standard ECG leads. Acquired data were statistically correlated by Spearman rank order correlation coefficient with dosulepin plasma levels. The average QTd evaluated from BSPM leads (+/-SD) in the dosulepin group was significantly higher [70 (+/-21) ms] than that in the control group [34 (+/-12) ms] (P< 0.001). Moreover, the correlation between QTd and the dosulepin plasma level was statistically significant as well (P< 0.001) with the value of correlation coefficient 0.7871. The QTd evaluated from standard 12 ECG leads was increased in dosulepin group as well [46 (+/-18) ms vs. 28 (+/-10) ms - P< 0.05] but we have not found any significant correlation of the QTd with the dosulepin plasma level. According to the above-mentioned results we can conclude that the QTd estimated from BSPM leads (but not that estimated from 12-lead ECG) could be used as a marker of the dosulepin effect on the myocardium.

Adult↗

Optimizing pacing lead design: redesign of the tined lead.

Technical data derived from experimental and clinical experience in the field of lead/catheter implants formed the basis for developing a set of technical design criteria for pacing leads. Four related levels of technical data were identified: Basic lead components, mode of installation, application site, and mode of use. When the technical data were evaluated, a joint goal between the medical and engineering community evolved--namely, to reduce the total transvenous lead-related reoperation rate (both acute and chronic) from 20-25 percent to below 5 percent. As a result, a new family of leads designed specifically to meet the less than or equal to 5 percent reoperation rate is now available; the first leads introduced are a radical redesign of an earlier tined lead. The development process and results, both experimental and clinical (N greater than 1,005), demonstrate the potential of careful technical definition and communication of biomedical problems between engineering and medical personnel.

Biomedical Engineering↗

[Use of epicardial leads for transvenous pacing lead insufficiency with venous thrombosis: a case report].

Recent progress in the electrode tip to prevent dislodgement makes difficult to extract itself in some patients. And when multiple leads are placed through a transvenous route, more frequent occurrence of venous thrombosis is easily suspected. We experienced a case of transvenous lead insufficiency with venous thrombosis. In this patient, two of unextractable transvenous leads were already placed, and venous thrombosis was detected by venography, so we implanted the new epicardial leads instead. In case of long-term placement of transvenous leads, especially when multiple, the possibility of venous thrombosis is ever thought, and the use of the extractable leads or anticoagulant therapy is recommended.

Aged↗

Pacemaker lead extraction in pacemaker endocarditis with lead vegetation: usefulness of transesophageal echocardiography.

While pacemaker endocarditis is rare, it is a complication that mandates removal of the permanent pacemaker system, including the electrode lead. Many modes of lead removal have been used. The choice of method is determined largely by lead type and chronicity (i.e., risk of substantial adhesions, hence, lead tip mobility). Patient selection has been based on general preoperative risk assessment. It is proposed that the presence of lead vegetation be considered in the decision-making process. Vegetation can be diagnosed by preoperative echocardiography, especially with clinical suspicion of embolism. Transesophageal echocardiography appears to be particularly sensitive. If vegetation is detected, open heart surgery should be strongly considered for lead removal as opposed to dilator sheath counter traction. The latter method risks shearing off the vegetation, which may result in septic--even massive--pulmonary embolus.

Cardiac Pacing, Artificial↗

Lead and hyperactivity: lead levels among hyperactive children.

Previous work has demonstrated an association between hyperactivity and increased body lead burdens in school-age children. In the present study it is shown that within a group of hyperactive children those for whom an organic etiology is present have lead burdens lower than in those for whom no apparent cause could be found. These data lead us to reject the notion that hyperactivity per se is responsible for the acquisition of elevated lead levels, and further strengthen the suspicion that for some children lower lead level absorption may be implicated in the development of the hyperkinetic disorder.

Central Nervous System Diseases↗

Evaluation of the effect of lead exposure on the liver in Egyptian lead tank welders.

In a group of Egyptian lead tank welders who were exposed to lead fumes for periods to 22 years the changes in serum lipids and some of the liver function tests which may elucidate the effect of lead on the liver were investigated. The results revealed increased blood lead level associated with decreased blood haemoglobin and increased urinary excretion of delta amino levulinic acid. However, no clinical abnormalities were recorded in the exposed group of the present work. Thus the increase in serum triglycerides and B-lipoprotein together with the lowering of the phospholipid/cholesterol ratio which were found may indicate premature development of atherosclerosis. Indirect evidence of the beginning of liver fattening was also provided by the increase in serum GOT, GPT, LDH enzymes and decreased albumin/globulin ratio besides the changes in serum lipid values. It is concluded therefore that lead poisoning may have a vascular as well as hepato-toxic action.

Adult↗