Device orientation of a leadless pacemaker and subcutaneous implantable cardioverter-defibrillator in canine and human subjects and the effect on intrabody communication.

Aims: The development of communicating modular cardiac rhythm management systems relies on effective intrabody communication between a subcutaneous implantable cardioverter-defibrillator (S-ICD) and a leadless pacemaker (LP), using conducted communication. Communication success is affected by the LP and S-ICD orientation. This study is designed to evaluate the orientation of the LP and S-ICD in canine subjects and measure success and threshold of intrabody communication. To gain more human insights, we will explore device orientation in LP and S-ICD patients. Methods and results: Canine subjects implanted with a prototype S-ICD and LP (both Boston Scientific, MA, USA) with anterior-posterior fluoroscopy images were included in this analysis. For comparison, a retrospective analysis of human S-ICD and LP patients was performed. The angle of the long axis of the LP towards the vertical axis of 0°, and distance between the coil and LP were measured. Twenty-three canine subjects were analysed. Median angle of the LP was 29° and median distance of the S-ICD coil to LP was 0.8 cm. All canine subjects had successful communication. The median communicating threshold was 2.5 V. In the human retrospective analysis, 72 LP patients and 100 S-ICD patients were included. The mean angle of the LP was 56° and the median distance between the S-ICD coil and LP was 4.6 cm. Conclusion: Despite the less favourable LP orientation in canine subjects, all communication attempts were successful. In the human subjects, we observed a greater and in theory more favourable LP angle towards the communication vector. These data suggests suitability of human anatomy for conductive intrabody communication.

Long-term performance of a novel communicating antitachycardia pacing-enabled leadless pacemaker and subcutaneous implantable cardioverter-defibrillator system: A comprehensive preclinical study.

BACKGROUND: Subcutaneous implantable cardioverter-defibrillators (S-ICDs) and leadless pacemakers (LPs) are intended to diminish transvenous lead-related complications. However, S-ICDs do not deliver antibradycardia pacing or antitachycardia pacing, and currently, there is no commercially available coordinated leadless option for patients with defibrillator and (expected) pacing needs. OBJECTIVE: We evaluated the performance, safety, and potential replacement strategies of a novel modular cardiac rhythm management (mCRM) system, a wirelessly communicating antitachycardia pacing-enabled LP and S-ICD in a preclinical model. METHODS: LP implantation was attempted in 68 canine subjects, and in 38 an S-ICD was implanted as well. Animals were evaluated serially up to 18 months. At all evaluations, communication thresholds (CTs) between the devices, LP electrical parameters, and system-related complications were assessed. Different replacement strategies were tested. RESULTS: The LP was successfully implanted in 67 of 68 (98.5%) and the concomitant S-ICD in 38 of 38 (100%). mCRM communication was successful in 1022 of 1024 evaluations (99.8%). The mean CT was 2.2 ± 0.7 V at implantation and stable afterward (18 months: 1.8 ± 0.7 V). In multivariable analysis, larger LP-to-S-ICD angle and dorsal posture were associated with higher CTs. At implantation, the mean pacing capture threshold, impedance, and R-wave amplitude were 0.3 ± 0.1 V, 898.4 ± 198.9 Ω, and 26.4 ± 8.2 mV. The mean pacing capture threshold remained stable and impedance and R-wave amplitudes were within acceptable ranges throughout (0.7 ± 0.4 V, 619.1 ± 90.6 Ω, and 20.1 ± 8.4 mV at 18 months). Different replacement strategies seem feasible. CONCLUSION: This first mCRM system demonstrated excellent performance up to 18 months in a preclinical model.

Acute and 3-Month Performance of a Communicating Leadless Antitachycardia Pacemaker and Subcutaneous Implantable Defibrillator.

OBJECTIVES: The primary objective was to assess the acute and 3-month performance of the modular antitachycardia pacing (ATP)-enabled leadless pacemaker (LP) and subcutaneous implantable cardioverter-defibrillator (S-ICD) system, particularly device-device communication and ATP delivery. BACKGROUND: Transvenous pacemakers and implantable cardioverter-defibrillators (ICDs) have considerable rates of lead complications. We examined the next step in multicomponent leadless cardiac rhythm management: feasibility of pacing (including ATP) by a LP, commanded by an implanted S-ICD through wireless, intrabody, device-device communication. METHODS: The combined modular cardiac rhythm management therapy system of the LP and S-ICD prototypes was evaluated in 3 animal models (ovine, porcine, and canine) both in acute and chronic (90 days) experiments. LP performance, S-ICD to LP communication, S-ICD and LP rhythm discrimination, and ATP delivery triggered by the S-ICD were tested. RESULTS: The LP and S-ICD were successfully implanted in 98% of the animals (39 of 40). Of the 39 animals, 23 were followed up for 90 days post-implant. LP performance was adequate and exhibited appropriate VVI behavior during the 90 days of follow-up in all tested animals. Unidirectional communication between the S-ICD and LP was successful in 99% (398 of 401) of attempts, resulting in 100% ATP delivery by the LP (10 beats at 81% of the coupling interval). Adequate S-ICD sensing was observed during normal sinus rhythm, LP pacing, and ventricular tachycardia/ventricular fibrillation. CONCLUSIONS: This study presents the preclinical acute and chronic performance of the combined function of an ATP-enabled LP and S-ICD. Appropriate VVI functionality, successful wireless device-device communication, and ATP delivery were demonstrated by the LP. Clinical studies on safety and performance are needed.

A model of fracture testing of soft viscoelastic tissues.

Fracture, or tear, toughness of soft tissues can be computed from the work of fracture divided by the area of new crack surface. For soft tissues without significant plastic deformation, total work, which can be measured experimentally, is composed of the sum of fracture and viscoelastic work. In order to deduce fracture work, a method is needed to estimate viscoelastic work. Two different methods (Ph.D. Dissertation, University of Minnesota, 2000; J. Mater. Sci.: Mater. Med. 12 (2001) 327) have been proposed to estimate viscoelastic work in a fracture test of a soft tissue. The relative merits of these methods are unknown because the true viscoelastic work in an experiment is unknown. In order to characterize the accuracy of these methods, a theoretical model of crack propagation of viscoelastic soft tissue in a tensile test is presented, from which the exact viscoelastic work is calculated. The material is assumed to obey the standard linear solid model. The "exact" solution for the viscoelastic work during the fracture is computed from the model and compared with the work estimated by the two methods. It was found that both methods tend to underestimate the viscoelastic work done, and thus overestimate the fracture work and fracture toughness, although the errors were greater with the Fedewa method. It was further found that low displacement rates can give rise to a "snap" effect, where rapid crack growth can cause a disproportionate amount of viscoelastic energy to be dissipated during unloading. This modeling approach may be useful in evaluating other experimental methods of soft tissue fracture.

The effects of displacement rate and proteoglycan digestion on the fracture resistance of tissue grown from chondrocyte culture.

Fracture toughness of cartilage and cartilage replacement tissues is important in injury and disease. For example, cartilage is thought to weaken before it fibrillates in the disease osteoarthritis. Since both loading rate and proteoglycan content affect viscoelastic properties, they may both affect fracture toughness of cartilage and cartilage analogs. In this study, fracture toughness of tissue grown in chondrocyte culture was measured as a function of loading rate and proteoglycan digestion. Control tissue and tissue digested with chondroitinase ABC (cABC) to remove proteoglycans were tested at displacement rates of 0.1 and 0.5 mm/sec. Displacement rate had no effect on fracture toughness for either control or digested tissue. Proteoglycan digestion reduced tissue thickness by 30% and when evaluated on a material basis increased fracture toughness. There was no interaction between digestion and loading rate. When the fracture toughness was normalized to collagen content, which removed the effect of tissue shrinkage, there was no effect of proteoglycan digestion on fracture toughness. These data suggest that proteoglycans do not contribute to tissue toughness, other than by reducing thickness and increasing collagen density.