leadless and non trans-venous technology: current …€¦ · trans-venous technology: current and...
TRANSCRIPT
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LEADLESS AND NON TRANS-VENOUS TECHNOLOGY:
CURRENT AND FUTURE DIRECTIONS
JONATHAN LOWY MD
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• 58 year old woman with severe rheumatic mitral stenosis, Tricuspid Insufficiency, Aortic Stenosis factor 5 Leiden, and Type II DM had prior AVR replacement in Ukraine 10 years
• Complete Heart block after surgery sternal infection, and she developed bilateral venous thrombosis of her upper extremity venous return.
• Epicardial post-surgical pacing wires began to fail after 7days with intermittent capture• Temporary femoral Trans-venous pacing was required • Surgeons did not want to place an epicardial lead and EP was uncomfortable with
anything permanent in the venous system due to risk of thrombosis. • She remained in the ICU for 36 days with temporary trans-venous pacing before being
transferred to our institution
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Tong, F Reddy,V Circulation. 2017;135:1458–1470. DOI: 10.1161/CIRCULATIONAHA.116.025037
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Why leadless pacemakers?• 1,000,000 pacemakers implanted worldwide
• 200,000 implanted in the US every year
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Leadless pacing
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Requirements for a leadless pacemakerDeliverableStable and SafeBattery life 8-12 yearsRate responseMRI compatibleTelemetry Remote Monitoring
Retrievable/ExtractableModular
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CURRENTLY THE MICRA SINGLE CHAMBER VVIR PACEMAKER IS
THE ONLY FDA APPROVED LEADLESS CARDIAC PACEMAKER
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NANOSTIM: ST. JUDE MEDICAL(NOT FDA APPROVED)
N Engl J Med 2015; 373:1125-113
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Nanostim Implants Suspended in 2016 prior to FDA approvalBattery failure in a small number of implants resulted in voluntary recall in 2016Delivery button malfunction in 2017
Per Abbott they are working on a dual chamber version of Nanostim with updated battery and design. Plans for a clinical IDE trial in the “near future” The plans for the dual chamber system have not been publically disclosed.
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MICRA MEDTRONIC-FDA APPROVED
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MICRA LEADLESS PACEMAKEREasy to Implant Battery life 8-12 yearsMRI compatibleRate response with 3 vector accelerometerRetrievable/Extractable +/-Reliable In animal models up to 3 devices implanted in the RV
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Updated performance of the Micra transcatheter pacemaker in the real-world setting: A comparison to the investigational study and a transvenous historical control
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Boston Scientific “EMPOWR”(Investigational Device)
32.1 mm x 6.0 mm0.8 cc
EMPOWER Delivery and Retrieval(Investigational Device & System)
Dedicated delivery and retrieval catheters
tether loop/ retrieval groove
20.7 Fr Preloaded delivery catheter withextendable inner catheter
Dedicated retrieval system with single & tri-loop snares
Active fixationtalons
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FDA PMA FOR MICRA:
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Data for 40k patients show 20% TV-lead malfunction at 10 years
1. Koneru, JN, Jones, PW, Hammill, EF, Wold, N, and Ellenbogen, KA, Risk Factors and Temporal Trends of Complications Associated With Transvenous Implantable Cardiac Defibrillator Leads. J Am Heart Assoc, 2018. 7(10).
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
1 2 3 4 5 6 7 8 9 10
Free
dom
from
Mec
hani
cal C
ompl
icat
ions
Mechanical Failure of Transvenous LeadsTrends from 10 Year Optum Data for > 40,000 Patients
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WHY DO WE NEED AN ALTERNATIVE TO TRANSVENOUS ICDS?
• Patients are living longer requiring lead durability that may not last a patient’s lifespan• Sicker patients with more systemic disease increasing the risk of infection• A vast majority of patients do not need pacing or ATP• Extraction of Transvenous systems is not without significant risks
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Evolution of S-ICD therapy
2å0022009
2015
2016
1st Generation
2nd Generation
3rd Generation
• EMBLEM Electrode (Model 3501)
• Electrode Delivery System (EDS)
• 2 Incision Technique Labeling
2017
• SMART Pass1
• MRI compatible1**
• AF MonitorTM 1
• Smaller, thinner,
longer-lasting device*
• LATITUDETM
compatible1
2012 Automated Screening Tool
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DETECTION
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CONDITIONAL ZONE DISCRIMINATORS
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ONGOING TRIALS:• UNTOUCHED:• Understanding Outcomes With the EMBLEM™ S-ICD in Primary Prevention Patients With Low Ejection Fraction
(UNTOUCHED)
• LATE BREAKING UPDATE AT HRS 2019
• PRAETORIAN TRIAL:• Prospective, RAndomizEd comparison of subcuTaneOus and tRansvenous ImplANtable cardioverter-defibrillator therapy.
• ATLAS S-ICD• AVOID TRANSVENOUS LEADS IN APPROPRIATE SUBJECTS
• RANDOMIZE S-ICD VS SINGLE CHAMBER ICD
• PRAETORIAN-DFT• RANDOMIZING DFT VS NO DFT WITH XRAY TO CONFIRM APPROPRIATE DEVICE LOCATION
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MEDTRONIC EV SUB-STERNAL ICD-EXPERIMENTAL-
• PILOT TRIAL: SPACE• 9 PATIENTS IMPLANTED IN AUSTRALIA AND
NEW ZEALAND
• HAS ABILITY TO DELIVER ATP AND POST SHOCK PACING
• WORLD WIDE STUDY INCLUDING US SITES NOW UNDWERWAY
IMAGE COURTESY MEDTRONIC
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Courtesy of Brandon Fellows BSCI
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WISE-CRT/SELECT LVEXPERIMENTAL NOT FDA APPROVED
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THE FUTURE:
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