The salty dog: serum sodium and potassium effects on modern pacing electrodes.

BACKGROUND: This study was conducted to characterize the behavior of chronic modern endocardial electrodes with capacitively coupled constant voltage pulse generators in canines. METHODS: Five animals were studied with chronic paired unipolar microporous platinum, and porous steroid-eluting electrodes in the ventricle. Screw-in and passive fixation electrodes were also implanted in the atrium. IV infusions of 500-800 mL of 50 meq KCl in 500 mL Ringer's solution, and 3% NaCl were given over periods of 120 and 80 minutes, respectively, during separate anesthetized monitors. RESULTS: Mean maximum Na+ and K+ achieved was 158 and 8.3 meq/L, respectively. During KCl infusion, ventricular threshold, current, and energy decreased. In the atrium, half the leads went to exit block at approximately 7.0 meq/L K+. Others continued to perform acceptably. The atrial electrogram decreased 70% with no change in the ventricular signal. No change in impedance occurred. During NaCl infusion, no changes in atrial or ventricular threshold occurred while current increased 21%-32%. This resulted in a 40%-55% increase in energy due to a 20% decrease in impedance. The atrial electrogram decreased 32%-36% while the ventricular amplitude decreased 25%. Slew rate decreased 19%-27%. Control studies for effects of heart rate, fluid volume, and anesthesia duration did not cause any changes. CONCLUSION: These data support the conclusion that threshold is a voltage mediated response. Thus, voltage thresholds, not energy, current or pulse duration is the most relevant parameter for safety margin determination. Atrial parameters should be followed during electrolyte imbalances. Correlation in humans is needed.

In vivo biostability of polyether polyurethanes with fluoropolymer and polyethylene oxide surface modifying endgroups; resistance to metal ion oxidation.

Polyether polyurethanes are subject to oxidation catalyzed by, and through direct (redox) reaction with transition metal ions (metal ion oxidation, MIO). The source of the ions is corrosion of metallic parts within an implanted device. A Shore 80A polyether polyurethane was modified with fluoropolymer (E80AF) or polyethylene oxide (E80AP) surface modifying end groups (SME). The SME migrates to the surface to form a covalently bonded monolayer, while maintaining the bulk properties of the polyurethane. In vitro tests in H(2)O(2) solution indicated that both SME's accelerated MIO. Tubing samples containing cobalt mandrels were implanted in the subcutis of rabbits for up to 2 years. In vivo, E80AF significantly slowed the rate of visible degradation, but did not prevent MIO. E80AP had virtually identical visual performance to the unmodified control in vivo. Infrared spectroscopy and molecular weight correlated well with visual appearance. When cracks were seen, polyether soft segment oxidation was occurring. Both E80AP and the control developed severe loss of molecular weight in vivo. The changes were much less severe for E80AF. Thus, contrary to in vitro test results, the PEO SME had no effect at all on MIO resistance, while the fluoropolymer SME produced a significant improvement in biostability.

In vivo biostability of polyether polyurethanes with fluoropolymer surface modifying endgroups: resistance to biologic oxidation and stress cracking.

A series of Shore 80A polyether polyurethanes were synthesized with from 0 to 6% fluoropolymer surface modifying endgroups (SME) to provide the bulk properties of the polyurethane with the surface properties of the fluoropolymer. It was theorized that the fluoropolymer would migrate to the surface, forming a monolayer barrier to the oxidants and crack-driving agents released by macrophages and foreign body giant cells in vivo. In a 12-week biostability screening test, samples strained to 400% elongation appeared to be highly stable. In a longer-term study, the fluoropolymer SME significantly delayed, but did not completely prevent the onset of microcracking and the development of environmental stress cracking in strained samples. Even so, the 4 and 6% SME polymers explanted at 2 years performed significantly better than the control. FTIR analysis did not correlate with SME concentration, but increased hydrogen-bonding index and loss of aliphatic ether (autoxidation) did correlate with the visual appearance and density of microcracks. Significant molecular weight reductions were seen for the SME-free control, but were small (within instrumental error) for the polymers with SME. The use of fluoropolymer as a SME does appear to be warranted as a means to improve polyether polyurethane biostability.

In vivo biostability of shore 55D polyether polyurethanes with and without fluoropolymer surface modifying endgroups.

Polyether polyurethanes are subject to autooxidation and environmental stress cracking (ESC) because of interactions with lysosomal oxygen-free radicals. Oxidation can also be catalyzed by and caused by direct (redox) reaction with transition metal ions (metal ion oxidation, MIO). The source of the ions is corrosion of metallic parts within an implanted device. A previous study on a Shore 80A polyether polyurethane modified with fluoropolymer surface modifying end groups demonstrated improved biostability over unmodified controls. We predicted that this could be extrapolated to the inherently more biostable Shore 55D version (E55DF). While it is difficult to demonstrate significant biodegradation in the harder polymers within a reasonable time frame, we did see excellent biologic autooxidation and ESC resistance for both E55DF and its unmodified Shore 55D (P55D) control. E55DF was slightly, but significantly more resistant to MIO than P55D. This was particularly evident in molecular weight distributions with P55D exhibiting a large decrease in number average molecular weight compared to no change for E55DF. Both were markedly superior to the softer Shore 80A control. It does appear that one can extrapolate accelerated in vivo biostability results with the softer polymers to their harder analogues.

In vivo biostability of polysiloxane polyether polyurethanes: resistance to biologic oxidation and stress cracking.

Polyether polyurethanes are extremely interesting for use in implantable devices. They are, however, susceptible to autoxidative degradation and stress cracking. One approach to improving biostability is to replace some of the polyether with polysiloxane. Shore 80A polyether polyurethanes with 20% (PS-20) and 35% (PS-35) polysiloxane were strained to 400% elongation and implanted in rabbits. Twelve weeks implant showed that both were significantly more biostable than their polysiloxane-free controls. After 18 months implant, PS-20 developed some localized tensile fractures. PS-35 showed no sign of visual damage. Infrared surface analysis does not allow direct evaluation of autoxidation because the Si--O--Si stretch peaks mask the polyether bands. Secondary indicators suggest possible very slight autoxidation of both PS-20 and PS-35 surfaces, but not enough to develop cracks. The polysiloxane-free controls did show substantial infrared evidence of autoxidation. Molecular weights of long-term PS-20 and PS-35 explants were negligibly lower. In comparison, the polysiloxane-free control suffered 35% molecular weight loss. Positive and negative controls performed as expected. PS-20 is recommended for devices that do not sustain high fixed loads. PS-35 is dramatically more biostable than its unmodified polyether analogues and is recommended for use in chronically implantable devices.

In vivo biostability of polysiloxane polyether polyurethanes: resistance to metal ion oxidation.

Polyether polyurethanes are subject to oxidation catalyzed by and through direct (redox) reaction with transition metal ions (cobalt), released by corrosion of metallic parts in an implanted device. Replacing part of the polyether with polysiloxane appears to reduce susceptibility to metal ion oxidation (MIO). In vitro studies indicated that polyurethanes containing 20-35% polysiloxane (PS-20 and PS-35) are about optimum. We implanted tubing samples containing cobalt mandrels in the subcutis of rabbits for periods up to 2 years. After 2 years, only traces of microscopic cracks were seen on half the PS-35 samples, PS-20 significantly delayed MIO, while the polysiloxane-free control was very severely degraded. Infrared spectroscopy established that polyether soft segment oxidation was occurring in PS-20. We could not directly evaluate oxidation in PS-35 because siloxane bands mask the aliphatic ether. Indirect FTIR evidence suggests that there is very slight polyether oxidation that develops early, and then seems to stabilize. The molecular weight of degraded PS-20 decreased. That of microcracked PS-35 decreased negligibly while that of undamaged PS-35 increased slightly after 2-year in vivo. The polysiloxane-free control was profoundly degraded. PS-20 has much improved MIO resistance, while that for PS-35 is highly MIO resistant compared with its polysiloxane-free control.

In vivo biostability of polyether polyurethanes with polyethylene oxide surface-modifying end groups; resistance to biologic oxidation and stress cracking.

Polyethylene oxide (PEO) on polymer surfaces has been reported to reduce cellular adhesion, a very desirable property for cardiac pacing leads. A Shore 80A polyether polyurethane with up to 6% PEO surface-modifying end groups (SME) was evaluated for its chronic in vivo biostability. In a short-term (12 week) screening test, strained samples appeared to develop the same surface oxidation as unmodified polymer, but did not produce visible cracking > or =500x, prompting a longer-term study. By the time the longer-term study was initiated, most of the PEO SME had disappeared from the starting material's surface. After 1 year in vivo, surface oxidation, shallow surface cracking, and environmental stress cracking (ESC) developed on highly strained samples to the point of failure, so that there was no significant difference between the SME polymer and its control (the same polymer without SME). No further change was seen for up to 2 years of implantation. Unstrained PEO SME polymer developed shallow surface cracking, but no ESC up to 2 years of implantation. Thus, PEO SME slightly delayed, but did not stop biodegradation, and under unstrained conditions, has no adverse effect on biostability.

Macrophage behavior on surface-modified polyurethanes.

Adherent macrophages and foreign body giant cells (FBGCs) are known to release degradative molecules that can be detrimental to the long-term biostability of polyurethanes. The modification of polyurethanes using surface modifying endgroups (SMEs) and/or the incorporation of silicone into the polyurethane soft segments may alter macrophage adhesion, fusion and apoptosis resulting in improved long-term biostability. An in vitro study of macrophage adhesion, fusion and apoptosis was performed on polyurethanes modified with fluorocarbon SMEs, polyethylene oxide (PEO) SMEs, or poly(dimethylsiloxane) (PDMS) co-soft segment and SMEs. The fluorocarbon SME and PEO SME modifications were shown to have no effect on macrophage adhesion and activity, while silicone modification had varied effects. Macrophages were capable of adapting to the surface and adhering in a similar manner to the silicone-modified and unmodified polyurethanes. In the absence of IL-4, macrophage fusion was comparable on the modified and unmodified polyurethanes, while macrophage apoptosis was promoted on the silicone modified surfaces. In contrast, when exposed to IL-4, a cytokine known to induce FBGC formation, silicone modification resulted in more macrophage fusion to form foreign body giant cells. In conclusion, fluorocarbon SME and PEO SME modification does not affect macrophage adhesion, fusion and apoptosis, while silicone modification is capable of mediating macrophage fusion and apoptosis. Silicone modification may be utilized to direct the fate of adherent macrophages towards FBGC formation or cell death through apoptosis.

Inhibition of bacterial and leukocyte adhesion under shear stress conditions by material surface chemistry.

Biomaterial-centered infections, initiated by bacterial adhesion, persist due to a compromised host immune response. Altering implant materials with surface modifying endgroups (SMEs) may enhance their biocompatibility by reducing bacterial and inflammatory cell adhesion. A rotating disc model, which generates shear stress within physiological ranges, was used to characterize adhesion of leukocytes and Staphylococcus epidermidis on polycarbonate-urethanes and polyetherurethanes modified with SMEs (polyethylene oxide, fluorocarbon and dimethylsiloxane) under dynamic flow conditions. Bacterial adhesion in the absence of serum was found to be mediated by shear stress and surface chemistry, with reduced adhesion exhibited on materials modified with polydimethylsiloxane and polyethylene oxide SMEs. In contrast, bacterial adhesion was enhanced on materials modified with fluorocarbon SMEs. In the presence of serum, bacterial adhesion was primarily neither material nor shear dependent. However, bacterial adhesion in serum was significantly reduced to < or = 10% compared to adhesion in serum-free media. Leukocyte adhesion in serum exhibited a shear dependency with increased adhesion occurring in regions exposed to lower shear-stress levels of < or = 7 dyne/cm2. Additionally, polydimethylsiloxane and polyethylene oxide SMEs reduced leukocyte adhesion on polyether-urethanes. In conclusion, these results suggest that surface chemistry and shear stress can mediate bacterial and cellular adhesion. Furthermore, materials modified with polyethylene oxide SMEs are capable of inhibiting bacterial adhesion, consequently minimizing the probability of biomaterial-centered infections.