Is there an adverse outcome from abandoned pacing leads?

BACKGROUND: Indications for extraction of an abandoned pacemaker lead (APL) are controversial. The purpose of this study was to determine whether or not APLs should be extracted in the absence of pacemaker-related problems. METHODS AND RESULTS: We retrospectively reviewed, from 1977 through 1998, all patients with retained, non-functional leads and identified 433-266 males and 167 females. Mean age at initial pacemaker implantation was 68[emsp4 ]years. These patients received a total of 259 atrial and 948 ventricular leads. Of the total of 1,207 leads, 611 became non-functional. A total of 531 non-functional leads were abandoned, of which 18 were later extracted: one APL in 345 patients, two in 78, and three in 10. Indications for new lead placement when non-functional leads were abandoned included capture and/or sensing failure (243), lead recall (177), lead fracture (86), pacing system replacement to the contralateral side (11), accommodating patient growth (5), pacemaker function upgrade (5), replacement with implantable cardioverter defibrillator (ICD, 2), interference with ICD (1), and unknown (1). Complications that were associated with pacemakers were found in 24 patients (5.5%)-pacemaker system infection (8 patients) and venous occlusion at the time of a subsequent procedure of new lead placement when APLs had already been in place (16) which resulted in APL extraction (7) or transfer of the pacemaker system to the contralateral side (9). Neither venous thrombosis nor other complications were found in the remaining 409 patients (94.5%). The incidence of complications was higher in patients with three APLs than in patients with two or fewer APLs (40% vs. 4.7%, P=1x10(-6)), in patients with four or more total lead implantations than in patients with three or fewer total lead implantations (26.2% vs. 0. 6%, P<1x10(-10)), and in patients with three or more procedures of new lead placements than in patients with two or fewer procedures of new lead placements (36.4% vs. 3.9%, P=1x10(-10)). Patients with complications were younger than those without complications both at the time of initial pacemaker implantation (59+/-16 vs. 68+/-17 y, P=0.01) and when non-functional leads were abandoned (63+/-15 vs. 71+/-16 y, P=0.04). Mean numbers of APLs, total leads implanted, and procedures of new lead placement were significantly larger in patients with complications than in those without complications (1.58+/-0.78 vs. 1.2+/-0.44, 4.96+/-1.23 vs. 2.66+/-0.8, and 2.13+/-0.85 vs. 1.25+/-0.53, P=0.03, 4x10(-9) and 4x10(-5), respectively). CONCLUSIONS: 1. With only 5.5% of patients having had pacemaker-related complications, the adverse outcome of APL is small. 2. Clinical clues to the possible occasion for pacemaker-related complications include three or more APLs, four or more total leads, three or more procedures of new lead placement, and a younger age at initial pacemaker implantation. 3. Patients with a large number of APLs, total lead implantations, and procedures of new lead placement should be carefully observed to detect possible pacemaker-associated complications.

Ventriculoatrial shortening achieved in Wolff-Parkinson-White syndrome by programmed right ventricular pacing.

A 47-year-old woman with a left-sided Kent bundle showed marked reduction of the ventriculoatrial conduction time during extrastimuli at the right ventricular apex and outflow tract. The degree of reduction was greater than 6 years ago. A 'supernormal conduction' in the ventricle and the Kent bundle could have been responsible for this phenomenon.

[Porphyria cutanea tarda in hemodialyzed patients].

Porphyria cutanea tarda (PCT) and similar vesiculobullous disorders have been described to develop frequently in patients with chronic renal failure during long-term hemodialysis. 9 cases of PCT in hemodialyzed patients and 1 case of PCT in continuous ambulatory peritoneal dialysis have been reported in Japan. Since these patients were often anuria, porphyrin analyzed in plasma, feces, and dialysate. Uroporphyrins, coproporphyrins and heptacarboxyric porphyrins in feces, and total porphyrins in plasma increased. The iron overload, aluminum hydroxide, plasticizers exuded from the tubing or other apparatus and some drug administered during dialysis are considered as triggering factors. Hemodialysis employed high-performance-membrane, hemodiafiltration, plasma exchange, were reported as successful treatment.

Cutaneous reactions induced by calcium channel blocker: high frequency of psoriasiform eruptions.

Fifteen cases with cutaneous reactions to calcium channel blockers (Ca-antagonist), dihydropiridine (including nicardipine, nifedipine, nisoldipine), verapamil, and diltiazem are reported. The patients from Yokohama City University Hospital and affiliated hospitals included 4 males and 11 females with cardiovascular diseases. Their average age was 64.7 (54 to 82) years. They had been taking Ca-antagonists for an average of 95 days (7 days to 10 years) before they developed dermatitis. The frequency of reactions to Ca-antagonists was high with diltiazem (5/16:31.25%) and dihydropyridine (7/16:43.75%), including nifedipine (4/7), nisoldipine (1/7), and nicardipine (2/7). Stevens-Johnson syndrome (MCOS) was associated only with verapamil. A notable type of eruption was the psoriasiform type, including exacerbation of psoriasis, which was resolved or easily controlled after discontinuation of the drug. Provocation tests verified the Ca-antagonist as the cause in 7 cases of psoriasiform eruption. The frequency of positive patch tests to Ca-antagonists was low except for diltiazem. Patch tests with diltiazem showed positive reactions in 54% (7 of 13 patients), based on our experience and papers published in Japan. Ca-antagonists are occasional causes of a wide spectrum of cutaneous reactions and should also be considered as causative factors in patients who develop psoriasiform eruptions or in patients whose psoriasis is exacerbated while using these drugs.

[Effects of Nd:YAG laser irradiation on ventricular myocardium in dogs using an artificial sapphire tip contact laser catheter].

To apply Nd:YAG laser irradiation through a new sapphire tip contact laser method to catheter ablation in treatment of tachy-arrhythmias, effects of laser irradiation on ventricular myocardium were investigated in 10 mongrel dogs. Nd:YAG lase (1064nm) discharges were delivered to different sites on the endomyocardium at power of 5, 10, 15, 20 or 25w with duration of 3, 5, or 10 seconds (sec.) respectively in closed beating hearts. Histopathologically, the lesion irradiated was clearly demarcated from the normal myocardium by the construction band necrosis zone. The depth of injured myocardium was less than 2mm with 3 sec. irradiations, with 5 sec. from 1 mm to 4 mm in proportion to power increase, with 10 sec. from 3mm to 8 mm in proportion to the power from 5w to 15w and could not be measured in cases of more than 20w irradiations. Although with every irradiation duration, the depth of injury increased in proportion to the power increase. With the same total energy, a longer time of irradiation produced deeper injury than a shorter time. This method makes it easier to keep the laser positioned to target than bare laser, and is suitable for use in catheter ablation.

A probable involvement of rice allergy in severe type of atopic dermatitis in Japan.

1006 patients with typical and atypical lesions of atopic dermatitis (AD) were analysed statistically. The clinical severity was closely correlated to serum IgE values and RAST (radio-allergosorbent test) positivity. The frequency of RAST-positive antigens was significantly correlated with serum IgE values (gamma = 0.712; p < 0.01). The analysis of multiple correlation between the clinical severity and each RAST score for mite, egg white and rice antigens suggested a strong contribution of rice allergy to the development of severe AD. 25 patients with severe AD and positive rice-RAST were treated by rice exclusion diet. The results were as follows: 9 cases remarkably responsive, 10 cases moderately responsive and 6 cases unresponsive. The rice-RAST titre decreased most remarkably in the 1st group. The wheat-RAST titre also decreased in the 1st, in spite of taking wheat foods every day, but increased in the 3rd. A probable role of rice allergy in severe AD in Japan is discussed.

Mass trial of hypoallergenic rice (HRS-1) produced by enzymatic digestion in atopic dermatitis with suspected rice allergy. HRS-1 Research Group.

The clinical usefulness of a hypoallergenic rice (HRS-1) which was produced by enzymatic decomposition of the constituent proteins of original rice was evaluated in a multicentre study in 44 subjects with recalcitrant atopic dermatitis (AD), who were suspected of having rice allergy. The subjects were fed for at least 4 weeks with HRS-1 instead of eliminating both regular rice and wheat from their daily diet. The extent of overall skin lesions was expressed by using the AD affected area and severity index (ADASI). A statistically significant decrease in ADASI was observed at the 2nd and the 4th week readings and at the end of the study. A provocation test with regular rice was carried out in 5 of 44 subjects following the HRS-1 therapy. An obvious increase in ADASI was found in all of these 5 cases just after this procedure. On final evaluation, 77% of the patients tested showed 'moderate' to 'remarkable' improvement, and 59% of the patients a 'moderate' to 'remarkable' reduction in use of the steroid ointment concomitantly used for the treatment. Finally, HRS-1 was evaluated as 'useful' or 'very useful' in 69% of the subjects.

[25 atopic dermatitis patients with positive RAST for rice were treated with a rice elimination diet (the mean duration of elimination: 5.2 months). The clinical effects and the change in RAST for rice and wheat, serum IgE values and the number of eosinophils were examined].

The results were as follows; 9 cases (36%) showed improvement, 10 cases (40%) mild improvement and 6 cases (24%) no improvement. Rice-RAST titers (PRU/ml) decreased in accordance with the clinical effects, namely most remarkably in the 1st group. Wheat-RAST titers also decreased noticeably in the 1st group even though they were eating wheat everyday, but increased in the 3rd group. In these cases the rice antigen may act on the production of IgE antibodies specific not only to rice but also to wheat as an initiator antigen. The serum IgE values increased in the 3rd group, but not in the other groups. In all groups, eosinophilia was seen, but no significant changes in condition after rice elimination diet were observed. Based on these results, the probable role of rice allergy in the pathogenesis of severe AD in Japan was discussed.

[Evaluation on equivalence of pharmacological properties between natural crude drugs and their cultured cells based on their components. Accelerative effect of lithospermi radix and inhibitory effect of coptidis rhizoma on proliferation of granulation tissue].

The present study was carried out to evaluate an equivalence of pharmacological properties between natural crude drugs and their cultured cells. The effects of ether extract of Lithospermi Radix and cultured cells of Lithospermum erythrorhizon Sieb. et Zucc. and aqueous extract of Coptidis Rizoma and cultured cells of Coptis japonica Makino var. dissecta Nakai on proliferation of granulation tissue in rats were compared. The ether extracts of Lithospermi Radix and the cultured cells enhanced proliferation of granulation tissue by the cotton pellet method. The potency of both extract was about the same, if results were compared with the corresponding doses which contained the same quantity of shikonin derivatives. On the other hand, the aqueous extracts of Coptidis Rhizoma and the cultured cells inhibited it. The potency of both extract was about the same, if results were compared with the corresponding doses which contained the same quantity of berberine-type alkaloids. From these results, to evaluate an equivalence of pharmacological properties between natural crude drugs and their cultured cells, it is concluded that their qualities and quantities are not so different each other and the almost same pharmacological effect expected on the basis of their uses is required.

Production of shikonin derivatives by cell suspension cultures of Lithospermum erythrorhizon : VI. Production of shikonin derivatives by a two-layer culture containing an organic solvent.

A two-layer culture method was established that uses an organic solvent to remove shikonin derivatives produced on cell surfaces during the culture of suspension cells of Lithospermum erythrorhizon. Some paraffins and a fatty acid ester made suitable solvents, whereas olefins and aromatic solvents extensively inhibited the production of shikonin derivatives. The yield of derivatives increased with an increase in the carbon chain length of the n-paraffin used as the solvent and when the oxygen supply was sufficient it reached the value found for the ordinary culture method.

Production of shikonin derivatives by cell suspension cultures of Lithospermum erythrorhizon. III. Comparison of shikonin derivatives of cultured cells and ko-shikon.

A method for quantitative analysis of shikonin derivatives using high pressure liquid chromatography (HPLC) was established. With this method the composition of shikonin derivatives in cultured cells and roots of Lithospermum erythrorhizon (ko-shikon) was compared. The composition of shikonin derivatives produced by cell suspension cultures was similar to that of the ko-shikon, and the composition in cultured cells was found to fluctuate less than that of the ko-shikon.

Production of shikonin derivatives by cell suspension cultures of Lithospermum erythrorhizon : I. Effects of nitrogen sources on the production of shikonin derivatives.

Shikonin derivatives were produced from cell suspension cultures of Lithospermum erythrorhizon for the first time. The results of studies on various culture media showed that the type of nitrogen source in the medium greatly influenced the production of these derivatives. When nitrate was the nitrogen source, stable production of shikonin derivatives by the cell suspension culture took place. We also found that ammonium as the nitrogen source conspicuously inhibited the production of shikonin derivatives.

Production of shikonin derivatives by cell suspension cultures of Lithospermum erythrorhizon : II. A new Medium for the production of shikonin derivatives.

An excellent new medium was developed for the production of shikonin derivatives by suspension cultures of Lithospermum erythrorhizon. We investigated the effects of all the components of White's medium on the production of these derivatives. Nitrate, phosphate, copper, sulfate and sucrose had especially marked effects. With the new, M-9, medium produced from these studies the yield of shikonin derivatives was 1400 mg/l and the yield for dried cells was about 12%, whereas it was 120 mg/l, or about 2% with White's medium.