Amniotic Membrane and its Use in Pacemaker Procedures
Introduction
Amniotic membrane is a thin avascular membrane lining the innermost side of the fetal placenta. It surrounds the developing embryo completely and sets the limits for the amniotic cavity, hosting the amniotic fluid within it. The structure and function of amnion has been investigated in the recent years, specifically for the pluripotent properties of the amniotic membrane cells, which show a promising future in field of regenerative medicine and tissue transplantation.
Amniotic membrane has anti-bacterial, anti-viral, anti-inflammatory and immunological characteristics, as well pro-
apoptotic and anti-angiogenic features. Amniotic membrane promotes epithelialization and an anti-tumorigenic tissue without any ethical issues pertaining to its use.
Due to these attractive properties the use of amniotic membrane has been implicated in several surgical procedures involving ocular surface reconstruction, genitor-urinary tract surgeries, surgeries involving the head and neck structures and its use has also been implicated in the field of dermatology.
Amniotic membrane can also be used in oncology, as amniotic membrane can prevent the delivery of oxygen and nutrients to the cancer cells, consequently disrupting their metabolism, growth, angiogenesis and metastasis and their ability to proliferate1.
Properties of the Human Amniotic Membrane
Amniotic membrane has been implicated to:
- Reduce inflammation
- Reduce scarring
- Reduce adhesion formation
- Facilitate healthy epithelialization
- Reduce vascularization
There are a number of growth factors, cytokines and protease inhibitors, such as fibroblast growth factor (FGF), Transforming growth factor (TGF), epithelial growth factor (EGF), IL-4 and 6, and macrobulin, are implicated to be present in a cryo-preserved amniotic membrane. Their presence, concentration and action account for most of the clinical effects that are observed.
What are the different forms of the membrane? 2
Amniotic membrane can be prepared in various forms for clinical use. These include
- Frozen membrane
- Dried membrane
- Fresh membrane
- Stabilized amniotic membrane
- Freeze derived irradiated membrane
- Cryo-preserved membrane
How can it be used in pacemaker procedures?
The incidence of cardiac implantable electronic devices has increased over the past decade. A pacemaker is a small device that is placed on the chest or the abdomen and is connected to the electrical conduction system of the heart. Cardiologists use it to treat arrhythmias, prevent sudden cardiac death and correct bardycardia. It maintains the sinus rhythm as the SA node can no longer maintain it. As this is procedure involves the insertion of leads into the chest, there is always a risk of infections.
The source of infection typically occurs during the procedure, or when the device generator has to be replaced3.A study conducted to determine the risk of developing infective endocarditis after installation of the pacemaker device concluded that endocarditis infection appeared in patients around the 3th month after it was installed. Other than this, pouch hematoma and inflammation were also observed. The causative agents were found be staph aureus and staph epidermidis4. Prophylactic antibiotics and using sterile techniques may reduce the risk of infection.
Now days the use of anti bacterial pouch which surrounds the pacemaker device, is becoming common. It has been implicated in reducing the risk of infection considerably. The pouch provides protection for about 10 days and it also helps stabilize the pouch. On an average, the pacemaker batteries need to be replaced every 4-6 years, but this time span varies depending on the patients and the device. It has been estimated that about 7% of the high risk patients develop infection as a complication following this procedure5.
Amniotic membrane allograft have proven its worth in ocular repairs, periodontal procedures, orthopedic repairs, and wound healing. It can potentially be used a substitute for the antibiotic pouch. Using an antibiotic pouch may be linked with development of resistance to the bacteria of that particular antibiotic. Amniotic membrane on the other hand has all the properties that make it the perfect fit to be used as an allograft around the pace maker to prevent infections and inflammation. It has a natural anti-microbial and anti-viral property and it easily in cooperates into the tissue it is used on6. As it has low immunogenicity, there is no chance of an immune reaction against it, making it safe to be implanted anywhere in the body7.
As the membrane is avascular it does not require a blood supply to maintain its function. During removal of the lead, there is a chance of developing inflammation and subsequent scarring on the heart which can lead to other complications. Amniotic membrane is a natural anti-inflammatory material, with recorded reduction in scar tissue formation with its use. It has been used in cardiac surgery to treat patients with constrictive pericarditis and has shown promising results8. All these properties make it a more superior choice to be used as a substitute for an antibiotic pouch.
References
- Mamede AC, Carvalho MJ, Abrantes AM, Laranjo M, Maia CJ, Botelho MF. Amniotic membrane: from structure and functions to clinical applications. Cell and tissue research. 2012 Aug 1;349(2):447-58.
- Sharma M, Kotwal B, Mahajan N, Kharyal S. Amniotic Membrane in Periodontics: An Insight.
- Klug D, Balde M, Pavin D, Hidden-Lucet F, Clementy J, Sadoul N, Rey JL, Lande G, Lazarus A, Victor J, Barnay C. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators. Circulation. 2007 Sep 18;116(12):1349-55.
- Cacoub P, Leprince P, Nataf P, Hausfater P, Dorent R, Wechsler B, Bors V, Pavie A, Piette JC, Gandjbakhch I. Pacemaker infective endocarditis. The American journal of cardiology. 1998 Aug 15;82(4):480-4.
- Gleva MJ, Poole JE. Prevention Of Cardiac Implantable Electronic Device Infections: Update And Evaluation Of The Potential Role For Capsulectomy Or The Antibiotic Pouch. JAFIB: Journal of Atrial Fibrillation. 2017 Feb 1;9(5).
- Zare-Bidaki M, Sadrinia S, Erfani S, Afkar E, Ghanbarzade N. Antimicrobial properties of amniotic and chorionic membranes: A comparative study of two human fetal sacs. Journal of Reproduction & Infertility. 2017 Apr 1;18(2).
- Castellanos G, Bernabé-García Á, Moraleda JM, Nicolás FJ. Amniotic membrane application for the healing of chronic wounds and ulcers. Placenta. 2017 Apr 10.
- Marsh KM, Ferng AS, Pilikian T, Desai AA, Avery R, Friedman M, Oliva I, Jokerst C, Schipper D, Khalpey Z. Anti-inflammatory properties of amniotic membrane patch following pericardiectomy for constrictive pericarditis. Journal of cardiothoracic surgery. 2017 Jan 26;12(1):6.