CHAPTER 2
CARDIAC PACEMAKER
OBJECTIVE
• At the end of the lecture, you will be able to:
Define pacemaker
Differentiate types of pacemaker
Understand principles of pacemaker
List function of pacemaker
INTRODUCTION
• Pacemakers are electrode devices that can be used to initiate the
heartbeat when the hearts intrinsic electrical system cannot effectively
generate a rate adequate to support cardiac output.
• Cardiac pacemaker is an electrical stimulator that produces
periodic electrical pulses that are conducted to electrodes normally
located within the lines of heart.
• The stimulus conducted to the heart causes it to contract.
CONT.…
• Pacemakers is an electronic device used to pace the heart when the
normal conduction pathway is damaged or diseased.
• This device uses electrical pulses to prompt the heart to beat at a
normal rate and rhythm. Pacemakers are used to treat heart rhythms
that are too slow, fast, or irregular.
• A patient who suffers from irregular heartbeat, or arrhythmia, may
need a pacemaker to keep his/her heart rate steady and regular.
• These abnormal heart rhythms are called arrhythmias.
THE HEART HAS AN INTRINSIC
PACEMAKER
• The heart generates electrical impulses that travel along a
specialized conduction pathway.
• This conduction process makes it possible for the heart to pump
blood efficiently.
COMPONENTS OF PACEMAKER
• Consist of:
– A generator
– One or more lead wires
– A power source (often a lithium
battery)
– Logic circuits that detect cardiac
electrical activity and determine
the appropriate response
Fast & Easy ECGs, 2E 6
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
PACEMAKER DESIGN
Pulse generator
• contains battery that provides the energy
for sending electrical impulses to the
heart as well as the circuits that deliver
the pacing stimuli.
• permanent pacemaker is encapsulated in a
metal can ,to protect the generator from
electromagnetic interference.
CONT.…
• It takes at least 10 µJ to pace the heart, more than 400 µJ
is likely to cause ventricular fibrillation.
PACEMAKER LEADS
• Pacemaker leads are electrical conductors (wires), covered with
insulation.
• They transmit the electrical impulses from the pulse generator to the
heart, and from the heart to the pulse generator.
• Delivers electrical impulse from the pulse generator to the heart.
• Medical devices used to generate and deliver electrical impulses to
the myocardium to stimulate a normal heartbeat.
HOW PACEMAKER WORKS?
• A pacemaker consists of a battery, a computerized generator and wires
with sensors at their tips.
• The battery powers the generator, and both are surrounded by a thin
metal [Link] wires connect the generator to the heart.
• A pacemaker helps to monitor and control the heart beat. The
electrodes detects hearts electrical activity and send data through the
wires to computer in the generator.
• If the heart rhythm is abnormal, the computer will direct the generator
to send electrical pulses to the heart. The pulses travel through the
wire to reach the heart.
PACEMAKER FUNCTION
1. Pacing function
2. Sensing function
3. Capture function
PACING
• Pacing refers to the regular output of electrical current, for the
purpose of depolarizing the cardiac tissue in the immediate vicinity of
the lead, with resulting propagation of a wave of depolarization
throughout that chamber.
TYPES OF PACEMAKER
• Permanent Pacemaker
• Temporary Pacemaker
PERMANENT PACEMAKER
• They are built into molded epoxy silicone rubber.
• Recent models include outer aluminum shield that guards against
interference from radiofrequency fields.
• Used to treat chronic heart condition
• Surgically placed transvenuosly under local anesthesia
• Pulse generator placed in a pocket subcutaneously ,can be adjusted
externally.
• Some implantable pacemakers have single fixed rate usually 70BPM
while others are dual model rates.
PERMANENT PACEMAKER
CONT.…
Temporary pacemaker
• Placed during emergencies
• Indicated for pts’ high degree heart block or
unstable bradycardia.
CATEGORIES OF PACEMAKER
There are 4 general categories of pacemaker.
• Asynchronous
• Demand
• R-wave inhibited
• AV synchronized
ASYNCHRONOUS PACEMAKER
• Asynchronous pacemaker produces pulses at a fixed rate in the 60 to
80 beats/min range.
• The standard rate is 70 beats/min.
• Its electric stimulus appears at a uniform rate regardless of what is going
on the heart or the rest of the body.
• Gives a fixed heart rate.
CONT.…
• Power supply: Supply energy to the pacemaker circuit. Primary battery
sources are used.
• Oscillator: establish pulse rate for the pacemaker.
• Pulse output circuit: Provides stimulating pulse to the heart. Generates
the actual electric stimulus that is applied to the heart.
• Lead wire: Carry electrical stimuli to the heart.
• Timing Circuit: Since it provides pulse at a constant rate regardless of
functioning of the heart. Determines when a stimulus should be applied to
the heart.
SYNCHRONOUS PACEMAKER
There are two general forms of synchronous pacemaker.
• Demand Pacemaker and Atrial-synchronous pacemaker.
• It consists of timing circuit, output circuit and electrodes as well feed
back loop.
DEMAND PACEMAKER
• The demand pacemaker adjusts its firing rate to the patients heart
rate. It contains circuitry that senses the ECG R wave and measure the
R to R interval.
• During the first quarter of this period, the pacemaker is dormant to
prevent response to the T wave feature of the [Link],during the last
three quarters of the R to R interval, it is a sense model.
• If an R wave is not sensed within this period, then pacemaker emits a
pulse.
BLOCK DIAGRAM OF
DEMAND PACEMAKER
CONT..
• Electrodes: serves to apply stimulus pulse and to detect electrical
signal.
• If during this interval a natural beat occurs in the ventricle, the
feedback circuit detects signal from electrodes and amplify it.
• This signal then resets timing circuits.
R-WAVE INHIBITED PACEMAKER
• The R-wave inhibited pacemaker is similar to the demand type, except
that the inhibited period of time for triggering is a bit long.
• The triggering circuits are inhibited for a period of time after each R
wave. The pulse is enabled,however,if no R wave occurs for a preset
period.
AV SYNCHRONIZED PACEMAKER
• The AV synchronized pacemaker responds to the ECG P wave, the
ECG feature created by contraction of the heart’s atria.
• The atrial pacer circuitry contains a P Q delay circuit that simulates
the propagation time in the heart’s electro conduction system.
• Once the pacemaker senses the P wave and the P Q delay of about
120 ms has elapsed, then the pacer will fire a pulse to stimulate the
ventricles into conduction.
CONT.…
• The AV pacer has the advantage that it will follow the changing heart
rate demands of the body.
• Pacers synchronized into the ventricles can result only in ventricular
contractions independent of the atrial heart rate set by the SA node.
• The AV pacer will usually track heart rates in the 50 to 150 beats/min
range but will revert to fixed rate if the atrial rate exceeds 150
beats/mins.
• This feature prevents atrial triggering if atrial flutter or atrial
tachycardia occurs.
PACEMAKER LEADS
Two type of pacemaker lead wire are used:
• Endocardial and Myocardial
• Endocardial leads is inserted through opening in a vein and then
threaded through venous system, right atrium and into the right
ventricles of the heart.
• Myocardial leads are connected directly to the heart muscle.
CONT.…
• If a screw(helix) is used to fix the lead to
the heart,the lead is known as Active
fixation lead.
• A passive fixation leads has tines ,which
are designed to engage the trabeculae on
the inner surface of the heart.
MONOPOLAR AND BIPOLAR LEAD
• Bipolar Mode: Both electrodes are inside a single catheter. The distal
tip is one electrode, while the second is located at short distance
behind the tip.
• These electrodes are made up of platinum-iridium alloy to
prevent interaction with body fluids.
CONT.…
• Bipolar sensing detects the intrinsic electrical activity occurring
between the tip electrode and the ring electrode of the lead.
• Unipolar sensing detects electrical activity occurring between the tip
of the lead.
PACEMAKER BATTERIES
• Mercury cells: Mercury cells are used in the last decade and have a life
span between 2 and 4 years.
• Lithium cells: It has life span more than 5 years.
CONT.…
• Principal power source of pacemaker is lithium iodine cell.
• Mercury pacemakers batteries are able to operate as long as 2 to
4 years.
• Nuclear power source of pacemaker is about 10 years life
expectancy. Generates heat by the natural decay of certain
radionuclides to generate electricity in a thermocouple.
• Pulse rate drops with decreased battery voltage.
SENSING
• Pacemaker sensing describes the response of a pacemaker to intrinsic
heartbeats.
• Ability of a device to detect intrinsic cardiac activity.
CONT.…
• The P waves, or atrial activity, are transmitted through the atrial lead (if
present) to the atrial channel of the pacemaker, and sensed as atrial
activity.
• Ventricular activity (the QRS complex) is transmitted through the
ventricular lead (if present) to the ventricular channel of the pacemaker,
and this is sensed as ventricular activity.
REFRACTORY PERIOD
• Pacemakers have refractory periods on each channel, which are
generally programmable. During the refractory periods, sensed events
are ignored.
• This is the period after a ventricular sensed or paced event, when the
atrial channel is refractory.
• The effect is that in a dual chamber tracking mode, a P wave that falls
shortly after the QRS complex (either a paced or intrinsic QRS) will
not be tracked.
TYPES OF PERMANENT
PACEMAKER
• Single-chamber
– One pacing lead is inserted into either the right atrium or right
ventricle but not both
• Dual-chamber
– Electrodes are placed into two chambers of the heart
– One lead paces the atrium while the other paces the ventricle
– By assisting the heart in coordinating the function between the atria
and ventricles, this type of pacemaker acts similarly to how the
heart naturally paces itself.
SINGLE CHAMBER SYSTEM
• The pacing lead is implanted in the atrium or ventricle,
depending on the chamber to be paced and sensed.
• Advantage: Implantation of a single lead
• Disadvantage:
• Single ventricular lead doesn’t provide AV synchrony
• Single atrial lead doesn’t provide ventricular backup if A to V
conduction is lost.
DUAL CHAMBER SYSTEM
• Have two leads; one lead is implanted in the atrium, the other
lead is implanted in the ventricle.
Benefits
• Provides AV synchrony
• Lower incidence of atrial fibrillation
• Lower risk of systemic embolism and stroke
• Lower incidence of new congestive heart failure
• Lower mortality and higher survival rates
CAPTURE FUNCTION
• Ability of the pacemaker to generate a response from the heart
(contraction) after electrical stimulation.
• Depolarization of atria/ventricles in response to a pacing stimulus.
• Two settings are used to ensure capture: Amplitude and Pulse width
AMPLITUDE
• Amplitude is the amount of voltage delivered to the heart by the
pacemaker
• Amplitude reflects the strength or height of the impulse.
• The amplitude of the impulse must be large enough to cause
depolarization( capture the heart)
• The amplitude of the impulse must be sufficient to provide an
appropriate pacing
PULSE WIDTH
• It is the time(duration) of pacing pulse expressed in
milliseconds(ms).
• Pulse width is the length of time each pacing pulse is delivered &
must be long enough for depolarization to disperse to the
surrounding tissue.
CONT…
• Rheobase: the lowest point on the curve is the lowest voltage that
results in myocardial depolarization at infinitely long pulse duration.
• Chronaxie(pulse duration time): the threshold pulse duration at
twice the rheobase voltage. The ideal pulse duration should be
greater than the chronaxie time.
FACTORS THAT AFFECT BATTERY
LONGEVITY INCLUDES:
• Lead impedance( opposition to current flow)
• Amplitude and pulse width setting
• Percentage paced and intrinsic events
• Rate responsive modes programmed ‘on’
IMPEDANCE CHANGES AFFECT PACEMAKER
FUNCTION AND BATTERY LONGEVITY
• High impedance reading reduces battery current drain and increases
longevity.
• Low impedance reading increases battery current drain and decreases
longevity.
• Impedance reading value ranges from 300 to 1500 ohm.
• High impedance lead will show impedance reading values greater than
1500 ohms.
WHEN USING OHM’S LAW:
• If you reduce the voltage by half, the current is also cut in half.
• If you reduce the impedance by half, the current doubles.
• If the impedance increases, the current decreases.
• Because permanent pacemaker generates a constant voltage, the
higher the pacing resistance, the lower the current drain, and the
lower the rate of battery depletion.
CATHODE
• An electrode that is in contact
with the heart tissue
• Negatively charged when
electrical current is flowing.
Cathode
ANODE
• An electrode that receives the
electrical impulse after
depolarization of cardiac tissue
• Positively charged when electrical
current is flowing
Anode
CONDUCTION PATHWAYS
• Body tissues and fluids are part of
the conduction pathway between
the anode and cathode
Anode
Tissue
Cathode
DURING PACING,THE IMPULSE:
Impulse onset
• Begins in the pulse generator *
• Flows through the lead and the
cathode (–)
• Stimulates the heart
• Returns to the anode (+)
A UNIPOLAR PACING SYSTEM CONTAINS A
LEAD WITH ONLY ONE ELECTRODE WITHIN
THE HEART, IN THIS SYSTEM, THE PULSE:
• Flows through the tip electrode(
cathode)
• Stimulates the heart
• Returns to the body tissue to
the anode
A BIPOLAR PACING SYSTEM THE PULSE:
• Flows through the tip electrode
located at the end of lead wire
• Stimulates the heart
• Returns to the ring electrode
above the lead tip
TYPES OF TEMPORARY PACEMAKER
There are 3 types of Temporary Pacemaker
1. Transvenous Invasive pacemaker( endocardial)
• It consists of lead that are threaded transvenously to the right
atrium or right ventricle and attached to external power source.
2. Trans thoracic Invasive pacing( Epicardial pacing)
• It is achieved by attaching an atrial and ventricle and attached to
epicardium during heart surgery. The leads are passed through the
chest wall and attached to external power source.
CONT.…
[Link] pacemaker( Non invasive pacing)
• It is used to provide adequate heart rate and rhythm to the patient
in an emergency situation.
CONCLUSION
• A pacemaker is an electronic device that provides repetitive
electrical stimuli to heart muscle when the patients intrinsic
pacemaker fails to provide perfusing rhythm.
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