RCET/BME/V Sem/BM 3591/Diagnostic and Therapeutic Equipment | Dr.

Jackson Daniel |

1.5 Cardiac Pacemaker Internal and External Pacemaker

 Cardiac pacemakers are medical devices designed to regulate the heart's rhythm.
They are broadly categorized into internal pacemakers (implantable) and
external pacemakers (temporary and external to the body)

Internal Pacemakers (Implantable Pacemakers)

 Definition: These are surgically implanted devices that provide long-term rhythm
management for patients with chronic heart rhythm disorders.
 Components:
1. Pulse Generator: Contains the battery and circuitry that generates
electrical impulses.
2. Leads/Electrodes: Flexible insulated wires that deliver the impulses from
the pulse generator to the heart and sense the heart’s electrical activity.
 Types:

 Single-chamber pacemaker: Stimulates one heart chamber,

either the atrium or the ventricle.
 Dual-chamber pacemaker: Coordinates impulses to both the
atrium and ventricle.
 Biventricular pacemaker (CRT): Synchronizes the left and right
ventricles in patients with heart failure (cardiac resynchronization
therapy).
 Indications:
 Bradycardia (slow heart rate)
 Heart block (electrical signal disruption)
 Sick sinus syndrome
 Certain cases of heart failure (with CRT)
1
 RCET/BME/V Sem/BM 3591/Diagnostic and Therapeutic Equipment | Dr. Jackson Daniel |

 Advantages:
 Long-term rhythm correction
 Improved quality of life for chronic heart rhythm issues
 Automated response to the heart's needs (rate-responsive
pacemakers)
 Surgery: Minimally invasive, usually done under local anesthesia.

External Pacemakers

 Definition: Temporary devices used for short-term rhythm management, typically

in emergencies or perioperative settings.
 Components:
1. External Generator: A box containing the power source and controls for
pacing parameters.
2. Leads/Electrodes:
 Transcutaneous Pacing: Electrodes placed on the chest wall.
 Transvenous Pacing: Leads are threaded into the heart through a
vein.
 Epicardial Pacing: Leads attached to the outer surface of the heart
during surgery.
 Indications:
o Temporary heart block

 Bradyarrhythmias post-cardiac surgery

 Drug toxicity causing heart rhythm disturbances
 Bridge to permanent pacemaker implantation
 Advantages:
 Non-invasive (for transcutaneous pacing)
 Adjustable pacing settings
 Ideal for temporary or emergency use
 Limitations:
 May be uncomfortable, especially with transcutaneous pacing
 Requires close monitoring

2
 RCET/BME/V Sem/BM 3591/Diagnostic and Therapeutic Equipment | Dr. Jackson Daniel |

 External pacemakers, which includes all types of pulse generators located

outside the body are normally connected through wires introduced into the right
ventricle via a cardiac catheter. Pulse generator strapped to the lower arm of
patient who is confined to bed or midsection of ambulatory patient.

Several pacing techniques are possible with both internal and external
pacemakers.

Non-competitive:

Non-competitive method which uses pulse generators that programmed either

ventricular or atria. Ventricular programmed pacemakers are designed to operate either
in a demand (R-wave-inhibited) or standby (R-wave-inhibited) mode. Atria-programmed
pacemakers are always synchronized with p-wave of the ECG.

Competitive Mode:

Asynchronous pacing is called competitive pacing because the fixed rate impulse may
occur along with natural pacing impulse generated by the heart. The first pulse generator
were fixed rate or asynchronous device that produced pulse at a fixed rate.

Fixed rate:

Fixed rate pacers are sometimes installed in elder patients whose SA nodes cannot
provide proper stimuli. Fixed rate pacers are used temporarily to determine the amplitude
of impulses needed to pace or capture the heartbeat

3
 RCET/BME/V Sem/BM 3591/Diagnostic and Therapeutic Equipment | Dr. Jackson Daniel |

Ventricular Programmed:

Both type of ventricular-programmed pulse generator, are used when connected to the
ventricles via electrodes, it is also able to sense the presence or absence of a naturally
occurring R wave.

R-wave inhibited (DEMAND)

The output of R-wave inhibited unit is suppressed as long as natural R waves. Thus its
output of an R-wave-inhibited held back when the heart is able to pace itself. Some
external demand-mode pacers may be adjusted to operate in a fixed-rate mode by
means of an accessible mode control. Some external demand pacers have a sense-
pace indicated that deflects each detected R wave. ON-OFF switch of external demand
pacers are provided with interlock mechanism to prevent accidentally turned OFF.

R-wave triggered (STANDBY):

R-wave triggered pulse generator is like the R-wave inhibited units it senses each
intrinsic R wave. But this pacer emits an impulse with the occurrence of each sensed R
wave. Thus the unit is triggered rather than inhibited by each R wave. When impulses
are transmitted to the cardium during its absolute refractory period there will be no effect
on normal heart activity. If the intrinsic heart rate falls below the present rate, the pacer
will automatically operate synchronously at its present rate to pace the heart. Ventricular-
triggered pacing is used less frequently than inhibited pacing. Evidence of pacing
impulses present on patient’s ECG.

Atrial Programmed:
 In such case of complete heart block ventricles impulses fails to depolarize. But
the atria are able to depolarize the heart block. So artial synchronous pacing’s
are used.

4
 RCET/BME/V Sem/BM 3591/Diagnostic and Therapeutic Equipment | Dr. Jackson Daniel |

 Here the pulse generator is connected through wires and electrodes to both the
atria and ventricles. The atrial electrode are couple’s atrial impulses to the pulse
generator, which then emits impulse to stimulate the ventricles via ventricular
electrode.
 Therefore, the heart is placed at the same rate as the natural pacemaker. Pulses
applied directly to the heart rate usually rectangular in shape with a duration of
(0.15 to 3 msec). Depending on the type of pulse generator and needs of patient
it used.

 Then the pulse amplitudes may vary range from 5 to 15 mA for adult, and less for
children. In emergency 10 times greater are required.
 Captured signal will occur at a higher and controlled by refractory control
oscillator.
 Therefore, the fixed rate pacemaker ON and the output is given to the output
amplifier. Then the signal is given to ventricle through electrodes

Difference between External and Internal Pacemakers

External Internal

The pacemaker is placed outside the The pacemaker is a surgically implanted

body. It may be in the form of wrist watch when if the skin near the chest or
or in the pocket, from that one terminal abdomen, with its outputs leads are
will go in the heart through the vein. connected directly to the heart muscle.

Endocardiac electrodes are applied to the Myocardiac electrodes are in contact with
heart. They are in contact with the inner the outer wall of the myocardium.
surface of the heart chamber.

It does not require open chest surgery. It requires open chest minor surgery to
place the pacemaker.

5
 RCET/BME/V Sem/BM 3591/Diagnostic and Therapeutic Equipment | Dr. Jackson Daniel |

Battery can be easily replaced and any Battery can be replaced only by minor
defect can be easily attended without the surgery and doctors help is needed to
help from doctor. rectify the defects.

During the placement of pacemaker During placement, swelling and pain due
swelling and pain do not arise due to to maximum foreign body reaction.
minimum foreign body reaction.

There is no safety for the pacemaker, There is 100% safety for circuit from the
particularly in case of child carrying the external disturbances.
pacemaker.

The external pacemaker are used for Implanted pacemaker are used for
temporary heart regularity. permanent heart regularity.

Pacemaker Batteries:

Pacemaker batteries are essential components that power these life-saving devices.
They provide the electrical energy needed to stimulate the heart and maintain a regular
heartbeat in individuals with certain heart conditions.

Types of Pacemaker Batteries:

1. Lithium Iodine Batteries: These are the most commonly used type and are
known for their long lifespan, typically lasting between 5 and 10 years.
2. Lithium Carbon Monofluoride and Lithium Polycarbon Fluoride Batteries:
These are used in leadless pacemakers and have a similar lifespan to lithium
iodine batteries.

Battery Life and Replacement:

 Lifespan: The lifespan of a pacemaker battery can vary depending on factors

such as the type of battery, the pacing mode, and the patient's individual heart
rhythm.
 Monitoring: Your cardiologist will regularly monitor your pacemaker's battery
level to ensure it's functioning properly.
6
 RCET/BME/V Sem/BM 3591/Diagnostic and Therapeutic Equipment | Dr. Jackson Daniel |

 Replacement: When the battery level becomes low, the entire pacemaker
device, including the battery, will need to be surgically replaced.

Important Considerations:

 Regular Check-ups: It's crucial to attend regular follow-up appointments with

your cardiologist to monitor your pacemaker's performance and battery health.
 MRI Safety: Some pacemakers are MRI-safe, while others are not. It's essential
to discuss this with your doctor if you need an MRI scan.

Innovations in Battery Technology

 Rechargeable Batteries:
o Used in some experimental or advanced devices, especially for newer
applications like neurostimulators.
o Not yet widely adopted in pacemakers due to the risks and inconvenience
of recharging.
 Nuclear-Powered Batteries:
o Previously explored for longevity but largely abandoned due to safety and
ethical concerns.
 Battery-Free Pacemakers:
o Emerging technologies explore the use of energy-harvesting systems:
 Converts the heart's motion or surrounding vibrations into electrical
energy.
 Still in the experimental phase but promising for the future.

*********