PACEMAKER

Introduction
A pacemaker is a medical device which uses electrical impulses, delivered by electrodes
contacting the heart muscles, to regulate the beating of the heart. The primary purpose of a
pacemaker is to maintain an adequate heart rate, either because the heart's native pacemaker is
not fast enough, or there is a block in the heart's electrical conduction system. Modern
pacemakers are externally programmable and allow the cardiologist to select the optimum
pacing modes for individual patients. Some combine a pacemaker and defibrillator in a single

implantable device. Others have multiple electrodes stimulating differing positions within
the heart to improve synchronisation of the lower chambers of the heart.

Methods of pacing

Percussive pacing
Percussive pacing, also known as transthoracic mechanical pacing, is the use of the closed
fist, usually on the left lower edge of the sternum over the right ventricle in the vena cava,
striking from a distance of 20 - 30 cm to induce a ventricular beat (the British Journal of
Anesthesia suggests this must be done to raise the ventricular pressure to 10 - 15mmhg to induce
electrical activity). This is an old procedure used only as a life saving means until an electrical
pacemaker is brought to the patient.[16]

Transcutaneous pacing
Transcutaneous pacing (TCP), also called external pacing, is recommended for the initial
stabilization of hemodynamically significant bradycardias of all types. The procedure is
performed by placing two pacing pads on the patient's chest, either in the anterior/lateral
position or the anterior/posterior position. The rescuer selects the pacing rate, and gradually
increases the pacing current (measured in mA) until electrical capture (characterized by a wide
QRS complex with a tall, broad T wave on the ECG) is achieved, with a corresponding pulse.
Pacing artifact on the ECG and severe muscle twitching may make this determination difficult.
External pacing should not be relied upon for an extended period of time. It is an emergency
procedure that acts as a bridge until transvenous pacing or other therapies can be applied.

Epicardial pacing (temporary)

Temporary epicardial pacing is used during open heart surgery should the surgical
procedure create atrio ventricular block. The electrodes are placed in contact with the outer wall
of the ventricle (epicardium) to maintain satisfactory cardiac output until a temporary
transvenous electrode has been inserted.
 ECG rhythm strip of a threshold determination in a patient with a temporary (epicardial)
ventricular pacemaker. The epicardial pacemaker leads were placed after the patient collapsed
during aortic valve surgery. In the first half of the tracing, pacemaker stimuli at 60 beats per
minute result in a wide QRS complex with a right bundle branch block pattern. Progressively
weaker pacing stimuli are administered, which results in asystole in the second half of the
tracing. At the end of the tracing, distortion results from muscle contractions due to a (short)
hypoxic seizure. Because decreased pacemaker stimuli do not result in a ventricular escape
rhythm, the patient can be said to be pacemaker-dependent and needs a definitive pacemaker.
Transvenous pacing (temporary)
Transvenous pacing, when used for temporary pacing, is an alternative to transcutaneous
pacing. A pacemaker wire is placed into a vein, under sterile conditions, and then passed into
either the right atrium or right ventricle. The pacing wire is then connected to an external
pacemaker outside the body. Transvenous pacing is often used as a bridge to permanent
pacemaker placement. It can be kept in place until a permanent pacemaker is implanted or until
there is no longer a need for a pacemaker and then it is removed.

Permanent pacing
Right atrial and right ventricular leads as visualized under x-ray during a pacemaker
implant procedure. The atrial lead is the curved one making a U shape in the upper left part of the
figure.
Permanent pacing with an implantable pacemaker involves transvenous placement of one or
more pacing electrodes within a chamber, or chambers, of the heart. The procedure is performed
by incision of a suitable vein into which the electrode lead is inserted and passed along the vein,
through the valve of the heart, until positioned in the chamber. The procedure is facilitated by
fluoroscopy which enables the physician or cardiologist to view the passage of the electrode lead.
After satisfactory lodgement of the electrode is confirmed the opposite end of the electrode lead
is connected to the pacemaker generator.

There are three basic types of permanent pacemakers, classified according to the number of
chambers involved and their basic operating mechanism:
 Single-chamber pacemaker. In this type, only one pacing lead is placed into a chamber
of the heart, either the atrium or the ventricle.

 Dual-chamber pacemaker. Here, wires are placed in two chambers of the heart. One lead
paces the atrium and one paces the ventricle. This type more closely resembles the natural
pacing of the heart by assisting the heart in coordinating the function between the atria
and ventricles.

 Rate-responsive pacemaker. This pacemaker has sensors that detect changes in the
patient's physical activity and automatically adjust the pacing rate to fulfill the body's
metabolic needs.

The pacemaker generator is a hermetically sealed device containing a power source,

usually a lithium battery, a sensing amplifier which processes the electrical manifestation of
naturally occurring heart beats as sensed by the heart electrodes, the computer logic for the
pacemaker and the output circuitry which delivers the pacing impulse to the electrodes.
 Most commonly, the generator is placed below the subcutaneous fat of the chest wall,
above the muscles and bones of the chest. However, the placement may vary on a case by case
basis.
The outer casing of pacemakers is so designed that it will rarely be rejected by the body's
immune system. It is usually made of titanium, which is inert in the body. The whole thing will
not be rejected, and will be encapsulated by scar tissue, in the same way a piercing is.
Basic function
Modern pacemakers usually have multiple functions. The most basic form monitors the
heart's native electrical rhythm. When the pacemaker fails to sense a heartbeat within a normal
beat-to-beat time period, it will stimulate the ventricle of the heart with a short low voltage pulse.
This sensing and stimulating activity continues on a beat by beat basis.
The more complex forms include the ability to sense and/or stimulate both the atrial and
ventricular chambers.
From this the basic ventricular "on demand" pacing mode is VVI or with automatic rate
adjustment for exercise VVIR - this mode is suitable when no synchronization with the atrial beat
is required, as in atrial fibrillation.

Biventricular pacing (BVP)

Three leads can be seen in this example of a cardiac resynchronization device: a right
atrial lead(solid black arrow), a right ventricular lead (dashed black arrow), and a coronary sinus
lead (red arrow). The coronary sinus lead wraps around the outside of the left ventricle, enabling
pacing of the left ventricle. Note that the right ventricular lead in this case has 2 thickened
aspects that represent conduction coils and that the generator is larger than typical pacemaker
generators, demonstrating that this device is both a pacemaker and a cardioverter-defibrillator,
capable of delivering electrical shocks for dangerously fast abnormal ventricular rhythms.
A biventricular pacemaker, also known as CRT (cardiac resynchronization therapy) is a
type of pacemaker that can pace both the septal and lateral walls of the left ventricle. By pacing
both sides of the left ventricle, the pacemaker can resynchronize a heart whose opposing walls do
not contract in synchrony, which occurs in approximately 25-50 % of heart failure patients.

Advancements in function
A major step forward in pacemaker function has been to attempt to mimic nature by
utilizing various inputs to produce a rate-responsive pacemaker using parameters such as the QT
interval, pCO - pCO2 (dissolved oxygen or carbon dioxide levels) in the arterial-venous system,
physical activity as determined by an accelerometer, body temperature, ATP levels, adrenaline,
etc. Instead of producing a static, predetermined heart rate, or intermittent control, such a
pacemaker, a 'Dynamic Pacemaker', could compensate for both actual respiratory loading and
potentially anticipated respiratory loading.

Patient considerations
Insertion
A pacemaker is typically inserted into the patient through a simple surgery using either
local anesthetic or a general anesthetic. The patient may be given a drug for relaxation before the
surgery as well. An antibiotic is typically administered to prevent infection. In most cases the
pacemaker is inserted in the left shoulder area where an incision is made below the collar bone
creating a small pocket where the pacemaker is actually housed in the patient's body. The lead or
leads (the number of leads varies depending on the type of pacemaker) are fed into the heart
through a large vein using a fluoroscope to monitor the progress of lead insertion. A temporary
drain may be installed and removed the following day. The actual surgery may take about an
hour.
Following surgery the patient should exercise reasonable care about the wound as it heals.
There is a followup session during which the pacemaker is checked using a "programmer" that
can communicate with the device and allows a health care professional to evaluate the system's
integrity and determine the settings such as pacing voltage output.
The patient may want to consider some basic preparation before the surgery. The most basic
preparation is that people who have body hair on the chest may want to remove the hair by
shaving or using a depilatory agent as the surgery will involve bandages and monitoring
equipment to be afixed to the body.
Since a pacemaker uses batteries, the device itself will need replacement as the batteries
lose power. Device replacement is usually a simpler procedure than the original insertion as it
does not normally require leads to be implanted. The typical replacement requires a surgery in
which an incision is made to remove the existing device, the leads are removed from the existing
device, the leads are attached to the new device, and the new device is inserted into the patient's
body replacing the previous device.

Pacemaker patient identification card

International pacemaker patient identification cards carry information such as; patient
data (between others, symptom primary, ECG, aetiology), pacemaker center (doctor, hospital),
IPG (rate, mode, date of implantation, MFG, type) and lead.

Living with a pacemaker

Periodic pacemaker checkups
Once the pacemaker is implanted, it is periodically checked to ensure the device is
operational and performing appropriately. Depending on the frequency set by the following
physician, the device can be checked as often as is necessary. Routine pacemaker checks are
typically done in-office every six (6) months, though will vary depending upon patient/device
status and remote monitoring availability.
At the time of in-office follow-up, the device will be interrogated to perform diagnostic testing.
These tests include:
 Sensing: the ability of the device to "see" intrinsic cardiac activity (Atrial and ventricular
depolarization).
 Impedance: A test to measure lead integrity. Large and/or sudden increases in
impedance can be indicative of a lead fracture while large and/or sudden decreases in
impedance can signify a breach in lead insulation.
 Threshold: this test confirms the minimum amount of energy (Both volts and pulse
width) required to reliably depolarize (capture) the chamber being tested. Determining
the threshold allows the Allied Professional, Representative, or Physician to program an
output that recognizes an appropriate safety margin while optimizing device longevity.

Lifestyle considerations
 A patient's lifestyle is usually not modified to any great degree after insertion of a
pacemaker. There are a few activities that are unwise such as full contact sports and
activities that involve intense magnetic fields.
 The pacemaker patient may find that some types of everyday actions need to be modified.
For instance, the shoulder harness of a vehicle seatbelt may be uncomfortable if the
harness should fall across the pacemaker insertion site.
  Any kind of an activity that involves intense magnetic fields should be avoided. This
includes activities such as arc welding possibly, with certain types of equipment, or
maintaining heavy equipment that may generate intense magnetic fields
 A 2008 U.S. study has found that the magnets in some portable music player headphones
may interfere with pacemakers when placed in close proximity.
 Some medical procedures may require the use of antibiotics to be administered before the
procedure. The patient should inform all medical personnel that they have a pacemaker.
Some standard medical procedures such as the use of Magnetic resonance imaging (MRI)
may be ruled out by the patient having a pacemaker.
 In addition, according to the American Heart Association, there are other devices that
cause risk with patients that have pacemakers, such as:
• anti-theft systems which are also known as electronic article surveillance (EAS) • metal
detectors for security • cell phones • extracorporeal shock-wave lithotripsy (ESWL) •
radiofrequency ablation (RFA) • short-wave or microwave diathermy • therapeutic radiation •
transcutaneous electric nerve stimulation (TENS)

Privacy and security

Security and privacy concerns have been raised with pacemakers that allow wireless
communication. Unauthorized third parties may be able to read patient records contained in the
pacemaker, or reprogram the devices, as has been demonstrated by a team of researchers.[31] The
demonstration worked at short range; they did not attempt to develop a long range antenna. The
proof of concept exploit helps demonstrate the need for better security and patient alerting
measures in remotely accessible medical implants.[31]

Other devices with pacemaker function

Sometimes devices resembling pacemakers, called ICDs are implanted. These devices are
often used in the treatment of patients at risk from sudden cardiac death. An ICD has the ability
to treat many types of heart rhythm disturbances by means of pacing, cardioversion, or
defibrillation.
BIBILIOGRAPHY

1. McWilliam JA (1889). "Electrical stimulation of the heart in man". Br Med J 1: 348–50.

doi:10.1136/bmj.1.1468.348.. Partial quote in "Electrical Stimulation of the Heart in Man -
1889", Heart Rhythm Society, Accessed May 11, 2007.

2. Lidwell M C, "Cardiac Disease in Relation to Anaesthesia" in Transactions of the Third

Session, Australasian Medical Congress, Sydney, Australia, Sept. 2-7 1929, p 160.

3. Mond H, Sloman J, Edwards R (1982). "The first pacemaker". Pacing and clinical
electrophysiology : PACE 5 (2): 278–82.

4. Aquilina O, "A brief history of cardiac pacing", Images Paediatr Cardiol 27 (2006), pp.17-
19.
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5. Weirich W, Gott V, Lillehei C (1957). "The treatment of complete heart block by the
combined use of a myocardial electrode and an artificial pacemaker". Surg Forum 8: 360–
3.