ROHINI COLLEGE OF ENGINEERING AND TECHNOLOGY
PACEMAKER
More number of peoples fall victim to heart attacks and more are critically injured
in accidents. Taking care of these patients in special care units in hospitals involves the
use of several types of specialized equipment, among which are cardiac pacemakers and
defibrillators.
Heart block occurs whenever the conduction system fails to transmit the pacing
impulse, from the atria to the ventricles properly.
• In first-degree block an excessive impulse delay at the AV junction it causes the P-
R interval to exceed 0.2 sec for normal adults.
• Second-degree block results in the complete but intermittent inhibition at the AV
mode.
• Third-degree block total and continuous impulse blockage.
Pacemaker:
Fig: Pulse generator fixed in abdomen
A device capable of generating artificial pacing impulses and delivering them to
the heart is known as a pacemaker system. It consists of a pulse generator and appropriate
electrodes.
Types of Pacemakers:
1. Internal Pacemakers
2. External Pacemakers
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Internal Pacemakers:
Internal pacemakers may be permanently implanted in patients whose SA nodes
have failed to function properly or those who suffer from permanent heart block because
of a heart attack. Internal pacemaker is defined as one in which the entire system inside
the body.
Internal pacemaker systems are implanted with the pulse generator placed in a
surgically formed pocket below the right or left clavicle in the left subcostal area. For
women’s it placed in beneath the right or left major pectoralis. Internal leads connect to
electrodes that directly contact the inside and right ventricle.
Exact location of the pulse generator depends on type of electrode used, nature of
the cardiac function, mode of pacing. Pulse generator must be completely self-contained
with a power source capable of operating a period of years.
Fig: Internal Pacemaker
External Pacemaker:
An external pacemaker usually consists of an externally worn pulse generator
connected to electrodes located. External pacemakers are used on patients with temporary
heart irregularities, including heart blocks. Also used for temporary management of certain
arrhythmias that may occur in patients during critical postoperative periods, during cardiac
surgery, especially in valves or septum.
Fig: Pacemaker strapped on arm
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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.
Types of pacing modes:
Several pacing techniques are possible with both internal and external pacemakers.
Fig: Classification of pacing modes
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.
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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.
Fig: Block diagram of standby mode
Artial 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. Here
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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.
Fig: Block diagram of Atrial program mode
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.
Block diagram of Components circuitry
Fig: Block diagram components of circuitry
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Timing circuit:
It consists of RC network and Reference voltage source and comparator. Which
determines the basic pacing rate of the pulse generator. Its output given to a second stage
RC network i.e., pulse with generator.
Pulse width circuit:
Determines the stimulating pulse duration.
Rate limit circuit:
Disable the comparator for a preset interval and thus limits the pacing rate to
maximum 120 pulse/min.
Voltage Monitor:
Senses cell depletion and signals the rate slowdown circuit and energy
compensation circuit of this event.
Output circuit:
Provides a voltage pulse to stimulate the heart rate slow down circuit. When cell
depletion occurred it shuts OFF some of the circuit. It cases the pulse duration to slow
down the rate 8 ± 3 beats/min.
Energy compensation circuit:
It causes the pulse duration to increase as the battery voltage decreases. Also to
maintain nearly constant stimulation energy to the heart.
Refractory circuit:
Provides a period of time following an output pulse or a sensed R-wave during the
amplifies will not respond to outside signals.
Sensing circuit:
Detects a spontaneous R-wave and reset the oscillator timing capacitor.
Reversion circuit:
Allows the amplifier to detect a spontaneous R wave in the presence of low level
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continuous wave interference. In absence of R wave, it allows oscillator to pace at its
present rate ± 1 beat/min.
Methods of Stimulation of pacemaker:
There are two methods of stimulation namely,
1. External stimulation
2. Internal stimulation
External Stimulation:
The external stimulation is used to restart the normal rhythm of the heart in case of
cardiac standstill, i.e., standstill can occur during open heart surgery or whenever there is
a sudden physical shock or accident. Generally, the paddle shaped electrodes are applied
on the surface of the chest and currents in the range of 20-150mA are used.
Internal Stimulation:
The internal stimulation is employed as long term pacing because of parameter
damage that prevents normal self-triggering of the heart. In internal stimulation, the
electrodes are in the form of Teflon coated stainless steel whereas in some cases during
restarting of the heart after open heart surgery Spoon like electrodes are employed.
In both methods of stimulation, bipolar electrodes and unipolar electrodes are
employed. In bipolar electrodes, there are stimulating electrode and contact electrode
which serves as return path for the current to the pacemaker, whereas in case of unipolar
electrode there is only the stimulating electrode and the return path for the current to the
pacemaker is made to the body fluids.
Difference between Internal and External Pacemaker:
Based on the placement of pacemaker, there are two types
• External pacemaker (temporary heart)
• Internal pacemaker or implanted pacemaker (permanent heart)
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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.
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.
Specification of Pacemaker:
1. Weight: 33-98 grams
2. Reliability: 3.5 – 18 years
3. End-of-life indicator: 2-10% drop in pulse rate
4. Pulse rate: 25-155 pulses per minute
5. Pulse width: 0.1-2.3 milliseconds
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6. Pulse amplitude: 2.5 to 10 volts
7. Battery capacity: 0.44-3.2 Amp-hours
Components of Pacemaker:
The pacemaker consists of Pulse generator, Electrodes and Battery. Pulse generator
is used to generate the pulses for heartbeat. The pulse should have the pulse to space ratio
1: 10000 and that should be negative going pulses to avoid the ionization of the muscles.
The pulse voltage is made variable to allow adjustments in the energy delivered by
the pacemakers to the heart during each pulse. During the pulse duration, the stimulus
voltage drives energy into heart muscles. The duration of each pulse is between 1 and 2
milliseconds.
Fig: Pacemaker pulses
The pulse repetition rate is usually 70 pulses/min, but many pacemakers are
adjustable in the range of 50-150 pulses/min. Output pulses from the pacemaker appear at
the pair of electrodes, used for triggering the heart. The electrodes are used to connect the
pacemaker and the heart. Generally, the unipolar electrodes are used. Battery is used to
work up the pacemaker.
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