PACEMAKERS

KOMAL (LCO21590)
SHRUTI CHANDEL(LCO215103)
WHAT ARE PACEMAKERS?
 Pacemakers are devices that can be placed in your body,
usually by surgery, to support the electrical system in your
heart. They can stabilize abnormal heart rhythms and
prevent problems that can disrupt or endanger your life.
 A pacemaker is a small, battery-operated device. This
device senses when your heart is beating too slowly. It
sends a signal to your heart that makes your heart beat at
the correct pace. A pacemaker is implanted under the
skin. This procedure takes about 1 hour in most cases.
You will be given a sedative to help you relax. You will be
awake during the procedure.
How does a pacemaker work?

The sinus node is the heart's natural
pacemaker. It's a small mass of specialized
cells in the top of the right atrium (upper
chamber of the heart). It produces the electrical
impulses that cause your heart to beat.
A chamber of the heart contracts when an
electrical impulse or signal moves across it.
For the heart to beat properly, the signal must
travel down a specific path to reach the
ventricles (the heart's lower chambers).
When the heart's natural pacemaker is
defective, the heartbeat may be too fast, too
slow or irregular. Rhythm problems also can
occur because of a blockage or abnormality of
your heart's electrical pathways.
An artificial pacemaker replaces the heart's
defective natural pacemaker functions. Most
pacemakers work only when they’re needed
(demand pacemakers).
The sensors (electrodes) at the end of the
wires (leads) detect abnormal heartbeats and
deliver electrical impulses to return your heart
to its normal rhythm.


TYPES OF PACEMAKERS
 EXTERNAL PACEMAKERS
An external pacemaker is a medical device that uses electrodes to regulate
the heart's rate and output. It's also known as a transcutaneous or artificial
pacemaker.
This temporary method is used to maintain cardiac output in all those
irreversible conditions where there is a need for a permanent pacemaker or
those reversible situations where permanent pacing is contraindicated .
Bradycardia is defined as a heart rate less than 60 beats per minute. However,
not all cases of bradycardia require pacing.
Rather, transcutaneous pacing should only be applied in situations that
include systolic blood pressure less than 90, heart rate less than 40, or if an
arrhythmia is compromising organ perfusion.
EXTERNAL PACEMAKERS
The pacing impulse is applied through metal electrodes placed on the
surface of the body. Electrode jelly is used for better contact and to
avoid burning of the skin underneath. An external pacemaker may
apply up to 80-mA pulses through 50-cm2 electrode on the chest. This
procedure is painful and therefore is used only in an emergency or a
temporary situation.
The pulses may be delivered:
(i) Continuously—When it is felt that the heart rate is below the pre-set
value. The impulse frequency is independent of the electrical activity
of the heart.
(ii) On demand R-wave synchronous pacing—Normally the pacemaker
is inoperative but it is activated when the heart rate falls below the
normal or pre-set value. In such a situation, beat to beat examination
of the time interval between two R-waves is done. When this interval
exceeds the pre-set value, the pacemaker comes into operation. In the
R-wave synchronous mode of operation, the external pacemaker can
be used to support an implanted unit shortly before re-implantation or
shortly after initial implantation to secure pacing
The figure determines the block diagram of external pacemaker.
The electronic circuit of a pacemaker consists of two parts,
namely the impulse-generating (oscillator) circuit and the
output circuit. The impulse-forming circuit determines the
frequency and duration of the impulses. This is usually a multi-
vibrator circuit with adjustable rate and fixed pulse width. The
output circuit determines the shape and amplitude of the
impulse.
IMPLANTABLE PACEMAKER
An implantable pacemaker is a small, battery-
powered device that is placed under the skin of the
chest to help regulate the heart's electrical
problems.
It can help relieve symptoms of a slow, irregular
heart rhythm by restoring normal heart rates.
Implantable pacemakers are usually permanent
and are often more complex than external
pacemakers. They are usually placed in the chest,
just below the collarbone. The procedure to
implant a pacemaker is considered minor surgery
and can usually be done using local anesthesia.
Implantable pacemakers can last from 5-15 years,
depending on how often patients need them.


Types of Implantable
Pacemakers:
There are three basic types of implantable pacemakers which are
designed to serve different purposes:
[Link]-Chamber Pacemakers – In a single-chamber pacemaker, only
one wire (pacing lead) is placed into a chamber of the heart. Sometimes
it is the upper chamber, or atrium. Other times it is the lower chamber, or
ventricle.

[Link]-Chamber Pacemakers – In dual chamber pacemakers, wires are

placed in two chambers of the heart. One lead paces the atrium and one
paces the ventricle. This approach more closely matches the natural
pacing of the heart. This type of pacemaker can coordinate function
between the atria and ventricles.

3. Rate-Responsive Pacemakers – These have sensors that

automatically adjust to changes in a person’s physical activity.
VENTRICULAR SYNCHRONOUS DEMAND
PACEMAKER
A ventricular synchronous demand pacemaker is
a medical device that triggers heart contractions
when the normal beat is interrupted. These
pacemakers are designed to generate a pulse
when the natural heart rate falls below 68 to 72
beats per minute.
Ventricular demand pacemakers deliver current to
the ventricles if the heart rate falls below a
predetermined level. They are also known as
episodic pacing.
Synchronous pacing is a demand mode that
coordinates the efforts of the cardiac
resuscitation system's pacemaker with the
patient's own cardiac electrical activity. The pacer
fires only when no complex is sensed for a
predetermined amount of time.


VENTRICULAR SYNCHRONOUS
DEMAND PACEMAKER
This is followed by an amplifier and threshold detector which is designed to
operate with a detection sensitivity of 1–2 mV.

Sensitivity of this order ensures reliable detection of cardiac signals sensed on the
electrodes which typically have amplitudes in the 1–30 mV range depending on
the electrode surface area and the sensing circuit loading impedance .

A refractory period (T1) is necessarily incorporated to limit the pulse delivery rate,
particularly in the presence of electromagnetic interference. It is meant to prevent
multiple re-triggering of the a stable multivibrator following a sensed or paced
contraction.

The free-running multivibrator provides a fixed rate mode with an interval of T2 via
the output driver circuit.

The output pulses of a length T3 synchronous with input signals that fall outside
the sensing refractory period T1 are thus delivered at the stimulating electrodes.
PROGRAMMABLE PACEMAKER
 A programmable pacemaker is a medical
device used to manage and regulate the
electrical activity of the heart. It is typically
implanted in a patient's chest, with wires (leads)
connected to the heart, and it helps maintain a
healthy heart rate by sending electrical
impulses to the heart muscles.
 The "programmable" aspect of a pacemaker
refers to the device's ability to be adjusted or
programmed to meet the specific needs of an
individual patient. A programmable pacemaker
consists of:
 The implantable pacemaker
 A physician's console containing the
programmer and a data printer
 A communicating head that transmits wireless
telemetry signals over the patient's chest
 Figure is a detailed block diagram of the multi-programmable pacemaker.
 It may be considered as being comprised of the three systems.
 System I controls the main timing functions of the pulse generator and
carries the rate limiter, the pulse output circuit and the stimulating function of
the electrode. Operating as directed by the programmable control circuit, this
system generates output pulses at the programmed rate, width and
amplitudes unless over-ridden by System 2.
 System 2 carries the sensing and signal discriminating function of the circuit.
Comprising the sensing function of the electrode, an RF filter, a signal
amplifier and comparator, this system identifies signals of cardiac origin and,
where appropriate, sends an inhibit signal to System 1.
 System 3 carries the programmable control circuit, the data validate circuit,
the reed switch and the master timing crystal. This system effects program
recognition, storage, and execution as well as control of the battery and
various test sequences.
RATE RESPONSIVE
PACEMAKERS
RATE RESPONSIVE PACEMAKERS
Rate-responsive pacemakers, also known as rate-
adaptive pacemakers, are a type of cardiac
pacemaker that can adjust a person's heart rate in
response to their physiological needs. Unlike
standard pacemakers that maintain a fixed heart
rate, rate-responsive pacemakers can increase or
decrease the pacing rate in real-time, depending on
factors such as physical activity, stress, or metabolic
demand.
A rate-responsive pacemaker uses a sensor to
detect changes in a patient's metabolic needs. The
pacemaker then adjusts the rate at which it delivers
stimulation pulses to the patient's heart.
Rate-responsive pacemakers use several
technologies to determine the optimal heart rate,
including:
A physiological sensor that detects changes in the
patient's metabolic needs
A built-in piezoelectric crystal that converts
mechanical energy related to vibration, muscle
tension, and body movement into electrical signals
 A sensor is used to convert a physiological variable in the patient to an
electrical signal that serves as an input to the controller circuit, which can
determine whether any artificial pacing is required or not.
 The control algorithm in a rate-responsive pacemaker plays a crucial role in
adjusting the pacing rate based on the physiological data received from
various sensors. The primary function of the control algorithm is to ensure
that the patient's heart rate is appropriately synchronized with their activity
levels and metabolic demands.
 In a rate-responsive pacemaker, the pulse generator is a crucial component
responsible for generating and delivering electrical impulses to the heart to
control the heart rate. Its function is to create the pacing signals that mimic
the heart's natural electrical activity.
 In a rate-responsive pacemaker, the lead wire and electrode system serves a
crucial role in delivering electrical signals to the heart and sensing the heart's
activity. These components play a significant role in ensuring that the
pacemaker can monitor the heart's rhythm and adjust the pacing rate as
needed based on the physiological sensors.
Packaging of Implantable
Pacemakers
 The integrated electronic circuit and the lithium-iodide power source constituting
the pulse generator are hermetically sealed separately and then both of them are
sealed within the stainless steel case, thus providing complete and enduring
isolation from the corrosive body environment. The pulse generator is
hermetically sealed by tungsten inert gas welding. The case is manufactured
either of titanium or of 316 L stainless steel and tested to a standard helium leak
rate of 2 ¥ 10–8 cc/s at one atmosphere.
 The materials exposed to the subcutaneous environment are medicalgrade epoxy,
medical-grade silicon rubber urethane (Stokes et al., 1979), acetal copolymer and
type 316L stainless steel, consisting approximately of 66.9% iron, 17% chromium,
12% nickel, 2.5% molybdenum and traces of carbon, manganese, and silicon. All
these materials have a long history in medical implants, and have been found to
be tissue-compatible.
 In spite of all the precautions taken in packaging the pacemakers, there are
situations in which pacemaker carrying person needs to be careful. For example,
Magnetic Resonance Imaging (MRI) tests employ powerful magnets to create
images. In case the person has to undergo an MRI test, the doctor must be
informed.
Power Sources for Implantable
Pacemakers
 The life of a pacemaker is determined by the current consumption of the
electronic circuit and the available energy in the unit. The first clinical
application of an implantable cardiac pacemaker (Elmquist and Senning, 1960)
used nickel-cadmium rechargeable cells. These pacemakers were only
marginally successful and were, therefore, abandoned.
 For a very long time, the zinc-mercury battery has been the preferred power
source for implantable cardiac pacemakers. Nevertheless, this battery has
been documented as being responsible for most pacemaker failures.
Subsequently, biological power sources and nuclear batteries were tried, but
without much success.
 Lithium Cells: The long-life lithium-iodine battery powered pacemaker
represents a significant advance in pacemaker technology. The lithium battery
is solid-state and consists of an anode of metallic lithium (Li) and a cathode of
molecular iodine (I2) bonded in complex form to an organic carrier. The solid
electrolyte consists of crystalline lithium-iodide (LiI). The following reaction
takes place:
 2Li + I2 = 2 LiI + e
Lithium Batteries: Lithium batteries are the most common power source
for implantable pacemakers. They are typically non-rechargeable and
provide a consistent source of power for several years, typically ranging
from 5 to 15 years, depending on the device's settings and the type of
battery used. Lithium batteries are preferred because of their high energy
density, which allows for a compact design.

Rechargeable Batteries: Some pacemaker models use rechargeable

lithium-ion batteries. These batteries can be recharged remotely through
a specialized external device. Rechargeable pacemakers are less
common but offer the advantage of potentially extending the device's
lifespan and reducing the need for battery replacement surgeries.
However, they require regular monitoring and recharging, which can be a
drawback for some patients.
The choice between non-rechargeable and rechargeable batteries
depends on the patient's specific needs and the recommendations of
their healthcare provider.
Type of Leads and Electrodes
 Pacemakers use leads and electrodes to sense the heart's electrical
activity and deliver electrical impulses to regulate the heartbeat. These
components are crucial for the proper functioning of the device. There are
various types of leads and electrodes used in pacemakers:
 Endocardial Leads:
 Unipolar Leads: These leads have a single electrode at the tip, which is
typically located in the right ventricle. The pacemaker case itself
serves as the return electrode. Unipolar leads are less common today
due to their greater risk of oversensing and unwanted electrical noise.
 Bipolar Leads: Bipolar leads have two electrodes: one at the tip and
another located further up the lead. The two electrodes work together
to sense and deliver electrical impulses. Bipolar leads are more
commonly used because they offer better sensing and pacing
accuracy than unipolar leads.
 Epicardial Leads:
 Epicardial leads are placed on the outer surface of the heart, typically
during open-heart surgery. They are less common than endocardial
leads and are often used when endocardial lead placement is
challenging or not feasible.
Screw-In Leads:
 Some modern pacemakers use screw-in leads with corkscrew-like tips
that can be screwed into the heart tissue. This design provides a secure
and stable lead placement, reducing the risk of dislodgment.
Active-Fixation Leads:
 These leads have a retractable helix or screw tip at the end. The helix can
be extended and screwed into the heart tissue, allowing for more precise
lead placement.
Passive-Fixation Leads:
 Passive-fixation leads rely on their design and positioning within the
heart's anatomy to stay in place without active screwing. They are held in
position by the natural pressure and geometry of the heart chambers.
Lead Insulation:
 Leads are insulated to prevent electrical interference and to ensure that
electrical impulses are delivered only to the desired heart tissue. Silicone
rubber or other biocompatible materials are commonly used for lead
insulation.
 Fixation Mechanisms:
 The fixation mechanism at the lead tip can vary depending on the lead
type. It can be a tined or helical structure to secure the lead in place, or it
can be a passive design that relies on the lead's shape and positioning for
stability.
Problem with Leads and
Electrodes
 The leads are implanted in the highly hostile environment of the human body.
They are constructed to be small in diameter, but still have to be very flexible,
which evidently reduces their reliability.
 Leads may fail due to a variety of reasons, which may include body rejection,
fibrotic tissue formation, displacement, erosion, medical complications,
migration through body tissue, breach of the lead insulation or failure by
breakage. Due to various reasons, manufacturers usually disclaim any
warranties with respect to leads.
 Technical reliability, therefore, is only one aspect of the lead problem.
Because of the faults in pacemaker leads, the concept of redundancy
systems or of the fail-safe lead has been introduced. In the fail-safe lead,
there is a secondary conducting pathway along the lead so that if the primary
conductor fails, sufficient current still flows via the secondary conductor to
maintain pacing.
Advantages of pacemakers
 Heart Rate Regulation: Pacemakers continuously monitor the heart's electrical
activity and provide electrical impulses to stimulate the heart muscle when the
natural pacemaker (the sinoatrial node) fails to maintain an appropriate heart
rate. This ensures that the heart maintains a consistent and healthy rhythm.
 Improved Quality of Life: Pacemakers can significantly improve the quality of life
for individuals with heart rhythm disorders. By preventing symptoms such as
dizziness, fatigue, fainting, and shortness of breath associated with bradycardia,
pacemakers enable patients to engage in regular activities and enjoy a more
active life.
 Customized Pacing: Modern pacemakers are programmable, allowing healthcare
providers to tailor the device's settings to match an individual patient's specific
needs. This adaptability ensures that the heart rate is appropriate for the
patient's age, activity level, and underlying heart condition.
 Remote Monitoring: Many pacemakers come equipped with remote monitoring
capabilities. This technology enables healthcare providers to monitor the device's
performance and the patient's heart rhythm remotely, reducing the need for
frequent in-person visits and providing early detection of potential issues.
 Prolonged Lifespan: Pacemakers have a long lifespan, with the battery typically
lasting between 5 to 15 years, depending on device settings and usage. This
means that patients often require fewer device replacements, reducing the
frequency of surgical procedures.
Minimally Invasive Implantation: Pacemaker implantation is a minimally
invasive procedure that typically involves a small incision and local
anesthesia. Patients usually experience a shorter recovery time and fewer
post-operative complications compared to more invasive heart surgeries.
Emergency Backup: In addition to maintaining a normal heart rate during
everyday activities, pacemakers can provide an emergency backup if a
more severe heart rhythm issue, such as heart block, occurs. This can be life
-saving in critical situations.
Enhanced Longevity: By preventing bradycardia-related symptoms and
complications, pacemakers can help extend the lifespan of individuals with
heart rhythm disorders.
Improved Exercise Tolerance: Pacemakers can help patients participate in
physical activities and exercise more effectively, as they ensure that the
heart rate adjusts appropriately to meet increased demands during exertion.
Management of Arrhythmias: In some cases, pacemakers can be combined
with other cardiac devices, like implantable cardioverter-defibrillators (ICDs),
to manage a wider range of arrhythmias and provide additional protection
against life-threatening heart rhythms.
Disadvantages of pacemakers
 Infection: Infection at the surgical site or around the device can occur.
Infections may require antibiotic treatment and, in severe cases, the
removal of the pacemaker.
 Lead Dislodgment: Leads, the wires that connect the pacemaker to the
heart, can become dislodged or fractured, which may necessitate lead
revision or replacement.
 Lead Perforation: In rare cases, leads can perforate the heart muscle or
other nearby structures during insertion, potentially causing serious
complications.
 Lead Malfunction: Leads can develop issues such as insulation
breaches, which can lead to inappropriate pacing or electrical
interference.
 Battery Depletion: The pacemaker's battery has a limited lifespan
(usually 5 to 15 years). When the battery is depleted, the patient will
require a surgical procedure to replace the entire device.
 Pain or Discomfort: Some patients may experience discomfort or pain
at the implantation site, especially in the immediate post-operative
period.
 Allergic Reaction: Rarely, patients may develop allergic reactions to the
materials used in the pacemaker or its leads.
Limited MRI Compatibility: While some pacemaker models are now MRI-
compatible, many older devices are not. MRI scans may cause interference with
the pacemaker's functioning, and in some cases, this can be unsafe.
Electromagnetic Interference: Certain electronic devices and strong
electromagnetic fields (e.g., from industrial equipment) can interfere with the
proper functioning of the pacemaker, causing it to pace inappropriately.
Lead Failure Over Time: Leads can degrade or malfunction over time due to wear
and tear, potentially requiring lead replacement.
Pocket Hematoma: In some cases, bleeding or hematoma formation can occur
at the surgical site where the pacemaker is implanted.
Psychological Impact: Some patients may experience anxiety, depression, or
psychological distress related to the presence of a pacemaker.
Device Migration: In rare instances, the entire pacemaker can shift or migrate
within the body, requiring repositioning.
Need for Periodic Follow-up: Patients with pacemakers require regular follow-up
appointments for device checks, and occasional adjustments may be needed.
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