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Pacemaker

W hat is it?
A pacemaker is an implanted medical device that stimulates the heart muscle with precisely timed
discharges of electricity, which cause the heart to beat in a manner very similar to the natural heart
rhythm. Pacemakers are prescribed for people whose hearts beat too slowly or irregularly.

A pacemaker consists of the following components:


Battery:
the pacemaker battery is the power supply. It is a small, sealed, lithium battery, that will generally last for
many years (the average battery lifetime is 8 years). The energy from the battery is delivered as tiny
electrical impulses that stimulate the heart.
Circuitry:
the circuitry is a kind of miniature computer inside the pacemaker. It controls the timing and intensity of
the electrical impulses delivered to the heart.
Case:
the battery and circuitry are sealed inside a metal case.
Connector block:
the plastic (epoxy) connector, which lies on top of the pacemaker's metal case, provides the connection
between the pacemaker and the lead(s).
The lead
The pacing lead is an insulated wire that carries the electrical impulse to the heart, and carries information
about the hearts natural activity back to the pacemaker. One end of the lead is connected to the
connector block. The other end is usually inserted through a vein and placed in the right ventricle or the
right atrium. Either one or two leads are used depending on the type of pacemaker. At a heart rate of 70
beats per minute, the lead will bend about 100,000 times a day! Therefore, leads are extremely flexible
and strong, so that they can withstand the twisting and bending caused by movement of the body and of
the beating heart.

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How does a pacemaker work?
A pacemaker has two essential tasks: pacing and sensing.
Pacing means that the pacemaker paces the heart in case the hearts own rhythm is interrupted, irregular,
or too slow.
Sensing means that the pacemaker monitors the hearts natural electrical activity. If a pacemaker senses
a natural heartbeat it will not stimulate the heart.
What types of pacing are there?
Depending on heart condition, doctor prescribes which chambers should be paced. Pacemakers are
designed for either (rate responsive) single chamber or (rate responsive) dual chamber pacing.

Single chamber pacing

Dual chamber pacing

In single chamber pacing, either the right atrium or the right ventricle is paced. Only one lead is used. The
pacemaker senses (monitors) electrical activity in either the atrium or the ventricle and determines
whether or not pacing is needed.
In dual chamber pacing, the pacemaker senses (monitors) electrical activity in both the atrium and the
ventricle and determines whether or not pacing is needed. Dual chamber pacemakers help the upper and
lower chambers of heart to beat in their natural sequence. This way, a paced heartbeat mimics a natural
heartbeat.
Rate responsive pacing
Rate responsive pacemakers can be single chamber or dual chamber pacemakers. Rate responsive
pacing is needed when heart cannot adjust its rate to meet the bodys demands. Normal heart rhythm
slows down or speeds up many times during the day depending on the level of activity and other factors.
It slows down while patent is resting or sleeping and it speeds up in response to exercise and excitement.
A rate responsive pacemaker uses (a) special sensor(s) that can recognize body changes.

Block diagram of a typical pacemaker

Components and Materials of Construction


A connector block,
made of polyurethane, is located at the top of the pacemaker. It serves to attach the pacemaker to the
pacemaker lead. Formerly, glass materials were used to comprise the connector block.The pulse
generator is encased in ASTM grade1 titanium. Titanium replaced ceramics and epoxy resin, which were

used for encapsulation of some pacemakers in the past, with silicone rubber. This upgrade to titanium
allowed patients to safely use appliances such as microwave ovens, because titanium helps to shield the
internal components and reduce the external electromagnetic interference
.A pacing lead is vital to the pacemaker system, because it transmits the electrical signal from the
pacemaker to the heart and information on the heart activity back to the pacemaker.
One or two leads may be used, depending on the type of pacemaker.
One end of the lead is attached to the connector block of the pacemaker. The other end is inserted
through a vein and placed in the right ventricle or right atrium of the heart. The lead is an insulated wire
consisting of a connector pin, lead body, fixation mechanism and at least one electrode. The connector
pin is the portion of the lead that is inserted into the connector block. The lead body is the insulated metal
wire that carries electrical energy from the pacemaker to the heart. The lead must be able to withstand
the flexing induced by the cardiac contractions in the warm and corrosive environment in the body. Thus,
the materials used must be inert, nontoxic, and durable. The lead body must be flexible, noncorrosive,
and durable. It must also be a good electrical conductor. The early lead body was insulated with
polyethylene. Currently, the lead body is insulated with a more resilient material such as silicone rubber
tubing or polyurethanes. Polyurethanes are generally stronger than silicone rubbers, which are easily
damaged. The strength of polyurethanes enables a thinner lead to be used in the pacemaker and offers
greater lead flexibility. Another advantage of polyurethanes is their very low coefficient of friction when
wet. However, metal-ion-induced oxidation may degrade polyurethanes, while silicones are not affected
by this mechanism of degradation. The fixation mechanism serves to hold the tip of the lead in place in
the heart. Currently, either a nickel-cobalt alloy with a silver core helix or an electrically active platinumiridium helix may be used to anchor the electrode of the lead to the surface of the heart.
Connector block

The electrode is located at the tip of the lead. It serves to deliver the electrical energy from the pacemaker
to the heart and information about the natural activity of the heart back to the pacemaker. Electrodes may
be composed of platinum, titanium, stainless steel, silver, or cobalt alloys. Titanium has been used
because it forms a nonconducting oxide layer at the surface. This surface prevents the exchange of
charge carriers across the boundary. Titanium also exhibits a high modulus of elasticity, high resistance to
corrosion, and high durability. Electrodes may be coated with iridium oxide to prevent nonconductive
layers from forming. The coated electrodes may also provide lower acute and chronic thresholds due to
the reduced local inflammation.
Drug-Eluting Leads- Leads have developed immensely since they were first introduced. The earliest leads
were attached to the outer surface of the heart. In the mid-1960s, transverse leads were introduced. They
could be inserted through a vein leading to the heart, thus eliminating the need to open the chest cavity
during implantation. In the 1970s, tined and active fixation leads were developed to replace smooth tip
leads. The prongs on the tined leads and the titanium alloy screws in the active fixation leads provide a
more secure attachment to the heart and are still used today

Electromagnetic Interference (EMI)


Implanted heart rhythm device is designed to work properly around most appliances and equipment. Most
things we handle or work near every day do not cause a problem. However, people with all types of
implanted devices do need to be aware that their device can be affected by electromagnetic interference
(EMI).

What is EMI?
EMI is the term used to describe the effect of an electromagnetic field on the operation of an implanted
heart rhythm device. Electromagnetic fields are invisible lines of force due to a combination of electrical
fields (produced by voltage) and magnetic fields (produced by current flow) that an object emits. EMI
occurs when the signals from an electromagnetic field temporarily interfere with the intended operation of
the implanted device.

How could EMI affect implantable devices (pacemaker or ICDs)?


In some cases, an implanted device may sense the electromagnetic signals produced by some objects
and misinterpret them as a rapid signal coming from patient heart.
A pacemaker (including the pacemaker contained within a defibrillator) may interpret the signals as heart
rhythm. It may respond by withholding its pacing.
A defibrillator may interpret the signals as a heart rhythm that needs therapy. This could cause the device
to deliver a shock that patent dont need. In rare cases, the device could withhold a necessary shock.
The effects of EMI are temporary. The closer the implanted device is to the item, the stronger the effect.
The farther away, the less effect will be experienced. EMI effects do not usually harm the device.

How can a magnet affect implanted device?


A magnet can also cause the implanted device to respond differently if the device gets within six inches of
the magnet. Defibrillator will respond to a magnet based on how the medico has programmed the device
to respond. A pacemaker will respond by temporarily pacing at a different pre-set rate.

Which items are not safe to use?

Body fat measuring scales


Magnetic mattresses or chairs
Jackhammers
MRI scans

Diathermy

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