BASICS OF PACEMAKER

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HISTORY

1958 Senning and Elmqvist Asynchronous (VVI) pacemaker implanted by thoracotomy and functioned for 3 hours Arne Larsson First pacemaker patient Used 23 pulse generators and 5 electrode systems Died 2001 at age 86 of cancer 1960 First atrial triggered pacemaker 1964 First on demand pacemaker (DVI) 1977 First atrial and ventricular demand pacing (DDD) 1981 Rate responsive pacing by QT interval, respiration, and movement 1994 Cardiac resynchronization pacing

What is a Pacemaker?

A Pacemaker System consists of a Pulse Generator plus Lead (s)

Implantable Pacemaker Systems Contain the Following Components:

Pulse generator- power source or battery
Lead

Leads Cathode (negative electrode) Anode (positive electrode)

Anode IPG

Body tissue
Cathode
S

The Pulse Generator

Contains a battery that provides the energy for sending electrical impulses to the heart

Houses the circuitry that controls pacemaker operations

Circuitry

Battery

Anatomy of a Pacemaker
Resistors Atrial connector Connector

Ventricular connector
Defibrillation protection Output capacitors

Hybrid

Clock
Reed (Magnet) switch Telemetry antenna

Battery

General Characteristics of Pacemaker Batteries

Hermeticity, as defined by the pacing industry, is an extremely low rate of helium gas leakage from the sealed pacemaker container low rate of self-discharge lithium iodine -a long shelf life and high energy density DDD drains a battery more rapidly

Power source
Longevity in single chamber pacemaker is 7 to 12 years. For dual chamber longevity is 6 to 10 years. Most pacemakers generate 2.8 v in the beginning of life which becomes 2.1 to 2.4 v towards end of life.
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Leads
Deliver electrical impulses from the pulse generator to the heart

Sense cardiac depolarisation

Lead

Lead Characterization
Position within the heart
Endocardial or transvenous leads Epicardial leads

Polarity
Unipolar Bipolar

Fixation mechanism
Active/Screw-in Passive/Tined

Insulator
Silicone Polyurethane

Shape
Straight J-shaped used in the atrium

Lead components
Conductor Connector Pin Insulation Electrode

Transvenous Leads - Fixation Mechanisms

 Passive fixation
The tines become lodged in the trabeculae

 Active Fixation
The helix (or screw) extends into the endocardial tissue Allows for lead positioning anywhere in the hearts chamber

Myocardial and Epicardial Leads

Leads applied directly to the heart
Fixation mechanisms include:
Epicardial stab-in Myocardial screw-in Suture-on

Active Fixation
Advantages

Passive Fixation

Easy fixation Less expensive & simple Easy to reposition Minimal trauma to patient Lower rate of dislodgement Lower thresholds Removability

Disadvantages

More expensive >Complicated implantation

Higher rate of dislodgement (>a/c) Difficult to remove chronic lead

 Cathode:-An electrode that is in contact with the heart Negatively charged

Anode:-receives the electrical impulse after depolarization of cardiac tissue Positively charged when electrical current is flowing
Anode

Cathode

A Unipolar Pacing System

Contains a lead with an electrode in the heart

Flows through the tip electrode (cathode)

Stimulates the heart

Returns through body fluid and tissue to the PG (anode)

+
Anode

Cathode

A Bipolar Pacing System Contains a lead with 2 electrodes in the heart

Flows through the tip electrode located at the end of the lead wire

Stimulates the heart Returns to the ring electrode above the lead tip
Anode

Cathode

Unipolar leads
One electrode on the tip & one conductor coil
Conductor coil may consist of multiple strands - (multifilar leads) Unipolar leads have a smaller diameter than bipolar leads Unipolar leads exhibit larger pacing artifacts on the surface ECG

Bipolar leads
Circuit is tip electrode to ring electrode Two conductor coils (one inside the other) Inner layer of insulation Bipolar leads are typically thicker than unipolar leads Bipolar leads are less susceptible to oversensing noncardiac signals (myopotentials and EMI)

Coaxial Lead Design

Unipolar
Advantages Smaller diameter Easier to implant Large spike

Bipolar
No pocket stimulation Less susceptible to EMI Programming flexibility

Disadvantages Pocket stimulation Far-field oversensing No programming flexibility

Larger diameter Stiffer lead body Small spike Higher impedance Voltage threshold is 30% higher

Electrodes
Leads have 1/> electrically active surfaces referred to as the electrodes Deliver an electrical stimulus, detect intrinsic cardiac electrical activity, or both Electrode performance can be affected by
Materials Polarization Impedance Pacing thresholds Steroids

Electrode Materials
The ideal material for an electrode
Porous (allows tissue ingrowth) Should not corrode or degrade Small in size but have large surface area Common materials
Platinum and alloys (titanium-coated platinum iridium) Vitreous carbon (pyrolytic carbon) Stainless steel alloys such as Elgiloy

 Voltage is the force that causes electrons to move through a circuit In a pacing system, voltage is:
Measured in volts Represented by the letter V Provided by the pacemaker battery Referred to as amplitude

Voltage

Current
The flow of electrons in a completed circuit In a pacing system, current is:
Measured in mA (milliamps) Represented by the letter I Determined by the amount of electrons that move through a circuit

 Constant-Voltage and Constant-Current Pacing Most permanent pacemakers are constantvoltage pacemakers Voltage and Current Threshold

Voltage threshold is the most commonly used measurement of pacing threshold

Pacing Thresholds

Defined as the minimum amount of electrical energy required to consistently cause a cardiac depolarization

Consistently refers to at least 5 consecutive beats

Low thresholds require less battery energy

Capture

Non-Capture

The Strength-Duration Curve

The strength-duration curve illustrates the relationship of amplitude and pulse width
Values on or above the curve will result in capture

Stimulation Threshold (Volts)

2.0 1.5 1.0

Capture
.50 .25 0.5 1.0 1.5

Duration Pulse Width (ms)

 Energy (J) = Voltage (V) Current (mA) Pulse Duration (PD in ms). Charge (C) = Current (mA) Pulse Duration (ms).

 At very low pulse width thresholds, the charge is low, but the energy requirements are high because of elevated current and voltage stimulation thresholds. At pulse durations of 0.40.6 ms, all threshold parameters - ideal At high pulse durations, the voltage and current requirements may be low, but the energy and charge values are unacceptable

Impedance
The opposition to current flow

In a pacing system, impedance is Measured in ohms Represented by the letter R (W for numerical values) The measurement of the sum of all resistance to the flow of current
Resistance is a term used to refer to simple electric circuits without capacitors and with constant voltage and current Impedance is a term used to describe more complex circuits with capacitors and with varying voltage and current

Impedance

Pacing lead impedance typically stated in broad ranges, i.e. 300 to 1500 Factors that can influence impedance

Resistance of the conductor coils Tissue between anode and cathode The electrode/myocardial interface Size of the electrodes surface area Size and shape of the tip electrode

Ohms Law is a Fundamental Principle of Pacing That:

Describes the relationship between voltage, current, and resistance

V
V=IXR I=V/R R=V/I

Impedance and Electrodes

Large electrode tip
Threshold Impedance Polarization

Small electrode tip

Threshold Impedance Polarization

Sensing
Sensing is the ability of the pacemaker to detect an intrinsic depolarization
Pacemakers sense cardiac depolarization by measuring changes in electrical potential of myocardial cells between the anode and cathode

An Electrogram (EGM) is the Recording of Cardiac Waveforms Taken From Within the Heart
Intrinsic deflection on an EGM occurs when a depolarization wave passes directly under the electrodes Two characteristics of the EGM are:
Signal amplitude(mv) Slew rate(v/sec)

Intrinsic R wave Amplitude

Typical intrinsic R wave amplitude measured from pacing leads in the Right Ventricle are more than 5 mV in amplitude
Intrinsic R wave in EGM

The Intrinsic R wave amplitude is usually much greater than the T wave amplitude

Undersensing . . .
Pacemaker does not see the intrinsic beat, and therefore does not respond appropriately

Intrinsic beat not sensed

Scheduled pace delivered

VVI / 60

Oversensing
...though no activity is present

Marker channel shows intrinsic activity...

VVI / 60

An electrical signal other than the intended P or R wave is detected

NASPE/ BPEG Generic (NBG) Pacemaker Code

I Chamber Paced II Chamber Sensed III Response to Sensing IV Programmable Functions/Rate Modulation V Antitachy Function(s)

V: Ventricle A: Atrium

V: Ventricle A: Atrium

T: Triggered P: Simple programmable I: Inhibited M: Multiprogrammable

P: Pace S: Shock D: Dual (P+S)

D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating O: None O: None O: None

R: Rate modulating O: None O: None

S: Single
(A or V)

S: Single
(A or V)

Pacemaker Timing
Pacing Cycle : Time between two consecutive events in the ventricles (ventricular only pacing) or the atria (dual chamber pacing) Timing Interval : Any portion of the Pacing Cycle that is significant to pacemaker operation e.g. AV Interval, Ventricular Refractory period