Biomedical Instrumentation I

Lecture-7: Defibrillators & Pacemakers

Dr Muhammad Arif, PhD

m.arif@faculty.muet.edu.pk
https://sites.google.com/site/mdotarif/teaching/bmi
 Fibrillation
As long as the muscle fibers of the heart contract synchronously, the heart
will function as an efficient blood pump. But certain problems can develop
that disturb synchrony. One of these problems (or arrhythmias) is fibrillation.

Fibrillation is a condition in which the muscle fibers of the heart quiver

randomly and erratically instead of contracting together.

Fibrillation is a spontaneous contraction of individual muscle fibers

specifically non-synchronized activity of the heart.

If the atrial portion of the heart is in fibrillation, then it is called atrial

fibrillation.

If the ventricles portion of the heart is in fibrillation, then it is called

ventricular fibrillation.
 Fibrillation

Figure:
(a) Normal waveform.
(b) Ventricular fibrillation.
(c) Ventricular tachycardia.
 Defibrillators
The defibrillator is an electrical device that delivers a pulse of therapeutic
current intended to reverse a ventricular fibrillation (VF) or a life-threatening
ventricular tachycardia (VT) in the heart of a patient.

The applied current pulse needs to be controlled very carefully. Because if it

is too small, it causes fibrillation, and if it is too large, it can cause burn
injuries.

Defibrillator before 1960 were ac models.

These machines applied 5 to 6 A of 60 Hz ac across the patient's chest for
250 to 1000 msec.
The success rate for ac defibrillation was rather low however, and the
technique was useless for correcting atrial fibrillation.
In fact, attempting to correct atrial fibrillation using ac often results in
producing ventricular fibrillation, a much more serious arrhythmia.
 Defibrillators
Since 1960, several different dc defibrillators have been devised.

These machines store a dc charge that can be delivered to the patient.

The principal difference between dc defibrillators is in the wave shape of the

charge delivered to the patient.

The most common forms are:

1. Lown
2. Monopulse
3. Tapered (dc) delay
4. Trapezoidal waveforms.
 Lown Defibrillator Waveform
In 1962, Dr Bernard Lown of Harward University introduced the waveform
that bears his name. The Lown waveform is shown in the figure.
The voltage and current applied to the patient's chest plotted against time.
The current will rise very rapidly to about 20 A under the influence of slightly
less than 3 kV.
The waveform then decays back to zero within 5 ms, and then produces a
smaller negative pulse also of about 5 msec.

Lown Defibrillator Waform

 Lown Defibrillator Waveform Circuit
A simplified circuit diagram of Lown defibrillator is shown in the figure.
 Lown Defibrillator Waveform
The charge delivered to the patient is stored in a capacitor and is produced
by a high-voltage dc power supply.
The operator can set the charge level using the set energy knob on the front
panel.
The knob controls the dc voltage produced by the high-voltage power
supply and so can set the maximum charge on the capacitor
The energy stored in the capacitor is given by:

where
U is the energy in joules (J)
C is the capacitance of C1, in farads (F)
V is the voltage across C1, (V)
 Lown Defibrillator Waveform
Example: Calculate the energy stored in a 16-F capacitor that is charged
to a potential of 5000 V dc.

Solution
 Monopulse Defibrillator
Waveform
The monopulse waveform shown in Figure is a modified Lawn waveform
and is commonly found in certain portable defibrillator.
It is created by a Lown waveform defibrillator circuit but without inductor L,
which create the negative second pulse.
Consequently, the waveform decays to zero in the exponential manner
expected of an R-C network.
 Tapered DC Delay Defibrillator
Waveform
This waveform differs from the others in that it uses a lower amplitude and
longer duration to achieve the energy level.
The energy transferred is proportional to the area under the square of the
curve, so we may attain the same energy as in other waveforms.
The double-humped waveform characteristic of tapered delay machines is
achieved by placing two L-C sections, such as in Lown waveform defibrillator
circuit, in cascade with each other.
 Trapezoidal Defibrillator Waveform
The trapezoidal waveform shown in figure is another low-voltage, long
duration shape.
The initial output potential is about 800 V, which drops continuously for
about 20 ms until it reaches 500 V, where it is terminated .
 Standard Anterior Paddle
The energy from a defibrillator is delivered through a set of high-voltage
paddle electrodes.
The type shown in Figure is called an anterior paddle.
 Standard Anterior Paddle

In this design the insulated handgrip is perpendicular to the metal electrode

surface.

The high-voltage cable enters from the side.

A thumb switch to control the discharge is mounted at the top of the grip.

A defibrillator paddle and cable set using two of these electrodes is called
an anterior-anterior set.

To defibrillate, one electrode is placed on the chest directly over the heart
while the second electrode is placed on the left side of the patient's chest.

A conductive paste is smeared on the electrodes to ensure an inefficient

transfer of charge and reduce any burning of the patient's skin.
 Posterior Paddle
This electrode is constructed flat and is designed so that the patient can lie on it.
Posterior paddles are always paired with one anterior paddle to form an anterior-
posterior pair .
 D-Ring Anterior Paddle
A more modem anterior paddle is the D-ring type shown in Figure.
This type of paddle is used on most current model defibrillators and has
been popular on portable models for some time.
 Internal Paddle
Internal paddle sets use two of these electrodes, but one may not have the
thumb switch.
There paddles are used during open-heart surgical procedures to apply the
electrical shock directly to the myocardium.
 Cardioverter
In certain types of arrhythmia (e.g., atrial fibrillation), the patient's ventricles
maintain their ability to pump blood. as evidenced by the existence of an R
wave feature in the ECG waveform.

These arrhythmias are also correctable by electrical shack to the heart, but
it is necessary to avoid delivering the shock during the ventricles' refractory
period (the T wave of the ECG waveform).

Sometime the shock intended to correct the problem will create a much
more serious arrhythmia such as ventricular fibrillation.

The shock is usually timed to occur approximately 30 sec after the R wave
peak.
 Cardioverter
Human operators cannot be trusted to time the ECG waveform properly to
avoid this problem, so an automatic electronic circuit is used.

A defibrillator machine equipped with the synchronizer circuit is called a

cardioverter .

A switch on the machine allows the operator to select either defibrillate or

cardiovert modes.
Cardioverter
 Pacemakers
A pacemaker is a device which provides artificial pacing impulses
and delivering them to the heart.
Pacemaker consists of a pulse generator and appropriate
electrodes.
In general, there are two types of Pacemaker.
Internal pacemakers may be permanently implanted in patients
whose SA nodes have failed to function properly or who suffer from
permanent heart block because of a heart attack.
An internal pacemaker is define as one in which the entire system is
inside the body.
In contrast, an external pacemaker usually consists of an externally
worn pulse generator connected to electrodes located on or within
the myocardium.
 Pacemakers
External pacemakers are used on patients with temporary heart
irregularities such as those encountered in the coronary patient
including heart blocks.
External pacemakers are used for short period of time.
Pacing Modes
 Pacing Modes

Asynchronous Pacing Mode

The simplest form of the pacemaker; not common any longer.

Asynchronous (does not synchronize with intrinsic (natural) heart rate (HR)).

Produces uniform stimulation regardless of cardiac activity (i.e. fixed heart-rate).

Used safely in points with no intrinsic ventricular activity.

Asynchronous pacing is called competitive pacing because the fixed-rate

impulses may occur along with natural pacing impulses generated by the heart
and would therefore be in competition with them in controlling the heartbeat.
 Pacing Modes

Asynchronous Pacing Mode

Block diagram shows components of competitive asynchronous

pacemaker.

Power supply provides energy

Oscillator controls pulse rate
Pulse output produces stimuli
Lead wires conduct stimuli
Electrodes transmit stimuli to the tissue
 Pacing Modes

Synchronous Pacing Mode

It provides intermittent stimulation as opposed to continuous stimulation as in

asynchronous pacemakers.

Prevents possible deleterious outcomes of continuous pacing (i.e. tachycardia,

fibrillation)
Minimizes competition between normal pacing
Two general types of synchronous pacing mode
i.Ventricular Programmed (Demand)
ii.Atrial-synchronous
 Pacing Modes

Ventricular Programmed (Demand) Pacing Mode

Contains two circuits

* One forms impulses
* One acts as a sensor
When activated by an R wave, sensing circuit either triggers or inhibits the
pacing circuit called Triggered or Inhibited pacers
Most frequently used pacer
Eliminates competition;
Energy sparing
 Pacing Modes

Ventricular Programmed (Demand) Pacing Mode

There are two types of ventricular programmed (demand) pacing mode

i.R-wave Inhibited
ii.R-wave Triggered

Both types of pacemakers sense the presence (or absence) of intrinsic R-wave.
The output of the R-wave inhibited unit is suppressed as long as natural R-
waves are present. Thus its output is held back or inhibited when the heart is able
to pace itself.
On the other hand, R-wave triggered pace emits an impulse with the occurrence
of each sensed R wave.
 Pacing Modes

Atrial-Synchronous Pacing Mode

In cases of complete heart block where the atria are able to depolarize but the
impulse fails to depolarize the ventricle, then atrial synchronous pacing may
be used.
Atrial programmed pacers are always synchronized with the P wave of the
ECG.
Here the pulse generator is connected through wires and electrodes to both
the atria and the ventricles.
The atrial electrode couples atrial impulses to the pulse generator which then
emits impulses to stimulate the ventricles via the ventricular electrodes.
In this way the heart is paced at the same rate as the natural pacemaker.
When the SA node rate changes because of sympathetic neuronal control, the
ventricle will change its rate accordingly but not above some maximum rate
(about 125 per minute) .
Questions?