No more wires!

Pacing the heart from within

John Thomas
 Objectives
• How do standard implantable pacemakers
work?
• What are the problems associated with the
current approach?
• What are leadless intracardiac pacemakers?
• Results of latest clinical trials
 What are artificial pacemakers?
• Definition: A medical device that uses
electrical impulses to regulate the rate of
cardiac contraction
• Indications:
– Bradycardia
– Heartblock
The evolution of pacemaker technology
• First implantable pacemaker: 1958
– Developed by Dr. Senning and Dr. Elmqvist
– Asynchronous pacemaker implanted by thoracotomy
– Arne Larsson - First pacemaker patient
• 1964 – First on demand pacemaker (DVI)
• 1977 – First atrial and ventricular demand
pacing (DDD)
• 1981 – Rate responsive pacing
• 1994 – Cardiac resynchronization pacing
Components of an artificial pacemaker
• Pulse Generator
• Electrical leads
Lead
• Cathode
• Anode
IPG

Anode

Cathode
 Pulse generator
• Is responsible for generating the electrical
impulse that will be sent to the heart
Main elements:
• Battery – provides the energy
(voltage) required for the operation
of the pacemaker

• Memory (RAM/ROM) - to store data

for diagnostic purposes

• Antenna - Monitors relevant heart

data to be accessed via
programmers

• Microprocessor – controls all

operations
 Pacing lead
• The pacing lead
delivers the pulse to Connector

the destination in Lead Body

the heart Active Fixation
Mechanism

• The lead has

electrode(s) on the Tip
Electrode
tip
• The tip of the lead is
fixed to the heart
 Fixation

Active fixation Passive fixation Active fixation

Tines Wingtips Screw
 Electrode
• Forms the interface between the electronic
system & the physiological system
• The electrode tips are made from titanium &
are housed within silicone rubbers
 Unipolar system
Contains one lead with one electrode in the heart
• Flows through the
tip electrode
(cathode)

• Stimulates the heart Anode

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

electrode above
the lead tip Cathode
 Types of Pacemakers
1. Asynchronous vs Synchronous
2. Single vs Dual Chamber
 Asynchronous pacemaker
• The first cardiac pacemakers
• Does not synchronize with the intrinsic HR
• Is most safe to use in patients with no intrinsic
ventricular activity
• If patient has ventricular activity, it may
compete with patient’s own conduction
system  VT
 Synchronous pacemakers
• Allows the pacemaker to pace according to
normal electrical activity of the heart
• Contains 2 circuits:
– Impulse generating circuit
– Sensing circuit
• The sensing circuit senses an R wave, and
then triggers or inhibits the pacing circuit
 Single chamber
• Atrial: Used when SAN is diseased/damaged
but AV conduction system remains intact
• Ventricular:
 Dual chamber
• Facilitates a normal sequence between atrial
& ventricular contraction
• Enables atrial contraction before ventricular
contraction  ensures more complete
ventricular filing and improved CO
• Contraindications:
– AF
– SVT
 Biventricular pacing
• The more leads the more the complications:
– Dislodgement
– Fracture
– Insulation break
– Infection
– Extraction issues
– Vein thrombosis
– Cardiac perforation
– Valve injury
– Endocarditis
• Potential advantages:
– No surgery; less infection risk
– Fewer complications (infection, erosion)
– Cosmetic benefits for the patient
– Cost-effectiveness
• Reduced length of hospital stay

• Improved efficiency
• Afd
• adf
 RV

epicardial trans-venous
requires thoracotomy sub-clavian or cephalic vein,
much less traumatic

19
The future – Leadless
pacemakers
Is there room for improvement?
 How will leadless pacing help?
• All these complications arise due to:
– Surgery
– The implantable pocket for housing the pulse generator
– Leads – the leads are the weakest points of the system.
The more leads that are present the greater the
complications.
• Leadless pacemakers:
– No surgery required – instead you have a transvenous
approach similar to PCI
– No requirement for a subcutaneous pocket
– No leads
The device
How it works – link to video:
• HOW DOES A LEADLESS PACEMAKER WORK?
• Unlike conventional pacemakers, a leadless pacemaker is placed
directly in the heart without the need for a surgical pocket and
pacing leads. The device is much smaller than a conventional
pacemaker and is comprised of a pulse generator that includes a
battery and a steroid-eluting electrode that sends pulses to the
heart when it recognizes a problem with the heart’s rhythm.
Leadless pacemaker technology is made up of computer chips and a
small, but long-lived battery in a sealed case that resembles a AAA
battery. The device is implanted through a vein that passes fairly
close to the outer surface of the upper thighs. Because the implant
procedure does not require surgery like a traditional procedure, it is
considered a less-invasive approach for patients who need
pacemaker technology
 Sensing lead
• This sends information about the heart’s
electrical system back to the pulse generator
• This allows the pulse generator to generate
the impulse at the required time
 Unipolar Bipolar
Advantages Smaller diameter No pocket stimulation
Easier to implant Less susceptible to EMI
Large spike Programming flexibility

Disadvantages Pocket stimulation Larger diameter

Far-field oversensing Stiffer lead body
No programming flexibility Undersenseing
Small spike
Higher impedance
Voltage threshold is 30%
higher
• Oversensing:
– Pacer interprets noncardiac electrical
signals as originating in the heart
– Detects extraneous signals such as those
produced by electrical equipment or the
activity of skeletal muscles (tensing,
flexing of chest muscles, SUX)
– Inhibits itself from pacing as it would a
true heart beat
• Undersensing
– Pacer fails to detect an intrinsic rhythm
– Paces unnecessarily
– Patient may feel “extra beats”
– If an unneeded pacer spike falls in the
latter portion of T wave, dangerous
tachyarrhythmias or V fib may occur (R on
T)
– TX: Increase sensitivity of pacer