Pacemakers

What is pacemaker
Device capable of generating artificial
pacing impulses and delivering them to
the heart

Internalimplanted
pacemakers
Permanently
in patients whose
SA nodes fail;
In patients who suffer from permanent
heart block due to hear attack.
The pulse generator must have a power
source lasting for years

External pacemakers
Have a externally worn pulse generator
connected to the electrodes on the
myocardium.
For patients with temporary heart
problems
Also for temporary management of
certain arrhythmias in patients
postoperative time/cardiac surgery

pacemakers

Pacemaker Components
Pulse Generator
Electronic Circuitry
Lead system

Pulse Generator
Lithium-iodine cell is the current standard
battery
Advantages:
Long life 4 to 10 years
Output voltage decreases gradually with time
making sudden battery failure unlikely

Lead Systems
Endocardial leads which are inserted
using a subclavian vein approach
Actively fixed to the endocardium using
screws or tines
Unipolar or bipolar leads

 Pacemaker has two main functions:

Sense intrinsic cardiac electrical activity
Electrically stimulate the heart
senses intrinsic cardiac activity in the
ventricle and when a preset interval of time
with no ventricular activity occurs it
depolarizes the right ventricle causing
ventricular contraction
Dual chamber pacer is more complicated
because the pacer has the ability to both
sense and pace either the atrium or the
ventricle; Possible to have only atrial, only
ventricular or both atrial and ventricular
pacing

Type of pacing modes

Block diagram: Refer Class notes
1.Competitive: Fixed rate
(asynchronous)
2.Non-Competitive : pulse generators
are programmed by ventricles or by atria.
Ventricular
programmed
pacemakers
operate in demand (R wave inhibited) or
stand-by (R-wave triggered) mode,
Atrial programmed pacemakers are always
synchronized with P wave of the ECG.

 Produce pulses at a fixed rate

Independent of natural cardiac activity
Fixed rate impulses may occur along with
natural pacing impulses and compete for
controlling the heart
beat. rate(nonCompetitive
: Fixed

synchronous)

(competitive) Fixed rate

pacemakers..
Used in elderly where SA node cannot

provide proper impulses

Used temporarily to determine the
amplitude of impulses needed to pace or
capture the heartbeat of a patient before
or during implantation of a permanent
unit.
The amplitude at which capture occurs is
pacing threshold

Fixed rate pacemakers..

(contd)
Failures are less in fixed rate
pacemakers.
Battery life is shorter (since continuous
operation).
Competition of control of heart rate

Synchronous-Non
competitive ventricular
programmed
Non
competitive
pacemakers

are
atrial

ventricular
programmed
or
programmed.
Ventricular programmed are connected to
ventricles via electrodes.
There are 2 types: Demand and standby
type.
Both demand and standby type are able
to sense presence or absence of R wave.

R wave inhibited
Output of the R wave inhibited unit (demand)
pacemaker-demand
is suppressed when there are natural R wave.
In case standstill or rate falls below the
preset rate of the pacer, the unit
automatically provides and output to pace
the heart.
Hence pace on demand. demand pacemaker
Demand pacemaker , in the absence of the R
wave, automatically functions in fixed rate
mode.

Block diagram of demand

type pacemaker (Refer
class
notes)
Explanation:
It consists of a timing circuit, output circuit
and electrodes.
A feedback loop is provided.
The timing circuit is set to run at a fixed
rate 60 to 80 beats per minute.
After each stimulus, the timing circuit
resets itself, waits for an interval to
provide the next stimulus and then
generates next pulse.

Demand type..
However if during this period natural beat
occurs in the ventricles, the feedback
circuit, senses the QRS part of the ECG
signal and amplifies it.
This signal is then used to reset the
timing circuit.
Again it awaits for a fixed interval, before
producing the next impulse.
This process repeats.

R wave triggered pacemaker -standby

Similar to R wave inhibited (demand) units,

these sense R wave. The unit is triggered by
each R wave.
With each sensed R wave, the unit produces
an impulse.
Thus the unit is triggered by R wave. Hence
it is R wave triggered pacemaker.
However, the pacing impulses are
transmitted to the myocardium during its
absolute refractory period .
(Absolute refractory period: following the
generation of an action potential, there is a
brief period of time during which the cell
cannot respond to new stimuli.)

 Hence these impulses will have no effect on

normal heart activity.
In case the hearts natural rate goes below
the preset rate of the pacer, the pacer
operates synchronously at its preset rate to
pace the heart.
Hence this pacemaker standby to pace when
required.

Atrial programmed
Block
diagram-Refer class notes
pacemakers

The pacemaker is designed to replace the

blocked conduction system of the heart.
The physiological pacemaker, at the SA
node, stimulates atria to contract and then
provides stimulus to the AV node, which
after appropriate delay, stimulates the
ventricles.
When the atria stimulated, the electrode
placed in the atria, detects the electrical
signal corresponding to atrial contraction (P
wave) and triggers the pacemaker in the
same way that it triggers the AV node.

Atrial programmed
v1-is the voltage detected by atrial electrodes.
pacemakers
This is amplified and passed through a gate to
monostable multivibrator (MMV) which
produces a pulse v2 of 120ms
(millisecond)duration.
120ms is the approximate delay of the AV
node.
The MMV of pulse 500ms is also triggered by
atrial pulse.
It produces v4, which causes the gate to block
any signals form the atrial electrodes for a
period of 500 ms following the contraction.
The falling edge of the v2 pulse triggers MMV
of 2ms duration.

Atrial programmed
pacemakers

Thus the pulse v2 acts as a delay,

allowing the ventricular stimulus pulse v3
to be produced 120ms following the atrial
contraction.
V3 controls the output circuit which
applies the stimulus to appropriate
ventricular electrodes.

Rate responsive pacing

Block diagram-refer class notes
Like the demand pacemaker, this
pacemaker stands by when there is
normal pacing.
The demands of the body during stressful
activities like exercises cannot be met fully
by the previously explained pacemakers.
Hence rate responsive pacemakers
A sensor senses the physiological variable
in the patient and converts it to electrical
signal which is then given to controller
circuit.

Rate responsive
pacing
The pacemaker is programmed to control

the heart rate on the basis of the

physiological variable sensed.
Physiological variable sensed are right
ventricle blood temperature, blood pH,
respiratory rate/volume etc.
Different variables require different control
algorithm like proportional control,
derivative based control etc.
For example, derivative control is used
when temperature of the venous blood is
sensed.