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1 INTRODUCTION
Heart rhythm problems (arrhythmia) occur when the electrical impulses produced by your heart that coordinate heartbeat do not function properly, causing your heart to beat too quickly, too slowly, or irregularly. Age increases the probability of experiencing an arrhythmia. It can occur in people who do not have heart disease. Some heart arrhythmias are harmless, though some types, such as ventricular tachycardia (fast heart rates), are serious and even life threatening. Pacemakers represent one of the earliest and most successful non pharmacological therapy for arrhythmias. Millions of pacemakers have been implanted since the very first pacemaker was implanted in 1958 by Elmquist and Senning. Drugs are no longer used except in the very acute setting before implantation of a temporary or permanent pacemaker.
Pacemaker
A pacemaker is a small device that's placed under the skin of your chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. Pacemakers are used to treat heart rhythms that are too slow, fast, or irregular. These abnormal heart rhythms are called arrhythmias. Pacemakers can relieve some symptoms related to arrhythmias, such as fatigue (tiredness) and fainting. A pacemaker can help a person who has an abnormal heart rhythm resume a more active lifestyle. If you have been found to have a heartbeat that is too slow, a pacemaker can be implanted in the body to take over the function. This small electronic device automatically monitors and regulates the heartbeat, by transmitting electrical impulses to stimulate the heart when it is beating too slowly. A pacemaker consists of a pacing lead and a pulse generator. Single chamber pacemakers have only a single lead while dual chamber pacemakers have two leads with one lead in the atrium and the other in the ventricle. Dual chamber pacemakers are more physiological but more expensive. The indications of pacing are now well established. The most important indication of pacing however remains complete heart block and the sick sinus syndrome which account for 95% of the indication for pacemakers implanted in Singapore. During the last pacemaker survey in 2005 in Singapore, the implant rate was 91 per million. With our ageing population, we can expect that the need for pacemaker implantation in Singapore will rapidly increase. In Europe, Japan and the USA, the implant rate is almost 300-1000 per million.
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 platinum-iridium helix may be used to anchor the electrode of the lead to the surface of the heart.
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.
Basic blocks of implantable pacemakers consist of ECG front end circuitry, ultra low power microcontroller, battery and output circuitry to stimulate heart. Heart signal is sensed by electrodes. Main emphasis must be given on size, weight, encapsulating material and increase in life span of battery up to 10 to 12 years. The front end senses voltage generated by the pumping action of the heart which is small signal with many noise components.This circuit consists of differential amplifier, filter, level shifter, synchronizing circuit etc. To pace abnormal heart with a pulse of 5 to 7.5 volts, multiplier along with switch network is used Implantable pacemaker consists of external comparator.Cardiac signal is sensed by unipolar or bipolar electrodes and is amplified by a low noise pre-amplifier, gain amplifier. It is filtered by second order low pass filter to get appropriate ECG. This signal is applied to the comparator. Comparator is used as a threshold detector, to detect the heart beat event executed by the heart and generates a pulse with every heartbeat. External comparator consists of two inputs i.e. ECG and threshold voltage. It generates pulse depending on the threshold voltage level. Output stage called charge pump, consists of voltage multiplier/pulse generator to stimulate heart. A high voltage pulse of 5 to 7.5Volts is delivered to the heart through pacing electrodes. The amplitude and pulse width must be customized for each patient. Supply Voltage Supervisor (SVS) is necessary to monitor battery voltage.
Flow chart
TYPES OF PACEMAKER PROGRAMMING
There are two main types of programming for pacemakers demand pacing and rateresponsive pacing. A demand pacemaker monitors your heart rhythm. It only electrically stimulates your heart if its beating too slow or if it misses a beat.
A rate-responsive pacemaker will speed up or slow down your heart rate depending on how active you are. To do this, the rate-responsive pacemaker monitors your sinus node rate, breathing, blood temperature, or other factors to determine your activity level. Most people who need a pacemaker to continually set the pace of their heartbeat have rate-responsive pacemakers.
CHAPTER 4 AFTERCARE
A patient will need to carry pacemaker identification card to indicate the type of pacemaker that has been implanted. Devices such as anti-theft systems in stores, airport screening devices and metal detectors may interfere with the devices performance although these occurrences are rare. Microwave ovens and other common household appliances usually do not interfere with the function of these devices. However, mobile phones should be placed more than 15 cm from the ICD to prevent possible interferenced. A patient with a pacemaker implanted should always inform his doctor or dentist before going for procedure which utilises medical or electronic devices for fear of potential interferences
Stay at least 2 feet away from industrial welders or electrical generators. You also need to avoid some medical procedures that can disrupt your pacemaker. These procedures include: Magnetic resonance imaging (also called MRI) Shock-wave lithotripsy to get rid of kidney stones Electrocauterization to stop bleeding during surgery Let all of your doctors, dentists, and medical technicians know that you have a pacemaker. You also should notify airport screeners. Your doctor can give you a card that states what kind of pacemaker you have. Carry this card in your wallet.
Reference:
https://wiki.engr.illinois.edu/display/BIOE414/Circuit+Operation http://thepansilu.blogspot.com/2011/01/cardiac-pacemakers-engineeringmarvels.html http://www.medicinenet.com/pacemaker/page5.htm#during http://www.cardiosmart.org/HeartDisease/CTT.aspx?id=898