CARDIAC PACEMAKER

Understanding the Heart's Electrical System

Our heart has its own internal electrical system that controls the rate and rhythm of our heartbeat. With
each heartbeat, an electrical signal spreads from the top of our heart to the bottom. As the signal travels, it
causes the heart to contract and pump blood. Each electrical signal normally begins in a group of cells
called the sinus node or sinoatrial (SA) node. As the signal spreads from the top of the heart to the
bottom, it coordinates the timing of heart cell activity.
irst, the heart!s two upper chambers, the atria contract. "his contraction pumps blood into the heart!s
two lower chambers, the ventricles. "he ventricles then contract and pump blood to the rest of the body.
"he combined contraction of the atria and ventricles is a heartbeat.
What is a natural pacemaker?
"he heart!s #natural# pacema$er is called the sinoatrial (SA) node or sinus node. %t!s a small mass of
speciali&ed cells in the top of the heart!s right atrium (upper chamber). %t ma$es the electrical impulses
that cause your heart to beat. A chamber of the heart contracts when an electrical impulse moves across it.
or the heart to beat properly, the signal must travel down a specific path to reach the ventricles, the
heart!s lower (pumping) chambers. "he natural pacema$er may be defective, causing the heartbeat to be
too fast, too slow or irregular. "he heart!s electrical pathways also may be bloc$ed.
What is an artificial pacemaker?
'ardiac pacema$ers are generally used to manage a slow or irregular heart rate. "he pacema$er system
applies precisely timed electrical signals to induce heart muscle contraction and cause the heart to beat in
a manner very similar to a naturally occurring heart rhythm. A pacema$er consists of a pulse generator, at
least one electrode, and one or two pacing leads connecting the pacema$er to the heart. "he casing of the
pulse generator functions as housing for the battery and circuits, which provide power.
%t is usually implanted between the s$in and pectoral muscle. "he sealed lithium iodine battery provides
electrical energy to the pacema$er. "his battery replaced the mercury(&inc battery in )*+,, e-tending the
life of some pacema$er models by over ). yr. "he circuitry converts the electrical energy to small electrical
signals.
Pacemaker electronics
/asic bloc$s of implantable pacema$ers consist of E'0 front end circuitry, ultra low power
microcontroller, battery and output circuitry to stimulate heart. 1eart signal is sensed by electrodes. 2ain
emphasis must be given on si&e, weight, encapsulating material and increase in life span of battery up to
). to )3 years. "he front end senses voltage generated by the pumping action of the heart which is small
signal with many noise components. "his circuit consists of differential amplifier, filter, level shifter,
synchroni&ing circuit etc. "o pace abnormal heart with a pulse of , to +., volts, multiplier along with
switch networ$ is used.
%mplantable pacema$er consists of e-ternal comparator. 'ardiac signal is sensed by unipolar or bipolar
electrodes and is amplified by a low noise pre(amplifier, gain amplifier. %t is filtered by second order low
pass filter to get appropriate E'0. "his signal is applied to the comparator. 'omparator is used as a
threshold detector, to detect the heart beat event e-ecuted by the heart and generates a pulse with every
heartbeat. E-ternal comparator consists of two inputs i.e. E'0 and threshold voltage. %t generates pulse
depending on the threshold voltage level. Output stage called charge pump, consists of
voltage multiplier4pulse generator to stimulate heart. A high voltage pulse of , to +.,5olts is delivered to
the heart through pacing electrodes. "he amplitude and pulse width must be customi&ed for each patient.
Supply 5oltage Supervisor (S5S) is necessary to monitor battery voltage.
A typical bloc$ diagram
56S% based analog4digital custom processor and interfacing peripherals are used in implantable
pacema$ers . Some ultra low power microcontrollers are available today which will be better choice for
crucial biomedical applications.7acema$er is a computer controlled real time system with predefined
tas$s priority. 2icrocontroller with optimi&ed software is basic component in it. 2icrocontroller to be
chosen must have low power consumption and re8uired memory space.
Components and Materials of Construction
A connector bloc$, made of polyurethane, is located at the top of the pacema$er. %t serves to attach the
pacema$er to the pacema$er lead. ormerly, glass materials were used to comprise the connector bloc$.
"he pulse generator is encased in AS"2 grade) titanium. "itanium replaced ceramics and epo-y resin,
which were used for encapsulation of some pacema$ers in the past, with silicone rubber. "his upgrade to
titanium allowed patients to safely use appliances such as microwave ovens, because titanium helps to
shield the internal components and reduce the e-ternal electromagnetic interference. A pacing lead is
vital to the pacema$er system, because it transmits the electrical signal from the pacema$er to the heart
and information on the heart activity bac$ to the pacema$er.
One or two leads may be used, depending on the type of pacema$er. One end of the lead is attached to the
connector bloc$ of the pacema$er. "he other end is inserted through a vein and placed in the right
ventricle or right atrium of the heart. "he lead is an insulated wire consisting of a connector pin, lead
body, fi-ation mechanism and at least one electrode. "he connector pin is the portion of the lead that is
inserted into the connector bloc$. "he lead body is the insulated metal wire that carries electrical energy
from the pacema$er to the heart. "he lead must be able to withstand the fle-ing induced by the cardiac
contractions in the warm and corrosive environment in the body. "hus, the materials used must be inert,
nonto-ic, and durable. "he lead body must be fle-ible, noncorrosive, and durable. %t must also be a good
electrical conductor. "he early lead body was insulated with polyethylene. 'urrently, the lead body is
insulated with a more resilient material such as silicone rubber tubing or polyurethanes. 7olyurethanes
are generally stronger than silicone rubbers, which are easily damaged. "he strength of polyurethanes
enables a thinner lead to be used in the pacema$er and offers greater lead fle-ibility. Another advantage of
polyurethanes is their very low coefficient of friction when wet. 1owever, metal(ion(induced o-idation
may degrade polyurethanes, while silicones are not affected by this mechanism of degradation. "he
fi-ation mechanism serves to hold the tip of the lead in place in the heart. 'urrently, either a nic$el(cobalt
alloy with a silver core heli- or an electrically active platinum(iridium heli- may be used to anchor the
electrode of the lead to the surface of the heart.
"he electrode is located at the tip of the lead. %t serves to deliver the electrical energy from the pacema$er
to the heart and information about the natural activity of the heart bac$ to the pacema$er. Electrodes may
be composed of platinum, titanium, stainless steel, silver, or cobalt alloys. "itanium has been used
because it forms a nonconducting o-ide layer at the surface. "his surface prevents the e-change of charge
carriers across the boundary. "itanium also e-hibits a high modulus of elasticity, high resistance to
corrosion, and high durability. Electrodes may be coated with iridium o-ide to prevent nonconductive
layers from forming. "he coated electrodes may also provide lower acute and chronic thresholds due to
the reduced local inflammation. 9rug(Eluting 6eads. 6eads have developed immensely since they were
first introduced. "he earliest leads were attached to the outer surface of the heart.
%n the mid()*:.s, transverse leads were introduced. "hey could be inserted through a vein leading to the
heart, thus eliminating the need to open the chest cavity during implantation. %n the )*+.s, tined and
active fi-ation leads were developed to replace smooth tip leads. "he prongs on the tined leads and the
titanium alloy screws in the active fi-ation leads provide a more secure attachment to the heart and are
still used today.
Trends
leadless pacemakers
"his is the 2edtronic wireless pacema$er, ;ust revealed at "E92E9 3.)., which can be implanted
directly into our heart via catheter and permanently latch itself into flesh with tiny claws. "hen, doctors
can wirelessly monitor and even control the device from a nearby phone.
!uclear "attery
"he nuclear battery in 2edtronic device had used metallic 7lutonium (7u 3<=)."he radiation produced by
7lutonium bombarded the walls of its container. "hen the heat was converted to an electric current by a
thermopile. A thermopile is a stac$ of thermocouples. "hose thermocouples directly converted the heat
into electricity using Seebec$ effect.
#atteryfree pacemakers
>ow there are so many researches going under this topic and there are evolving methods. One such
method is combining the implanted device with a microgenerator producing electricity every time the
patient moves, effectively eliminating the need for an internal battery.
$ireless pacemakers
"hese are the pacema$ers that communicate wirelessly with a monitoring service, which is in turn
accessed daily by the doctor. "he device can be reprogrammed using wireless signals. "his method
reduces the no of surgeries that the patient has to undergo.
SMScapa"le pacemakers
"he latest application is an S2S(enabled pacema$er that can automatically send messages to a
cardiologist!s cellphone, allowing the doctor to monitor a patient!s condition. "he unit was developed by
9utch manufacturer /iotroni$, and the first implant was performed at 5? ?niversity 2edical 'enter in
Amsterdam.
Hacking risks to heart de%ices
9evices are used to wirelessly communicate with the implanted defibrillator or pacema$er. "hose devices
are obviously only sold directly to physicians by a select group of companies but, as the researchers warn,
it is at least conceivable that hac$ers could transmit the same radio signals using another device, allowing
them to shut down the defibrillator or deliver a shoc$, or possibly even obtain a patient!s medical
information.