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.

First, the heart's two upper chambers, the atria contract. This contraction pumps blood into the heart's
two lower chambers, the ventricles. The ventricles then contract and pump blood to the rest of the body.
The combined contraction of the atria and ventricles is a heartbeat.
What is a natural pacemaker?
The heart's "natural" pacemaker is called the sinoatrial (SA) node or sinus node. It's a small mass of
specialized cells in the top of the heart's right atrium (upper chamber). It makes the electrical impulses
that cause your heart to beat. A chamber of the heart contracts when an electrical impulse moves across it.
For the heart to beat properly, the signal must travel down a specific path to reach the ventricles, the
heart's lower (pumping) chambers. The natural pacemaker may be defective, causing the heartbeat to be
too fast, too slow or irregular. The heart's electrical pathways also may be blocked.
What is an artificial pacemaker?
Cardiac pacemakers are generally used to manage a slow or irregular heart rate. The pacemaker 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 pacemaker consists of a pulse generator, at
least one electrode, and one or two pacing leads connecting the pacemaker to the heart. The casing of the
pulse generator functions as housing for the battery and circuits, which provide power.




It is usually implanted between the skin and pectoral muscle. The sealed lithium iodine battery provides
electrical energy to the pacemaker. This battery replaced the mercury-zinc battery in 1975, extending the
life of some pacemaker models by over 10 yr. The circuitry converts the electrical energy to small electrical
signals.

Pacemaker electronics
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.

A typical block diagram
VLSI based analog/digital custom processor and interfacing peripherals are used in implantable
pacemakers . Some ultra low power microcontrollers are available today which will be better choice for
crucial biomedical applications.Pacemaker is a computer controlled real time system with predefined
tasks priority. Microcontroller with optimized software is basic component in it. Microcontroller to be
chosen must have low power consumption and required memory space.
Components and Materials of Construction
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.
Trends
lead-less pacemakers
This is the Medtronic wireless pacemaker, just revealed at TEDMED 2010, which can be implanted
directly into our heart via catheter and permanently latch itself into flesh with tiny claws. Then, doctors
can wirelessly monitor and even control the device from a nearby phone.




Nuclear battery
The nuclear battery in Medtronic device had used metallic Plutonium (Pu 238).The radiation produced
by Plutonium bombarded the walls of its container. Then the heat was converted to an electric current by
a thermopile. A thermopile is a stack of thermocouples. Those thermocouples directly converted the heat
into electricity using Seebeck effect.
Battery-free pacemakers
Now 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.
wireless pacemakers
These are the pacemakers that communicate wirelessly with a monitoring service, which is in turn
accessed daily by the doctor. The device can be reprogrammed using wireless signals. This method
reduces the no of surgeries that the patient has to undergo.
SMS-capable pacemakers
The latest application is an SMS-enabled pacemaker that can automatically send messages to a
cardiologist's cellphone, allowing the doctor to monitor a patient's condition. The unit was developed by
Dutch manufacturer Biotronik, and the first implant was performed at VU University Medical Center in
Amsterdam.
Hacking risks to heart devices
Devices are used to wirelessly communicate with the implanted defibrillator or pacemaker. Those 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 hackers could transmit the same radio signals using another device, allowing
them to shut down the defibrillator or deliver a shock, or possibly even obtain a patient's medical
information.