02 Technical Aspects of Pacing System

The Four Parts of the Pacing System

1. Implantable pulse
generator
2. Lead (s)
3. Programmer
4. And the patient!

The Pulse Generator

Casing (a.k.a. can)
Titanium (biocompatible, lightweight, stronger than
steel)
Connector (a.k.a. header)
Leads plug into ports in the clear epoxy header
Components
Diodes, resistors, oscillator, microchips
Battery
The largest single component inside the pulse
generator
Lithium iodide or other new batteries developed by
different companies (e.g. Quasar QMR in SJM)

Pacemaker
(or Implantable Pulse Generator, IPG)

Getting Smaller!
In the past 50 years pacemakers have been radically downsized!
Year

Weight

Longevity

1950s

300 g

Few months

2000s

30 g

10 years

2014

19 g

> 10 years

The Can

Setscrews
Feedthroughs

Tightening the Setscrews

Pacemaker Headers
VS-1
Short aperture
May or may not have sealing rings
Use with IS-1 leads

VS-1A (not made by St Jude Medical)

Long aperture
No sealing rings
Use with IS-1 and 3.22 mm long pin leads with sealing rings

VS-1B
Long aperture
Sealing rings
Use with IS-1 and 3.2 mm leads with or with out sealing rings

XL Devices
VS1B also known as L connector
One screw to secure each lead
Passive connection made for the bipolar ring
Long aperture
Sealing rings
Compatible with all IS-1 / 3.2 mm leads

Standard Small Can Devices

VS-1 connector
Short aperture
Therefore, not compatible with older style 3.2 mm leads

Sealing rings

Components
Diodes and resistors
Manage current flow through the pulse generator
Diodes keeps current going the right direction
Resistors impede current flow to channel it appropriately
Crystal oscillator
The time clock of the pulse generator
Microchips
Memory, intelligence, functions, features
More reliable, smaller, more efficient than previously

Pulse Generator Circuitry

Components of a Pacemaker
Components

Functions

Battery

The source of energy to deliver impulse &

To operate the circuits in the pacemaker
Generally make from Lithium Iodide or others

Pacing Circuit

To pace the heart when required

(Demand Mode)

Sensing Circuit

Response to sensing event

(sense the intrinsic signal from heart)

13

The History of Pacemaker Batteries

First came mercury zinc
Emitted a gas that interfered with hermetic seal of
pulse generator
The nuclear age
Early 1970s
Next was nickel cadmium
Rechargeable systems
Today: lithium iodide or others
Powerful, lightweight
Predictable discharge

Pacing

Pulse
Amplitude

Output Parameters

Pulse begins

Pulse width

Pulse ends

Capture Threshold
Capture threshold is the minimum amount of electrical
energy required to consistently depolarize (or capture)
the heart
Capture threshold is stated in two output parameters:
Pulse amplitude, stated in volts
Pulse width or duration, stated in milliseconds
Capture threshold may also be called
Pacing threshold
Stimulation threshold

Capture Threshold Testing

Decrease amplitude or pulse width until LOC is reached.
The last value with 1:1 capture is your threshold.

1.0V is the V-Capture Threshold

Acute-to-Chronic Thresholds

Strength-Duration Curve

Chronaxie Point
Rheobase

Threshold Test
Method:
1. Start doing the threshold test at rate which is 10-20 bpm
above the intrinsic rate.
2. Fix the value of pulse width (e.g. @ 0.5ms ) and decrease
the amplitude output until loss of capture, or
3. Fix the value of amplitude (e.g. @ 2.5V) and decrease the
pulse width output until loss of capture.
Mode for doing threshold test:
Atrium:
DDD
AAI (only if the patient has good AV
conduction, but not recommended)
Ventricle:
DDD
VVI

Threshold Test
Output Setting:
2 x Amplitude Threshold with fixed pulse width
3 x Pulse Width Threshold with fixed amplitude (if PW Threshold 0.3ms)

e.g.

e.g.

V-threshold = 1.0 V @ 0.5 ms

Suggested V. Output = 2.0 V, 0.5 ms
(Normally, the amplitude of the output will not lower
than 2.0 V.)
A-threshold = 0.2 ms @ 2.5 V
Suggested A. Output = 2.5V, 0.6 ms

Sensing

Sensing
Sensing refers to the pacemakers ability to see intrinsic
cardiac activity and, if appropriate, to respond to it
Most pacemaker patients have some intrinsic cardiac
activity
Some pacemaker patients require only intermittent
pacing

Surface ECG/Intracardiac EGM

Surface ECG: graphic depiction of hearts electrical signals

recorded from electrodes on the bodys surface

Intracardiac EGM: graphic depiction of the hearts electrical

signals recorded by electrodes from inside the heart (pacing lead)

26

Sensitivity Safety Margin

Sensing thresholds are not constant and vary with many
factors
The sensitivity safety margin allows reliable sensing even
with fluctuations in the sensing threshold
Using this formula, the safety margin should be at least 2
at implant

Safety margin

Sensing Threshold
Sensitivity Setting

Sensing threshold

Sensitivity
mV

Vs

Vs

5
2,5
0
2,5
5

intracardial signal

Sensing threshold

Sensitivity: 5 mV

mV

Vs

Vs

Vs

Vs

Vs

Vs

5
2,5
0
2,5
5
Sensitivity : 2,5 mV

intracardial signal

Sensing Test
Suggested Sensitivity Setting:
1/2 or 1/3 of the amplitude of the intrinsic IEGM signal
e.g. P-wave = 2.4 mV
Suggested range = 0.5 1.0 mV
(If the patient has AF history, setting atrial sensitivity
> 1mV may cause undersensing during AF.)
e.g.

R-wave = 7 mV
Suggested range = 2.0 3.5 mV

The number should be:

High enough to filter the noise
Low enough to sense the intrinsic IEGM signal

Pacing Leads

Types of Leads- Stable Positioning

Two main types of leads, transvenous lead and epicardial lead

Transvenous Leads
Lead access to heart
via the cephalic,
subclavian or axillary
veins
By Passive or active
fixation
Placed in Endocardial
layer
31

Epicardial Leads
By open heart surgery

By active fixation

Placed in Epicardial layer

Epicardial Leads

Epicardial leads

32

Transvenous Leads

Transvenous leads

Passive fixation

33

Active fixation

General Transvenous Lead Design

The pacing lead conducts electricity from the
pacemaker to the heart.

34

Lead Fixation
Mechanical stability (fixation)
Passive fixation (tine)
Active fixation (screw-in: Fixed or retractable)
J shape for atrial

Passive Fixation
Tine

35

Active Fixation
screw-in

Bipolar & Unipolar

A Unipolar Pacing System Contains a Lead with Only One

Electrode Within the Heart; In This System, the Impulse:

Flows through the tip

electrode (cathode)
Stimulates the heart
Returns through body
fluid and tissue to the
IPG (anode)

+
Anode

Cathode

Unipolar leads
Unipolar leads may have a
smaller diameter lead body
than bipolar leads
Unipolar leads usually exhibit
larger pacing artifacts on the
surface ECG
Unipolar lead but pacemaker
programmed to bipolar
=> No pacing
=> Dangerous for pacemaker
dependent patients

A Bipolar Pacing System Contains a Lead with

Two Electrodes Within the Heart.
In This System, the Impulse:
Flows through the tip
electrode located at
the end of the lead
wire
Stimulates the heart
Returns to the ring
electrode above the
lead tip
Anode

Cathode

Bipolar leads
Bipolar leads are less
susceptible to oversensing
noncardiac signals
(myopotentials and EMI)
Inner coil : cathode ve
Outer coil : anode +ve

Coaxial Lead
Design

Lead Terminal Pins

Cordis 6mm

Lead Terminal Pins (VS = Voluntary Standard)

VS1B

VS1A

VS1

Lead Terminal Pins (IS = International Standard)

IS1 Standard Connector

Different 3.2 mm Long Bore Connectors

VS 1A / IS -1

VS 1B / IS -1

IS -1
VS 1B
VS.1A Cordis 3.2 mm

Different 3.2 mm Short Bore Connectors

VS 1

IS -1

IS -1
VS 1B
VS.1A Cordis 3.2 mm

Programmer

Programmer
Programmer Cover
(movable to uncover
the screen)

Signal Light (to show

the degree of
strength of
Programmer Head /
Wand on locating
the CIED)

Emergency Button
(for VVI Pacing or
Defibrillation)

LCD Display a
Touch Screen for
selecting parameters
(by finger or Stylus)

Button to release
Programmer Cover
Programmer Head /
Wand (for
Interrogation)

Real-time ECG
Printing Button (with
different speed @
12.5mm/s; 25mm/s
& 50mm/s)
Thermal Printer &
Paper Tray

Surface ECG (Limb

Lead) Cable

Conclusion
Pacemakers have been around over half a century
The pulse generator
Receives and interprets signals
Delivers output pulses
Radically downsized since the early days but with
longer service life
The rest of the system
Lead(s)
Programmer
And the patient!