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Assignment “Therapeutic and Prosthetic Devices
This covers the following topics in detail: 1. Cardiac Pacemakers 2. Electrical Stimulation 3. Defibrillators 4. Cardiovertors Now the details of the above described topics:-
1. CARDIAC PACEMAKERS:
The cells that create these rhythmical impulses are called pacemaker cells, and they directly control the heart rate. Artificial devices also called Pacemakers can be used after damage to the body's intrinsic conduction system to produce these impulses synthetically.
1.1 Control via the SA node:
Although all of the heart's cells possess the ability to generate these electrical impulses (or action potentials), a specialized portion of the heart, called the Sinoatrial Node, is responsible for the whole heart's beat. The sinoatrial node (SA node) is a group of cells positioned on the wall of the right atrium, near the entrance of the superior vena cava. These cells are modified cardiac Myocytes. They possess some contractile filaments, though they only contract relatively weakly. Cells in the SA node will spontaneously depolarize, resulting in contraction, approximately 100 times per minute. This native rate is constantly modified by the activity of sympathetic and parasympathetic nerve fibers, so that the average resting cardiac rate in adult humans is about 70 beats per minute. Because the sinoatrial node is responsible for the rest of the heart's electrical activity, it is sometimes called the PRIMARY PACEMAKER. If the SA node doesn't function, or the impulse generated in the SA node is blocked before it travels down the electrical conduction system, a group of cells further down the heart will
become the heart's pacemaker, this is known as an ectopic pacemaker. These cells form the atrioventricular node (AV node), which is an area between the atria and ventricles, within the atrial septum. The cells of the AV node normally discharge at about 40-60 beats per minute, and are called the SECONDARY PACEMAKER. Further down the electrical conducting system of the heart, the Bundle of His, the left and right branches of this bundle, and the Purkinje fibres, will also produce a spontaneous action potential if they aren't inhibited by other electrical activity. These TERTIARY PACEMAKERS fire at a rate between 30-40 per minute. Even individual cardiac muscle cells will contract rhythmically on their own. The reason the SA node controls the whole heart is that its action potentials are released most often; this triggers other cells to generate their own action potentials. In the muscle cells, this will produce contraction. The action potential generated by the SA node, passes down the cardiac conduction system, and arrives before the other cells have had a chance to generate their own spontaneous action potential. This is the normal conduction of electrical activity within the heart.
1.2 Generation of action potentials:
There are three main stages in the generation of an action potential in a pacemaker cell. Since the stages are analogous to contraction of cardiac muscle cells, they have the same naming system. This can lead to some confusion. There is no phase one or two, just phases zero, three and four. 1. Phase 4 - Pacemaker potential The key to the rhythmical firing of pacemaker cells is that, unlike muscle and neurons, these cells will slowly depolarize by themselves. As in all other cells, the resting potential of a pacemaker cell (-60mV to -70mV) is caused by a continuous outflow or "leak" of potassium ions through ion channel proteins in the membrane that surrounds the cells. The difference is that this potassium permeability decreases as time goes on, partly causing the slow depolarization. As well as this, there is a slow inward flow of sodium, called the funny current, as well as an inward flow of calcium. This all serves to make the cell more positive. This relatively slow depolarization continues until the threshold potential is reached. Threshold is between -40mV and -50mV. When threshold is reached, the cells enter phase 0. 2. Phase 0 - Upstroke Though much faster than the depolarization caused by the funny current and decrease in potassium permeability above, the upstroke in a pacemaker cell is relatively slow compared to that in an axon. The SA and AV node do not have fast sodium channels like neurons, and the depolarisation is mainly caused by a slow influx of calcium ions. (The funny current also increases). The calcium is let into the cell by voltage-sensitive calcium channels that open when the threshold is reached.
3. Phase 3 - Repolarization The calcium channels are rapidly inactivated, soon after they open. Sodium permeability is also decreased. Potassium permeability is increased, and the efflux of potassium (loss of positive ions) slowly repolarises the cell.
1.1Indications The decision to implant a permanent pacemaker for bradyarrhythmias usually is based on the major goals of symptom relief (at rest and with physical activity), restoration of functional capacity and quality
FIGURE 1.1 The pacing systems comprise a programmer, pulse generator, and lead. There are two programmers pictured above; one is portable, and the other is an office-based unit.
of life, and reduced mortality. As with other healthcare technologies, appropriate use of pacing is the intent of indications guidelines established by Medicare and other third-party payors. In 1984 and again in 1991, a joint commission of the American College of Cardiology and the American Heart Association established guidelines for pacemaker implantation [Committee on Pacemaker Implantation,1991]. In general, pacing is indicated when there is a dramatic slowing of the heart rate or a failure in the connection between the atria and ventricles resulting in decreased cardiac output manifested by such symptoms as syncope, light-headedness, fatigue, and exercise intolerance. Failure of impulse formation and/or conduction is the overriding theme of all pacemaker indications.
There are four categories of pacing indications: 1. Heart block (e.g., complete heart block, symptomatic 2° AV block) 2. Sick sinus syndrome (e.g., symptomatic bradycardia, sinus arrest, sinus exit block) 3. Myocardial infarction (e.g., conduction disturbance related to the site of infarction) 4. Hypersensitive carotid sinus syndrome (e.g., recurrent syncope)
Within each of these four categories the ACC/AHA provided criteria for classifying a condition as group I (pacing is considered necessary), group II (pacing may be necessary), or group III (pacing is considered inappropriate).New indications for cardiac pacing are being evaluated under the jurisdiction of the Food and Drug Administration. For example,hypertrophic obstructive cardiomyopathy(HOCM) is one of these new potential indications, with researchers looking at dual-chamber pacing as a means of reducing left ventricular outflow obstruction. Though efforts in these areas are ongoing and expanding, for now they remain unapproved as standard indications for pacing. 1.2 Pulse Generators The pulse generator contains a power source, output circuit, sensing circuit, and a timing circuit (Fig. 1.2). A telemetry coil is used to send and receive information between the generator and the programmer.Rate-adaptive pulse generators include the sensor components along with the circuit to process the information measured by the sensor.
Modern pacemakers use CMOS circuit technology. One to 2 kilobytes of read-only memory (ROM) are used to direct the output and sensing circuits; 16–512 bytes of random-access memory (RAM) are used to store diagnostic data. Some manufacturers offer fully RAM-based pulse generators, providing greater storage of diagnostic data and the flexibility for changing feature sets after implantation. All components of the pulse generator are housed in a hermetically sealed titanium case with a connector block that accepts the lead(s). Because pacing leads are available with a variety of different connector sites and configurations, the pulse generator is available with an equal variety of connectors. The outer casing is laseretched with the manufacturer, name, type (e.g., singleversus dual-chamber), model number, serial number,and the lead connection diagram for each identification.Once implanted, it may be necessary to use an x-ray to reveal the identity of the generator. Some manufacturers use radiopaque symbols and ID codes for this purpose, whereas others give their generators characteristic shapes.
fig:--1.2 Internal view of pulse generator. Sensing Circuit Pulse generators have two basic functions, pacing and sensing. Sensing refers to the recognition of an appropriate signal by the pulse generator. This signal is the intrinsic cardiac depolarization from the chamber or chambers in which the leads are placed. It is imperative for the sensing circuit to discriminate between these intracardiac signals and unwanted electrical interference such as far-field cardiac events,diastolic potentials, skeletal muscle contraction, and pacing stimuli. An intracardiac electrogram (Fig. 1.3) shows the waveform as seen by the pacemaker; it is typically quite different from the corresponding event as shown on the surface ECG. Sensing (and pacing) is accomplished with one of two configurations, bipolar and unipolar. In bipolar,the anode and cathode are close together, with the anode at the tip of the lead and the cathode a ring electrode about 2 cm proximal to the tip. In unipolar, the anode and cathode may be 5–10 cm apart. The anode is at the lead tip and the cathode is the pulse generator itself usually
located in the pectoral region).
FIGURE 1.3The surface ECG (ECG LEAD II) represents the sum total of the electrical potentials of all depolarizing tissue. The intracardiac electrogram (V EGM) shows only the potentials measured between the lead electrodes. This allows the evaluation of signals that may be hidden within the surface ECG.
FIGURE 1.4:-This is a conceptual depiction of the bandpass filter demonstrating the typical filtering of unwanted signals by discriminating between those with slew rates that are too low and/or too high.
In general, bipolar and unipolar sensing configurations have equal performance. A drawback of the unipolar approach is the increased possibility of sensing non cardiac signals: The large electrode separation may, for example, sense my opotentials from skeletal muscle movement, leading to inappropriate inhibition of pacing. Many newer pacemakers can be programmed to sense or pace in either configuration.Once the electrogram enters the sensing circuit, it is scrutinized by a bandpass filter (Fig. 1.4). The frequency of an R-wave is 10 to 30 Hz. The center frequency of most sensing amplifiers is 30 Hz. T-waves are slower, broad signals that are composed of lower frequencies (approximately 5 Hz or less). Far-field signals are also lower-frequency signals, whereas skeletal muscle falls in the range of 10–200 Hz.At the implant, the voltage amplitude of the R -wave (and the P -wave, in the case of dual-chamber pacing) is measured to ensure the availability on an adequate signal.R-wave amplitudes are typically 5–25 mV, and P-wave amplitudes are 2–6 mV. The signals passing through the sense amplifier are compared to an adjustable reference voltage called the sensitivity. Any signal below the reference voltage is not sensed, and those above it are sensed. Higher-sensitivity settings (high-reference voltage) may lead to substandard sensing, and a lower reference voltage may result in oversensing. A
minimum 2:1 safety margin should be maintained between the sensitivity setting and the amplitude of the intracardiac signal.The circuit is protected from extremely high voltages by a Zener diode.The slope of the signal is also surveyed by the sensing circuit and is determined by the slew rate (the time rate of change in voltage). A slew rate that is too flat or too steep may be eliminated by the bandpass filter. On the average, the slew rate measured at implant should be between 0.75 and 2.50 V/s.The last line of defense in an effort to remove undesirable signals is to “blind” the circuit at specific times during the cardiac cycle. This is accomplished with blanking and refractory periods. Some of these periods are programmable. During the blanking period the sensing circuit is turned off, and during the refractory period the circuit can see the signal but does not initiate any of the basic timing intervals.Virtually all paced and sensed events begin concurrent blanking and refractory periods, typically ranging from 10–400 ms. These are especially helpful in dual-chamber pacemakers where there exists the potential for the pacing output of the atrial side to inhibit the ventricular pacing output, with dangerous consequences for patients in complete heart block.Probably the most common question asked by the general public about pacing systems is the effect of electromagnetic interference (EMI) on their operation. EMI outside of the hospital is an infrequent problem, though patients are advised to avoid such sources of strong electromagnetic fields as arc welders,high-voltage generators, and radar antennae. Some clinicians suggest that patients avoid standing near antitheft devices used in retail stores. Airport screening devices are generally safe, though they may detect a pacemaker’s metal case. Microwave ovens, ham radio equipment, video games, computers, and office equipment rarely interfere with the operation of modern pacemakers. A number of medical devices and procedures may on occasion do so, however; electrocautery, cardioversion and defibrillation, MRI,lithotripsy, diathermy, TENS units, and radiation therapy.Pacemakers affected by interference typically respond with temporary loss of output or temporary reversion to asynchronous pacing (pacing at a fixed rate, with no inhibition from intrinsic cardiac events).The usual consequence for the patient is a return of the symptoms that originally led to the pacemaker implant.
Output Circuit Pacing is the most significant drain on the pulse generator power source. Therefore, current drain must be minimized while maintaining an adequate safety margin between the stimulation threshold and the programmed output stimulus. Modern permanent pulse generators use constant voltage. The voltage remains at the programmed value while current fluctuates in relation to the source impedance.Output energy is controlled by two programmable parameters, pulse amplitude and pulse duration.Pulse amplitudes range from 0.8–5 V and, in some generators, can be as high as 10 V (used for troubleshooting or for pediatric patients). Pulse duration can range from 0.05– 1.5 ms. The prudent selection of these parameters will greatly influence the longevity of the pulse generator.The output pulse is generated from the discharge of a capacitor charged by the
battery. Most modern pulse generators contain a 2.8 V battery. The higher voltages are achieved using voltage multipliers (smaller capacitors used to charge the large capacitor). The voltage can be doubled by charging two smaller capacitors in parallel, with the discharge delivered to the output capacitor in series. Output pulses are emitted at a rate controlled by the timing circuit; output is commonly inhibited by sensed cardiac signals. Timing Circuit The timing circuit regulates such parameters as the pacing cycle length, refractory and blanking periods,pulse duration, and specific timing intervals between atrial and ventricular events. A crystal oscillator generating frequencies in the kHz range sends a signal to a digital timing and logic control circuit, which in turn operates internally generated clocks at divisions of the oscillatory frequency.A rate-limiting circuit is incorporated into the timing circuit to prevent the pacing rate from exceeding an upper limit should a random component failure occur (an extremely rare event). This is also referred to as “runaway” protection and is typically 180–200 ppm. Telemetry Circuit Today’s pulse generators are capable of both transmitting information from an RF antenna and receiving information with an RF decoder. This two-way communication occurs between the pulse generator and the programmer at approximately 300 Hz. Real-time telemetry is the term used to describe the ability of the pulse generator to provide information such as pulse amplitude, pulse duration, lead impedance, battery impedance, lead current, charge, and energy. The programmer, in turn, delivers coded messages to the pulse generator to alter any of the programmable features and to retrieve diagnostic data. Coding requirements reduce the likelihood of inappropriate programming alterations by environmental sources of radiofrequency and magnetic fields. It is also prevents the improper use of programmers from other manufacturers. Power Source Over the years, a number of different battery technologies have been tried, including mercuryzinc,rechargeable silver-modified-mercuric-oxide-zinc, rechargeable nickel-cadmium, radioactive plutonium or promethium, and lithium with a variety of different cathodes. Lithiumcupric-sulfide and mercuryzinc batteries were associated with corrosion and early failure. Mercury-zinc produced hydrogen gas as a by-product of the battery reaction; the venting required made it impossible to hermetically seal the generator. This led to fluid infiltration followed by the risk of sudden failure.The longevity of very early pulse generators was measured in hours. With the lithium-iodide technology now used, longevity has been reported as high as 15 years. The clinical desire to have a generator that is small and full-featured yet also long-lasting poses a formidable challenge to battery designers. One response by manufacturers has been to offer different models of generators, each offering a different balance between therapy, size, and longevity. Typical battery capacity is in the range of 0.8–3.0 amp-hours.
Many factors affect longevity, including pulse amplitude and duration, pacing rate, single- versus dualchamber pacing, degree to which the patient uses the pacemaker, lead design, and static current drain from the sensing circuits. Improvements in lead design are often overlooked as a factor in improving longevity, but electrodes used in 1960 required a pulse generator output of 675 μ J for effective stimulation,whereas the electrodes of the 1990s need only 3–6 μJ.Another important factor in battery design lies in the electrolyte that separates the anode and the cathode. The semisolid layer of lithium iodide that is used gradually thickens over the life of the cell,increasing the internal resistance of the battery. The voltage produced by lithium-iodine batteries is inversely related to this resistance and is linear from 2.8 V to approximately 2.4 V, representing about 90% of the usable battery life. It then declines exponentially to 1.8 V as the internal battery resistance increases from 10,000 Ω to 40,000 Ω (Fig. 1.5).When the battery reaches between 2.0 and 2.4 V (depending on the manufacturer), certain functions of the pulse generator are altered so as to alert the clinician. These alterations are called the electivereplacement indicators (ERI). They vary from one pulse generator to another and include signature decreases in rate, a change to a specific pacing mode, pulse duration stretching, and the telemetered battery voltage. When the battery voltage reaches 1.8 V, the pulse generator may operate erratically or cease to function and is said to have reached “end of life.” The time period between appearance of the ERI and end-of-life status averages about 3 to 4 months.
FIGURE 1.5 The initial decline in battery voltage is slow and then more rapid after the battery reaches the ERI voltage. An important aspect of battery design is the predictability of this decline so that timely generator replacement is anticipated.
1.3 Leads Implantable pacing leads must be designed not only for consistent performance within the hostile environment of the body but also for easy handling by the implanting physician. Every lead has four major components (Fig. 1.6): the electrode, the conductor, the insulation, and the connector pin(s). The electrode is located at the tip of the lead and is in direct contact with the myocardium. Bipolar leads have a tip electrode and a ring electrode (located about 2 cm proximal to the tip); unipolar leads have tip electrodes only. A small-radius electrode provides increased current density resulting in lower stimulation thresholds. The electrode also increases resistance at the electrode-myocardial interface, thus lowering the current drain further and improving battery longevity. The radius of most electrodes is 6–8 mm 2 , though there are clinical trials underway using a “high-impedance” lead with a tip radius as low as 1.5 mm 2. Small electrodes, however, historically have been associated with inferior sensing performance. Lead designers were able to achieve both good pacing and good sensing by creating porous-tip electrodes containing thousands of pores in the 20–100 μ m range. The pores allow the ingrowth of tissue, resulting in the necessary increase in effective sensing area while maintaining a small pacing area. Some commonly used electrode materials include platinum-iridium. Elgiloy (an alloy of cobalt, iron, chromium, molybdenum, nickel, and manganese), platinum coated with platinized titanium, and vitreous or pyrolytic carbon coating a titanium or graphite core. Another major breakthrough in lead design is the steroid-eluting electrode. About 1 mg of a corticosteroid (dexamethasone sodium phosphate) is contained in a silicone core that is surrounded by the electrode material (Fig. 1.7). The “leaking” of the steroid into the myocardium occurs slowly over several years and reduces the inflammation that results from the lead placement. It also retards the growth of the fibrous sack that forms around
FIGURE 1.7:-The steroid elution electrode.
the electrode which separates it from viable myocardium. As a result,the dramatic rise in acute thresholds that is seen with nonsteroid leads over the 8 to 16 weeks postimplant is nearly eliminated. This makes it possible to program a lower pacing output, further extending longevity. Once a lead has been implanted, it must remain stable (or fixated). The fixation device is either active or passive. The active fixation leads incorporate corkscrew mechanisms, barbs, or hooks to attach themselves to the myocardium. The passive fixation leads are held into place with tines that become entangled into the netlike lining (trabeculae) of the heart. Passive leads generally have better acute pacing and sensing performance but are difficult to remove chronically. Active leads are easier to remove chronically and have the advantage of unlimited placement sites. Some implanters prefer to use active-fixation leads in the atrium and passive-fixation leads in the ventricle. The conductor carries electric signals to the pulse generator and delivers the pacing pulses to the heart. It must be strong and flexible to withstand the repeated flexing stress placed on it by the beating heart. The early conductors were a single, straight wire that was vulnerable to fracturing. They have evolved into coiled (for increased flexibility) multifilar (to prevent complete failure with partial fractures) conductors.The conductor material is a nickel alloy called MP35N. Because of the need for two conductors,bipolar leads are usually larger in diameter than unipolar leads. Current bipolar leads have a coaxial design that has significantly reduced the diameter of bipolar leads. Insulation materials (typically silicone and polyurethane) are used to isolate the conductor. Silicone has a longer history and the exclusive advantage of being repairable. Because of low
tear strength, however,silicone leads tend to be thicker than polyurethane leads. Another relative disadvantage of silicone is its high coefficient of friction in blood, which makes it difficult for two leads to pass through the same vein.A coating applied to silicone leads during manufacturing has diminished this problem. A variety of generator-lead connector configurations and adapters are available. Because incompatibility can result in disturbed (or even lost) pacing and sensing, an international standards (IS-1) has been developed in an attempt to minimize incompatibility. Leads can be implanted epicardially and endocardially.Epicardial leads are placed on the outer surface of the heart and require the surgical exposure of a small portion of the heart. They are used when venous occlusion makes it impossible to pass a lead transvenously, when abdominal placement of the pulse generator is needed (as in the case of radiation therapy to the pectoral area), or in children (to allow for growth).Endocardial leads are more common and perform better in the long term. These leads are passed through the venous system and into the right side of the heart. The subclavian or cephalic veins in the pectoral region are common entry sites. Positioning is facilitated by a thin, firm wire stylet that passes through the central lumen of the lead, stiffening it. Fluoroscopy is used to visualize lead positioning and to confirm the desired location. Manufacturers are very sensitive to the performance reliability of the leads. Steady improvements in materials, design, manufacturing, and implant technique have led to reliability well in excess of 99% over 3-year periods. 1.4 Programmers Noninvasive reversible alteration of the functional parameters of the pacemaker is critical to ongoing clinical management. For a pacing system to remain effective throughout its lifetime, it must be able to adjust to the patient’s changing needs. The programmer is the primary clinical tool for changing settings, for retrieving diagnostic data, and for conducting noninvasive tests. The pacing rate for programmable pacemakers of the early 1960s was adjusted via a Keith needle manipulated percutaneously into a knob on the side of the pacemaker; rotating the needle changed the pacing rate. Through the late 1960s and early 1970s, magnetically attuned reed switches in the pulse generator made it possible to noninvasively change certain parameters such as rate, output, sensitivity,and polarity. The application of a magnet could alter the parameters which were usually limited to only one of two choices. It wasn’t until the late 1970s, when radiofrequency energy was incorporated as the transmitter of information, that programmability began to realize its full potential. Radiofrequency transmission is faster, provides bidirectional telemetry, and decreases the possibility of unintended programming from inappropriate sources. Most manufacturers today are moving away from a dedicated proprietary instrument and toward a PC-based design. The newer designs are generally more flexible, more intuitive to use, and more easily updated when new devices are released. Manufacturers and clinicians alike are
becoming more sensitive to the role that time-efficient programming can play in the productivity of pacing clinics, which may provide follow-up for as many as 500–1000 patients a year.
1.5 system operation Pacemakers have gotten steadily more powerful over the last three decades, but at the cost of steadily greater complexity. Manufacturers have come to realize the challenge that this poses for busy clinicians and have responded with a variety of interpretive aids (Fig. 1.8) Much of the apparent complexity of the timing rules that determine pacemaker operation is due to a design goal of mimicking normal cardiac function without interfering with it. One example is the dualchamber feature that provides sequential stimulation of the atrium before the ventricle.Another example is rate response, designed for patients who lack the normal ability to increase their heart rate in response to a variety of physical conditions (e.g., exercise). Introduced in the mid1980s,rate-responsive systems use some sort of sensor to measure the change in a physical variable correlated to heart rate. The sensor output is signal-processed and then used by the output circuit to specify a target pacing rate. The clinician controls the aggressiveness of the rate increase through a variety of parameters (including a choice of transfer function); pacemakerresident diagnostics provide data helpful in titrating the rate-response therapy. The most common sensor is the activity sensor, which uses piezoelectric materials to detect vibrations caused by body movement. Systems using a transthoracic-impedance sensor to estimate pulmonary minute ventilation are also commercially available. Numerous ther sensors (e.g., stroke volume, blood
FIGURE 77.8 The Marker Channel Diagram is just one tool that makes interpretation of the ECG strip faster and more reliable for the clinician. It allows quick checking of the timing operations of the system.
temperature or pH, oxygen saturation, preejection interval, right ventricular pressure) are in various stages of clinical research or have been market released outside the United States. Some of these systems are dual-sensor, combining the best features of each sensor in a single pacing system.To make it easier to understand the gross-level system operation of modern pacemakers, a five-letter code has been developed by the North American Society of Pacing and Electrophysiology and the British Pacing and Electrophysiology Group [Bernstein et al., 1987]. The first letter indicates the chamber (or chambers) that are paced. The second letter reveals those chambers in which sensing takes place, and the third letter describes how the pacemaker will respond to a sensed event. The pacemaker will “inhibit”the pacing output when intrinsic activity is sensed or will “trigger” a pacing output based on a specific previously sensed event. For example, in DDD mode: D: Pacing takes place in the atrium and the ventricle.D: Sensing takes place in the atrium and the ventricle.D: Both inhibition and triggering are the response to a sensed event. An atrial output is inhibited with an atrial-sensed event, whereas a ventricular output is inhibited with a ventricular-sensed event;a ventricular pacing output is triggered by an atrial-sensed event (assuming no ventricular event occurs during the A-V interval).The fourth letter in the code is intended to reflect the degree of programmability of the pacemaker but is typically used to indicate that the device can provide rate response. For example, a DDDR device is one that is programmed to pace and sense in both chambers and is capable of sensor-driven rate variability. The fifth letter is reserved specifically for antitachycardia functions (Table 77.1).Readers interested in the intriguing details of pacemaker timing operations are referred to the works listed at the end of this chapter.
1.6Clinical Outcomes and Cost Implications The demonstrable hemodynamic and symptomatic benefits provided by rate-responsive and dual-chamberpacing have led U.S. physicians to include at least one of these features in over three-fourths of implants in recent years. Also, new prospective data [Andersen et al., 1993] support a hypothesis investigated retrospectively since the mid-1980s: namely, that pacing the atrium in patients with sinus node dysfunction can dramatically reduce the incidence of such lifethreatening complications as congestive heart failure and stroke associated with chronic trial fibrillation.Preliminary analysis of the cost implications suggest that dual-chamber pacing is significantly cheaper to the U.S. healthcare system than is single-chamber pacing over the full course of therapy, despite the somewhat higher initial cost of implanting the dual-chamber system. 1.7conclusion Permanent cardiac pacing is the beneficiary of three decades of advances in a variety of key technologies:biomaterials, electrical stimulation, sensing of bioelectrical events, power sources, microelectronics, transducers,signal analysis, and software development. These advances, informed and guided by a wealth of clinical experience acquired during that time, have made pacing a cost-effective cornerstone of cardiac arrhythmia management.
2. ELECTRICAL STIMULATION: 2.1 DEFINITIONS:Electrical stimulation is defined as the use of an electrical current to transfer energy to a wound. The type of electricity that is transferred is controlled by the electrical source. Capacitatively coupled electrical stimulation involves the transfer of electric current through an applied surface electrode pad that is in wet (electrolytic) contact ( capacitatively coupled) with the external skin surface and /or wound bed. When capacitatively coupled electrical stimulation is used, two electrodes are required to complete the electric circuit. Electrodes are usually placed over wet conductive medium, in the wound bed and on the skin a distance away from the wound. When discussing electrical stimulation, it is important to distinguish the waveform used for the protocol. Although there are many waveforms available on electrotherapy equipment, the one that has the most thorough and consistent evaluation in vitro, in animal studies and in controlled clinical trials is monophasic twin peaked high voltage pulsed current (HVPC).The pulse width varies with a range from 20-200 microseconds. The HVPC devices also allow for selection of polarity and variation in pulse rates both of which seem to be important in wound healing. It is a very safe current because it's very short pulse duration prevents significant changes in both tissue
pH and temperature. Therefore, the most tested and safe type of stimulation is the one recommended. 2.2 THEORY AND SCIENCE OF THE THERAPY:Chronic electrical stimulation provides one of the "cleanest" views of muscle adaptation to increased use. This model has long been used by basic scientists to study skeletal muscle adaptation since it induces a repeatable, quantifiable amount of "exercise." Thus, we have been able to synthesize a collection of such studies in a manner that provides a fairly global view of muscle structural and physiological changes that occur in response to the stimulation. It is known that muscles which perform different tasks, in addition to having different muscle architecture, respond to different electrical input. For example, skeletal muscles that play a postural role, and thus have a high proportion of slow fibers, are physiologically activated at low frequencies. Conversely, muscles with a very high proportion of fast fibers may be activated only intermittently with high frequency bursts of electrical activity. The fact that electrical activity and muscle properties seem to be intimately interrelated provides an experimental basis for understanding muscle plasticity. The best documented effects of electrical stimulation on skeletal muscle are those that occur after chronic, low-frequency stimulation (similar to the activity of a "slow" muscle) is imposed upon a predominantly "fast" muscle. If the stimulator is activated at a nominal frequency of about 10 Hz and allowed to operate 8-24 hours per day, a well-defined progression of changes is observed whereby the fast muscle first changes its metabolic and then its contractile properties to completely "transform" into a "slow" muscle. Based on time-series studies and single fiber biochemistry that the changes that occur result from a true transformation of a single fast fiber into a slow fiber and not from selective loss of fast fibers with subsequent slow fiber regeneration or proliferation. The fast fibers actually become slow fibers. In fact, even the physical appearance of the stimulated muscle approaches that of the more postural muscles by taking on a "deep red" appearance.
Photograph of control (top) and experimentally stimulated (bottom) rabbit tibialis anterior muscles. Note the dark (deep red) appearance of the stimulated muscle which reflects the dramatic capillary proliferation and myoglobin content.
Defibrillation is the definitive treatment for the life-threatening cardiac arrhythmias ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator. This depolarizes a critical mass of the heart muscle, terminates the arrhythmia, and allows normal sinus rhythm to be reestablished by the body's natural pacemaker, in the sinoatrial node of the heart.
Defibrillators can be external, transvenous, or implanted, depending on the type of device used. Some external units, known as automated external defibrillators (AEDs), automate the diagnosis
of treatable rhythms, meaning that lay responders or bystanders are able to use them successfully with little, or in some cases no, training.
Typical view of defibrillation in progress, with the operator at the head.
Defibrillation was first demonstrated in 1899 by Prevost and Batelli, two physiologists from University of Geneva, Switzerland. They discovered that small electric shocks could induce ventricular fibrillation in dogs, and that larger charges would reverse the condition. The first use on a human was in 1947 by Claude Beck, professor of surgery at Western Reserve University. Beck's theory was that ventricular fibrillation often occurred in hearts which were fundamentally healthy, in his terms "Heart too good to die", and that there must be a way of saving them. Beck first used the technique successfully on a 14 year old boy who was being operated on for a congenital chest defect. The boy's chest was surgically opened, and manual cardiac massage was undertaken for 45 minutes until the arrival of the defibrillator. Beck used internal paddles either side of the heart, along with procaine amide, a heart drug, and achieved return of normal sinus rhythm. These early defibrillators used the alternating current from a power socket, transformed from the 110-240 volts available in the line, up to between 300 and 1000 volts, to the exposed heart by way of 'paddle' type electrodes. The technique was often ineffective in reverting VF while morphological studies showed damage to the cells of the heart muscle post mortem. The nature of the AC machine with a large transformer also made these units very hard to transport, and they tended to be large units on wheels.
3.1.1 Closed-chest method
Until the early 1950s, defibrillation of the heart was possible only when the chest cavity was open during surgery. The technique used an alternating current from a 300 or greater volt source delivered to the sides of the exposed heart by 'paddle' electrodes where each electrode was a flat or slightly concave metal plate of about 40 mm diameter. The closed-chest defibrillator device which applied an alternating current of greater than 1000 volts, conducted by means of externally applied electrodes through the chest cage to the heart, was pioneered by Dr V. Eskin with assistance by A. Klimov in Frunze, USSR in mid 1950s.
Move to direct current
A circuit diagram showing the simplest (non-electronically controlled) defibrillator design, depending on the inductor (damping), producing a Lown, Edmark or Gurvich Waveform In 1959 Bernard Lown commenced research into an alternative technique which involved charging of a bank of capacitors to approximately 1000 volts with an energy content of 100-200 joules then delivering the charge through an inductance such as to produce a heavily damped sinusoidal wave of finite duration (~5 milliseconds) to the heart by way of 'paddle' electrodes. The work of Lown was taken to clinical application by engineer Barouh Berkovits with his "cardioverter". The Lown waveform, as it was known, was the standard for defibrillation until the late 1980s when numerous studies showed that a biphasic truncated waveform (BTE) was equally efficacious while requiring the delivery of lower levels of energy to produce defibrillation. A side effect was a significant reduction in weight of the machine. The BTE waveform, combined with automatic measurement of transthoracic impedance is the basis for modern defibrillators.
3.1.2 Portable units become available
A major breakthrough was the introduction of portable defibrillators in ambulances. This was pioneered in the early 1960s by Prof. Frank Pantridge in Belfast. Today portable defibrillators are one of the most important tools carried by ambulances. They are the only proven way to resuscitate a person who has had a cardiac arrest unwitnessed by EMS who is still in persistent ventricular fibrillation or ventricular tachycardia at the arrival of pre-hospital providers. Gradual improvements in the design of defibrillators, and partly based on the work developing implanted versions (see below) have lead to the availability of Automated External Defibrillators, which can analyze the heart rhythm by themselves, diagnosing the shockable
rhythms, and then charging to treat. This means that no clinical skill is required in their use, allowing lay people to respond to emergencies effectively.
3.1.3 Change to a biphasic waveform
Until the late 1980s, external defibrillators delivered a Lown type waveform which was a heavily damped sinusoidal impulse having a mainly uniphasic characteristic. Biphasic defibrillation, however, alternates the direction of the pulses, completing one cycle in approximately 10 milliseconds. Biphasic defibrillation was originally developed and used for implantable cardioverter-defibrillators. When applied to external defibrillators, biphasic defibrillation significantly decreases the energy level necessary for successful defibrillation. This, in turn, decreases risk of burns and myocardial damage. Ventricular fibrillation (VF) could be returned to normal sinus rhythm in 60% of cardiac arrest patients treated with a single shock from a monophasic defibrillator. Most biphasic defibrillators have a first shock success rate of greater than 90%.
Mechanism of Defibrillation
The corrective measure is to extinguish the rapidly occurring waves of excitation by simultaneously depolarizing most of the cardiac cells with a strong electric shock. The cells then can simultaneously repolarize themselves, and thus they will be back in phase with each other. Despite years of intensive research, there is still no single theory for the mechanism of defibrillation that explains all the phenomena observed. However, it is generally held that the defibrillating shock must be adequately strong and have adequate duration to affect most of the heart cells. In general, longer duration shocks require less current than shorter duration shocks. This relationship is called the strengthduration relationship and is demonstrated by the curve shown in Fig.. Shocks of strength andduration above and to the right of the current curve (or above the energy curve) have adequate strength to defibrillate, whereas shocks below and to the left do not. From the exponentially decaying current curve an energy curve can also be determined (also shown in Fig. ), which is high at very short durations due to high current requirements at short durations, but which is also high at longer durations due to additional energy being delivered as the pulse duration is lengthened at nearly constant current.Thus, for most electrical waveforms there is a minimum energy for defibrillation at approximate pulse durations of 3–8 ms. A strength-duration charge curve can also be determined as shown in Fig. 7,which demonstrates that the minimum charge for defibrillation occurs at the shortest pulse duration
fig :-Strength-duration curves for current, energy, and charge. Adequate current shocks are above and to the right of the current curve. (Modified from Tacker WA, Geddes LA, 1980.Electrical Defibrillation,Boca Raton,Fla, CRC Press, with permission.)
tested. Very-short-duration pulses are not used, however, since the high current and voltage required is damaging to the myocardium. It is also important to note that excessively strong or long shocks may cause immediate refibrillation, thus failing to restore the heart function.In practice, for a shock applied to electrodes on the skin surface of the patient’s chest, durations are on the order of 3–10 milliseconds and have an intensity of a few thousand volts and tens of amperes.The energy delivered to the subject by these shocks is selectable by the operator and is on the order of 50–360 joules for most defibrillators. The exact shock intensity required at a given duration of electric pulse depends on several variables, including the intrinsic characteristics of the patient (such as the underlying disease problem or presence of certain drugs and the length of time the arrhythmia has been present), the techniques for electrode application, and the particular rhythm disorder being treated (more organized rhythms require less energy than disorganized rhythms).
3.2.1 Manual external defibrillator:
External defibrillator / monitor
The units are used in conjunction with (or more often have inbuilt) electrocardiogram readers, which the clinician uses to diagnose a cardiac condition (most often fibrillation or tachycardia although there are some other rhythms which can be treated by different shocks). The clinician will then decide what charge (voltage) to use, based on their prior knowledge and experience, and will deliver the shock through paddles or pads on the patient's chest.
Manual internal defibrillator
These are the direct descendants of the work of Beck and Lown. They are virtually identical to the external version, except that the charge is delivered through internal paddles in direct contact with the heart. These are almost exclusively found in operating theatres, where the chest is likely to be open, or can be opened quickly by a surgeon.
3.2.2 Automated external defibrillator (AED)
An AED at a railway station in Japan. The AED box has information on how to use it in Japanese, English, Chinese and Korean, and station staffs are trained to use it. These simple to use units are based on computer technology which is designed to analyze the heart rhythm itself, and then advise whether a shock is required. They are designed to be used by lay persons, who require little training. They are usually limited in their interventions to delivering high joule shocks for VF and VT (ventricular tachycardia) rhythms, making them generally limiting for use by health professionals, who could diagnose and treat a wider range of problems with a manual or semi-automatic unit. The automatic units also take time (generally 10-20 seconds) to diagnose the rhythm, where a professional could diagnose and treat the condition far quicker with a manual unit. These time intervals for analysis, which require stopping chest compressions, have been shown in a number of studies to have a significant negative effect on shock success. This effect led to the recent change in the AHA defibrillation guideline (calling for two minutes of CPR after each shock without analyzing the cardiac rhythm) and a statement in the ACLS Provider Manual that AEDs should not be used when manual defibrillators and trained operators are available. Automated external defibrillators are generally either held by trained personnel who will attend incidents, or are public access units which can be found in places including corporate and government offices, shopping centres, airports, restaurants, casinos, hotels, sports stadiums, schools and universities, community centres, fitness centres and health clubs.
An automated external defibrillator, open and ready for pads to be attached The locating of a public access AED should take in to account where large groups of people gather, and the risk category associated with these people, to ascertain whether the risk of a sudden cardiac arrest incident is high. For example, a centre for teenage children is a particularly low risk category (as children very rarely enter heart rhythms such as VF or VT, being generally young and fit, and the most common cause of paediatric cardiac arrest is trauma - where the heart
is more likely to enter asystole or PEA, where an AED is no use), whereas a large office building with a high ratio of males over 50 is a very high risk environment. In many areas, emergency services vehicles are likely to carry AEDs, with some Ambulances carrying an AED in addition to a manual unit. In addition, some police or fire service vehicles carry an AED for first responder use. Some areas have dedicated community first responders, who are volunteers tasking with keeping an AED and taking it to any victims in their area. It is also increasingly common to find AEDs on transport such as commercial airlines and cruise ships. In order to make them highly visible, public access AEDs often are brightly coloured, and are mounted in protective cases near the entrance of a building. When these protective cases are opened, and the defibrillator removed, some will sound a buzzer to alert nearby staff to their removal but do not necessarily summon emergency services. All trained AED operators should also know to phone for an ambulance when sending for or using an AED, as the patient will be unconscious, which always requires ambulance attendance.
3.2.3 Semi-automated external defibrillators
These units are a compromise between a full manual unit and an automated unit. They are mostly used by pre-hospital care professionals such as paramedics and emergency medical technicians. These units have the automated capabilities of the AED but also feature an ECG display, and a manual override, where the clinician can make their own decision, either before or instead of the computer. Some of these units are also able to act as a pacemaker if the heart rate is too slow and perform other functions which require a skilled operator.
3.2.4 Implantable Cardioverter-defibrillator (ICD)
Also known as automatic internal cardiac defibrillator (AICD). These devices are implants, similar to pacemakers (and many can also perform the pacemaking function). They constantly monitor the patient's heart rhythm, and automatically administer shocks for various life threatening arrhythmias, according to the device's programming. Many modern devices can distinguish between ventricular fibrillation, ventricular tachycardia, and more benign arrhythmias like supraventricular tachycardia and atrial fibrillation. Some devices may attempt overdrive pacing prior to synchronize cardioversion. When the life threatening arrhythmia is ventricular fibrillation, the device is programmed to proceed immediately to an unsynchronized shock. There are cases where the patient's ICD may fire constantly or inappropriately This is considered a medical emergency, as it depletes the device's battery life, causes significant discomfort and anxiety to the patient, and in some cases may actually trigger life threatening arrhythmias. Some emergency medical services personnel are now equipped with a ring magnet to place over the device, which effectively disables the shock function of the device while still allowing the pacemaker to function (if the device is so equipped). If the device is shocking frequently, but appropriately, EMS personnel may administer sedation.
3.2.5 Interface with the patient
The most well-known type of electrode is the traditional metal paddle with an insulated handle. This type must be held in place on the patient's skin while a shock or a series of shocks is delivered. Before the paddle is used, a gel must be applied to the patient's skin, in order to ensure a good connection and to minimize electrical resistance, also called chest impedance (despite the DC discharge). These are generally only found on the manual external units. Another type of resuscitation electrode is designed as an adhesive pad. When a patient has been admitted due to heart problems, and the physician or nurse has determined that he or she is at risk of arrhythmia, they may apply adhesive electrodes to the patient in anticipation of any problems that may arise. These electrodes are left connected to a defibrillator. If defibrillation is required, the machine is charged, and the shock is delivered, without any need to apply any gel or to retrieve and place any paddles. These adhesive pads are found on most automated and semiautomated units. Both solid- and wet-gel adhesive electrodes are available. Solid-gel electrodes are more convenient, because there is no need to clean the patient's skin after removing the electrodes. However, the use of solid-gel electrodes presents a higher risk of burns during defibrillation, since wet-gel electrodes more evenly conduct electricity into the body. Adhesive electrodes are designed to be used not only for defibrillation, but also for non-invasive pacing and electrical cardioversion. While the paddles on a monitor/defibrillator may be quicker than using the patches, adhesive patches are superior due to their ability to provide appropriate EKG tracing without the artifact visible from human interference with the paddles. Adhesive electrodes are also inherently safer than the paddles for the operator of the defibrillator to use, as they minimize the risk of the operator coming into physical (and thus electrical) contact with the patient as the shock is delivered, by allowing the operator to stand several feet away. Another inconvenience of the paddles is the requirement of around 25lbs of pressure to be applied while defibrillating.
Defibrillator design has resulted from medical and physiologic research and advances in hardware technology.It is estimated that for each minute that elapses between onset of ventricular fibrillation and the first shock application, survival to leave hospital decreases by about 10%. The importance of rapid response led to development of portable, battery-operated defibrillators and more recently to automatic external defibrillators (AEDs) that enable emergency responders to defibrillate with minimal training.All clinical defibrillators used today store energy in capacitors. Desirable capacitor specifications include small size, light weight, and capability to sustain several thousands of volts and many chargedischarge cycles. Energy storage capacitors account for at least one pound and usually several pounds of defibrillator weight.
Block diagram of a typical defibrillator. (From Feinberg B. 1980.Handbook Series in Clinical Laboratory Science,vol 2, Boca Raton, Fla, CRC Press, with permission.)
It is the most general type of Cardioverter being used these days.
4.1 Implantable cardioverter-defibrillator
An Implantable cardioverter-defibrillator (ICD), also known as an Automated implantable cardioverter-defibrillator (AICD), is a small battery-powered electrical impulse generator which is implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation. The device is programmed to detect cardiac arrhythmia and correct it by delivering a jolt of electricity. In current variants, the ability to revert ventricular fibrillation has been extended to include both atrial and ventricular arrhythmias as well as the ability to perform biventricular pacing in patients with congestive heart failure or bradycardia. The process of implantation of an ICD is similar to implantation of a pacemaker. Similar to pacemakers, these devices typically include electrode wire/s which pass through a vein to the right chambers of the heart, usually being lodged in the apex of the right ventricle. The difference is that pacemakers are more often temporary and generally designed to consistently correct bradycardia, while AICDs are often permanent safeguards against sudden abnormalities. ICDs constantly monitor the rate and rhythm of the heart and can deliver therapies, by way of an electrical shock, when the electrical manifestations of the heart activity exceeds the preset number. More modern devices can distinguish between ventricular fibrillation and ventricular tachycardia (VT), and may try to pace the heart faster than its intrinsic rate in the case of VT, to try to break the tachycardia before it progresses to ventricular fibrillation. This is known as fastpacing, overdrive pacing, or anti-tachycardia pacing (ATP). ATP is only effective if the underlying rhythm is ventricular tachycardia, and is never effective if the rhythm is ventricular fibrillation. Many modern ICDs use a combination of various methods to determine if a fast rhythm is normal, ventricular tachycardia, or ventricular fibrillation. Rate discrimination evaluates the rate of the lower chambers of the heart (the ventricles) and compares it to the rate in the upper chambers of the heart (the atria). If the rate in the atria is faster than or equal to the rate in the ventricles, then the rhythm is most likely not ventricular in origin, and is usually more benign. If this is the case, the ICD does not provide any therapy.
Rhythm discrimination will see how regular a ventricular tachycardia is. Generally, ventricular tachycardia is regular. If the rhythm is irregular, it is usually due to conduction of an irregular rhythm that originates in the atria, such as atrial fibrillation. Morphology discrimination checks the morphology of every ventricular beat and compares it to what the ICD believes is a normally conducted ventricular impulse for the patient. This normal ventricular impulse is often an average of a multiple of beats of the patient taken in the recent past.
The term ventilator are used to describe the equipment that mate be employed continuously or intentmittently to improve ventillaton of the lungs and to supply humidity or aerosols,medictions to the pulmonary tree.Most ventilators use positive pressure during inhalation to inflate the lungs with various gases or mixture of gases.Expiration is usually passive although under certain conditions pressure may be applied d uring the expiratory phase as well,in order to improve arterial oxygen tension.
Most respirators are classified as assistor,controllers and can operated in any of three dif erent modes.These modes differ in the method by which insiparation.
1.ASSIST mode: Inspiration is triggered by patientA pressure sensor responde to the slight negative pressure that occurs each times the patient intends to inhale and triggers the apparatus to begin inflating the lungs.Assist mode is used for patients who are able to control their breathing
but are unable to inhale a sufficient amount of air without assistance.
2.CONTROL mode:Breathing is control by timer set to provide the desire respiration rate.Controlled ventilation is required for patients who are unable to breath on their own.
3.ASSIST-CONTROL mode:The apparatus is normally triggered by the patient’s attempt to breath,as in the assist mode.If the patient fails to breath within a predetermined time,a timer automatically triggers the device to inflate the lungs.This mode is most frequently used in critical care settings.
Once inspiration has been triggered,inflation of the lungs continues unless one of the following condition occurs :
1.The delivered gas reaches a predetermined pressure in the proximal or a upper airways.A ventilator that operates primarily in this manner is said to be pressure cycled.
2.A predetermined volume of gas has been deliverd to the patient.This is the primary mode of operation of volume cycled ventilators.
3.The air or oxygen has been applied for predetermined time.This is the characteristic mode of operation for time cycled ventilators.
The many type of ventilator in clinical use can be characterized by two basic types: The first is pressure cycled,positive pressure assistor controller.The device is powered pneumatically from a source of gas and requires no electrical power.Devices in this category may contain an electrical power compresure or can be used with a separate compressure to permit ventilation with ambient air. Second is volume cycled ventilator called volume respirator.This type of device uses a piston or bellows to dispense a precisely control volume for each breath.In the critical care setting where the patient has pulmonary abnormalities and require predeictable volumes and
concentrations of the gas,this type of ventilators are preferred.
Adjustable pressure limit and alarms for safety are available in most devices of this type.
Transcutaneous electrical nerve stimulator (TENS):
TENs provide impulses required for electrotherapy to track the pain.The square wave or spike wave are equally effective relieving pain.In most of the stimulator the adjustment settings are providing for controlling amplitude by the control of voltage,current and width for each pulse .Electrodes are placed at specific sites on the body for treatment of pain.The current in pulsating form travels through the electrodes and in to the skin stimulatig specific nerve pathways to produce a massaging sensation that reduces the perception of pain.Normally the stimulation is based arounnd a 500ms spike pulse having an adjustable amplitude of 0-75mA and an adjustable freq of 12-100 pulses per second. In TENS,the electrodes are commonly moulded from silicon rubber,loaded with carbon particles to provide proper conductance.the electrodes are made thin to achieve confirmability.Useful carbon loaded silicon have a minimum resistivity of 10 ohm cm.
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