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that result in heart block and adams stokes attacks in patients leads to losing consciousness By use of this artificial pacemaker, the abov defects in heart can be eliminated Even in drug therapy the failure within the year is about 50%, but in this therapy lowers to 15%...
Like all miscle tissue, the heart muscle can be stimulated with an electric shoch, the min energy required is about 10microJ For better stimulation, energy at range of 100microJ is applied that is a pulse of 5 V, 10mA for 2 millisec is used These pulses should have the pulse to space ratio 1:10000 The pulse repetition rate is usually 70 pulses/min but many PM are adjustable range of 50-150 pulses/min
Typical range of pacemaker parameter Pulse rate -25-155 pulses/min pulse width -0.1-2.3 millisec pulse amplitude -2.5-10 volt battery capacity -0.44-3.2 -amp-hour weight -33-98 grams size -22-80 cm3 encapsulization -silicon rubber, stainless steel,titanium
Pacing or stimulation can be classified into two types as follows., EXTERNAL stimulation is employed to restart the normal rhythm of heart in the case of cardiac stand still energy to this type of electrode is in the range of 20510 mA INTERNAL stimulation is employed in cases requiring long term pacing due to permanent damage that prevents normal self triggering of heart Current for this electrode will range from 2-15mA
Pacemakers are placed outside the body, it may be in the form of wrist watch or in pocket, form that a wire will go into heart through a vein The electrodes are called ENDOCARDIAC It does not necessiate the open chest surgery During placement swelling and pain do not arise to min foreign body reaction Here there is no safety for the pacemaker Mostly these are used for temporary heart irregularities
The pacemaker is miniaturized and is surgically implanted beneath the skin near to chest or abdomen with its o/p leads are connected to the heart muscle The electrodes are called as MYOCARDIAC It requires an open chest surgery to place the circuit During placement swelling and pain arise due to foreign material reaction Here there is cent percent safety for the circuit from external damage Mostly these are used for permanent heart damages
Based on the mode of operation of the pacemaker, they can be divided into five types., * Ventricular asynchronous pacemaker * Ventricular synchronous pacemaker * Ventricular inhibited pacemaker * Atrial synchronous pacemaker * Atrial sequential Ventricular inhibited pacemaker
This pacemakers are used for patients with either a stable, total AV block, a slow atrial rate or atrial arrhythmia This the 1st PM that can be used in atrium or ventricle It is similar to a simple ASTABLE MULTIVIBRATOR, this produces a stimulus at a fixed rate similar to heart rhythm In earlier days, TV type of blocking oscillator with a transformer was used to generate stimulus, But now-a-days fixed rate generator fabricated on a single chip with square wave generator is used along with a positive triggered monostable multivibrator
A square wave generator is designed using a 1 microF and a resistor of 500 Kohmwith a voltage detector circuit The O/P of this unit provides a positively and negatively going square wave with equal duration for positive and negative pulse The period of square wave generator is given by
According to the fig., T=0.8589 sec , the value can be changed by changing the value or the value of time constant RC The max O/P voltage is equal to
The square wave generator is a astable multivibrator which periodically switches between the O/P voltage and the O/P of a square generator is coupled to the positive edge triggered monostable multivibrator The I/P in the positive trigger will pass through the capacitor Cc and the diode The capacitor Cc is chosen to make five time equal value to the pulse duration TD
= 5*0.16*10^-6[1200/2.2] = 0.437 milli sec Thus this PM can delivers the pulse with period T=0.8589 sec and pulse duration TD = 0.437 milli sec
Using a fixed rate pacemaker, the heart rate cannot be increased to match greater physical effort Stimulation with a fixed impulse frequency results in the ventricle and atria beating at different rates Possibility for ventricular fibrillation will be more.
This type pacemakers are used for patient with short time AV block or bundle block, usually this type does not compete with the normal heart activity Separate sensing electrode is not needed, since a single electrode placed at the right ventricle both sense the Rwave and delivers the stimulation The R-wave from the atrial generated ventricular contraction triggers the pacemaker which provides an impulse falling in the lower part of the normal QRS complex If R-wave from the atrial generated ventricular contraction absent , then the pacemaker provides impulse at the frequeny of 70 impulse/min.
Using the sensing electrode, the heart rate is detected and it is given to the timing circuit in the pacemaker, if the detected rate of the heart is below a certain min level, the fixed rate pacemaker is turned on to pace the heart The lead used to detect the R wave is now used to stimulate the heart, if a natural contraction occurs, the PM timing circuit is reset so that it will time its next pulse to detect heart beat Suppose the pacemaker may detect the noise and interpret as its ventricular excitation, but it is eliminated by the incorporation of refractory period circuit In heart blocks P wave occurs randomly, by using a high pass filter with lower cut off frequency at 20 Hz will eliminates the P wave
To arrest the ventricular fibrillation, this circuit can be used The power consumption is reduced and there is no chance of getting side effects due to competition between natural and artificial pacemaker pulses. When R wave is appearing with lesser amplitude, the circuit amplifies it and delivers it in proper. If the R wave period is too low or too high, the asynchronous pacer in the circuit is working upto the returning of the heart into normal one.
Atrial and ventricular contraction are not synchronized The olden type pacemakers are more sensitive to external electromagnetic interference such as microwave ovens, security metal detector and so on., thus the patients could not work in radio or T.V. they could not undergo diathermy treatment and further could not ride motor or scooters
In previous type of pacemaker if the R wave is present then the stimulus is generated, but in this type if the R wave is missing for a preset period of time the pacer will supply a stimulus Therefore if the heart rate falls below a predetermined min the pacer will turn on and provide the heart a stimulus, hence it is called as “Demand pacemaker” It uses a piezoelectric sensor, which senses each activity of the patient and automatically increases or decreases its rate
This type of pacemaker is used for young patient with a mostly stable block, it has many uses in physiologic investigation. It can act as a temporary pacer for atrial fibrillation The atrial activity is picked up by a sensing electrode placed in a tissue close to the dorsal wall of the atrium. The detected p wave is amplitude and a delay of 0.12sec is provided by the AV delay circuit The signal is then given to trigger the resetable multivibrator and the O/P is given to the amplifier which produces the desired stimulus to be applied to the heart. The stimulus is delivered to the ventricle by a ventricular electrode
It has the capacity of stimulating both the atria and ventricle and adopts its method of stimulating to the patients need If the atrial function fails this pacer will stimulate the atrium and then sense the subsequent ventricular beat, if is works properly it will discontinue its ventricular stimulating function However if the atrial beat is not conducted to the ventricle on sensing this will fire the ventricle at a preset interval of 0.12sec
Now-a-days the “programmable pacemakers” which can work in any mode depending upon the patients need are available A magnet is placed over the pacer on the skin of the patient in order to activate a reed switch the pacer into any of the modes discussed so far Further this type of pacer facilitates to change the pulse rate, pulse amplitude and pulse width by external coded impulse, by using this type any alteration can be done immediately in the case of emergency.
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