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UNIT 3

CARDIAC PACEMAKERS
• Pacemakers are the device that is capable of producing
artificial pulse for the heart to work normally. It has two main
components as Generator and Electrodes.
• Pulse generator should develop pulse at a ratio 1:10000. It
should be capable to produce negative pulse to avoid muscle
ionization. The pulses produced are variable in nature, such
that energy given to the heart can be controlled.
• Duration of each pulse is 1 to 2 milli seconds. The pulse
repetition rate is 70 pulses/min. usually unipolar or bipolar
electrodes are chosen for electrode setup.
• The electrical stimulation to the pacemaker can be of two
type’s external and internal stimulation. There are different
types of batteries used namely Mercury cell, Lithium cells and
rechargeable batteries.
Types of Pacemakers
• Internal Pacemakers
• The entire unit is placed inside the human body. It is used for the
patient whose SA node has completely failed to function or for who
suffers from heart block. The device is placed with a surgery. Pulse
generator is placed in a pocket below right or left clavicle. For women it
is placed near pectoral muscle. Electrodes are connected to the
generator, and they contact the myocardium directly. The location of
pacemaker depends on the factor like Nature of heart disease, type of
electrode used and pacemaker operation mode. This does not have
external power supply. It already consists of battery that can work
continuously for a time.
• External Pacemakers
• Here external pulse generator circuit and electrode are used. They are
placed inside myocardium. This type id suitable for patient who suffers
from temporary heart block and disorders. It is very importantly used
for patients who suffer from arthymias and coronary disease. Since the
generator is placed external, they are connected to electrodes via wires
and introduced into ventricles. The setup is attached with belt on the
lower arm of the patient.
Pacing Modes of Operation in a
Pacemaker
• The pacing modes of the pacemaker are classified as Competitive
and Non – competitive modes.
• Competitive Mode of the Pacemaker(ASYNCHRONOUS)
• The competitive mode of pulse generators produces fixed rate pulses
that are independent of natural cardiac activity. Instead, the fixed rate
pulses are generated alongside with heart’s natural pulses. It
competes with them to control the heartbeat. This fixed rate
pacemakers are implanted for the patient whose SA node has failed
from its operation. The disadvantage of this type is less battery life.
• Non – Competitive Mode of the Pacemaker(SYNCHRONOUS)
• This type of pacing mode either generates ventricular programmed or
atrial programmed pulses. Among these, the ventricular-programmed
pacemaker will operate in either demand mode (R wave stopped) or
standby mode (R wave triggers). Atrial programmed pacemaker works
in synchronization with P wave of ECG waveform.
Ventricular Asynchronous Pacemaker
(Fixed Rate Pacemaker)
• This type of pacemaker is installed in atrium or ventricles
for the patients who suffer from total AV block and atrial
arrhythmia. The generated impulses and normal heartbeat
competes with each other. When looking into the electrical
circuit of the pacemaker it has square wave generator and
monostable multivibrators.
• DESIGN
Disadvantage:
• In this type of pacemaker heartbeat cannot be altered.
• When the impulse in atrium and ventricles beats at
different rate ventricular fibrillation occurs.
Ventricular Synchronous Pacemaker
(Standby Pacemaker)
• This type of pacemaker is used for patients who suffer from a short
period of AV block. The electrode is placed in the right ventricle and
it senses R wave. R wave triggers the pacemaker. The detected
signal is given to amplifier and filter circuit. this pacemaker does not
compete with normal heart beat signal. Filters remove the
unwanted noise signal, hence P wave is removed. The obtained
signal is given to the refractory period and timing circuit. If it
detects heartbeat below a particular level, fixed rate pacemaker
block is turned on. The impulses from fixed rate pacemaker is
amplified and given through electrode. On the other case, if
heartbeat is normal fixed rate pacemaker block is not turned on.
The pacemaker delivers impulses only when R wave is detected and
remains at certain level. This type of pacemaker avoids ventricular
fibrillation.
Ventricular Inhibited Pacemaker
(Demand Pacemaker)
• The timing circuit consists of RC network, reference voltage source
and a comparator. Comparator is used to determine the pacing rate
of generator. The obtained output is given to the second RC network.
• The duration of stimulating pulse is determined with pulse width
circuit. After this, the signal goes to the third RC network, which is
rate-limiting circuit. It disables comparator and helps to limit pacing
rate.
• The final output obtained is given as impulse for stimulating heart.
• Voltage monitor circuit controls the rate and used as energy
compensation circuit. Rate slow down circuit stops amount of
current that goes to the basic timing. This helps to slow down the
pulse rate during depletion of cell.
• Sensing circuit identifies R wave and resets the oscillator timing of
capacitor. When R wave is absent, the oscillator in the circuit
produces pulses at preset rate.
• The inhibited pacemaker makes heart to produce pulse that can beat
at its own rhythm whenever possible. When R wave is missing for a
short time period, pacemaker will turn ON to produce stimulus for
heart. Hence, it is called Demand Pacemaker.
Atrial Synchronous Pacemaker

• This pacemaker is used for patients with stable


block and it provides temporary pacing. The
electrode placed in the atrium senses the P wave.
The sensed signal is given to amplifier circuit,
which amplifies the P waveform. The signal is
given to the delay circuit to give a delay of 0.12
second. The output from the delay circuit is given
to the refractory and preset multivibrator block.
When amplitude of P wave is not normal, fixed
rate pacemaker is ON. Fixed pacemaker will be
OFF if amplitude is normal.
ATRIAL SEQUENTIAL VENTRICULAR
INHIBITED PACEMAKER
• It has the capablity of stimulating both the atria
and ventricles and adopts its method of
stimulation to the patients needs.
• If the atrial function fails , this pacemaker will
stimulate the atrium and then sense the
subsequent ventricular beat. If its working
properly it will discontinue its ventricular
stimulating function.
• If atrial beat is not able to conduct to the
ventricle, the pacemaker on sensing this will fire
the ventricle at a preset interval of 0.12 sec
DEFIBRILLATORS
• What is Fibrillation?
• When heart pumps blood through heart muscles, they
spread over atria and makes the heart chambers to
contract together. The condition at which synchronization
of heart muscle is lost is known as fibrillation. During this
fibrillation condition, the normal rhythmic contraction of
atria and ventricles does not occur. They are replaced with
irregular twitching of muscle walls.
• There are two types of fibrillation namely atrial fibrillation
and ventricular fibrillation.
• Atrial Fibrillation is due to atrial muscles. During atrial
fibrillation condition, a ventricle does not function
normally. Before the atrial contraction, almost all blood
flows into ventricles.
• Ventricular Fibrillation
• Ventricular fibrillation occurs due to ventricle fibrillation. It is
more dangerous than the atrial fibrillation. During this
condition, ventricles cannot pump blood. In this condition
uncoordinated movement of ventricle walls results in body
abnormality. Therefore, it has to be treated immediately to
avoid death of the patient. This condition can be made as a
regular rhythm when a high voltage shock is applied to heart.
Sudden application of shock makes the heart muscles to
contract simultaneously.
• Defibrillators are the device that produces myocardial depolarization and
stops the condition of fibrillation. Even after giving sufficient shock to the
patient, if the heart does not contract intact, pacemakers are used to restart
the myocardium contraction. Defibrillator is used to treat sudden cardiac
arrest.
• Types of Defibrillators
• Two types of defibrillators are showing below.
• External Defibrillator
• External defibrillator is pressed on the chest using paddle shaped electrodes.
The electrode has a bottom made of copper disc with a diameter range of 3 to
5 cm for children and 8 to 10 cm for adults. It has an insulated handle to hold
the device.
• The voltage value required ranges from 1000V to 6000V. Electrode gel is
applied on the chest before placing the electrode so that the contact
impedance on the chest is around 100 Ω.
• In general, a D.C defibrillator can deliver about 50 to 400 J of energy for 1 to 5
milli seconds. Therefore, the amount of current that passes through chest is
between 10 to 60 amperes.
• Electrodes can be placed on two ways either in anterior – anterior position or
in anterior – posterior position. In anterior – anterior position current flows
through the heart. In this position, one paddle is placed above the heart apex
and another paddle on the sternum. Hence, the current flows in the direction
of bottom to top of the heart. Whereas, in anterior – posterior position blood
flows to chest from behind through heart.
• Internal Defibrillator
• This type of defibrillator is used when chest is opened. Electrodes
are in shape of large spoons and they have an insulated handle.
Internal d.c defibrillator uses voltage values range between 50 V to
1000 V to provide shock. The electrodes used are in direct contact
with the heart so the contact impedance is 50 Ω. Hence, the amount
of current passing through heart is about 1 to 20 amperes. The
amount of excitation energy required for internal defibrillator is
between 15 to 50 J for a time of 2.5 to 5 millisecond.
• Need for Insulation Handle
• When a person applies electrode on the patient he has to be
prevented from accidental shocks so insulated handles are provided.
To discharge the defibrillator a thumb switch is present on one or
both handles. To charge the defibrillator in modern devices a charge
switch is placed on the handle of the paddle.
AC Defibrillators
• In AC defibrillation, a shock of 50 Hz a.c frequency is applied to the chest
for a time of 0.25 to 1 second through electrodes. The procedure of
applying electric shock to resynchronize heart is known as Countershock.
Defibrillation continues until patient responds to the treatment.
• AC defibrillator consists of a step-up transformer with primary and
secondary winding, and two switches. A.C supply is given through switches
and fuse to primary winding of the transformer. The timing circuit is
connected with switch, which is used to preset the time for the
defibrillator to deliver shock to the patient.
• A resistive and a simple capacitor network or monostable multivibrator
forms the timing circuit. It is triggered with a foot switch or a push button
switch. Various tapping are available along the secondary winding. They
are connected to the electrodes that delivers electric shock to the heart of
the patient.
• Voltage value ranging between 250 V to 750 V is applied for AC external
defibrillation. For safety reasons, secondary coil should be isolated from
earth to avoid shock. For internal fibrillation voltage values between 60 V
to 250 V is applied. To produce uniform and simultaneous contraction of
DC defibrillator
• Ventricular fibrillation is avoided when high-energy shock is passed
through discharging capacitor that is exposed to heart or chest of the
patient.
• DC defibrillator consists of auto transformerT1 that acts as primary of
the high voltage transformer T2. A diode rectifier rectifies the output
voltage from T2. It is connected to vacuum type-high voltage over
switch. At position A, switch is connected to one end of the capacitor.
When connected in this position capacitor charges to a voltage.
• A foot switch present on the handle of the electrode is used to deliver
shock to the patient. Now the high voltage switch changes it position
to B that makes the capacitor to discharge to the heart through
electrodes.
• To slow down the discharge from the capacitor an inductor L is placed
in one of the electrode lead. This L induces a counter voltage that
reduces the capacitor discharge value.
• Passage of high current may damage the
myocardium and the chest wall. To reduce this
risk, some defibrillators produce dual peak
aveform.
• This keeps the stimulus at peak voltage for a
longer time.
Synchronised D.C defibrillator
SQUARE WAVE DEFIBRILLATOR

• Here the capacitor is discharged through the


subject by turning on a series silicon controlled
rectifier. When sufficient energy has been
delivered to the subject a shunt SCR short circuits
the capacitor and terminates the pulse.
Double Square Pulse Defibrillator
• Used after open heart surgery.If the chest is open
only lower energy electric shock should be given.
• Instead of 800-1500V, here 8-60V double pulse is
applied with a mean energy of 2.4 watt-sec.
• When the first pulse is delivered, some of the
fibrillating cells will be excitable and will be
depolarised.However cells which are refractory
during the occurrence of first pulse will continue
to fibrillate.
• Second pulse operate on latter group of cells
Biphase dc defibrillator
• Delivers dc pulses alternatively in opposite
directions.
Renal functioning of kidney
• When a person has problem in natural kidney functioning
artificial kidney machine is used. The process of removing
impurities from blood is called hemodialysis.
• Waste products are formed in the body during bodily
metabolism. So, natural kidneys are used to remove those
wastes. Single kidney has the capability to clear the waste
products from blood. Nephrons are the smallest functional
units of kidney. Urine is formed in body through nephrons.
• Formation of urine is done in three process
 Blood plasma filtration.
 Secretion of urea, uric acid and phosphates.
 Reabsorption of water, glucose and chloride.
• Each nephron has glomerulus. It performs the filtration process.
• Blood from arteries enter glomerulus for filtering. It also consists of
tubeles, which does active secretion and reabsorption. The
components like water, glucose, amino acids, salts, urea, uric acid and
creatinine are removed and filtered from the body.
• At the entrance of the tubele, the process of reabsorption takes place.
So here, glucose, amino acid, protein, water and salt are reabsorbed.
• When a particular chemical in the blood increases, tubeles does not
perform complete reabsorption. Therefore, if a person has complete
renal failure, he develops uremia.
• During this stage, broken metabolic products are not excreted. Instead,
they are accumulated in the body itself. Thus, the quantity of urea and
creatinine levels increase.
• By this, the acid base balance of the body gets affected leading to the
development of acidosis. Due to this acidosis, potassium level in the
blood increases and affects the heart. Eventually the patient will die
soon.
• Therefore, to avoid such conditions artificial kidneys are used and
process of dialysis is performed.
Haemodialysis

• When a person does not have normal kidney


functioning, he is given a treatment. Dialysis is the
medical treatment given for kidney failures. It helps to
collect the waste products from blood and removes it.
It also restores the normal pH value of blood with help
of artificial kidney machine.
• Three important process in dialysis are Diffusion,
Osmosis and Ultrafiltration.
There are two types of dialysis
• Extra Corporeal Dialysis (Hemodialysis)
• Intra Corporeal Dialysis (Peritoneal Cavity Dialysis)
Extra Corporeal Dialysis (Hemodialysis)
Intra Corporeal Dialysis (Peritoneal
Cavity Dialysis)
• In this method, the abdomen of the patient acts as
semipermeable membrane. A catheter is inserted into
the abdomen. Around 1.5 to 2 liters of dialysate
solution is passed into the abdomen cavity. The process
of diffusion takes place for 30 minutes, after which the
dialysate solution is removed from the abdomen. The
same procedure continues for 20 to 30 times to
remove all the wastage from the body. In the entire
process, temperature has to be maintained at 37oC for
which thermistor can be used. To monitor the volume
of dialysate solution, a timing circuit is used. For
example, it stops the circuit if more than 2 liters of
dialysate solution passes into the peritoneal cavity.
• The timing circuit also helps to monitor the
diffusion rate. As already said, diffusion process
happens for 30 minutes. If the timing of diffusion
increases, the timing circuit gives an indication to
stop the process. A suction pump is used to
remove the dialysate solution from the abdomen
cavity. After this process, fresh and new dialysate
solution passes to the abdomen cavity. Quantity
of 2 litre of dialysate is removed from the patient
body. If suppose the quantity is less, alarm of the
timing circuit is activated. This helps doctors to
monitor the patient at a regular basis.
Mechanical Functioning of Heart
• There are two main types of circulation in our body.
• circulatory path for blood flows via lungs, it is Pulmonary
Circulation.
• Whereas, the path that supplies oxygen to the body cells is
systemic circulation.
• Heart pumps blood to the entire body. The pumping of blood
happens due to the contraction of heart muscles. Coronary
artery supplies blood to the heart muscles.
• The two valves namely superior vena cava and inferior vena
cava is used for entry of blood into right artery. Inferior vena
cava collects the blood from the body organs and the legs.
However, the superior vena cava collects blood from head
and hands
• The blood circulated in the heart is collected with help of
coronary sinus and sends them to right atrium. When the
right atrium is filled with blood, the heart muscles start to
contract. Due to this, blood flows into the right ventricle via
tricuspid valve. When the pressure inside right ventricle
becomes higher than the right atrial pressure, tricuspid valve
is closed.
• The other valve called semilunar valve is opened due to the
pressure inside right ventricle. Now the blood flows to the
lungs through pulmonary artery. Lungs are the organ, which
provides purification of blood in our body. So now, when the
blood reaches lungs, blood is oxygenated and given to left
atrium via pulmonary veins.
• Once the left atrium is filled with pure blood, the mitral valve
is opened. The blood is pumped to left ventricle. The valve is
closed, when pressure is high in the left ventricle. During the
cycle, left ventricle is filled with blood and opens the aortic
valve. Through aortic valve blood is sent to body organs like
hands, legs, head and coronary artery.
• Pumping action is divided into two parts as systole and
diastole. The period of ventricle contraction is Systole. The
time for the blood to fill the heart chamber is Diastole.
Heart Lung Machine
• What is Cardiopulmonary Bypass?
• It removes heart and lungs from circulation.
• It is used during open heart surgery.
• For example it is used for coronary artery bypass and
valve repair.
• Machine does the normal function of heart.
• What is Heart Lung Machine?
• It replaces the heart and lungs function.
• It helps for blood pumping, to oxygenate blood, to set
body temperature.
• Functioning of lung is replaced with Oxygenator.
• Blood pump does the Heart operation.
• Surgical Procedure in which Heart Lung Machine is Used
• Coronary artery bypass surgery.
• Cardiac valve replacement.
• During repair of large septum defect.
• Heart Transplantation and lung transplantation.
• Main components of a Heart Lung Machine
• Pump
• Cannula
• Reservoir
• Oxygenator
• Temperature control
• Filter
• Roller/ centripetal pumps
Working of a Heart Lung Machine
• To withdraw blood from the body, a cannula (tube) is inserted
in the right atrium, vena cave . The collected blood is sent to
cardiopulmonary bypass machine.
• Oxygenator performs the function of lungs. After the blood is
purified, filtered and cooled, with the help of second of
cannula in aorta or femoral artery the blood is pumped back.
• A third cannula is placed near heart is used to flush potassium
solution that can stop the heart functioning.
• A suction device is used to receive blood from heart and give it
to the reservoir. Blood from the vein is collected separately and
the receiving reservoir stores it.
• During the surgery procedure, receiving reservoir collects the
accumulated blood with help of coronary sinus pump.
• From the receiving reservoir, blood is sent to settling reservoir or
also named as debubbling reservoir.
• The collected blood goes to the oxygenator, where the blood is
purified. From the oxygenator, blood is given to the heat
exchanger via arterial blood pump.
• This process happens at a lower temperature condition, when
our body consumes less amount of oxygen. Brain damages are
also avoided when the process is done at low temperature. The
time limit for the entire process has to be maintained else, it will
result in breakdown of red blood cells.
Components of the Heart Lung
Machine
• Blood Pumps
• The general characteristics of blood pump are as
follows.
• It should pump up to 6 liters / minute regardless of
the outflow pressure
• Pumping action should not affect the blood
components
• Easy to clean and replace
• The calibration of pump should be done carefully
Pulsatile Pump
• There are two chambers in the pulsatile
pumps namely inner and outer chamber.
• The inner chamber is compressed when the
blood is injected into the outer chamber.
There is an outflow valve, through which
blood is ejected.
• After the blood is completely ejected, the
inner chamber becomes normal shaped. After
this, again, blood pump is filled with blood
and the same process continues.
Non-Pulsatile Pump
• In this type, a roller is used to squeeze the tube filled
with blood. This generates non-pulsatile blood flow.
• The most commonly used non-pulsatile pump is the
roller pump as shown in figure below.
• The tube carrying blood is placed in-between pump
housing and the roller. The tube has a tendency to move
forward when the roller passes over it. So it is provided
with a stopper to stop its movement. So when the roller
moves, the blood in the tube also moves forward. The
clearance between the pump and roller can be controlled
automatically which helps to prevent high pressure on
the blood flowing in the tube.
• Traps and Filters
• These are used to control and prevent problem of embolism
during bypass. Air embolus is an air bubble that is introduced
during the circulation. Large embolus has blood clots, tissue
particles that are mixed with blood and it blocks the artery.
Whereas, small emboli are produced due to fat globules and
red cells. So traps and filters are used to prevent these
embolisms from reacting with the circulatory system.
• Heat Exchanger
• Used to regulate the body temperature at 37oC. It is used to
reduce the blood temperature during surgery procedure.
Under hypothermia condition, after surgery procedure heat
exchanger is used to rewarm the blood. Heat exchange is
done by two methods. In external heat exchange method,
heat exchanger is added to the blood circuit directly. Another
method is heat exchanger is built within the oxygenator itself.
Oxygenators

• They perform the functions of lungs. It is also


called as Artificial Lung. An ideal oxygenator
should oxygenate 5 liters of blood per minute.
Various types of oxygenators are available.
Bubble Oxygenators
• In this method, oxygen is bubbled through
blood column. The blood is made to flow in a
slanting path. By this carbon dioxide is
removed from the blood. To remove the
bubbles from the blood, beads, sponges and
mesh coated with silicon are used. Silicon
reduces the surface tension of bubbles and
prevents the bubble formation. Hence, the
embolism is prevented.
• Film Oxygenators
• In this method, a thin layer of blood is applied
on the rotating disc or metal screen. An
oxygen mixture flows on this thin layer of
blood. Horizontal cylinder is the shape of
rotating disc type. It rotates at a speed of 120
RPM. The blood is at lower level. On top of it a
layer of blood is spread. Oxygen is given to the
oxygenator. The blood is washed from the
disc.
• Membrane Oxygenators
• In this method, oxygenation happens when
oxygen and blood flows in opposite direction
via thin porous membrane. Blood flows on
one side of the membrane and oxygen flows
on other side of the membrane.
• Membrane is made up of microporous
polyethylene which has high permeablity for
oxygen
Liquid-liquid oxygenators
• Oxygen dissolved flouridised organic fluid and
blood are flowing in opposite directions and
oxygenation of blood takes place.
• Flouridized organic liquid is the working liquid
which readily dissolves oxygen and carbon
dioxide which then diffuse to and from the
blood.