PACEMAKER

INTRODUCTION:-
A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural
pacemaker) is a medical device that uses electrical impulses, delivered by electrodes
contacting the heart muscles, to regulate the beating of the heart. The primary purpose of a
pacemaker is to maintain an adequate heart rate, either because the heart's native
pacemaker is not fast enough, or there is a block in the heart's electrical conduction system.
Modern pacemakers are externally programmable and allow the cardiologist to select the
optimum pacing modes for individual patients. Some combine a pacemaker and defibrillator
in a single implantable device. Others have multiple electrodes stimulating differing
positions within the heart to improve synchronisation of the lower chambers of the heart.

History:-
In 1899, J A McWilliam reported in the British Medical Journal of his experiments in which
application of an electrical impulse to the human heart in asystole caused a ventricular
contraction and that a heart rhythm of 60-70 beats per minute could be evoked by impulses
applied at spacings equal to 60-70/minute

The late 1960s, several companies, including ARCO in the USA, developed isotope powered
pacemakers, but this development was overtaken by the development in 1971 of the
lithium-iodide cell by Wilson Greatbatch. Lithium-iodide or lithium anode cells became the
standard for future pacemaker designs.

Methods of pacing:-
Percussive pacing:-
Percussive pacing, also known as transthoracic mechanical pacing, is the use of the closed
fist, usually on the left lower edge of the sternum over the right ventricle in the vena cava,
striking from a distance of 20 – 30 cm to induce a ventricular beat (the British Journal of
Anesthesia suggests this must be done to raise the ventricular pressure to 10 - 15mmHg to
induce electrical activity). This is an old procedure used only as a life saving means until an
electrical pacemaker is brought to the patient

Transcutaneous pacing:-
Transcutaneous pacing (TCP), also called external pacing, is recommended for the initial
stabilization of hemodynamically significant bradycardias of all types. The procedure is
performed by placing two pacing pads on the patient's chest, either in the anterior/lateral
position or the anterior/posterior position. The rescuer selects the pacing rate, and
gradually increases the pacing current (measured in mA) until electrical capture
(characterized by a wide QRS complex with a tall, broad T wave on the ECG) is achieved,
with a corresponding pulse. Pacing artifact on the ECG and severe muscle twitching may
make this determination difficult

Epicardial pacing (temporary:-

Temporary epicardial pacing is used during open heart surgery should the surgical
procedure create atrio ventricular block. The electrodes are placed in contact with the outer
wall of the ventricle (epicardium) to maintain satisfactory cardiac output until a temporary
transvenous electrode has been inserted.

Transvenous pacing (temporary):-

Transvenous pacing, when used for temporary pacing, is an alternative to transcutaneous
pacing. A pacemaker wire is placed into a vein, under sterile conditions, and then passed
into either the right atrium or right ventricle. The pacing wire is then connected to an
external pacemaker outside the body. Transvenous pacing is often used as a bridge to
permanent pacemaker placement. It can be kept in place until a permanent pacemaker is
implanted or until there is no longer a need for a pacemaker and then it is removed.

Living with a pacemaker

Periodic pacemaker checkups
Two types of remote monitoring devices used by pacemaker patients.

Once the pacemaker is implanted, it is periodically checked to ensure the device is

operational and performing appropriately. Depending on the frequency set by the following
physician, the device can be checked as often as is necessary. Routine pacemaker checks are
typically done in-office every six (6) months, though will vary depending upon patient/device
status and remote monitoring availability.

At the time of in-office follow-up, the device will be interrogated to perform diagnostic
testing. These tests include:

 Sensing: the ability of the device to "see" intrinsic cardiac activity (Atrial and
ventricular depolarization).
 Impedance: A test to measure lead integrity. Large and/or sudden increases in
impedance can be indicative of a lead fracture while large and/or sudden decreases
in impedance can signify a breach in lead insulation.
 Threshold: this test confirms the minimum amount of energy (Both volts and pulse
width) required to reliably depolarize (capture) the chamber being tested.
Determining the threshold allows the Allied Professional, Representative, or
Physician to program an output that recognizes an appropriate safety margin while
optimizing device longevity.

As modern pacemakers are "on-demand", meaning that they only pace when
necessary, device longevity is affected by how much it is utilized. Other factors
affecting device longevity include programmed output and algorithms (features)
causing a higher level of current drain from the battery.
An additional aspect of the in-office check is to examine any events that were stored since the
last follow-up. These are typically stored based on specific criteria set by the physician and
specific to the patient. Some devices have the availability to display intracardiac electrograms
of the onset of the event as well as the event itself. This is especially helpful in diagnosing the
cause or origin of the event and making any necessary programming changes.

Lifestyle considerations

A patient's lifestyle is usually not modified to any great degree after insertion of a pacemaker.
There are a few activities that are unwise such as full contact sports and activities that involve
intense magnetic fields.

The pacemaker patient may find that some types of everyday actions need to be modified. For
instance, the shoulder harness of a vehicle seatbelt may be uncomfortable if the harness
should fall across the pacemaker insertion site.

Any kind of an activity that involves intense magnetic fields should be avoided. This includes
activities such as arc welding possibly, with certain types of equipment, or maintaining heavy
equipment that may generate intense magnetic fields (such as an MRI (Magnetic Resonance
Imaging Machine)).

However, in February 2011 the FDA approved a new pacemaker device called the Revo MRI
SureScan which is the first to be proven safe for MRI use. There are several limitations to its
use including certain patients qualifications, body parts, and scan settings.

A 2008 U.S. study has found that the magnets in some portable music players, when placed
within an inch of pacemakers, may cause interference.

Some medical procedures may require the use of antibiotics to be administered before the
procedure. The patient should inform all medical personnel that they have a pacemaker.
Some standard medical procedures such as the use of Magnetic resonance imaging (MRI)
may be ruled out by the patient having a pacemaker.

In addition, according to the American Heart Association, some home devices have a remote
potential to cause interference by occasionally inhibiting a single beat. Cellphones available
in the United States (less than 3 watts) do not seem to damage pulse generators or affect how
the pacemaker works

Turning off the pacemaker

According to a consensus statement by the Heart Rhythm Society, it is legal and ethical to
honor requests by patients, or by those with legal authority to make decisions for patients, to
deactivate implanted cardiac devices. Lawyers say that the legal situation is similar to
removing a feeding tube. A patient has a right to refuse or discontinue treatment, including a
pacemaker that keeps him or her alive. Physicians have a right to refuse to turn it off, but they
should refer the patient to a physician who will. Some patients believe that hopeless,
debilitating conditions like strokes, in combination with dementia, can cause so much
suffering to themselves and their families that they would prefer not to prolong their lives
with supportive measures, such as cardiac devices.
Privacy and security

Security and privacy concerns have been raised with pacemakers that allow wireless
communication. Unauthorized third parties may be able to read patient records contained in
the pacemaker, or reprogram the devices, as has been demonstrated by a team of researchers.
The demonstration worked at short range; they did not attempt to develop a long range
antenna. The proof of concept exploit helps demonstrate the need for better security and
patient alerting measures in remotely accessible medical implants.

Complications

A possible complication of dual-chamber artificial pacemakers is pacemaker-mediated

tachycardia (PMT), a form of reentrant tachycardia. In PMT, the artificial pacemaker forms
the anterograde (atrium to ventricle) limb of the circuit and the atrioventricular (AV) node
forms the retrograde limb (ventricle to atrium) of the circuit. Treatment of PMT typically
involves reprogramming the pacemaker.
REFERENCE:-

 Mary Louise Turgeon (2005). Clinical hematology: theory and procedures.

Lippincott Williams & Wilkins. pp. 401 28 October 2010.
 Straus SE, Thorpe KE, Holroyd-Leduc J (October 2006). "How do I perform a lumbar
puncture and analyze the results to diagnose bacterial meningitis?". JAMA 296 (16):
2012–22.
 WWW.google.com