International Journal of Engineering Research & Technology (IJERT)

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Vol. 2 Issue 4, April - 2013

Ventricular Synchronous Demand Pacemaker

Aditya. R[1],Sharath Kumar. B. V[2],
R.V.College Of Engineering,Bangalore-560059

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Abstract Another advantage of the demand pacemaker is

that firing less often allows it to reserve its battery
The aim is to provide information about the power for a much longer period of time than fixed
artificial pacemakers and also information about rate pacemakers. Demand pacemakers are also
the available pacemakers, their features and the advantageous because they protect against a
need of pacemakers. condition known as ventricular asystole.
Ventricular asystole refers to the lack of
mechanical and electrical activity in the heart—a
1. Introduction condition that can cause a person to faint and is in
Artificial pacemakers, also called pacemakers,
many cases fatal. In sensing the absence of a
discharge electrical impulses in two ways. They
heartbeat, the demand pacemaker sends an
can be programmed to emit electrical impulses at a
electrical impulse to catalyse the heart to prevent
steady rate that does not respond to the activity of
fainting or death from occurring
the heart. These are known as fixed-rate
pacemakers. Alternatively, demand pacemakers can
discharge electrical impulses when the heart rate Figure
falls outside of a predetermined zone or skips a
beat. Demand pacemakers are thus used to regulate
arrhythmias, which are heart rhythms that are
irregular, where the heart beats either too rapidly or
too slowly.
Pacemakers that work on demand are known as
permanent pacemakers. They are implanted to
regulate heart-rate problems that occur over
extended periods of time. In 1958, Wilson
Greatbatch and W.M. Chardack created the first
implantable permanent pacemaker. Just six years
later in 1964, Greatbatch designed
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the demand pacemaker, which became available for This pacemaker is one with "a ventricular
use in 1966. stimulating pulse generator delivering its output
synchronously with the natural ventricular activity
The advantages of using demand pacemakers are
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and asynchronously in the absence of natural

realized shortly after this. ventricular activity". Ventricular synchronous
pacemakers are modifications of atrial synchronous
One advantage of a demand pacemaker is that they pacemakers. They have a similar upper and lower
prevent the occurrence of what are known as safeguard escape rate, but utilize a single
competitive beats. They occur when the heart’s ventricular electrode for sensing and stimulation.
intrinsic pace-making mechanism and an fixed- We have a lower trigger sensitivity, an almost
rate pacemaker stimulate a heartbeat at the same immediate response to a trigger stimulus, logic to
time. This simultaneous firing usually happens differentiate the QRS from the P and T waves,
because arrhythmias are only intermittent. When refractory period of about 400 millisecond, and a
they are not occurring, the heart’s magnetic-switch asynchronous mode. They are
intrinsic pacemaker fires and the heart beats non-competitive with ventricular activity except in
normally. A fixed-rate pacemaker cannot detect very rare instances and insensitive to non-
intrinsic heartbeats and will emit electrical transmitted atrial activity.
impulses at the same time that the hearts own Special problems or deficits associated with the
pacemaker fires, causing the competitive beats. use of pacemaker include the following:
Once thought to be harmless, competitive beats (1) During sustained synchronous stimulation, the
have been associated with higher mortality rates threshold to pace is uncertain, and its adequacy
and health problems in pacemaker patients. must be checked periodically by overdrive
stimulation or magnetic conversion to
The demand pacemaker senses the activity of the asynchronous pacing.
heart, which allows it to refrain from emitting (2) Failure to sense (electrode malposition ,battery
electrical impulses while the heart is intrinsically depletion, or signal decrement) results in fixed-rate
firing. This eliminates the possibility for pacing and, if the pacing threshold is sustained,
competitive beats to occur. Doing so has increased competition with spontaneous rhythms.
the clinical applicability of pacemaker treatment for (3) The synchronous-pacer artefact consistently
conditions that would elicit a competitive beat from distorts the electrocardiogram even during sinus
a fixed-rate pacemaker, but would benefit from rhythm. Magnetic mode pacing allows occasional
some sort of pacing nonetheless. breakthrough of un paced spontaneous beats if the

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rhythm is at or over the escape rate, but this Figure

engenders competition and is avoided when the
need to see a true complex is the highest, i.e.,
during an acute coronary.
(4) Extra systoles that come within the refractory
period of a paced beat are not sensed, and the next
paced beat, cycling at the escape rate from the
previous paced beat, results in a tachycardia triplet.
Prolongation of the refractory period enhances this
effect and allows the paced "escape" beat to come
uncomfortably close to the T wave of the "missed"
spontaneous beat. These mixtures of spontaneous
and ectopic beats, with synchronous and paced
beats, are difficult to interpret and often alarming to
the uninitiated
(5) A wide variety of transient
"interference"currents, including those produced by
the magnetic or radiofrequency tripping of the
magnetic switch, wire breaks, faulty connections, .
short circuits, whipping catheter motions, and tall T
waves, are equated with QRS signals by the sensor VENTRICULAR SYNCHRONOUS PACEMAKERS
circuit. This results in an erratic, frequently
competitive, pacing output. With repetitive stimuli, They are preferred for short periods of AV block.
however, the response rate cannot exceed the top Using sensing electrode heart rate is detected & is
design output of the pacemaker (a fail-safe feature). given to timing circuit of pacemaker. If the heart
A positive effect of this interference sensitivity is rate is below a min rate then pacemaker is turned
that these pulse generators may be externally on.The lead used to detect the R wave is now used
triggered to overdrive rates (to their upper escape to stimulate the heart. If natural contraction occurs
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limits), which is useful in the treatment of post then asynchronous pacer's timing circuitis reset so
implantation multifocal extra systoles or that it will tie its next pulse to detect the heart beat
intermittent tachyarrhythmia’s. else produce pulse at its present rate
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(6) Late synchronization occasionally occurs with

the stimulus rate in the QRS. Rarely , it reaches the
vulnerable zone and initiates early or repetitive
contractions. In right-sided trans venous pacing, it
has been ascribed to origination of the contraction
on the left with delayed conduction to the right
.There may also be a specific latency, with either
ventricle, particularly in recent infarction
(7) The ventricular synchronous pacemaker has the
shortest mean longevity of battery life due to
constant pacing, often above the escape rate, and
the additional current drain of the sensing circuit.

ADVANTAGES

1. To arrest the ventricular fibrillation, this

circuit can be used.

2. Power consumption is reduced

DISADVANTAGES:

1. Atrial and ventricular contractions are not

synchronized.

2. The circuit is more sensitive to eternal

electromagnetic interference

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Demand Mode Pacing 2.

It controls the pumping action of the
ventricles at a set rate.
In demand mode pacing, the pacer senses the 3. It restores "communication" between the
patient’s intrinsic heart rate, and will pace if the atria and ventricles, making them work
intrinsic signal is slower than the rate programmed together correctly.
4. It increases the heart rate, when required,
by the clinician. For example, if the patient’s heart
in response to physical activity demands,
rate becomes slower than the prescribed setting, the when your heart is beating normally, the
pacer will send an electrical stimulus. If the pacer new types of pacemakers(demand
senses that the heart rate is faster than the pacing pacemakers) will not be activated. It will
rate, it inhibits an electrical signal. only activate when your natural heart rate
is slower than the programmed rate. The
The advantages of demand mode pacing are: rate can be changed to meet your needs.
competition between the pacemaker stimuli and the This is done via an external device that
intrinsic heart rate is minimized, decreasing the risk communicates to your pacemaker. The
pacemaker can also be programmed to not
of R on T and the number of pace pulses introduced
activate at times when your natural heart
is minimized reducing patient discomfort. For this rate would normally slow down, e.g. when
reason, demand mode pacing is primarily used as sleeping.
the default setting. During demand mode pacing, DISADVANTAGES
Philips’ ALS defibrillators detect R waves, or
beats. Intrinsic beats are defined as those that are 1) Some discomfort and bruising around your
generated naturally by the patient. Paced, or pacemaker site. Paracetamol is required to
captured beats are defined as those that are a result ease this pain, Although rare
of delivered pacing energy. Philips’ ALS complications may include infection at the
defibrillators also define the paced refractory implantation site, introduction of air into
period, which is simply a period of time after the the space between the lung and chest wall,
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delivery of a pace pulse. The refractory period is perforation of the heart (requiring urgent
approximately 340 ms for pacing rates less than or drainage of the blood from the sac, stroke,
equal to 80 pulses per minute (PPM), and heart attack, and damage to blood vessels).
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approximately 240 ms for pacing rates greater than

2) There are only a few devices in the
or equal to 90 PPM.The Philips’ ALS defibrillator
environment today that which can
pacer uses a very simple algorithm for determining
interfere with a pacemaker. Arc welding
if a detected R wave is intrinsic or paced. If the
equipment and equipment with powerful
detected QRS falls within the refractory period of a
magnets have the potential to interfere
pace pulse the beat is considered paced, otherwise
with the pace generator. Most home
it is considered intrinsic. With the pacer on, the
appliances, such as a microwave, do NOT
defibrillator marks intrinsic beats with a dot the R-
interfere with a pacemaker. Cell phones in
wave Clinicians must not rely solely on the
the U.S. do NOT interfere with
defibrillator’s classification of beats as intrinsic or
pacemakers, but you should still keep
paced to determine electrical capture. Consider the
them away from the pacemaker area
situation where the patient’s intrinsic HR is 62, and
the pacer is set at a rate of 60. Since the two rates COMPANIES DEALING WITH PACE
are very close, pacer spikes and intrinsic beats may MAKERS
occur very close to each other for several seconds.
In this circumstance, the defibrillator may think the
beats are paced based on its simple timing
algorithm, but in fact the beats are intrinsic and the
timing coincidental. There may also be cardiac
conditions which can cause a truly paced beat to
fall outside of the refractory period

ADVANTAGES Royal Philips Electronics launched a new service

that provides 24-hour, web-based remote
1. Pacemaker implantation is a safe
procedure. monitoring follow up services for patients with

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pacemakers. The new service, which was made enables them to spot even subtle abnormalities.
available to cardiology practices in August, is the This keen analysis resulted in a .009% per cent
first large-scale service of its kind in the error rate over the past 12 months. And with
U.S.Pacemakers are a critical part of treatment for 24/7surveillance, the cardiologists are alerted to
patients with a wide range of heart conditions, and critical patient data in real-time, without having to
they must be checked frequently to ensure proper be on-call.
function.

Philips has offered Trans telephonic (data

transmission via phone)follow-up services for 35
years. Leveraging this experience, Philips is
expanding its portfolio to include the latest
pacemaker technology. Remote monitoring is
becoming the gold standard of care for surveillance
of patients with cardiac implantable electronic
devices. Scientific data has demonstrated remote
monitoring allows earlier detection of patient issues
than standard in-clinic follow up.

Philips brings unprecedented convenience and

patient care quality to cardiology practices by
conducting web based remote monitoring of their
pacemaker patients. Philips technicians review,
summarize and triage each pacemaker test and
ELITE
provide clinically appropriate, customized
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notification to support timely and informed patient The heart's natural pacemaker is an electrical
management for the physicians. Philips will be timing device that controls the rate of the heart's
applying to its web-based service the same robust muscular contractions, enabling the heart to pump
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,proprietary follow-up processes that they've used blood under the wide range of demands
for all remote monitoring services, which have encountered in daily life. Everyone’s heart speeds
increased patient compliance (i.e., patients up or slows down under different conditions and
completing regular checks of their pacemaker may on occasion appear to flutter or miss a beat.
function) from 60 per cent to greater than 90 per However, sometimes the heart's electrical system
cent. ―With the Philips web-based remote malfunctions and serious rhythm disorders result.
monitoring service, we can do more with less. We These cardiac arrhythmias can be debilitating and
get more frequent even life-threatening, but the recent availability of
artificial pacemakers and the recent advent of
Clinical information without using staff resources,
implantable defibrillators have revolutionized
allowing our staff to re-focus their time on other
treatment. Today, physicians can help patients by
bill able services. And, the service has helped us
using electronic devices that directly counter these
improve our billing processes," said Syed Samee,
serious rhythm disturbances. Implantable electronic
M.D., F.A.C.C.,Cardiologist, Blessing Physician
devices have been developed to treat both
Services, Quincy.
abnormally slow heart rates (bradycardias) and
excessively rapid heart rates (tachycardia). Such
rhythm disorders arise because of disruptions to the
normal production or transmission of electrical
impulses within the heart.
The team of Philips certified cardio graphic
technicians undergo intensive training and average The heart's natural pacemaker is the sinus node
more than 15years of experience in pacemaker and (SN), located in the upper right atrium near the
implantable cardioverter defibrillator (ICD) follow- point where blood returning from the head and
up. The technicians analyze and interpret more than limbs re-enters the heart. Specialized cells in this
1,000 pacemaker transmissions per day, which node emit electrical impulses at the rate of about 70

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per minute. These impulses spread throughout the

atria and travel to the ventricles via the atrio-
ventricular node (AV node).The electrical system
ensures that impulses reach the right part of the
heart at the right time and at the right pace,
coordinating the contraction of the heart muscle so
that it can pump effectively. When the sinus node
fails to generate impulses or transmission is
blocked in some part of the electrical system, an SEIMENS
abnormally slow heart rate can result. Assuming
that this bradycardia is not the side effect of a It was in autumn 1958: At the age of only 43,
medication or produced by some other reversible Swede Arne Larsson’s life appears to be almost
condition, the most likely cause is disease in the over. He suffers from arrhythmia, which is further
sinus node, the AV node, or some other part of the aggravated due to a virus infection. 28 beats per
conduction pathway. minute is his heart rate – the heart of a healthy
adult beats 70 times a minute. Larsson passes out
If the patient is experiencing these symptoms and perpetually and must be reanimated 20-30 times
the heart rate is extremely slow (below 45 or 50), every day. There is in fact no prospect of cure.
the condition may be markedly improved by an However, his wife Else-Marie is not willing to put
artificial pacemaker. There are, however, many up with her husband’s imminent destiny. She learns
people who function normally with slow heart rates from the newspapers that the cardiologist Professor
of 40-50 and evidence of some degree of heart Ǻke Senning at Karolinska Hospital in Stockholm
block. Pacemakers are generally reserved for those is working on the development of an implantable
with symptoms and advanced degrees of block. cardiac pacemaker together with the physician and
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engineer Rune Elmqvist. Mrs. Larsson is convinced
that this will be her husband’s rescue – although
there was actually no adequate device available for
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human beings at that time, and experiments had so

far only been performed on animals.

ST JUDE MEDICAL PACE MAKERS

The St. Jude Medical product portfolio includes

implantable cardioverter defibrillators (ICDs),
cardiac resynchronization therapy (CRT) devices,
pacemakers, electrophysiology catheters, mapping
and visualization systems, vascular closure devices,
structural heart products, heart valve replacement
and repair products, spinal cord stimulation and
deep brain stimulation devices.

. First pacemaker from Siemens

Thanks to the untiring persuasiveness of his wife,

Arne Larsson received the first cardiac pacemaker
implant on October 8, 1958 in a secretly performed
emergency surgery. Rune Elmqvist, who developed

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this first pacemaker worldwide, was an engineer at through a recovery period of several hours and
Siemens-Elema and had also worked as a often is allowed to go home the day of the
cardiologist before. Due to the urgency, he cast the procedure.
components of this first device with epoxy resin in
a shoe polish tin. Two electrodes connected to the In India the cost starts around Rs 45000/- and goes
pacemaker released the stimulation energy to the up to Rs 1, 80,000/-depending on the requirement
heart. However, this first model had to be replaced and quality.
with a new pacemaker after only several hours. Yet
CONCLUSION
the technology advanced rapidly. There were ever
complex models providing for an unsound heart’s After studying the various types of pace makers
specific requirements. Today, the pacemaker is and their applications, we selected Ventricular
standard in modern cardiology and has a life cycle Synchronous Demand Pace maker. We got an
of ten years. opportunity to go through the working and
development of the pace maker. This topic also
COMPARISON BETWEEN VARIOUS
increased my curiosity in the field of Bio Medical
COMPANIES
Instrumentation.
COMPANY LIFE* BATTERY COST
The various aspects covered in this Topic are
history, working, development, advantages and dis-
SEIMENS 25 YEARS LI-IODINE Rs 60000/-
BATTERY advantages, companies dealing with pace makers
and comparison between them. In the course of my
study we found out that demand pace makers are in
large demand in India, around 3 lakh people in
PHILIPS 25 YEARS LI-IODINE Rs 45000/ to
BATTERY 50000/- India are using this type of pace maker. Also the
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cost of it is significantly higher when compared to
other types.
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Also, the quality of pace makers available in India

ELITE APPROX RADIO NOT
50 YEARS ACTIVE AVAILABLE is lesser than that available abroad. For example
IN INDIA .The pace maker ELITE which runs on Radio
active battery is not available in India. So there is a
dearth of good pacemakers in India.
ST JUDE 30 JUDE LI-IODINE Rs 80000/-
Thus we conclude our topic with the following
observations:

1) The pace makers of this type are being

*(LIFE REFERS TO THE LIFETIME OF THE very widely used around the world and
PACE MAKER ONLY) with newer and newer technologies pace
makers which take energy from the heart
and work are being invented.
PACEMAKER IMPLANTATION IN INDIA
2) A large amount of work is in progress in
This procedure is done under local anaesthesia and development of more efficient type of
is usually an outpatient procedure. A small incision batteries. But the cost and quality of Pace
is made just under the collarbone. The pacemaker maker in India is a cause of concern.
is inserted into the heart through a blood vessel
which runs under the collarbone. Once the lead is
REFERENCES
in place it is tested to make sure it is in the right 1) www.nhlbi.nih.gov >> Heart & Vascular
place and it's functional. The lead is then attached Diseases › Pacemaker
to the generator, which is placed just under the skin
through the incisions made earlier. Once the 2) en.wikipedia.org/wiki/Artificial_cardiac_p
procedure has been completed the patient goes acemaker

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3) onlinelibrary.wiley.com › ... › Vol 2 Issue

2

4) D. J. Woollens, ―To beat or not to beat:

the history and development of heart
pacemakers‖, Engineering Sci. Education
J., vol. 4, pp. 259-268,1995.

5) www.anesthesia-
analgesia.org/content/52/5/703.full.pd

6))Canbury, Catherine. Surviving

Technological Innovation in the Pacemaker
Industry, 1959-1990. Garland Pub., 1997.

7)Ellenbogen, Kenneth, ed. Clinical Cardiac

Pacing. Saunders, 1995

8)Moses, H., J. Schneider, B. Miller, and G.

Taylor. A Practical Guide to Cardiac
Pacing. Little, Brown and Co., 1991
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Bibliography
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1 ADITYA.R
DEPT OF INSTRUMENTATION
TECHNOLOGY,RVCE
BANGALORE-59
sachingowdamb@gmail.com

2. SHARATH KUMAR.B.V
DEPT OF INSTRUMENTATION
TECHNOLOGY,RVCE
,BANGALORE-59
sachingowdamb@gmail.com

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