A

Seminar Report On

ARTIFICIAL PACEMAKERD
Submitted to Shivaji University Kolhapur
in partial fulfillment of the requirements
for the degree of

Batchlor of Engineering
In
Instrumentation Engineering
By
Mr. Amarsinh R. Satpute
Under the guidance of
Prof.M.N.Phadanis

Department of Instrumentation Engineering

Padmabhooshan Vasantraodada Patil Institute of Technology, Budhgaon

October 2015

PADMABHOOSHAN VASANTRAODADA PATIL

INSTITUTE OF TECHNOLOGY
Budhgaon

CERTIFICATE

This

is

to

certify

that

the

dissertation

titled

ARTIFICIAL

PACEMAKERDsubmitted by
Mr. Amarsinh R. Satpute.
is record of bonafide work carried out by her, under my guidance, in partial fulfillment of the requirement for the award of the Degree of Batchlor of Engineering
in Instrumentation of Shivaji University Kolhapur.
Date:
Place :Budhgaon

Prof. M. N. Phadnis
Guide
(Dept.ofInstru. Enggi.)

Prof.Dr. S.S. Admuthe

H.O.D.
(Dept. of Instru. Enggi.)

Prof. S. V. Joshi
principal
(P.V.P,I.T.Budhgaon.)

ACKNOWLEDGEMENT
I take a great pleasure in presenting this seminar report and I glad to express my special
thanks to Prof.M.N.Phadnis for their excellent, timely guidance and constructive suggestions
during the preparation of the seminar. This seminar wouldnt have been successful without his
encouragement till the presentation. I thank a lot for his guidance and timely help, which made
this a reality.
I express deep sense of gratitude to the library and staff members for their co-operation.
And finally I express my sincere thanks to all those who have directly or indirectly helped me.
Mr. Amarsinh R. Satpute

ABSTRACT
This paper presents an approach for integrated simulation of pacemaker models and heart
models, each developed
with the appropriate formalism. Heart models are developed in MathWorks, a powerful tool for
the simulation of complex systems, whereas pacemakers are developed in PVS, a theoremproving environment enabling both simulation and formal verification of safety requirements.
The two tools communicate over a Web-based interface, which makes it possible to integrate the
simulation of the MathWorks model of the heart and the PVS model of the pacemaker. In this
paper, we illustrate the architecture developed for integrated
simulation of the pacemaker-heart system and present an example application for realistic
models.

INDEX

SR NO

CONTENT

PAGE NO

Introduction

Block Diagram

Hardware Detail

10

Flowchart of System

22

Advantages and Disadvantages

23

Conclusion

24

References

25

Introduction
Artificial pacemakers are a two-part electrical system that includes a pulse generator
(pacemaker) and one or two leads which deliver impulses to the heart. The leads also carry
signals back from the heart. By "reading" these signals, the pulse generator is able to
monitor the heart's activity and respond appropriately. A pacemaker helps to pace the heart
when the natural rate is too slow to pump enough blood to the body (bradycardia).
The pacer's electrical pulses travel through leads to heart. The pulses are timed to flow at
regular intervals just like heart's natural electrical signals would. Pacer has 2 functions:
pacing and sensing (The third function is programming) Pacing Pacer sends electrical signals
to heart through pacing leads. Each electrical signal is called a pacing pulse. The pacing pulse
begins heart beat Sensing Leads send information about heart's electrical system back to the
pacer.
This allows the pacer not to interfere with a natural, healthy heart beat
Sensing Functions:
Level detection (amplitude)
Filter (band-pass filter)
Amplifier

How a healthy heart works?

Chambers Of The Heart

The heart contains 4 chambers: the right atrium, left atrium, right ventricle, and left
ventricle. The atria are smaller than the ventricles and have thinner, less muscular walls than the
ventricles. The atria act as receiving chambers for blood, so they are connected to the veins that
carry blood to the heart. The ventricles are the larger, stronger pumping chambers that send blood
out of the heart. The ventricles are connected to the arteries that carry blood away from the heart.
The chambers on the right side of the heart are smaller and have less myocardium in their heart
wall when compared to the left side of the heart. This difference in size between the sides of the
heart is related to their functions and the size of the 2 circulatory loops. The right side of the
heart maintains pulmonary circulation to the nearby lungs while the left side of the heart pumps
blood all the way to the extremities of the body in the systemic circulatory loop.

valves of the heart

The heart functions by pumping blood both to the lungs and to the systems
of the body. To prevent blood from flowing backwards or regurgitating back
into the heart, a system of one-way valves are present in the heart. The
heart valves can be broken down into two types: atrioventricular and
semilunar valves.

Atrioventricular valves. The atrioventricular (AV) valves are located in

the middle of the heart between the atria and ventricles and only allow blood
to flow from the atria into the ventricles. The AV valve on the right side of
the heart is called the tricuspid valve because it is made of three cusps
(flaps) that separate to allow blood to pass through and connect to block
regurgitation of blood. The AV valve on the left side of the heart is called
the mitral valve or the bicuspid valve because it has two cusps. The AV
valves are attached on the ventricular side to tough strings called chordae
tendineae. The chordae tendineae pull on the AV valves to keep them from
folding backwards and allowing blood to regurgitate past them. During the
contraction of the ventricles, the AV valves look like domed parachutes with
the chordae tendineae acting as the ropes holding the parachutes taut.

Semilunar valves. The semilunar valves, so named for the crescent moon shape of their
cusps, are located between the ventricles and the arteries that carry blood away from the heart.
The semilunar valve on the right side of the heart is the pulmonary valve, so named because it
prevents the backflow of blood from the pulmonary trunk into the right ventricle. The semilunar
valve on the left side of the heart is theaortic valve, named for the fact that it prevents
the aorta from regurgitating blood back into the left ventricle. The semilunar valves are smaller
than the AV valves and do not have chordae tendineae to hold them in place. Instead, the cusps

Conduction System of the Heart

The heart is able to both set its own rhythm and to conduct the signals necessary to maintain
and coordinate this rhythm throughout its structures. About 1% of the cardiac muscle cells in the
heart are responsible for forming the conduction system that sets the pace for the rest of the
cardiac muscle cells.
The conduction system starts with the pacemaker of the hearta small bundle of cells known
as the sinoatrial (SA) node. The SA node is located in the wall of the right atrium inferior to
the superior vena cava. The SA node is responsible for setting the pace of the heart as a whole
and directly signals the atria to contract. The signal from the SA node is picked up by another
mass of conductive tissue known as the atrioventricular (AV) node.
The AV node is located in the right atrium in the inferior portion of the interatrial septum. The
AV node picks up the signal sent by the SA node and transmits it through the atrioventricular
(AV) bundle. The AV bundle is a strand of conductive tissue that runs through the interatrial
septum and into the interventricular septum. The AV bundle splits into left and right branches in
the interventricular septum and continues running through the septum until they reach the apex
of the heart. Branching off from the left and right bundle branches are many Purkinje fibers that
carry the signal to the walls of the ventricles, stimulating the cardiac muscle cells to contract in a
coordinated manner to efficiently pump blood out of the heart.

Coronary Systole and Diastole

At any given time the chambers of the heart may found in one of two states:

Systole. During systole, cardiac muscle tissue is contracting to push blood out of the
chamber.

Diastole. During diastole, the cardiac muscle cells relax to allow the chamber to fill with
blood. Blood pressure increases in the major arteries during ventricular systole and decreases
during ventricular diastole. This leads to the 2 numbers associated with blood pressuresystolic
blood pressure is the higher number and diastolic blood pressure is the lower number. For

example, a blood pressure of 120/80 describes the systolic pressure (120) and the diastolic
pressure (80).

The cardiac cycle includes all of the events that take place during one heartbeat. There are 3
phases to the cardiac cycle: atrial systole, ventricular systole, and relaxation.

Atrial systole: During the atrial systole phase of the cardiac cycle, the atria contract and
push blood into the ventricles. To facilitate this filling, the AV valves stay open and the semilunar
valves stay closed to keep arterial blood from re-entering the heart. The atria are much smaller
than the ventricles, so they only fill about 25% of the ventricles during this phase. The ventricles
remain

in

diastole

during

this

phase.

Ventricular systole: During ventricular systole, the ventricles contract to push blood into
the aorta and pulmonary trunk. The pressure of the ventricles forces the semilunar valves to open
and the AV valves to close. This arrangement of valves allows for blood flow from the ventricles
into the arteries. The cardiac muscles of the atria repolarize and enter the state of diastole during
this

phase.

Relaxation phase: During the relaxation phase, all 4 chambers of the heart are in diastole
as blood pours into the heart from the veins. The ventricles fill to about 75% capacity during this
phase and will be completely filled only after the atria enter systole. The cardiac muscle cells of
the ventricles repolarize during this phase to prepare for the next round of depolarization and
contraction. During this phase, the AV valves open to allow blood to flow freely into the
ventricles while the semilunar valves close to prevent the regurgitation of blood from the great
arteries into the ventricles.

Blood Flow through the Heart

Deoxygenated blood returning from the body first enters the heart from the superior and inferior
vena cava. The blood enters the right atrium and is pumped through the tricuspid valve into the

right ventricle. From the right ventricle, the blood is pumped through the pulmonary semilunar
valve into the pulmonary trunk.
The pulmonary trunk carries blood to the lungs where it releases carbon dioxide and absorbs
oxygen. The blood in the lungs returns to the heart through the pulmonary veins. From the
pulmonary veins, blood enters the heart again in the left atrium.
The left atrium contracts to pump blood through the bicuspid (mitral) valve into the left ventricle.
The left ventricle pumps blood through the aortic semilunar valve into the aorta. From the aorta,
blood enters into systemic circulation throughout the body tissues until it returns to the heart via
the vena cava and the cycle repeats.
The Electrocardiogram

The electrocardiogram (also known as an EKG or ECG) is a non-invasive device that measures
and monitors the electrical activity of the heart through the skin. The EKG produces a distinctive
waveform in response to the electrical changes taking place within the heart.
The first part of the wave, called the P wave, is a small increase in voltage of about 0.1 mV that
corresponds to the depolarization of the atria during atrial systole. The next part of the EKG
wave is the QRS complex which features a small drop in voltage (Q) a large voltage peak (R)
and another small drop in voltage (S). The QRS complex corresponds to the depolarization of the
ventricles during ventricular systole. The atria also repolarize during the QRS complex, but have
almost no effect on the EKG because they are so much smaller than the ventricles.
The final part of the EKG wave is the T wave, a small peak that follows the QRS complex. The
T wave represents the ventricular repolarization during the relaxation phase of the cardiac cycle.
Variations in the waveform and distance between the waves of the EKG can be used clinically to
diagnose the effects of heart attacks, congenital heart problems, and electrolyte imbalances.

The sounds of a normal heartbeat are known as lubb and dupp and are caused by blood
pushing on the valves of the heart. The lubb sound comes first in the heartbeat and is the
longer of the two heart sounds. The lubb sound is produced by the closing of the AV valves at

the beginning of ventricular systole. The shorter, sharper dupp sound is similarly caused by
the closing of the semilunar valves at the end of ventricular systole. During a normal heartbeat,
these sounds repeat in a regular pattern of lubb-dupp-pause. Any additional sounds such as liquid
rushing or gurgling indicate a structure problem in the heart. The most likely causes of these
extraneous sounds are defects in the atrial or ventricular septum or leakage in the valves.

Cardiac Output
Cardiac output (CO) is the volume of blood being pumped by the heart in one minute. The
equation used to find cardiac output is: CO = Stroke Volume x Heart Rate Stroke volume is the
amount of blood pumped into the aorta during each ventricular systole, usually measured in
milliliters. Heart rate is the number of heartbeats per minute. The average heart can push around
5 to 5.5 liters per minute at rest. Prepared by Tim Taylor, Anatomy and Physiology Instructor
the left side of the body and the other 1/3 is on the right.

Pericardium

The heart sits within a fluid-filled cavity called the pericardial cavity. The walls and lining of the
pericardial cavity are a special membrane known as the pericardium. Pericardium is a type of
serous membrane that produces serous fluid to lubricate the heart and prevent friction between
the ever beating heart and its surrounding organs. Besides lubrication, the pericardium serves to
hold the heart in position and maintain a hollow space for the heart to expand into when it is full.
The pericardium has 2 layersa visceral layer that covers the outside of the heart and a parietal
layer that forms a sac around the outside of the pericardial cavity.

Structure of the Heart Wall

The heart wall is made of 3 layers: epicardium, myocardium and endocardium.

Epicardium. The epicardium is the outermost layer of the heart wall and is just another
name for the visceral layer of the pericardium. Thus, the epicardium is a thin layer of serous
membrane that helps to lubricate and protect the outside of the heart. Below the epicardium is the
second,

thicker

layer

of

the

heart

wall:

the

myocardium.

Myocardium. The myocardium is the muscular middle layer of the heart wall that
contains the cardiac muscle tissue. Myocardium makes up the majority of the thickness and
mass of the heart wall and is the part of the heart responsible for pumping blood. Below the
myocardium

is

the

thin

endocardium

layer.

Endocardium. Endocardium is the simple squamous endothelium layer that lines the
inside of the heart. The endocardium is very smooth and is responsible for keeping blood from
sticking to the inside of the heart and forming potentially deadly blood clots.
The thickness of the heart wall varies in different parts of the heart. The atria of the heart have a
very thin myocardium because they do not need to pump blood very faronly to the nearby
ventricles. The ventricles, on the other hand, have a very thick myocardium to pump blood to
the lungs or throughout the entire body. The right side of the heart has less myocardium in its
walls than the left side because the left side has to pump blood through the entire body while the
right side only has to pump to the lungs.

Heart Failure
When the heart muscle is too weak to effectively pump blood through the body, heart
failure, or cardiomyopathy, sets in. Early diagnosis and treatment can stop or slow down
the worsening of heart failure.

Heart Valve Problems

Heart valve problems can be inherited or develop on their own, affecting the hearts
ability to push blood from chamber to chamber. Medication and surgery are treatment
options.

Electrical Disorders
Arrhythmias that start in the hearts upper chambers, the atria, include:

Atrial

Fibrillation

(AF

or

AFib)

More than 2 million people in the U.S. have atrial fibrillation. In AFib, the heartbeat is
irregular and rapid due to disorganized signals from the hearts electrical system. The
upper chamber of the heart may beat as often as 300 times a minute, about four times
faster than normal. Though AFib isn't life threatening, it can lead to other rhythm
problems, feeling tired all the time, and heart failure (with symptoms such as filling up
with fluid, swelling in hands, legs and feet, shortness of breath). People with AFib are
five times more likely to have a stroke compared to people without the condition. Doctors
often prescribe blood thinners (anticoagulants) to patients with AFib to reduce this higher
risk of stroke.

Atrial Flutter (AFL)

Atrial flutter is similar to AFib because it also causes a fast beat in the atrium. However,
AFL is caused by a single electrical wave that circulates very rapidly in the atrium, about
300 times a minute. This leads to a very fast, but steady, heartbeat.

Disease Categories
Electrical: Abnormal heart rhythms (arrhythmias) are caused by problems with the electrical
system that regulates the steady heartbeat. The heart rate may be too slow or too fast; it may stay
steady or become chaotic (irregular and disorganized). Some arrhythmias are very dangerous and
cause sudden cardiac death, while others may be bothersome but not life threatening.
Circulatory: High Blood Pressure and coronary artery disease (blockage in the pipes of the
heart) are the main causes of blood vessel disorders. The results, such as stroke or heart attack,
can be devastating. Fortunately, there are many treatment options.

Structural: Heart muscle disease (cardiomyopathy) and congenital abnormalities (problems

present from birth) are two problems that can damage the heart muscle or valves.

Millions of people experience irregular heartbeats, called arrhythmias, at some point in their
lives. Most of the time, they are harmless and happen in healthy people free of heart disease.
However, some abnormal heart rhythms can be serious or even deadly. Having other types of
heart disease can also increase the risk of arrhythmias.

Cardiac pacemaker
This article is about the natural pacemaker in the heart. For the medical device that
simulates the function, see artificial cardiac pacemaker.

The
contraction of heart (cardiac) muscle in all animals is initiated by electrical impulses known as
action potentials. The rate at which these impulses fire control the rate of cardiac contraction or
the heart rate. The cells that create these rhythmical impulses are called pacemaker cells, and
they directly control the heart rate.
In humans, and occasionally in animals, a mechanical device called an artificial pacemaker (or
simply "pacemaker") may be used after damage to the body's intrinsic conduction system to
produce these impulses synthetically.

Contents

1 Control

1.1 Primary (SA node)

1.2 Secondary (AV junction and Bundle of His)

2 Generation of action potentials

2.1 Phase 4 - Pacemaker potential

2.2 Phase 0 - Upstroke

2.3 Phase 3 - Repolarization

3 See also

4 References

Control
Schematic representation of the sinoatrial node and the atrioventricular bundle of His. The
location of the SA node is shown in blue. The bundle, represented in red, originates near the
orifice of the coronary sinus, undergoes slight enlargement to form the AV node. The AV node
tapers down into the bundle of HIS, which passes into the ventricular septum and divides into
two bundle branches, the left and righbundles. The ultimate distribution cannot be completely
shown in this diagram.

Primary (SA node)

One percent of the cardiomyocytes in the myocardium possess the ability to generate electrical
impulses (or action potentials)spontaneously. A specialized portion of the heart, called the
sinoatrial node (SA node), is responsible for atrial propagation of this potential.
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 cardiomyocytes. They possess
rudimentary contractile filaments, but contract relatively weakly compared to the cardiac
contractile cells.[1]
The pacemaker cells are connected to neighboring contractile cells via gap junctions, which
enable them to locally depolarize adjacent cells. Gap junctions allow the passage of positive
cations from the depolarization of the pacemaker cell to adjacent contractile cells. This starts the
depolarization and eventual action potential in contractile cells. Having cardiomyocytes
connected via gap junctions allow all contractile cells of the heart to act in a coordinated fashion
and contract as a unit. All the while being in sync with the pacemaker cells; this is the property
that allows the pacemaker cells to control contraction in all other cardiomyocytes.
Cells in the SA node spontaneously depolarize, ultimately resulting in contraction, approximately
100 times per minute. This native rate is constantly modified by the activity of sympathetic and
parasympathetic nerve fibers via the autonomic nervous system, 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.

Secondary (AV junction and Bundle of His)

If the SA node does not function properly and is unable to control the heart rate, a group of cells
further down the heart will become the ectopic pacemaker of the heart. These cells form the
atrioventricular node (or AV node), which is an area between the left atrium and the right
ventricle within the atrial septum, will take over the pacemaker responsibility.
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 is the Bundle of His. The left and
right branches of this bundle, and the Purkinje fibres, will also produce a spontaneous action
potential at a rate of 30-40 beats per minute, so if the SA and AV node both do not function these
cells can become pacemakers. It is important to realize that these cells will be initiating action
potentials and contraction at a much lower rate than the primary or secondary pacemaker cells.
The SA node controls the rate of contraction for the entire heart muscle because its cells have the
quickest rate of spontaneous depolarization, thus they initiate action potentials the quickest. The
action potential generated by the SA node passes down the electrical conduction system of the
heart, and depolarizes the other potential pacemaker cells (AV node) to initiate action potentials
before these other cells have had a chance to generate their own spontaneous action potential,
thus they contract and propagate electrical impulses to the pace set by the cells of the SA node.
This is the normal conduction of electrical activity in the heart.

Generation of action potentials

There are 3 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 1 or 2, just phases 0, 3, and 4.

Phase 4 - Pacemaker potential

The key to the rhythmic firing of pacemaker cells is that, unlike other neurons in the body, these
cells will slowly depolarize by themselves and do not need any outside innervation from the
autonomic nervous system to fire action potentials.
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 in pacemaker cells is that this potassium permeability
(efflux) decreases as time goes on, partly causing the slow depolarization. Also there is a slow,
continuous inward flow of sodium, called the funny current.These two relative ion concentration
changes slowly depolarize (make more positive) the inside membrane potential (voltage) of the
cell, giving these cells their pacemaker potential. When the membrane potential gets depolarized

to about -40mV it has reached threshold (cells enter phase 0), allowing an action potential to be
generated.

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 slow compared to that in an
axon.
The SA and AV node do not have fast sodium channels like neurons, and the depolarization is
mainly caused by a slow influx of calcium ions. (The funny current also increases). The calcium
enters the cell via voltage-sensitive calcium channels that open when the threshold is reached.
This calcium influx produces the rising phase of the action potential, which results in the reversal
of membrane potential to about +10mV, where it peaks. It is important to note that intracellular
calcium causes the muscular contraction in contractile cells, and is the effector ion. In heart
pacemaker cells, phase 0 depends on the activation of L-type calcium channels instead of the
activation of voltage-gated fast sodium channels, which are responsible for initiating action
potentials in contractile cells (non-pacemaker). For this reason, the pacemaker action potential
rising phase slope is more gradual than that of the contractile cell (image 2).[7]

Phase 3 - Repolarization
The reversal of membrane potential triggers the opening of potassium leak channels, resulting in
the rapid loss of potassium ions from the inside of the cell, causing repolarization (Vm gets more
negative). The calcium channels are also inactivated, soon after they open. Also sodium
permeability into the cell becomes decreased as the sodium channels become inactivated. These
ion concentration changes across the membrane slowly repolarize the cell to resting membrane
potential (-60mV). Another important note at this phase is that ionic pumps restore ion
concentrations to pre-action potential status. The sodium-calcium exchanger ionic pump works
to pump calcium out of the intracellular space, thus effectively relaxing the cell. The
sodium/potassium pump restores ion concentrations of sodium and potassium ions by pumping

sodium out of the cell and pumping (exchanging) potassium into the cell. Restoring these ion
concentrations is vital because it enables the cell to reset itself and enables it to repeat the
process of spontaneous depolarization leading to activation of an action potential.

See also
Natural pacemaker: The natural pacemaker of the heart is the sinus node, one of the major
elements in the cardiac conduction system, the system that controls the heart rate. This
stunningly designed system generates electrical impulses and conducts them throughout the
muscle of the heart, stimulating the heart to contract and pump blood.

The sinus node consists of a cluster of cells that are situated in the upper part of the wall of the
right atrium (the right upper chamber of the heart). The electrical impulses are generated there.
The sinus node is also called the sinoatrial node or, for short, the SA node.
The electrical signal generated by the sinus node moves from cell to cell down through the heart
until it reaches the atrioventricular node (AV node), a cluster of cells situated in the center of
the heart between the atria and ventricles. The AV node serves as a gate that slows the electrical
current before the signal is permitted to pass down through to the ventricles. This delay ensures
that the atria have a chance to fully contract before the ventricles are stimulated. After passing
the AV node, the electrical current travels to the ventricles along special fibers embedded in the
walls of the lower part of the heart.

The autonomic nervous system, the same part of the nervous system as controls the blood
pressure, controls the firing of the sinus node to trigger the start of the cardiac cycle. The
autonomic nervous system can transmit a message quickly to the sinus node so it in turn can
increase the heart rate to twice normal within only 3 to 5 seconds. This quick response is
important during exercise when the heart has to increase its beating speed to keep up with the
body's increased demand for oxygen.

Patient information: Pacemakers (Beyond the Basics)

Authors
Brian Olshansky, MD
David L Hayes, MD
Section Editor
Leonard I Ganz, MD, FHRS, FACC
Deputy Editor
Brian C Downey, MD, FACC
Find Print ShareThis

INTRODUCTION

Pacemakers are electronic devices that stimulate the heart with electrical impulses to maintain or
restore a normal heartbeat. This topic review will discuss pacemakers, when they may be

necessary or appropriate, the types of pacemakers that are available, and the precautions patients
need to take after having a pacemaker placed.

THE HEART'S CONDUCTION SYSTEM AND "NATURAL PACEMAKER"

The heart has its own built-in electrical system, called the conduction system (figure 1). The
conduction system sends electrical signals throughout the heart that determine the timing of the
heartbeat and cause the heart to beat in a coordinated, rhythmic pattern. The conduction system
stimulates precise contractions of the heart's chambers to ensure that blood is pumped effectively.
The electrical signals, or impulses, of the heart are generated by specialized tissue called the
sinoatrial (SA) or sinus node (figure 1). The sinus node is sometimes called the heart's "natural
pacemaker." Each time the sinus node generates a new electrical impulse; that impulse spreads
out through the heart's upper chambers, called the right atrium and the left atrium (figure 2). This
electrical impulse stimulates the atria to contract, pumping blood into the lower chambers of the
heart (the right and left ventricles).
The electrical impulse then spreads to another area of specialized tissue located between the atria
and the ventricles, the atrioventricular (AV) node. The AV node momentarily slows down the
spread of the electrical impulse, to allow the left and right atria to finish contracting.
From the AV node, the impulse spreads into a system of specialized fibers called the bundle of
His and the right and left bundle branches (figure 1). These fibers distribute the electrical
impulse rapidly to all areas of the right and left ventricles, stimulating them to contract in a
coordinated way. With this contraction, blood is pumped from the right ventricle to the lungs,
and from the left ventricle throughout the body.

ARRHYTHMIAS
The heart's conduction system must function normally for the heart to beat properly and to pump
blood effectively to meet the body's needs. Problems with the flow of electrical impulses in the
heart are called arrhythmias, which is a general term meaning that there is an abnormality in the
pattern of electrical conduction or electrical rhythm.

Bradyarrhythmias Bradyarrhythmias are heart rhythm abnormalities that cause an abnormally

slow heartbeat. Most bradyarrhythmias are due to one of two kinds of problems: sinus
bradycardia or heart block.
Sinus bradycardia occurs when the heartbeat is too slow because the heart's "natural pacemaker"
is operating too slowly. Although some people (for example, competitive athletes) may have a
slow heartbeat as a result of good health, in others sinus bradycardia is an abnormal condition
that requires treatment.
Heart block is a term for a delay or interruption in the heart's conduction system, causing the
electrical impulses to travel too slowly or to be stopped. There are several kinds of heart block,
classified according to location (where in the conduction system the block occurs) and degree
(whether the block is mild, causing delayed conduction, or severe, causing conduction to stop).
In first-degree atrioventricular (AV) block, all electrical impulses reach the ventricles from the
atria, but are abnormally slowed as they pass through the AV node.
In second-degree AV block, some atrial impulses fail to reach the ventricles ("dropped beats"),
resulting in a slow or an irregular heart rate.
In third-degree AV block, the most serious form, no atrial impulses are conducted to the
ventricles. This condition is sometimes called complete heart block. For the heart to continue to
beat, a separate electrical impulse (called an escape rhythm) may be generated in the ventricles.
Without an escape rhythm, the ventricles (the chambers that pump blood throughout the body)
stop beating.
In right bundle branch block (RBBB), impulses are not conducted by the right bundle branch.
Electrical impulses reach the right ventricle only by traveling through the heart muscle from the
left ventricle. As a result, activation of the right ventricle is delayed.
In left bundle branch block (LBBB), impulses are not conducted by the left bundle branch.
Electrical impulses reach the left ventricle only by traveling through the heart muscle from the
right ventricle. As a result, activation of the left ventricle is delayed.

Arrhythmia symptoms The symptoms of arrhythmias vary, depending upon the specific
arrhythmia and other factors, especially if there is underlying heart disease. While some people
may have no symptoms, others may have various symptoms and signs. Symptoms may include:
Fainting episodes (syncope) (see "Patient information: Syncope (fainting) (Beyond the
Basics)")
Dizziness or lightheadedness (presyncope)
Palpitations (a sensation of the heart pounding)
Confusion
Extreme fatigue
Shortness of breath
Impaired ability of the heart to pump enough blood to meet the body's needs (heart failure)
The decision to treat an arrhythmia with a pacemaker (or any other treatment) depends in part
upon whether the person has symptoms or not as well as the severity of the symptoms.
Underlying causes A variety of conditions can lead to the development of cardiac
arrhythmias. Some of the more common causes include:
Coronary artery disease, where there is a malfunction or damage of the heart due to narrowing
or blockage of arteries supplying blood to heart muscle
Damage from a heart attack and the development of scar tissue in the muscle of the heart
Certain structural heart malformations present at birth (congenital heart defects)
Inherited genetic abnormalities that are not necessarily associated with a structural problem of
the heart, but may result in an arrhythmia (such as the long QT syndrome)

Abnormalities in the control and regulation of the heart rate and vascular tone by the nervous
system, leading to fainting (called neurocardiogenic syncope)
Diseases of heart muscle tissue, called cardiomyopathies (see "Patient information: Dilated
cardiomyopathy (Beyond the Basics)" and "Patient information: Hypertrophic cardiomyopathy
(Beyond the Basics)")
Therapy with certain medications that may alter the heart's normal rhythm
Normal aging of heart muscle

TEMPORARY AND PERMANENT PACEMAKERS

Artificial pacemakers are electronic devices that stimulate the heart with electrical impulses to
maintain or restore a normal rhythm in people with slow heart rhythms. There are many
situations in which an artificial pacemaker may be recommended.

Most commonly, a pacemaker is used for a slow heart rate (bradyarrhythmia) as described above.
The decision to use such a device, as well as which specific type, will depend upon multiple
factors, including:
The exact nature and underlying cause of the arrhythmia
Whether the condition is temporary or permanent
The presence or absence of symptoms as described above
The anticipated frequency of pacing
The underlying cardiac conditions
How they work An artificial pacemaker provides an electrical impulse (or "discharge") that
can stimulate the heart, thus restoring or maintaining a regular heartbeat. Although various types
of artificial pacemaker devices are available, they generally include the following components:
A thin metal box or case called a pulse generator (picture 1), which contains the power source
producing the electrical impulses of the pacemaker. In addition, the pulse generator contains a
small computer processor that can be programmed to set the rate of the pacemaker, the pattern of
pacing, the energy output, and various other parameters. The pulse generator for most modern
permanent pacemakers weighs one to two ounces. (See 'Types of pacemakers' below.)
Flexible insulated wires or leads carry electrical impulses from the generator to the heart
muscle and relay information concerning the heart's natural activities back to the pacemaker.
There may be several such wires, or leads, placed within the heart, most commonly in the right
atrium and right ventricle.
The pacing lead most commonly incorporates one or two electrical "poles." An electrical
impulse is transmitted to the heart muscle when needed, and the lead is also able to sense the
heart's intrinsic electrical activity.

Types of pacemakers A variety of types of pacemakers and modes of pacing have been
developed to restore or sustain a regular heartbeat in different ways. All contemporary
pacemakers sense the intrinsic activity and stimulate the heart only when the intrinsic heart rate
falls below the programmed pacing rate. Essentially all contemporary pacemakers also
incorporate rate responsive capability. This depends on a "sensor" incorporated into the
pacemaker that can sense activity or respiratory rate and can alter the heart rate based on the
perceived physiologic need.
Pacemakers may also be single, dual, or triple chambered:
Single-chamber pacemakers have one lead to carry impulses to and from either the right atrium
or right ventricle.
A dual-chamber pacemaker characteristically has two leads, one to the right atrium and one to
the right ventricle, which can allow a heart rhythm that more naturally resembles the normal
activities of the heart and reflects intrinsic depolarization.
Triple-chambered pacemakers typically have one lead in the right atrium, one to stimulate the
right ventricle, and one to stimulate the left ventricle. These devices are used in patients who
have weakened heart muscle (which results in heart failure). These pacemakers "resynchronize"
the ventricles and may improve the efficiency of the contraction of the heart. They are also
commonly referred to as "biventricular pacemakers."
Temporary pacemakers Temporary pacemakers are intended for short-term use during
hospitalization. They are used because the arrhythmia is expected to be temporary and eventually
resolve, or because the person requires temporary treatment until a permanent pacemaker can be
placed.
The pulse generator of a temporary pacemaker is located outside the body, and may be taped to
the skin or attached to a belt or to the patient's bed.
Patients with temporary pacemakers are hospitalized and continuously monitored. Members of
the healthcare team will perform regular examinations to monitor for any possible complications.

Permanent pacemakers Permanent pacemakers are pacemakers that are intended for long-term
use.
Indications Specific guidelines have been established concerning the conditions when a
permanent pacemaker is (I) definitely beneficial, useful, and effective, (II) may be indicated, or
(III) is not useful or effective and, in some cases, may be harmful. Patients should speak with
their healthcare provider concerning these guidelines and how they apply to their specific case.
As a general rule, permanent pacing is recommended for certain conditions that are chronic or
recurrent and not due to a transient cause. Permanent pacing may be considered necessary or
appropriate for certain people with symptomatic bradyarrhythmia or, less commonly, to help
prevent or terminate tachyarrhythmia.
Implantation The pacemaker is most commonly implanted into soft tissue beneath the skin in
an area below the clavicle, which is known as prepectoral implantation; this is located under the
skin and fat tissue but above the pectoral muscle. The pacemaker leads are typically inserted into
a major vein (transvenously) and advanced until the leads are secured within the proper region(s)
of heart muscle. The other ends of the leads are attached to the pulse generator (figure 3).
Less commonly, the pulse generator is placed under the skin of the upper abdomen.
Generally the pacemaker is implanted in a sterile laboratory or operating room by a specialist
(cardiologist, surgeon, or cardiac electrophysiologist) with experience in this procedure. Local
anesthesia and often conscious sedation are used to make the procedure as pain-free as possible.
General anesthesia is rarely required. The position of the pacemaker leads is usually checked
using X-ray imaging (called fluoroscopy). The length of the procedure depends upon the type of
device being placed.
Recovery from the procedure is rapid, but there may be some restrictions on arm movement and
activities for the first two to four weeks. Lead dislodgement is more common in the first few
weeks after implantation. The hospital stay is usually brief, and the procedure can be performed
as an outpatient. Uncommon but possible risks associated with permanent pacemaker

implantation include collapsed lung (pneumothorax), infection, perforation/tamponade, and

bleeding.
Once implanted, pacemakers can be programmed to change the baseline heart rate, the upper
heart rate at which the pacemaker will pace, and heart rate changes that should occur with
exercise.
Follow-up care People who have a permanent pacemaker will require periodic surveillance of
the implanted device. The status of the pacemaker will be regularly checked or "interrogated"
(often done remotely using a telephone or a secure web-based system) to provide information
regarding the type of heart rhythm, the functioning of the pacemaker leads, the frequency of
utilization of the pacemaker, the battery life, and the presence of any abnormal heart rhythms.
All contemporary devices are programmable with information and settings that can be altered
and stored. Information is obtained by transmitting data from the pulse generator to a
programmer, usually done during a follow-up office visit. However, with newer pulse generators
it may be possible to obtain information about the pacemaker's performance by downloading
data from the patient's device to the internet and then to the caregiver's office. In older devices,
pacemaker status can be checked routinely via the telephone using a trans-telephonic device.

The pulse generators are usually powered by lithium batteries that function for an
average of five to eight years before they need to be replaced. When the batteries
start to wear out, they do so in a very slow and predictable fashion, allowing
sufficient time to be detected and pulse-generator replacement planned. Replacing
the pulse generator usually requires a simple procedure in which a skin incision is
made over the old incision, the old generator is removed, and a new generator is
implanted and joined with the existing leads, assuming the existing leads are
functioning normally.
The pacemaker leads are usually used indefinitely, unless a specific problem
occurs (eg, the lead loses contact with the heart, the lead breaks, or the lead is not

functioning properly). In such circumstances, the lead may require replacement.

Often, the old lead is left in place but disconnected from the pulse generator and
capped, and a new lead is inserted. Removal of an old lead is feasible but difficult
in most cases, because of the formation of scar tissue binding the lead to the blood
vessels and heart muscle. Lead removal is usually necessary if the system becomes
infected.

AVOIDING ELECTROMAGNETIC INTERFERENCE

Although contemporary pacemakers are less susceptible to interference than older models,
electromagnetic energy can interfere in some cases. Thus, experts advise that people with
pacemakers be aware of the following:
Household appliances Pacemaker manufacturers do not recommend any special precautions
when using normally functioning common household appliances such as microwave ovens,
televisions, radios, toasters, and electric blankets.
Cellular phones Evidence suggests that cellular phones do not cause interference with
permanent pacemakers. While some older generation pacemakers and implantable cardioverterdefibrillators (ICDs) did occasionally experience interference from cellular telephones, clinical
experience suggests that there is no significant interference between pacemakers or ICDs and
modern wireless communication devices or portable media players.

Anti-theft systems Electromagnetic anti-theft security systems are often found in or near the
workplace, at airports, in stores, at courthouses, or in other high-security areas. Although
interference with a pacemaker is possible, it is unlikely that any clinically significant interference
would occur with the transient exposure associated with walking through such a field. Based
upon several studies and observations, experts advise that patients with pacemakers should:
Be aware of the location of anti-theft systems and move through them at a normal pace
Avoid leaning on or standing close to an anti-theft system
Metal detectors at airports Similar to antitheft systems, metal detectors at airports can
potentially interfere with pacemakers, although this is unlikely. Such exposure has been shown to
cause interference in some cases and may be related to the duration of exposure and/or distance
between the security system and the pacemaker. Metal detectors will likely be triggered by the
presence of a pacemaker and therefore at places such as airports, it will be important for
individuals with pacemakers to carry an identification card for their pacemaker, and airport
personnel will likely prefer to do a manual search.
External electrical equipment External electrical fields do not seem to cause a problem for
most people with a pacemaker. However, in workplaces that contain welding equipment or
strong motor-generator systems, because interference can inhibit pacing, it is recommended that
a person with an implanted cardiac device remain at least two feet from external electrical
equipment, verify that the equipment is properly grounded, and leave the immediate locale if
lightheadedness or other symptoms develop.
Diagnostic or therapeutic procedures Certain types of surgery and procedures may interfere
with pacemakers. Most importantly, the use of electrocautery can inhibit pacemaker function. It
is not uncommon therefore that a pulse generator may require specific reprogramming before the
procedure and programming back to its baseline condition after the procedure. In some instances,
a magnet is all that is required on the device to make sure that there is no problem with the
device during the procedure. Such procedures include:

Magnetic resonance imaging (MRI), which uses a strong magnetic field that is pulsed on and
off at a rapid rate. For most patients with a pacemaker, this procedure is a relative
contraindication.
Transcutaneous electrical nerve/muscle stimulators (TENS), a method of pain control.
Diathermy, which heats body tissues with high-frequency electromagnetic radiation or
microwaves.
Extracorporeal shock wave lithotripsy, the use of sound waves to break up gallstones and
kidney stones.
Therapeutic radiation for cancer or tumors, which can cause permanent pacemaker damage.
Any surgery in which electrocautery is being used. The risks are greatest when the
electrocautery is being performed close to the pulse generator.
Thus, doctors, dentists, and other healthcare providers should be informed about a person's
pacemaker. If a procedure associated with pacemaker interference is contemplated, the possible
benefits, risks, and alternatives should be considered and discussed, as appropriate. People with
pacemakers should carry a medical identification card for emergencies.

https://en.wikipedia.org/wiki/Artificial_cardiac_pacemakerLiving with a Pacemaker or

Implantable Cardioverter Defibrillator (ICD)
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<< Back to Diseases and Conditions
Pacemakers and ICDs generally last five to seven years or longer (depending on usage and the
type of device) and, in most cases, allow a person to lead a normal life. In addition, advances in
device circuitry and insulation have reduced the interference risk from machinery, such as
microwaves, which, in the past, may have altered or otherwise affected these surgically

implanted cardiac devices. Even so, certain precautions must be taken into consideration when a
person has a pacemaker or ICD.
What precautions should I take with my pacemaker or ICD?
The following precautions should always be considered. Discuss the following in detail with
your doctor:

Although it is generally safe to go through airport or other security detectors (they will
not damage the pacemaker or ICD), inform airport security personnel that you have a
pacemaker before you go through security, as the device may set off the alarm. Also, if
you are selected for a more detailed search, politely remind security that the hand-held
metal-detecting wand should NOT be held over the pacemaker for a prolonged period of
time (more than a second or two), as the magnet inside the detecting wand may
temporarily change the operating mode of your device. Do not lean against or stay near
the system longer than necessary.

Avoid magnetic resonance imaging (MRI) machines or other large magnetic fields, as
these may affect the programming or function of the pacemaker (except for special types
of pacemakers or ICDs that are designed to tolerate MRI scans). Also, the rapidly

changing magnetic field within the MRI scanner can, in theory, cause heating of the
pacemaker leads. In general, there are alternatives to MRI for people with pacemakers,
but if your doctor determines that you absolutely need an MRI scan, discuss this
thoroughly with your cardiologist before proceeding. If he or she and you agree to go
ahead, you should be closely monitored by a cardiologist, with a pacemaker
programming device immediately available, during MRI scanning.

Abstain from diathermy (the use of heat in physical therapy to treat muscles).

Turn off large motors, such as cars or boats, when working on them since they may
temporarily "confuse" your device.

Avoid certain high-voltage or radar machinery, such as radio or television transmitters,

arc welders, high-tension wires, radar installations, or smelting furnaces.

Cell phones available in the U.S. (less than 3 watts) are generally safe to use.
Advancements in cell phone frequency technology could potentially impact device
function. A general guideline is to keep cell phones at least six inches away from
your device. Avoid carrying a cell phone in your breast pocket over your pacemaker or
ICD.

MP3 player headphones may contain a magnetic substance that could interfere with your
device function when in very close contact. It is recommended that the headphones be
kept at least 1.2 inches or 3 centimeters (cm) away from the device. They can be worn
properly in the ears and not pose this risk. Do not drape your headphones around your
neck, put your headphones in your breast pocket, or allow a person with headphones in
to press against your device.

If you are having a surgical procedure performed by a surgeon or dentist, tell your
surgeon or dentist that you have a pacemaker or ICD. Some surgical procedures will
require that your ICD be temporarily turned off or set to a special mode; however, this
will be determined by your cardiologist. Temporarily changing the mode on your
pacemaker can be performed noninvasively (no additional surgery is required), but
should only be performed by qualified medical personnel.

Shock wave lithotripsy, used to get rid of kidney stones, may disrupt the function of your
device without appropriate preparation. Ensure that your doctor is aware you have a
pacemaker or ICD before scheduling this procedure.

Therapeutic radiation, such as that used for cancer treatments, can damage the circuits in
your device. The risk increases with increased radiation doses. Appropriate precautions
should be taken. Inform your doctor that you have a pacemaker or ICD before undergoing
radiation treatments.

Always carry an ID card that states you have a pacemaker or ICD. It is recommended that
you wear a medic alert bracelet or necklace if you have a device.

Always consult your doctor or device company if you have any questions concerning the use of
certain equipment near your pacemaker or ICD.

Can I participate in regular, daily activities with a pacemaker or

ICD?
Once the device has been implanted, people with pacemakers or ICDs should be able to do the
same activities everyone else in their age group is doing. When you have a pacemaker or ICD,
you may still be able do the following:

Exercise on advice from your doctor

Drive your car or travel if cleared by your doctor

Return to work

Work in the yard or house

Participate in sports and other recreational activities

Take showers and baths

Continue sexual relationships

When involved in a physical, recreational, or sporting activity, a person with a pacemaker or ICD
should avoid receiving a blow to the area over the device. A blow to the chest near the

pacemaker or ICD can affect its functioning. If you do receive a blow to that area, see your
doctor.
Always consult your doctor if you feel ill after an activity, or when you have questions about
beginning a new activity.

How can I ensure that my pacemaker or ICD is working

properly?
Although your device is built to last at least five years, you should always have it checked
regularly to ensure that it is working properly. Different doctors may have different schedules for
checking devices, and most are checked in the home using a telephone and special equipment
provided by your device manufacturer. Your doctor will recommend in-person device checks at
specific intervals as well. Any device setting changes must be made in person, by a trained
medical professional, using a device programmer.
Battery life, lead wire condition, and various functions are checked by performing a device
interrogation. During an interrogation the device is noninvasively connected to a device
programmer using a special wand placed on the skin over the pacemaker or ICD. The data is
transmitted from the device to the programmer and evaluated. Most in-home device interrogation
systems use wireless technology to connect the device to special equipment that records the data
and sends it to your doctor.
Your doctor may ask you to check your pulse rate periodically. Report any unusual symptoms or
symptoms similar to those you had prior to the device insertion to your health care
provider immediately.
Always consult your doctor for more information, if needed.

How to check your pulse

As the heart forces blood through the arteries, you feel the beats by firmly pressing on the
arteries, which are located close to the surface of the skin at certain points of the body. The pulse
can be found on the side of the lower neck, on the inside of the elbow, or at the wrist. When
taking your pulse:

Using the first and second fingertips, press firmly but gently on the arteries until you feel
a pulse.

Begin counting the pulse when the clock's second hand is on the 12.

Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate
beats per minute).

When counting, do not watch the clock continuously, but concentrate on the beats of the
pulse.

If unsure about your results, ask another person to count for you.

It is probably better to check the wrist (radial artery) pulse than a neck (carotid artery)
pulse. If you must check a neck pulse, do not press hard on the neck, and never press on
both sides of the neck at the same time, as this can cause some people to pass out.

ADVANTAGES

 For normal heart rhythm.

Proper functioning of heart.
Proper supply of blood to all organs.
It saves the life.

DISADVANTAGES

The patient cant do heavy work.

The patient cant use cellphone within 15 cm range.
Magnetic field is affected.Regular checking must needed

CONCLUSION

Using artificial pacemaker we can save the life.

It helps to maintain the blood pressure. I conclude that this is very useful technology for
human life

ERENCES

Molding and verification of dual chamber implantable Pacemaker.(ieee-paper_ENNSY

LVANIA,CHILADENTHIA)
Handbook of Biomedical Instrumentation. (-R.S.KHANDPUR)
WWW.MEDTRONICS.COM.