WO1979000070A1 - Stimulateur cardiaque - Google Patents

Stimulateur cardiaque Download PDF

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Publication number
WO1979000070A1
WO1979000070A1 PCT/GB1978/000007 GB7800007W WO7900070A1 WO 1979000070 A1 WO1979000070 A1 WO 1979000070A1 GB 7800007 W GB7800007 W GB 7800007W WO 7900070 A1 WO7900070 A1 WO 7900070A1
Authority
WO
WIPO (PCT)
Prior art keywords
electrode
circuit
sensing
electrodes
switch
Prior art date
Application number
PCT/GB1978/000007
Other languages
English (en)
Inventor
S Joseph
Original Assignee
S Joseph
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by S Joseph filed Critical S Joseph
Publication of WO1979000070A1 publication Critical patent/WO1979000070A1/fr

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Classifications

    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/362—Heart stimulators
    • A61N1/365—Heart stimulators controlled by a physiological parameter, e.g. heart potential
    • A61N1/368—Heart stimulators controlled by a physiological parameter, e.g. heart potential comprising more than one electrode co-operating with different heart regions
    • A61N1/3686—Heart stimulators controlled by a physiological parameter, e.g. heart potential comprising more than one electrode co-operating with different heart regions configured for selecting the electrode configuration on a lead
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/36128—Control systems
    • A61N1/36146—Control systems specified by the stimulation parameters
    • A61N1/36182—Direction of the electrical field, e.g. with sleeve around stimulating electrode
    • A61N1/36185—Selection of the electrode configuration
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/362—Heart stimulators
    • A61N1/365—Heart stimulators controlled by a physiological parameter, e.g. heart potential
    • A61N1/368—Heart stimulators controlled by a physiological parameter, e.g. heart potential comprising more than one electrode co-operating with different heart regions

Definitions

  • This invention relates to apparatus for stimulating the activity of the heart, such apparatus being known generally as "Pacemakers" and will be referred to herein by that term.
  • the normal sequence of electrical activation of the heart begins from the sino-atrial (SA) node in the high right atrium (RA); the electrical impulses traverse the atria to reach the specialised atrio-ventricular (AV) conduction system of the heart through which they pass to reach the ventricles.
  • SA sino-atrial
  • AV atrio-ventricular
  • the two main pathologies which disturb this sequence are atrio-ventricular (AV) block when the impulse fails to reach the ventricles which then beat at their own intrinsically slow and unreliable rate, and SA node disease which causes a defect in initial impulse formation and hence a slow and unreliable beating of the whole heart.
  • Pacemakers as currently in use may include an electrode which stimulate the atrium or an electrode to stimulate the ventricle of a heart.
  • an electrode which stimulate the atrium or an electrode to stimulate the ventricle of a heart.
  • Cardiac pacing is, at present, usually accomplished by a ventricular stimulation electrode in order to overcome atrio-ventricular block.
  • the pacemaker is connect ed through a catheter electrode to one of the ventricles of heart.
  • the latter mode has the advantage of retaining both atrial-contraction and physiological ventricular contraction with increase cardiac performance but it has two main disadvantages;
  • the catheter electrode position in the atrium is mechanically less stable when the transvenous route is usedfor the catheter than in the ventricular; 2.
  • the patient with SA node disease may progress to acquire AV conduction disease with concommitant loss of ventricular stimulation.
  • Atrial pacing has not been widely practised.
  • a disturbance in the position or function of the atrial electrode may prevent the stimulus from activating the atrium; this is known as atrial exit block.
  • the effect of cardiac pacing is then lost; similarly the onset of AV conduct from activating the ventricles with loss of ventricular contraction.
  • the electrodes are implanted surgically such a changeover requires a major operation and even if the catheter carrying the electrode is initially inserted transvenously, some disturbance is involved and particularly under circumstances where a changeover might become necessary the disturbance is particularly undesirable.
  • apparatus for stimulating the heart comprising a first electrode for stimulating one of the atria of thet heart and a second electrode for stimulating one of the ventricles of the heart, means for supplying electrical pulses to one or other of the electrodes and switching means either controllable from externally of the body or automatically within the apparatus, said switching means enabling pulses to be applied selectively to the first and second of the electrodes. If the apparatus includes provision for sensing a parameter of the operation of the body, then the said switching means, or possibly another switching means, may be used to effect a change over from the sensing of one parameter to another.
  • Three pacemakers embodying the invention will no be described, by way of example, with reference to the accompanying diagrammatic drawings, in which: Figure 1 is a diagram of a dual pacemaker in accordance with the invention;
  • FIG. 2 is a diagram of a triple mode pacemaker in accordance with the invention.
  • FIG 3 is a diagram of another embodiment pacemaker
  • Figure 4 is a series of electrocardiographic diagrams
  • Figure 5 is a diagram of a modification of embodiment of Figure 3.
  • the invention is applicable to pacemakers implanted both surgically and by the use of a catheter placed in the heart transvenously. Again, the invention can be applied to a variety of different circuits and those illustrated in the accompanying drawings are noc exhaustive of the possible circuits to which the invention is applicable, As is conventional the pacemaker may have a unipolar electrode in the heart. with the other electrode on outside of the pacemaker casing. Alternatively, both electrodes may be at the end of a catheter. The invention is applicable to both electrode systems.
  • the pacemaker comprises an energy source 10 example a mercury-zinc or a lithium based cell, connected to a timing circuit 12 which is arranged to receive messages from a sensing circuit 14 and to deliver an output to an output circuit which supplies electrical pulses selectively either to an atrial electrode 18 or to a ventricular electrode 20 through a switch 22.
  • the sensing circuit receives a feed-back from the atrial or ventricular electrode 18,22.
  • a detector circuit 24 for detecting external programming may be connected to the timing circuit 12 or to the output circuit 16. This external programming enables changes of frequency, amplitude or width of the pulses supplied to the electrode.
  • the energy source, the timing, output, sensing, programming, and detector circuits are all conventional.
  • the sensing circuit 14 detects intrinsic cardiac electrical activity through the catheter electrode 18,20 which is normally the same as the electrode which carries the pacing pulses. When the intrinsic cardiac activity exceeds a predetermined rate, the amplified signal from the heart either blocks or triggers, as appropriate, the timing circuit
  • the switch device 22 may be electronic, for example a semi-conductor switch, or may be electro-mechanical but should have a low resistance whichever switch is selected. Such a switch can be actuated by a static or pulsating magnetic field from externally of the patient's body through a detector circuit 26. Once the switching operation has been carried out the switch will remain in the same position until subjected to another magnetic field when this is required.
  • a reed switch is incorporated, electrical pulses are fed to a detector, a counter and a decoder which will operate the switch 22.
  • the output and sensing circuits 14, 16, of the pacemaker are connected to one of the two electrodes 18, 20. through the switch 22 and this enables both sensing and pacing to be effected through either electrode and further this allows for atrial pacing and sensing or alternatively ventricular pacing and sensing.
  • the basic circuits are the same as in the first embodiment and are given the same reference numerals, but two switches 30, 32 are incorporated, one of which 30 determines the electrode 18, 20 to be connected to the output circuit 16 of the pacemaker and the other 32 of which determines the electrode connected to the sensing circuit 14 of the pacemaker. It follows that one electrode can be used for sensing and the other for pacing.
  • the circuit of Figure 2 thus allows for a third mode, namely ventricular sensing and atrial pacing which could be used in the event that atrial sensing fails but atrial pacing is retained.
  • the circuit also gives a fourth possible mode, namely atrial sensing and ventricular pacing but this is undesirable physiologically and would be avoided by appropriate blocking, circuitry or incorporation of an appropriate cut-out circuit in a programming device.
  • pacemakers embodying the invention By the use of either of the hereinbefore described pacemakers embodying the invention, some of the disadvantages of atrial stimulation are believed to be circumvented.
  • pacemakers embodying the invention as described with reference to Figure 2 are intended to achieve atrial pacing with its attendant advantages, in the event that atrial sensing fails, the switch can be operated to allow ventricular pacing and further in the event that both atrial sensing and pacing fail, the switch means can be operated to allow both ventricular sensing and pacing.
  • the output terminal switching may be arranged to occur automatically by the provision of an additional circuit within the pacemaker so providing an additional safeguard for the patient. This may be in addition to the external programming means described with reference to Figures 1 and 2.
  • An additional sensing circuit 34 is incorporated in the pacemaker (Fig 3) which receives an input from the timing circuit 12 and from the ventricular electrode 20 and is cap of delivering an output to the switch 22.
  • the switch is activated on receipt of a signal from the timing circuit 12 and is disabled on receipt of a signal from the ventricular electrode 20 at any time in the subsequent 300 msec. If no signal is received from the ventricular electrode 20 within 300 msec after activation it emits a signal which activates switch 22 changing the output from the output circuit (16) from the atrial 18 to the ventricular electrode 20.
  • FIG. 4 represents the electrocardiogram in various paced and unpaced modes.
  • St represents pacemaker stimuli
  • 'p' represents spontaneous or paced atrial activation
  • 'qrs' represents ventricular activation following normal AV conduction
  • 'QRS' represents ventricular activation after ventricular pacing.
  • the initial beat is an atrial paced beat p followed by normal AV conduction and ventricular qrs activation.
  • the second beat is spontaneous and occurs within the escape period of the demand pacemaker the output of which is inhibited according to known methods.
  • both beats follow atrial pacing and normal AV conduction.
  • C the initial atrially paced beat p is followed by delayed AV conduction and ventricular qrs activation occurs more than 300msec after St1; sensing circuit 34. therefore switches the output of the pacer to the ventricular electrode and St2 is followed by ventricular activation.
  • Atrial exit block there is atrial exit block and St1 is not followed by atrial activation.
  • spontaneous atrial activation p is followed by ventricular contraction qrs within 300msec of St1, after the second stimulus (St2) the activation qrs falls outside the 300msec period, and the output of the pacemaker would be switched to the ventricular electrode for the third beat.
  • St2 spontaneous atrial activation p is followed by ventricular contraction qrs within 300msec of St1
  • the second stimulus (St2) the activation qrs falls outside the 300msec period, and the output of the pacemaker would be switched to the ventricular electrode for the third beat.
  • the pacer output is switched to the ventricular electrode.
  • the sensing circuit 30 will receive no activation from the timing circuit 12 and will not activate switch 22.
  • sensing circuit 31 receives its actuating signal from the proximal (internal) side of the switch 22.
  • the sensing circuit 34 would then activate switch 22 if the 'qrs' signal from ventricular electrode 20 fell more than 300 msec beyond either a signal from output circuit 16 or a 'p' wave which traversed the switch 22 from the atrial electrode 18.
  • switch 22 After activation of switch 22 to transmit and deliver signals from ventricular electrode 20 is and in order to prevent a reversion from ventricular pacing via ventricular electrode 20 to atrial pacing via atrial electrode 18, which might occur due to triggering of the sensing circuit 34 via a 'qrs' activation transmitted from ventricular electrode through switch 22, an additional blocking circuit could be inserted between sensing circuit 34 and switch 22, such that the switch 22 could only be activated from sensing circuit 34 once, although external programming by means of detector circuit 26 in Figures 1 and 2 could still effect further activation of switch 22.
  • these programmable output and input terminal pacemakers are intended primarily to allow the safe institution of atrial pacing .with the ability to change from atrial to ventricular pacing without the need for surgical intervention in the event of the problems outlined above associated with atrial pacing, these pacemakers may also have additional applications. They would for example allow the connection of the pacemaker by two electrodes tothe same part of the heart such as two ventricular electrodes, each electrode being conventional, allowing duplication of the electrode. This would be advantage because at the present time, when more long-lasting energy sources are being developed, it is the electrodes which have become the limiting feature of the pacemaker system; after a period of several years the electrodes are liable to fracture requiring surgical intervention even though the energy source has notbecome exhausted. Indeed it is common practice, when the electrodes are sutured to the outside of the heart by means of a major surgical procedure, to attach two electrodes, the second of which is normally 'capped' and left lying loose in the event of future need.
  • both electrodes could be attached and in the event of failure of one electrode from whatever cause, the second could be used without surgical intervention.
  • An alternative use would be for testing experiment al electrodes.
  • a variety of experimental and new electrodes is appearing at the present time and more are likely to be developed in the future. Although they are always teste first in the experimental animal, there is always an ethical problem with initial application in the human.
  • the use of programmahle output terminal pacemaker would allow ethically acceptable use of such an experimental electrode together with a conventional electrode, thus allowing change from experiment al to conventional electrode should the former fail from whatever cause.

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  • Health & Medical Sciences (AREA)
  • Heart & Thoracic Surgery (AREA)
  • Cardiology (AREA)
  • Life Sciences & Earth Sciences (AREA)
  • Biomedical Technology (AREA)
  • Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
  • Radiology & Medical Imaging (AREA)
  • Engineering & Computer Science (AREA)
  • Animal Behavior & Ethology (AREA)
  • General Health & Medical Sciences (AREA)
  • Public Health (AREA)
  • Veterinary Medicine (AREA)
  • Biophysics (AREA)
  • Physiology (AREA)
  • Neurosurgery (AREA)
  • Neurology (AREA)
  • Electrotherapy Devices (AREA)

Abstract

L'invention concerne un stimulateur cardiaque. On peut stimuler le coeur dans l'une des oreillettes ou dans l'un des ventricules et l'invention concerne l'implantation de deux electrodes (18, 20) (qui peuvent etre dans le meme emplacement) et l'utilisation de moyens (22 ou 30 et 32) Pour changer automatiquement ou a volonte l'electrode active. L'invention est applicable a la stimulation de coeurs qui n'ont pas un battement regulier.
PCT/GB1978/000007 1977-07-27 1978-07-25 Stimulateur cardiaque WO1979000070A1 (fr)

Applications Claiming Priority (2)

Application Number Priority Date Filing Date Title
GB31636/77 1977-07-27
GB3163677 1977-07-27

Publications (1)

Publication Number Publication Date
WO1979000070A1 true WO1979000070A1 (fr) 1979-02-22

Family

ID=10326126

Family Applications (1)

Application Number Title Priority Date Filing Date
PCT/GB1978/000007 WO1979000070A1 (fr) 1977-07-27 1978-07-25 Stimulateur cardiaque

Country Status (3)

Country Link
EP (1) EP0006878A1 (fr)
NL (1) NL7807920A (fr)
WO (1) WO1979000070A1 (fr)

Cited By (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
EP0064940A1 (fr) * 1981-05-04 1982-11-17 BIOTRONIK Mess- und Therapiegeräte GmbH & Co Ingenieurbüro Berlin Entraîneur cardiaque
EP0114679A2 (fr) * 1983-01-21 1984-08-01 Telectronics N.V. Stimulateur cardiaque avec circuit d'entrée/sortie programmable pour l'usage avec des électrodes unipolaires et bipolaires

Citations (7)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
GB1082752A (en) * 1964-05-06 1967-09-13 Yissum Res Dev Co Cardiac pacemaker
US3433228A (en) * 1966-05-06 1969-03-18 Cordis Corp Multimode cardiac pacer
US3595242A (en) * 1969-03-26 1971-07-27 American Optical Corp Atrial and ventricular demand pacer
US3805796A (en) * 1971-05-10 1974-04-23 Cordis Corp Implantable cardiac pacer having adjustable operating parameters
US3857399A (en) * 1970-03-24 1974-12-31 F Zacouto Heart pacer
FR2369836A1 (fr) * 1976-11-03 1978-06-02 Medtronic Inc Stimulateur implantable avec dispositif d'alarme
DE2701104A1 (de) * 1977-01-12 1978-07-13 Medtronic France S A Herzschrittmacher

Patent Citations (7)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
GB1082752A (en) * 1964-05-06 1967-09-13 Yissum Res Dev Co Cardiac pacemaker
US3433228A (en) * 1966-05-06 1969-03-18 Cordis Corp Multimode cardiac pacer
US3595242A (en) * 1969-03-26 1971-07-27 American Optical Corp Atrial and ventricular demand pacer
US3857399A (en) * 1970-03-24 1974-12-31 F Zacouto Heart pacer
US3805796A (en) * 1971-05-10 1974-04-23 Cordis Corp Implantable cardiac pacer having adjustable operating parameters
FR2369836A1 (fr) * 1976-11-03 1978-06-02 Medtronic Inc Stimulateur implantable avec dispositif d'alarme
DE2701104A1 (de) * 1977-01-12 1978-07-13 Medtronic France S A Herzschrittmacher

Cited By (3)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
EP0064940A1 (fr) * 1981-05-04 1982-11-17 BIOTRONIK Mess- und Therapiegeräte GmbH & Co Ingenieurbüro Berlin Entraîneur cardiaque
EP0114679A2 (fr) * 1983-01-21 1984-08-01 Telectronics N.V. Stimulateur cardiaque avec circuit d'entrée/sortie programmable pour l'usage avec des électrodes unipolaires et bipolaires
EP0114679A3 (en) * 1983-01-21 1984-08-22 Cordis Corporation Cardiac pacer having input/output circuit programmable for use with unipolar and bipolar pacer leads

Also Published As

Publication number Publication date
NL7807920A (nl) 1979-01-30
EP0006878A1 (fr) 1980-01-23

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