1. History and Overview of Cardiac
Implantable Electronic Devices
成大醫院心導管室
放射師 王亦聖

2. Contents




Brief of cardiac pacing
Overview of battery and generator
Lead technology
Pacemaker Mode and NBG code

3. ECG history

4. Cardiac Pacing

5. History of Pacemaker
Arne Larsson
1958, Siemens-Elema
In 1994 Siemens sold its entire pacemaker business to the
American company St. Jude Medical

6. History of Pacemaker

7. Indications and CIED Products

8. Pacemaker

9. Modern Pacemaker
Fully programmable dual chamber pacing
Rate response to activity and metabolic changes
Telemetry of pacer function
Incorporated algorithms to respond to change in
intrinsic rhythms
 Store patients arrhythmic events





10. Pacing System
+

11. Pacemaker Components
Connector
Electric
component
Battery

12. Battery Technology
Mercury-Zinc
Battery

13. Battery Technology
Li-I battery Lithium Battery
[V]
Lithiumiodine
3,0
30 µA
2,0
1.8 V
Phase 1
Phase 2
Phase 3
1,0
0
1
2
3
4
[Ah]

14. Pacing Lead
 Unipolar
•
•
•
•
•
 Bipolar
Large spike
More sensitive to interference
Pectoral muscle stimulation
More susceptible to EMI
Smaller lead diameter
• Small spike
• More sensitive to intrinsic
cardiac signals
• No myopotential inhibition
• EMI protected
• Less crosstalk
Anode
“+”
Unipolar
Anode
“+”
Cathod
“-”
Cathod
“-”
Bipolar

15. Pacing Lead
 Passive lead
 Tined lead
 Active lead
 Screwed lead

16. Steroid Delivery
 MCRD steroid
 (Monolithic Controlled Release Delivery)
 < 1 mg Dexamethasone
Sodium Phosphate
mplitude (Volt)
3.5
3.0
2.5
 
2.0   
1.5
1.0 




0.5


0 4 8 12 16 20


With steroid


52
Weeks

17. Myocardial and Epicardial Leads
 Leads applied directly to the
heart
 Fixation mechanisms include:
 Epicardial stab-in
 Myocardial screw-in
 Suture-on

18. Fundamentals of Electricity
 Ohm’s Law
6V
I=6/3=2A
U=IXR
U = Voltage (Volt, V)
I = Current (Ampere, A)
R = Resistance ( Ohm, Ω)
3Ω
12 V
6Ω
I = 12 / 6 = 2 A

19. Pacing Impedance
Insulation Defect
<250 Ohm
Normal Pacing
Impedance
300 Ohm~1500
Ohm
Lead fracture
>1500 Ohm

20. Battery Capacity and Longevity

21. How pacemaker works
 Pacing : Amplitude (V), Pulse width (ms)
Pulse Amplitude (V)
Capture
Noncapture
Pulse Width (ms)

22. How Pacemaker Works
 Sensing- Choosing sensitivity
Sensitivity
10.0 mV
Sensitivity
5.0 mV
Sensitivity 1.0 mV
23

23. Considerations in Sensitivity Programming
 To make the device more sensitive (to pick up signals it
might be missing), lower the mV setting
 To make the device less sensitive (to avoid detecting noncardiac signals), increase the mV setting
 Sensitivity should
 Pick up low-amplitude cardiac signals
 Avoid very low-amplitude non-cardiac signals
24

24. NBG Code
I
II
III
IV
V
Chamber(s)
Paced
Chamber(s)
Sensed
Response to
Sensing
Rate
Modulation
Multisite
Pacing
O = None
A = Atrium
V = Ventricle
D = Dual (A +
O = None
A = Atrium
V = Ventricle
D = Dual (A +
O = None
T = Triggered
I = Inhibited
D = Dual (T +
O = None
R = Rate
O = None
A = Atrium
V = Ventricle
D = Dual (A +
V)
V)
modulation
I)
NASPE/BPEG Generic
NASPE is the North American Society of Pacing and Electrophysiology
BPEG is the British Pacing and Electrophysiology Group
V)

25. Mode Selection Considerations
 Status of Atrial Rhythm
 Intrinsic
 Presence of Atrial
Tachyarrhythmias:
 Acute/Chronic
 Status of AV Conduction
 Normal Slowed Blocked
 Presence of Chronotropic
Incompetence
26
Single Chamber ?
Dual Chamber ?
Rate Modulation?

27. ICD

28. History of the AICD
Milestones
 1969 - Dr. Mirowski and Dr. Morton Mower
begin collaborating and develop the first
experimental model

29. History of AICD Therapy
Milestones
 1975 - The first device is implanted and tested in an
animal
 1980 - The first patient is implanted with an AICD
device

30. Whats Inside an ICD?

31. ICD Leads-DF1 and IS-1
Two DF-1, One IS-1
IS-1 (Pace/ Sense)
DF-1 (Shock)

32. DF4 Development History
 Project began in 2004
 First submissions September 2007
35

33. Dual Coil Lead
Proximal
Shock
Electrode
Distal
Shock
Electrode
Single Coil Lead

34. Dual coil v.s. Single coil
Dual Coil
Single Coil
Advantange
Lower DFT
May easier to
remove
Disadvantage
Difficult to
remove
Higher DFT

35. ICD Modules
Electrogram and Data Storage
Special Functions
no sr eve R
i
y par e hT
not ac fi ssa C
i i
l
Measurements
gn s ne S
i
Induction

36. Therapy
High Voltage shock
 Uses of High Voltage Therapy
 To terminate:
 Ventricular Tachycardia
 Ventricular Fibrillation
Ph
ase
1
se
Pha
2
Thanks, I needed that!

37. Therapy
Anti-tachycardia pacing (ATP)

38. Detection - Fixed Gain/ Sensitivity
NSR
PVT

39. Automatic Sensitivity Control (ASC)
Automatic Sensitivity Tracking
GAIN
From Sense/Pace
Leads
FILTER
Threshold adjusts
+ and - to adapt
to the signal
THRESHOLD
COMP
Sensed Event

40. Defib with slow VT and Fast VT
No therapy
Non-Treatment
SVT discrimination, VT
therapy deliver when VT
indicated
VF therapy
deliver
Treatment
Treatment
Treatment
Tach A
(Slow VT)
Tach B
(Fast VT)
(ATP and
CV Shocks)
(ATP and
CV Shocks)
500 ms
(120 bpm)
375 ms
(160 bpm)
Sinus
>500 ms
(<120 bpm)
Fib
(Shock)
300 ms
(200 bpm)

41. CRT (Cardiac Resynchronization
Therapy)

42. Ventricular Resynchronization with CRT
Pacing @ left lateral free wall in addition
to right side
Symmetric lateral and septal wall
conduction & contraction
More efficient pump
46

43. Optimal LV Lead Placement
Coronary Sinus
approach
Right Atrial
Lead
Left Lateral Free wall
LV Lead
Right Ventricular Lead
47

44. Venograms and LV Lead Placement
Anterior
Right
Lateral
Basal
Posterior
Align to CS
OS/ Middle
Vein
Mid
LAO
AP
Apical
RAO

45. Final LV Lead Position

46. Final LV Lead Position

47. Thanks for your
attention