25th September 2012
life in the slow lane :
bradycardia – past history
Chris Plummer
history of bradycardia pacing
basic principles
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electrical activity of the heart
stimulation of the heart
external pacing
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high voltage
battery technology
internal pacing
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thoracotomy
trans-venous
current technology.
basic principles
Alessandro Volta
1745-1827
basic principles
Luigi Galvani
1791
basic principles
Marie Francois Bichat (1701 - 1802)
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experiments on decapitated humans
...no shortage of experimental material
during the French Revolution...
various experiments
electricical stimulation of hearts.
basic principles
Hugo von Ziemssen (1829 - 1902)
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German professor of pathology: Erlangen
cold-water treatment for typhoid fever
diseases of larynx & digestive tract
experimented with electrotherapeutics
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application of strong solutions of antiseptics and
other compounds locally to treat disease
sponge
exchange of ions by electrolysis.
basic principles
Catharina Serafin (1879)
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46-year-old woman from Prussia
left chest wall tumour excised
went to Von Ziemssen for wound healing
electrotherapeutics...
...changes in heart rate with electrical
stimulation...
basic principles
John MacWilliam (1857-1937)
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studied in Leipzig under Carl Ludwig
1889: application of electricity across the
chest to “excite rhythmic contraction”
“to stimulate by direct means the action
of the heart which has been suddenly
enfeebled or arrested in diastole by
causes of a temporary or transient
character”.
the need for pacing
sudden death in hospital
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chloroform anaesthesia
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VF or asystole
increasing use of domestic electricity
children
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still-born infants
cardiac surgery
(10% mortality after VSD closure from heart block).
invasive pacing
Mark C Lidwill (1878-1969)
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anaesthetist Crown St. Women's
Hospital in Sydney
resuscitation of stillborn infants
unipolar system - needle electrode
inserted into the heart, indifferent plate
electrode soaked in concentrated saline
solution on the skin – 16V
pulsed ventricular stimulation for 10 min
1929 first human successful pacing
no records or photographs...
invasive pacing
Albert Hyman (1893-1972)
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cardiologist in New York
management of the "stopped heart"
advocated "intracardial therapy“
injection of stimulants to the atria &
ventricles
...“irritable point from which a wave of excitation
may arise normally and sweep over the heart
along its accustomed pathways... In other words,
the artificial pacemaker produces the same effect
as that previously discussed in regard to the
mechanical prick of an injecting needle"
invasive pacing
the “Hymanotor”
external pacing
Paul Zoll (1911-1999)
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cardiac surgeon in Boston
first transthoracic pacing 1952
2ms pulses of 100-150V across the
chest, at 60 stimuli per minute
external pacing
Paul Zoll (1911-1999)
transvenous pacing
John Bardeen, William Shockley and
Walter Brattain (1947)
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two gold point contacts were applied to a
crystal of germanium, a signal was
produced with the output power greater
than the input
first silicon transistor was produced
by Texas Instruments in 1954.
transvenous pacing
Clarence Walton Lillehei (1918-1999)
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professor of surgery Minnesota University
“father of open heart surgery”
epicardial then transvenous pacing first
use of a small, external, portable, batterypowered pacemaker
invented by Earl Bakken, whose small
company (Medtronic) designed and
repaired electronics for the University of
Minnesota hospital.
transvenous pacing
Earl E. Bakken (1918-1999)
implantable epicardial pacing
Arne Larsson (1915-2001)
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1958 diagnosed with a fatal disease
CHB with Stokes-Adams attacks
Mrs Larsson would not accept her
husband’s death
she persuaded Åke Senning & Rune
Elmqvist, to implant, the first human
pacemaker on 8th October 1958
Arne Larsson died at the age of 86 on
28th December 2001, 43 years, 22
pacemakers and 5 electrode systems
later, from an unrelated malignancy.
implantable epicardial pacing
Wilson Greatbatch (1919-2001)
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electrical engineer
pioneer of battery technology
Chardack-Greatbatch pacemaker used
Mallory mercuric oxide-zinc cells
(mercury battery)
two transistor, transformer
coupled blocking oscillator circuit
encapsulated in epoxy resin.
timeline – 1960s
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epicardial → transvenous leads
thoracotomy + GA→ percutaneous + LA
“demand" pacemakers.
timeline – 1970s
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"tined” passive fixation and "screw-in" for active fixation
mercury oxide-zinc battery → lithium-iodine → nuclear (!)
titanium case
Cordis Omni: first externally programmable pacemaker.
timeline – 1980s
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rate-modulation (A. Rickards 1982)
rate response hemodynamic sensor (R. Chirife 1988).
steroid-eluting leads
ICD technology (Mirowski & Mower).
timeline – 1990s
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microprocessor technology
detection and storage of events
multiple algorithms → automaticity
size reduction.
conclusions
conclusions
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rapid progress over 50 years
many technical challenges
many new innovations
challenge to deliver appropriate
treatment to all.