History of Pacing and Device Therapy

1
50th Anniversary of First Pacemaker
Implantation James C. Mullin, M.D. October 17th,
2008
2
Hippocrates (460 375 BC)
Those who suffer from frequent and strong faints
without any manifest cause die suddenly.
3
Galen Ancient Rome

• Ancient China (280 BC) Wang Shu-he wrote 10
  books about the pulse.
• The Greeks called the pulse sp and sphygmology
  deals with the theory of the pulse .
• Galen, in Roman times, interpreted the various
  types of pulses according to the science of the
  day each organ in each disease has its own
  unique form of pulse.

4
Animals with electricity
Used to treat madness, gout, arthritis
5
Geronimo Mercuriale and Syncope

• Recognized the relationship between a slow pulse
  and syncope
• Ubi pulsus sit rarus semper expectanda est
  syncope.

6
Sir William Harvey
He restarted an arrested pigeons heart by a
simple flick of the finger.
De Motu Cordis on the motion of the heart and
blood in animals - 1628
7
A Pulse Diagram by Valentini - 1713
8
Ben Franklin stayed dry under an overhang with
the kite string connected to a key to ground it
(1747).
Russian Professor Richards did not. First human
sacrifice to the science of electricity.
9
Electrical Therapy and the Heart

• 1640s Publications speculated about the
  bio-electric nature of the cardiovascular system.
• 1774 Squires made reference to the external
  stimulation of the heart in the Registers of the
  Royal Human Society. The patient was a young
  girl.
• 1775 Danish physicist Nickolev Abildgaard
  conducted the first studies on electrical energy
  on a living organism.
• Placed electrodes on either side of a chickens
  head and delivered energy the chicken dropped
  dead
• Then applied electrodes to different parts of the
  body
• When placed across the chest, the hen sat up and
  staggered away (presumably having been
  defibrillated)
• It is said that the hen then laid an egg (not
  proven)

10
Luigi Galvani (1737-1798)

• Electricity was inherent in all muscle tissue
• Studies were performed in frog hearts and
  skeletal muscle

11
Alexander von Humboldt - 1797

• Found a dead bird in his garden
• Placed a blade of zinc in the beak
• Placed a shaft of silver in the rectum
• Delivered an electric shock
• The bird flapped its wings and attempted to walk
• He experimented on himself with less than
  pleasant results.

12
Alessandro Volta (1745 1827)

• Demonstrated that electricity could be produced
  by two dissimilar metals

• The battery allowed electrical current to be
  produced by means other than electrostatic
  machines

13
Marie Francois Xavier Bichat (1701-1802)

• Experimented on decapitated humans
• Source French Revolution and the Guillotine
• Able to make hearts beat again using electric
  current

14
Aldini (1762 1834) - Reanimation

• Alleviation of cardiac syncope using galvanic
  energy studied in animals and cadavers

1804
15
Hugo von Ziemssen and Catherine Serafin

• Could apply electrical stimuli to the heart and
  change the heart rate

• Chest tumor excised
• A thin layer of skin closed the chest cavity over
  the heart

16
On-Off Stimulation of Catherines Heart

• Down arrows applied, Up arrows - withdrew

These are pulse wave recordings, not electrical
recordings
17
John Mac William

• In 1889, he described the application of
  electricity across the chest
• To excite rhythmic contraction (of the heart)
  which has been suddenly enfeebled or arrested in
  diastole by causes of a temporary or transient
  character
• First integrated theory of cardiac pacing but it
  would be a little more than half a century before
  there was effective therapy

18
Gerbezius-Morgagni-Adams-Stokes Syndrome
Gerbezius 1717 symptoms of bradycardia Morgagni
1761 causal relationship between slow pulse and
syncope Adams 1827 cerebral symptoms may be due
to heart rhythm disorder Stokes 1846
pseudo-epileptic loss of consciousness due to
slow pulse
Ventricular activity
Atrial activity
This was Arne Larssons indication for pacing
19
Wenckebach 2nd Degree AV block

• Described by Karel Frederick Wenckebach in 1899
  based on the physical exam
  
  
• The ECG as a clinical tool was not yet available

20
Augustus Desire Waller (1856-1922)

• Recorded the first surface electrocardiogram
  using the Lippman capillary electrometer to
  deflect a light beam.
• He learned that each beat of the heart gives an
  electric charge, beginning at one end of the
  organ and spreading to the other end.
• He believed that he could measure the
  electromotive properties of the heart from the
  surface of the body.

21
Wallers ECG
Left hand in H2SO4
(Sulfuric acid)
Right hand to Hg (Mercury)
22
Augustus Waller and Jimmy
I do not imagine that electrocardiography is
likely to find any very extensive use in the
hospital. It can on rare and occasional use to
afford a record of some rare anomaly of cardiac
action.
23
Willem Einthoven 1860 - 1927

• Father of Electrocardiography

Electrodes were salt water
24
Einthovens Electrocardiograph Machine
An entire lab was dedicated to the ECG (EKG)
25
The Electrocardiogram
Einthoven named the deflections starting high in
the alphabet as pulse wave recordings had labels
like a, c
26
First Temporary Pacemakers (Lidwell and Hyman)

• Mark Lidwell Australian anesthesiologist -1928
• Used alternating current
• Required a needle to be stuck into the ventricle
• This saved the life of a newborn in cardiac
  arrest
• Albert Hyman NY Cardiologist 1932
• Became interested in reviving the stopped heart
  by means of intracardial therapy (a mechanical
  stimulus, intracardiac needle with or without
  chemicals, electricity)
• Initially tried intracardiac injection of
  medications
• Then turned to electrical stimulation via a grant
  awarded in April 1930. Success in 43 cases by
  March 1932.
• Coined the term artificial pacemaker
• Powered by a spring-wound hand-crank motor
• Designed and built by his brother who was an
  engineer

27
Hand-operated Pacemaker by Albert Hyman
Hyman AS, Resuscitation of the stopped heart by
intracardiac therapy, Arch Int Med 1932 50
283-305
28
Hymans Artificial Pacemaker and needles
Hymanotor mfg by Adlanco, a U.S. division of
Siemens
29
Wilfred Bigelow and John Callaghan

• Hypothermia was used to reduce metabolic demand
  and produce asystole to permit cardiac surgery
• Re-warming was not sufficiently fast to restore a
  heart beat
• Started experimenting with sino-atrial node
  stimulation
• During an experiment on a dog in 1949, the heart
  stopped suddenly. Bigelow reports, Out of
  options and in desperation, I gave the left
  ventricle a good poke with a probe I was holding.
  All four chambers of the heart responded.
  Further pokes clearly indicated that the heart
  was beating normally with good blood pressure.

30
Grass Stimulator

• The principal devices available during the 1940s
  and 1950s
• Converted AC to DC
• Stimulation rate, voltage output, pulse width
  could be adjusted
• Utilized a monophasic rectangular pulse of 2 20
  ms in duration

31
John Hopps
Developed a temporary pacemaker utilizing vacuum
tubes while working for the National Research
Council of Canada. This was intended for atrial
pacing.
32
Paul Zoll Father of Modern Pacing
Non-Invasive Pacing
Pacing ON Pacing OFF
Pacing ON
Zoll, New Engl J Med 1952 247 768-771
33
Paul Zoll and the External Pacemaker
Intolerable pain associated with pacing in most
patients
Patients often had to be totally sedated to
tolerate pacing
34
Paul Zoll reminisces about Pacing

• The idea for electric stimulation to resuscitate
  the patients from cardiac arrest came to me
  during the War (WW II) when I observed Dwight
  Harken doing surgical removal of foreign bodies
  from the cardiac chambers and wall. I was
  impressed with the responsiveness of the heart to
  mechanical stimulation.
• It had also been known since Galvani that
  electrical currents applied to the heart can
  produce effective cardiac contractions.
• Therefore I thought it altogether too bad that
  patients with ventricular standstill should die
  for want of an appropriate stimulus to the heart.
• In 1950, I heard John Callaghan speak at a
  surgical meeting on stimulating the sino-atrial
  node but this would not help patients with AV
  block
• The high spot of the whole project was that
  stimulation across the two sides of the chest was
  as effective as the esophageal one.
• His first patient died after 20 minutes but
  autopsy revealed it was due to myocardial
  punctures from prior resuscitative attempts.

Initial attempts involved esophageal lead
35
C. Walton Lillehei 1919 - 1999

• Dr. Lillehei was a cardiac surgeon.
• Patients, following heart surgery, often had a
  slow heart rate.
• Worked with Earl Bakken, founder of Medtronic
• Designed a battery powered external pacemaker to
  be connected to wires inserted into or on the
  heart muscle at the time of open heart surgery
  (1957)

By mid-1958, the temporary pmkr had been used on
18 pts with 1 death
36
(No Transcript)
37
Seymour Furman

• Developed the temporary transvenous ventricular
  lead as a surgical resident (1958).
• The temporary pacemaker that he used was
  line-powered and needed to be wheeled on a cart.
• The patient could ambulate as far as the
  electrical power cord would allow.
• Made innumerable contributions to the art and
  science of pacing
• He felt strongly about sharing his ideas in the
  public domain (publishing) and was opposed to
  patents.

Pacing was maintained for 96 days
38
2006
39
Arne Larsson (1915 2001)

• At the age of 43, he was admitted to the
  Karolinska Hospital with recurrent fainting
  spells upwards of 30/day associated with
  Stokes Adams attacks.
• He had been in the hospital for months when his
  wife heard about work being done by Dr. Ake
  Senning and Dr. Rune Elmqvist on pacemakers.
• His wife Else contacted Dr. Ake Senning and
  pleaded with him to make a pacemaker for her
  husband.
• Drs. Senning and Elmqvist knew the problems with
  an external device so felt that it should be
  internal as Arnes condition was not temporary
  and would require chronic therapy.
• They placed the circuitry in a Kiwi shoe polish
  can and back-filled it with medical grade epoxy
  (Araldite).

40
Arne Larsson October 8, 1958

• Dr. Elmqvist made two pacemakers.
• Dr. Senning did not realize (nor did anyone) that
  electrocautery could damage the transistors (of
  which there were two).
• In that the need for pacing was intermittent,
  three hours after the first surgery, Mr. Larsson
  had another spell and the pacemaker was
  non-functional.
• Although not on the same calendar day but within
  the first 24 hour period, Mr. Larsson also
  received the worlds second fully implanted
  pacemaker.

41
Arne Larsson
22 pacemakers 26 procedures (some to
replace/revise the pacing lead) He became an
ambassador for this nascent device industry. He
died from a malignancy some 43 years after his
original implant.
42
1998 40th Anniversary of Pacing
Arne Dr. Senning
Dr. Elmqvist
43
Comments from Arne Larsson on the 40th
Anniversary of Implantable Cardiac Pacing

• Because of my rhythm disorder, I fainted very
  often. At home, in my office and in the streets.
  In 1958 my condition was so bad that my wife was
  told that there was nothing more the doctors
  could do for me.
• The best medicine was in fact whiskey, and I can
  assure you that it was a sight when the nurse
  entered my room in the morning with a whisky
  bottle and a glass on the tray, to the envy of my
  room mates
• Today (1998), you dont think of a pacemaker
  implantation as something sensation. You do
  agree, dont you.
• Well, ladies and gentlemen, then you are all
  wrong. It is a sensation for the patient.

44
Wilson Greatbatch

• Worked with Earl Bakken on the early design of
  the permanent pacemakers
• Chardack-Greatbatch pacemaker mfg by Medtronic
• Founded a company in Clarence, NY, providing
  batteries to most of the pacemaker manufacturers
• Has developed many of the components used in
  pacemakers today

45
Chardack, Surgery 1960 48
46
Some early manufacturers
American Optical
General Electric
Cordis
47
Increasing complexity discrete components
48
Increasing Complexity Improved Batteries
Cordwood Construction
Discrete Components
Hermetically sealed components
Integrated Circuits
49
1958 to 2008 Side-by Side comparison
50
1958 to 2008 - Implant
Open thoracotomy
Leads inserted through vein General anesthesia
Local anesthesia /
sedation 3 to 4 hours
1 to 2 hours Weeks in hospital
Same day discharge
51
1958 to 2008 Size and Components
38 cc, 83 grams
12 cc, 29 grams 24 cm2, 16 mm thick
19 cm2, 6.0 mm thick 2
transistors
20,000,000 transistors Longevity lt 1 yr
Up to 20 years, at
least 5 yr
52
1958 to 2008 - Options
Modes of operation 1 (preset) Over
20 Rates 1 (preset)
30 to 180 pulses/min Rate Response None
Tailored to
patient Parameter combinations 1
Trillions
53
Programmable options
Trillions of potential combinations
54
Milestones in Cardiac Pacing

• The asynchronous fixed-rate pacemaker
• Demand function
• Programmability
• Dual Chamber Pacing
• Rate modulation and automatic adjustment of
  pacemaker parameters to optimize device function
• Internal diagnostics
• Multisite pacing for management of arrhythmias
  and heart failure
• Ability to download acquired data internal to the
  pacemaker from home by telephone or modem

What is the most important advance?
55
Impact and Goals of Pacing Therapy
Normal
1958 VOO
Goal Restore the abnormal cardiac rhythm as
close to normal as possible!
Dead
1958
2008
56
Thank You
Painted Lady 29 August 2008