CHAPTER NO.

HUMAN HEART

1.1 HEART ANATOMY

It is composed of four chambers, two upper (the atria) and two lower (the ventricles).
It works as a pump to send oxygen-rich blood through all the parts of the body. A
human heart beats an average of 100,000 times per day. During that time, it pumps
more than 4,300 gallons of blood throughout the entire body.

Fig 1.1 Structure of Human Heart [2]

Right Ventricle: The lower right chamber of the heart. During the normal cardiac
cycle, the right ventricle receives deoxygenated blood as the right atrium contracts.
During this process the pulmonary valve is closed, allowing the right ventricle to fill.
Once both ventricles are full, they contract. As the right ventricle contracts, the
1

tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid
valve prevents blood from returning to the right atrium, and the opening of the
pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs
for oxygenation of the blood The right and left ventricles contract simultaneously;
however, because the right ventricle is thinner than the left, it produces a lower
pressure than the left when contracting. This lower pressure is sufficient to pump the
deoxygenated blood the short distance to the lungs.
Left Ventricle: The lower left chamber of the heart. During the normal cardiac cycle,
the left ventricle receives oxygenated blood through the mitral valve from the left
atrium as it contracts. At the same time, the aortic valve leading to the aorta is closed,
allowing the ventricle to fill with blood. Once both ventricles are full, they contract.
As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The
closure of the mitral valve prevents blood from returning to the left atrium, and the
opening of the aortic valve allows the blood to flow into the aorta and from there
throughout the body. The left and right ventricles contract simultaneously; however,
because the left ventricle is thicker than the right, it produces a higher pressure than
the right when contracting. This higher pressure is necessary to pump the oxygenated
blood throughout the body.
Right Atrium: The upper right chamber of the heart. During the normal cardiac
cycle, the right atrium receives deoxygenated blood from the body (blood from the
head and upper body arrives through the superior vena cava, while blood from the
legs and lower torso arrives through the inferior vena cava). Once both atria are full,
they contract, and the deoxygenated blood from the right atrium flows into the right
ventricle through the open tricuspid valve.
Left Atrium: The upper left chamber of the heart. During the normal cardiac cycle,
the left atrium receives oxygenated blood from the lungs through the pulmonary
veins. Once both atria are full, they contract, and the oxygenated blood from the left
atrium flows into the left ventricle through the open mitral valve.
Superior Vena Cava: One of the two main veins bringing deoxygenated blood from
the body to the heart. Veins from the head and upper body feed into the superior vena
cava, which empties into the right atrium of the heart.

Inferior Vena Cava: One of the two main veins bringing deoxygenated blood from
the body to the heart. Veins from the legs and lower torso feed into the inferior vena
cava, which empties into the right atrium of the heart.
Aorta: The central conduit from the heart to the body, the aorta carries oxygenated
blood from the left ventricle to the various parts of the body as the left ventricle
contracts. Because of the large pressure produced by the left ventricle, the aorta is the
largest single blood vessel in the body and is approximately the diameter of the
thumb. The aorta proceeds from the left ventricle of the heart through the chest and
through the abdomen and ends by dividing into the two common iliac arteries, which
continue to the legs.
Atrial septum: The wall between the two upper chambers (the right and left atrium)
of the heart.
Pulmonary trunk: A vessel that conveys deoxygenated blood from the right ventricle
of the heart to the right and left pulmonary arteries, which proceed to the lungs. When
the right ventricle contacts, the blood inside it is put under pressure and the tricuspid
valve between the right atrium and right ventricle closes. The only exit for blood from
the right ventricle is then through the pulmonary trunk. The arterial structure
stemming from the pulmonary trunk is the only place in the body where arteries
transport deoxygenated blood.
Pulmonary veins: The vessels that transport oxygenated blood from the lungs to the
left atrium. The pulmonary veins are the only veins to carry oxygenated blood.
Pulmonary Valve: One of the four one-way valves that keep blood moving properly
through the various chambers of the heart. The pulmonary valve separates the right
ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the
deoxygenated blood collected in the right ventricle to flow to the lungs. It closes as
the ventricles relax, preventing blood from returning to the heart.
Aortic Valve: One of the four one-way valves that keep blood moving properly
through the various chambers of the heart. The aortic valve, also called a semi-lunar
valve, separates the left ventricle from the aorta. As the ventricles contract, it opens to
allow the oxygenated blood collected in the left ventricle to flow throughout the body.
It closes as the ventricles relax, preventing blood from returning to the heart. Valves
3

on the hearts left side need to withstand much higher pressures than those on the right
side. Sometimes they can wear out and leak or become thick and stiff.
Mitral Value: One of the four one-way valves that keep blood moving properly
through the various chambers of the heart. The mitral valve separates the left atrium
from the left ventricle. It opens to allow the oxygenated blood collected in the left
atrium to flow into the left ventricle. It closes as the left ventricle contracts,
preventing blood from flowing backwards to the left atrium and thereby forcing it to
exit through the aortic valve into the aorta. The mitral valve has tiny cords attached to
the walls of the ventricles. This helps support the valves small flaps or leaflets.
Tricuspid Valve: One of the four one-way valves that keep blood moving properly
through the various chambers of the heart. Located between the right atrium and the
right ventricle, the tricuspid valve is the first valve that blood encounters as it enters
the heart. When open, it allows the deoxygenated blood collected in the right atrium
to flow into the right ventricle. It closes as the right ventricle contracts, preventing
blood from flowing backwards to the right atrium, thereby forcing it to exit through
the pulmonary valve into the pulmonary artery.
Atria: The two upper cardiac chambers that collect blood entering the heart and send
it to the ventricles. The right atrium receives blood from the superior vena cava and
inferior vena cava. The left atrium receives blood from the pulmonary veins. Unlike
the ventricles, the atria serve as collection chambers rather than as primary pumps, so
they are thinner and do not have valves at their inlets.
Ventricles: The two lower cardiac chambers that collect blood from the upper
chambers (atria) and pump it out of the heart. Because the ventricles pump blood
away from the heart, they have thicker walls than the atria so that they can withstand
the associated higher blood pressures. The right ventricle pumps oxygen-poor blood
through the pulmonary artery and to the lungs. The left ventricle pumps oxygen-rich
blood through the aorta and to the rest of the body.[6]
1.2 WORKING OF HEART
The heart's cycle begins when oxygen-poor blood from the body flows into the right
atrium. Next the blood flows through the right atrium into the right ventricle, which
serves as a pump that sends the blood to the lungs. Within the lungs, the blood
4

releases waste gases and picks up oxygen. This newly oxygen-rich blood returns from
the lungs to the left atrium through the pulmonary veins. Then the blood flows
through the left atrium into the left ventricle. Finally, the left ventricle pumps the
oxygen-rich blood out through the aorta and from there to all parts of the body. The
human body has about 5.6 liters

(6 quarts) of blood, all of which circulates through

the body three times every minute.[3]

1.3 SINOATRIAL NODE

Normal sinus rhythm is established by the sinoatrial (SA) node, the heart's pacemaker.
The SA node is a specialized grouping of cardiomyocytes in the upper and back walls
of the right atrium very close to the opening of the superior vena cava. The SA node
has the highest rate of depolarization. The atrioventricular (AV) node is a second
cluster of specialized myocardial conductive cells, located in the inferior portion of
the right atrium within the atrioventricular septum. The septum prevents the impulse
from spreading directly to the ventricles without passing through the AV node. There
is a critical pause before the AV node depolarizes and transmits the impulse to the
atrioventricular bundle. This delay in transmission is partially attributable to the small
diameter of the cells of the node, which slow the impulse. Also, conduction between
nodal cells is less efficient than between conducting cells.[3]

CHAPTER NO. 2
5

INTRODUCTION TO PACEMAKER

2.1 PACEMAKER
A pacemaker is a small device which is inserted into the chest of the patient and is
fitted with the heart in order to control heart rhythms. This device is designed to
detect the slow heart rate. Whenever slow heart rate is detected, it sends small
electrical signals to correct it. Not only in case of slow heart rate but even if the
heartbeat is too fast, it becomes very difficult for the the patient to survive. Both these
situations can be averted by the use of pacemakers . The problems that occur with the
rhythm of heartbeat are known as Arrhythmias. When the heartbeat is too fast, it is
called tachycardia and when it is too slow, it is called bradycardia. All these problems
can be solved using a small electronic device called pacemaker. A pacemaker is a
medical device that uses electrical impulses, delivered by electrodes contracting the
heart muscles, to regulate the beating of the heart.
The primary purpose of a pacemaker is to maintain an adequate heart rate, either
because the heart's natural pacemaker is not fast enough, or there is a block in
the heart's electrical conduction system. Modern pacemakers are externally
programmable and allow the cardiologist to select the optimum pacing modes for
individual patients. Some combine a pacemaker and defibrillator in a single
implantable device. Others have multiple

electrodes stimulating differing positions

within the heart to improve synchronisation of the lower chambers (ventricles) of the
heart.[1]

2.2 DEFIBRILLATORS
Defibrillation is

dysrhythmias, ventricular

common

treatment

fibrillation and

pulse

for

life-threatening cardiac

less ventricular

tachycardia.

Defibrillation consists of delivering a therapeutic dose of electrical energy to the heart

with a device called a defibrillator. This depolarizes a critical mass of the heart
muscle, terminates the dysrhythmia and allows normal sinus rhythm to be
reestablished by the body's natural pacemaker, in the sinoatrial node of the heart.
Defibrillators can be external, transvenous, or implanted (implantable cardioverter6

defibrillator), depending on the type of device used or needed. Some external units,
known as automated external defibrillators (AEDs), automate the diagnosis of
treatable rhythms, meaning that lay responders or bystanders are able to use them
successfully with little or no training at all.[7]
2.2.1 INTERFACE WITH THE PATIENT
The connection between the defibrillator and the patient consists of a pair of
electrodes, each provided with electrically conductive gel in order to ensure a good
connection and to minimize electrical resistance, also called chest impedance (despite
the DC discharge) which would burn the patient. Gel may be either wet (similar in
consistency to surgical lubricant) or solid (similar to gummi candy). Solid-gel is more
convenient, because there is no need to clean the used gel off of patient's skin after
defibrillation (the solid gel is easily lifted off of the patient). However, the use of
solid-gel presents a higher risk of burns during defibrillation, since wet-gel electrodes
more evenly conduct electricity into the body. Paddle electrodes, which were the first
type developed, come without gel, and must have the gel applied in a separate step.
Self-adhesive electrodes come prefitted with gel. There is a general division of
opinion over which type of electrode is superior in hospital settings; the American
Heart Association favors neither, and all modern manual defibrillators used in
hospitals allow for swift switching between self-adhesive pads and traditional
paddles. Each type of electrode has its merits and demerits, as discussed below.[7]
2.2.2 PADDLE ELECTRODES

Fig 2.1 A Pair of Defibrillator Paddles [7]

The most well-known type of electrode (widely depicted in films and television) is the
traditional metal paddle with an insulated (usually plastic) handle. This type must be
held in place on the patient's skin with approximately 25 lbs of force while a shock or
a series of shocks is delivered. Paddles offer a few advantages over self-adhesive
pads. Many hospitals in the United States continue the use of paddles, with disposable
gel pads attached in most cases, due to the inherent speed with which these electrodes
can be placed and used. This is critical during cardiac arrest, as each second of
nonperfusion

means

tissue

loss.

Modern

paddles

allow

for

monitoring

(electrocardiography), though in hospital situations, separate monitoring leads are

often already in place. Paddles are reusable, being cleaned after use and stored for the
next patient. Gel is therefore not preapplied, and must be added before these paddles
are used on the patient. Paddles are generally only found on manual external units.[7]

2.2.3 SELF-ADHESIVE ELECTRODES

Newer types of resuscitation electrodes are designed as an adhesive pad, which
includes either solid or wet gel. These are peeled off their backing and applied to the
patient's chest when deemed necessary, much the same as any other sticker. The
electrodes are then connected to a defibrillator, much as the paddles would be. If
defibrillation is required, the machine is charged, and the shock is delivered, without
any need to apply any additional gel or to retrieve and place any paddles. Most
adhesive electrodes are designed to be used not only for defibrillation, but also
for transcutaneous pacing and synchronized electrical cardioversion. These adhesive
pads are found on most automated and semi-automated units and are replacing
paddles entirely in non-hospital settings. In hospital, for cases where cardiac arrest is
likely to occur (but has not yet), self-adhesive pads may be placed prophylactically.
Pads also offer an advantage to the untrained user, and to medics working in the suboptimal conditions of the field. Pads do not require extra leads to be attached for
monitoring, and they do not require any force to be applied as the shock is delivered.
Thus, adhesive electrodes minimize the risk of the operator coming into physical (and
thus electrical) contact with the patient as the shock is delivered by allowing the
operator to be up to several feet away. (The risk of electrical shock to others remains
unchanged, as does that of shock due to operator misuse.) Self-adhesive electrodes are
8

single-use only. They may be used for multiple shocks in a single course of treatment,
but are replaced if (or in case) the patient recovers then reenters cardiac arrest.[7]
2.2.4 PLACEMENT OF ELECTRODES

Fig. 2.2 Placement of Electrodes For Defibrillation [7]

Resuscitation electrodes are placed according to one of two schemes. The anteriorposterior scheme is the preferred scheme for long-term electrode placement. One
electrode is placed over the left precordium (the lower part of the chest, in front of the
heart). The other electrode is placed on the back, behind the heart in the region
between the scapula. This placement is preferred because it is best for non-invasive
pacing. The anterior-apex scheme can be used when the anterior-posterior scheme is
inconvenient or unnecessary. In this scheme, the anterior electrode is placed on the
right, below the clavicle. The apex electrode is applied to the left side of the patient,
just below and to the left of the pectoral muscle. This scheme works well for
defibrillation and cardioversion, as well as for monitoring an ECG.

CHAPTER NO. 3

NEED OF PACEMAKER

As explained above in most of the cases, pacemakers are required to prevent the heart
rate of the patient from going too slow. But it can be helpful in the reverse case also.
i.e. correcting the heart rate that is going too fast. Another reason that requires the
pacemaker implantation is the heart block which can also be corrected using a
pacemaker. This disorder (Heart block) may occur as a result of aging or heart attack.
These disorders may prove to be extremely harmful for the patient and may take the
life of the patient within seconds if precautions are not taken. Mostly these disorders
happen because there is no cell in the heart that beats fast enough to maintain its
proper functioning. This is because there is a block somewhere in the electrical
pathway. This block doesnt allow the electrical activity to reach all the necessary
portions of the heart muscles.[1]

10

CHAPTER NO. 4

PACEMAKER WORKING

As we know pacemaker consists of battery, computerized generator, and wires with

electrodes. The battery powers the generator and wires connect the generator to the
heart. A pacemaker generator sends the electrical pulses to correct the heart rhythm. A
computer chip figures out what types of electrical pulses to send to the heart and when
those pulses are needed. To do this, the computer chip uses the information it receives
from the wires connected to the heart. It also may use information from sensors in the
wires that detect your movement, blood temperature, breathing, or other factors that
indicate your level of physical activity. In this way, it can make your heart beat faster
when you exercise. The computer chip also records your heart's electrical activity and
heart rhythms. Pacemakers have one to three wires that are each placed in different
chambers of the heart. The wires in a single-chamber pacemaker usually carry pulses
between the right ventricle (the lower right chamber of your heart) and the generator.
The wires in a dual-chamber pacemaker carry pulses between the right atrium and the
right ventricle and the generator. The pulses help coordinate the timing of these two
chambers contractions. The wires in a triple-chamber pacemaker are used for heart
muscle weakness and carry pulses between an atrium and both ventricles and the
generator. The pulses help coordinate the timing of the two ventricles with each other.
[1]

11

CHAPTER NO. 5

METHODS OF PACING

5.1 PERCUSSIVE PACING

Percussive pacing, also known as transthoracic mechanical pacing, is the use of the
closed fist, usually on the left lower edge of the sternum over the right ventricle in
the vena cava, striking from a distance of 20 30 cm to induce a ventricular beat
(the British Journal of Anaesthesia suggests this must be done to raise the ventricular
pressure to 1015 mmHg to induce electrical activity). This is an old procedure used
only as a life saving means until an electrical pacemaker is brought to the patient.
5.2 TRANSCUTANEOUS PACING
Transcutaneous pacing (TCP), also called external pacing, is recommended for the
initial stabilization of hemodynamically significant bradycardias of all types. The
procedure is performed by placing two pacing pads on the patient's chest, either in the
anterior/lateral position or the anterior/posterior position. The rescuer selects the
pacing rate, and gradually increases the pacing current (measured in mA) until
electrical capture (characterized by a wide QRS complex with a tall, broad T wave on
the ECG) is achieved, with a corresponding pulse.

Fig. 5.1 PQRST Complex [10]

12

Pacing artifact on the ECG and severe muscle twitching may make this determination
difficult. External pacing should not be relied upon for an extended period of time. It
is an emergency procedure that acts as a bridge until transvenous pacing or other
therapies can be applied.
5.3 EPICARDIAL PACING
Temporary epicardial pacing is used during open heart surgery becuase the surgical
procedure create atrio-ventricular block. The electrodes are placed in contact with the
outer wall of the ventricle (epicardium) to maintain satisfactory cardiac output until a
temporary transvenous electrode has been inserted.
5.4 TRANSVENOUS PACING
Transvenous pacing, when used for temporary pacing, is an alternative to
transcutaneous pacing. A pacemaker wire is placed into a vein, under sterile
conditions, and then passed into either the right atrium or right ventricle. The pacing
wire is then connected to an external pacemaker outside the body. Transvenous pacing
is often used as a bridge to permanent pacemaker placement. It can be kept in place
until a permanent pacemaker is implanted or until there is no longer a need for a
pacemaker and then it is removed.

5.5 SUBCLAVICULAR PACING

Permanent pacing with an implantable pacemaker involves transvenous placement of
one or more pacing electrodes within a chamber, or chambers, of the heart, while the
pacemaker is implanted inside the skin under the clavicle. The procedure is performed
by incision of a suitable vein into which the electrode lead is inserted and passed
along the vein, through the valve of the heart, until positioned in the chamber. The
procedure is facilitated by fluoroscopy which enables the physician to view the
passage of the electrode lead. After satisfactory lodgement of the electrode is
confirmed, the opposite end of the electrode lead is connected to the pacemaker
generator.[1]

13

CHAPTER NO. 6

TYPES OF PACEMAKER

6.1 INTERNAL PACEMAKER

Fig. 6.1 Internal Pacemaker [9]

Internal pacemaker implanted for permanent heart blocks. It is placed in left side of
chest. Leads are connected directly inside the right ventricle of heart. Lasts for 7 to 10
years depending on battery life. Internal pacemaker are those may be permanently
implanted in patients whose SA Nodes have failed to function properly or who suffer
from permanent heart blocks. An internal pacemaker is defined as one in which the
entire system is inside the body. Internal pacemaker systems are implanted with pulse
generator placed in surgical formed pocket below the right or left clavicle.

Fig. 6.2 Internal Pacemaker Position [8]

14

Internal leads connected to electrodes are directly contacted to the inside of the right
ventricle or surface of the myocardium. The exact location of the pulse generator
depends primarily on the type of electrode used, nature of cardiac disorder and the
method of pacing. As all the parts are in body so power must be self contained, with
the power source capable of continuously operating the unit for a period of years.
6.2 EXTERNAL PACEMAKER
It is temporary system recommended for irregular heartbeats. Its lies outside the
patients body. A small electrode is threaded through a vein into the heart. This
pacemaker consists of a pulse generator and appropriate electrodes. External
pacemaker usually consists of an externally worn pulse generator connected to
electrode located on or within the myocardium. External pacemaker are use on
patients with temporary heart irregularities, such as those encountered in the coronary
patient, including heart attacks.

Fig. 6.3 External Pacemaker [11]

15

CHAPTER NO. 7

FUTURE SCOPE

With the increase in number of senior citizens in the world, there will be a greater
percentage of population who require pacemakers, so the research continue to develop
the promising device which last long, more reliable and more versatile. Advances in
the battery such as using radio isotopes for power will improve the longevity of the
implanted pacemaker Developments in microelectronics will provide even for a
smaller one.

16

CHAPTER NO. 8

CONCLUSION

Cardiac pacing remains an important tool in the treatment of various cardiac

conditions. The general practitioner should understand the current indications,
limitations, and basic functions of pacemakers. Further technological advances and
results of ongoing clinical trials will further our understanding of cardiac
pathophysiology and extend the indications for evidence-based pacemaker therapy.
Thus electronics help us to change the life of those people who are suffering from the
heart problems and several other serious medical disorders. So pacemaker has been
the solution for the heart patients. Lets wish that the electronics helps the coming
generations to solve more problems.

17

CHAPTER NO. 9

REFERENCES

1)http://en.wikipedia.org/wiki/Artificial_cardiac_pacemaker
2)https://www.google.co.in/search?
q=human+heart&newwindow=1&source=lnms&tbm=isch&sa=X&ei=bDseVYGJI9L
JuASl_4DICA&ved=0CAcQ_AUoAQ&biw=1366&bih=667#imgdii=_&imgrc=4Qv
ZOpREdRHYZM%253A%3Bf-Cr2PCQDN4pdM%3Bhttp%253A%252F
%252Fdivi.gxrg.org%252Fandroid%252Fheart-diagram-quiz-i8.jpg%3Bhttp%253A
%252F%252Fimgkid.com%252Fhuman-heart-images-for-kids.shtml
%3B1171%3B1272
3) http://en.wikipedia.org/wiki/Heart
4)http://seminarprojects.com/Thread-artificial-pacemaker-fullreport#ixzz3WFNhSknk
5)http://www.nhlbi.nih.gov/health/health-topics/topics/pace/
6) http://www.nhs.uk/conditions/pacemakerimplantation/pages/introduction.aspx
7) http://en.wikipedia.org/wiki/Defibrillation
8) https://www.google.co.in/search?q=pacemaker+position
9) https://www.google.co.in/search?q=pacemaker&biw
10) http://www.cyberphysics.co.uk/topics/medical/heart/PQRST.html
11) https://www.google.co.in/search?q=external+pacemaker&biw

18