U.S. patent application number 10/011506 was filed with the patent office on 2002-08-08 for current waveform for anti-bradycardia pacing for a subcutaneous implantable cardioverter-defibrillator.
This patent application is currently assigned to Cameron Health, Inc.. Invention is credited to Mezack, Gary R., Ostroff, Alan H., Rissman, William J..
Application Number | 20020107544 10/011506 |
Document ID | / |
Family ID | 21750682 |
Filed Date | 2002-08-08 |
United States Patent
Application |
20020107544 |
Kind Code |
A1 |
Ostroff, Alan H. ; et
al. |
August 8, 2002 |
Current waveform for anti-bradycardia pacing for a subcutaneous
implantable cardioverter-defibrillator
Abstract
A power supply for an implantable cardioverter-defibrillator for
subcutaneous positioning between the third rib and the twelfth rib
and using a lead system that does not directly contact a patient's
heart or reside in the intrathorasic blood vessels and for
providing anti-bradycardia pacing energy to the heart, comprising a
capacitor subsystem for storing the anti-bradycardia pacing energy
for delivery to the patient's heart; and a battery subsystem
electrically coupled to the capacitor subsystem for providing the
anti-bradycardia pacing energy to the capacitor subsystem.
Inventors: |
Ostroff, Alan H.; (San
Clemente, CA) ; Rissman, William J.; (Coto de Caza,
CA) ; Mezack, Gary R.; (Norco, CA) |
Correspondence
Address: |
Jonathan L. Pettit
Brobeck, Phleger & Harrison LLP
12390 El Camino Real
San Diego
CA
92130-2081
US
|
Assignee: |
Cameron Health, Inc.
|
Family ID: |
21750682 |
Appl. No.: |
10/011506 |
Filed: |
November 5, 2001 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10011506 |
Nov 5, 2001 |
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09663607 |
Sep 18, 2000 |
|
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10011506 |
Nov 5, 2001 |
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09663606 |
Sep 18, 2000 |
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Current U.S.
Class: |
607/4 |
Current CPC
Class: |
A61N 1/3975 20130101;
A61N 1/3956 20130101; A61N 1/3968 20130101; A61N 1/3756 20130101;
A61N 1/375 20130101; A61N 1/39622 20170801; A61N 1/3906
20130101 |
Class at
Publication: |
607/4 |
International
Class: |
A61N 001/39 |
Claims
What is claimed is:
1. A power supply for an implantable cardioverter-defibrillator for
subcutaneous positioning between the third rib and the twelfth rib
and using a lead system that does not directly contact a patient's
heart or reside in the intrathorasic blood vessels and for
providing anti-bradycardia pacing energy to the heart, the power
supply comprising: a capacitor subsystem for storing the
anti-bradycardia pacing energy for delivery to the patient's heart;
and a battery subsystem electrically coupled to the capacitor
subsystem for providing the anti-bradycardia pacing energy to the
capacitor subsystem.
2. The power supply of claim 1, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately one milliamp to approximately 250 milliamps.
3. The power supply of claim 2, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately one milliamp to approximately 50 milliamps.
4. The power supply of claim 2, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately 50 milliamps to approximately 100 milliamps.
5. The power supply of claim 2, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately 100 milliamps to approximately 150 milliamps.
6. The power supply of claim 2, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately 150 milliamps to approximately 200 milliamps.
7. The power supply of claim 2, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately 200 milliamps to approximately 250 milliamps.
8. The power supply of claim 1, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 1 millisecond to approximately 40 milliseconds.
9. The power supply of claim 8, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 1 millisecond to approximately 10 milliseconds.
10. The power supply of claim 8 wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 10 milliseconds to approximately 20 milliseconds.
11. The power supply of claim 8 wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 20 milliseconds to approximately 30 milliseconds.
12. The power supply of claim 8 wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 30 milliseconds to approximately 40 milliseconds.
13. The power supply of claim 1, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform further comprising a
portion that is positive in polarity and a portion that is negative
in polarity.
14. The power supply of claim 1, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform that is provided at a
rate of approximately 20 to approximately 120 stimuli/minute.
15. The power supply of claim 25, wherein the biphasic waveform is
provided after a patient's heart rate is greater than or equal to
approximately 20 beats/minute.
16. The power supply of claim 1, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately one milliamp to approximately 250
milliamps.
17. The power supply of claim 16, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately one milliamp to approximately 50
milliamps.
18. The power supply of claim 16, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately 50 milliamps to approximately 100
milliamps.
19. The power supply of claim 16, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately 100 milliamps to approximately 150
milliamps.
20. The power supply of claim 16, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately 150 milliamps to approximately 200
milliamps.
21. The power supply of claim 16, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately 200 milliamps to approximately 250
milliamps.
22. The power supply of claim 1, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 1 millisecond to approximately 40
milliseconds.
23. The power supply of claim 22, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 1 millisecond to approximately 10
milliseconds.
24. The power supply of claim 22, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 10 milliseconds to approximately 20
milliseconds.
25. The power supply of claim 22, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 20 milliseconds to approximately 30
milliseconds.
26. The power supply of claim 22, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 30 milliseconds to approximately 40
milliseconds.
27. The power supply of claim 1, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform that is either
positive or negative in polarity.
28. The power supply of claim 1, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform that is provided at a
rate of approximately 20 to approximately 120 stimuli/minute.
29. The power supply of claim 28, wherein the monophasic waveform
is provided after a patient's heart rate is greater than or equal
to approximately 20 beats/minute.
30. Current output system for an implantable
cardioverter-defibrillator using a lead system that does not
directly contact a patient's heart or reside in the intrathorasic
blood vessels and for providing anti-bradycardia pacing energy to
the heart, the power supply comprising: an energy storage system
for storing the anti-bradycardia pacing energy for delivery to the
patient's heart; and an energy source system electrically coupled
to the capacitor subsystem for providing the anti-bradycardia
pacing energy to the capacitor subsystem.
31. Current output system of claim 30, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a peak current
that is approximately one milliamp to approximately 250
milliamps.
32. Current output system of claim 31, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a peak current
that is approximately one milliamp to approximately 50
milliamps.
33. Current output system of claim 31, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a peak current
that is approximately 50 milliamps to approximately 100
milliamps.
34. Current output system of claim 31, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a peak current
that is approximately 100 milliamps to approximately 150
milliamps.
35. Current output system of claim 31, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a peak current
that is approximately 150 milliamps to approximately 200
milliamps.
36. Current output system of claim 31, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a peak current
that is approximately 200 milliamps to approximately 250
milliamps.
37. Current output system of claim 30, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a pulse width
that is approximately 1 millisecond to approximately 40
milliseconds.
38. Current output system of claim 37, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a pulse width
that is approximately 1 millisecond to approximately 10
milliseconds.
39. Current output system of claim 37, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a pulse width
that is approximately 10 milliseconds to approximately 20
milliseconds.
40. Current output system of claim 37, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a pulse width
that is approximately 20 milliseconds to approximately 30
milliseconds.
41. Current output system of claim 37, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform having a pulse width
that is approximately 30 milliseconds to approximately 40
milliseconds.
42. Current output system of claim 30, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform further comprising a
positive voltage portion and a negative voltage portion.
43. Current output system of claim 30, wherein the anti-bradycardia
pacing energy comprises a biphasic waveform that is provided at a
rate of approximately 20 to approximately 120 stimuli/minute.
44. Current output system of claim 43, wherein the biphasic
waveform is provided after a patient's heart rate is greater than
or equal to approximately 20 beats/minute.
45. Current output system of claim 30, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately one milliamp to approximately 250
milliamps.
46. Current output system of claim 45, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately one milliamp to approximately 50
milliamps.
47. Current output system of claim 45, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately 50 milliamps to approximately 100
milliamps.
48. Current output system of claim 45, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately 100 milliamps to approximately 150
milliamps.
49. Current output system of claim 45, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately 150 milliamps to approximately 200
milliamps.
50. Current output system of claim 45, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a peak current
that is approximately 200 milliamps to approximately 250
milliamps.
51. Current output system of claim 30, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 1 millisecond to approximately 40
milliseconds.
52. Current output system of claim 51, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 1 millisecond to approximately 10
milliseconds.
53. Current output system of claim 51, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 10 milliseconds to approximately 20
milliseconds.
54. Current output system of claim 51, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 20 milliseconds to approximately 30
milliseconds.
55. Current output system of claim 51, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform having a pulse width
that is approximately 30 milliseconds to approximately 40
milliseconds.
56. Current output system of claim 30, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform that is either
positive or negative in polarity.
57. Current output system of claim 30, wherein the anti-bradycardia
pacing energy comprises a monophasic waveform that is provided at a
rate of approximately 20 to approximately 120 stimuli/minute.
58. Current output system of claim 57, wherein the monophasic
waveform is provided after a patient's heart rate is greater than
or equal to approximately 20 beats/minute.
59. An implantable cardioverter-defibrillator for subcutaneous
positioning between the third rib and the twelfth rib within a
patient, the implantable cardioverter-defibrillator comprising: a
housing having an electrically conductive surface on an outer
surface of the housing; a lead assembly electrically coupled to the
housing and having an electrode, wherein the lead assembly does not
directly contact the patient's heart or reside in the intrathorasic
blood vessels; a capacitor subsystem located within the housing and
electrically coupled to the electrically conductive surface and the
electrode for storing anti-bradycardia pacing energy and for
delivering the anti-bradycardia pacing energy to the patient's
heart through the electrically conductive surface and the
electrode; and a battery subsystem electrically coupled to the
capacitor subsystem for providing the anti-bradycardia pacing
energy to the capacitor subsystem.
60. The implantable cardioverter-defibrillator of claim 59, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a peak current that is approximately one milliamp to
approximately 250 milliamps.
61. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a peak current that is approximately one milliamp to
approximately 50 milliamps.
62. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a peak current that is approximately 50 milliamps to
approximately 100 milliamps.
63. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a peak current that is approximately 100 milliamps to
approximately 150 milliamps.
64. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a peak current that is approximately 150 milliamps to
approximately 200 milliamps.
65. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a peak current that is approximately 200 milliamps to
approximately 250 milliamps.
66. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a pulse width that is approximately 1 millisecond to
approximately 40 milliseconds.
67. The implantable cardioverter-defibrillator of claim 66, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a pulse width that is approximately 1 millisecond to
approximately 10 milliseconds.
68. The implantable cardioverter-defibrillator of claim 66, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a pulse width that is approximately 10 milliseconds to
approximately 20 milliseconds.
69. The implantable cardioverter-defibrillator of claim 66, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a pulse width that is approximately 20 milliseconds to
approximately 30 milliseconds.
70. The implantable cardioverter-defibrillator of claim 66, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
having a pulse width that is approximately 30 milliseconds to
approximately 40 milliseconds.
71. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
further comprising a portion that is positive in polarity and a
portion that is negative in polarity.
72. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a biphasic waveform
that is provided at a rate of approximately 20 to approximately 120
stimuli/minute.
73. The implantable cardioverter-defibrillator of claim 72, wherein
the biphasic waveform is provided after a patient's heart rate is
greater than or equal to approximately 20 beats/minute.
74. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a peak current that is approximately one milliamp to
approximately 250 milliamps.
75. The implantable cardioverter-defibrillator of claim 74, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a peak current that is approximately one milliamp to
approximately 50 milliamps.
76. The implantable cardioverter-defibrillator of claim 74, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a peak current that is approximately 50 milliamps to
approximately 100 milliamps.
77. The implantable cardioverter-defibrillator of claim 74, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a peak current that is approximately 100 milliamps to
approximately 150 milliamps.
78. The implantable cardioverter-defibrillator of claim 74, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a peak current that is approximately 150 milliamps to
approximately 200 milliamps.
79. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a peak current that is approximately 200 milliamps to
approximately 250 milliamps.
80. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a pulse width that is approximately 1 millisecond to
approximately 40 milliseconds.
81. The implantable cardioverter-defibrillator of claim 80, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a pulse width that is approximately 1 millisecond to
approximately 10 milliseconds.
82. The implantable cardioverter-defibrillator of claim 80, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a pulse width that is approximately 10 milliseconds to
approximately 20 milliseconds.
83. The implantable cardioverter-defibrillator of claim 80, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a pulse width that is approximately 20 milliseconds to
approximately 30 milliseconds.
84. The implantable cardioverter-defibrillator of claim 80, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
having a pulse width that is approximately 30 milliseconds to
approximately 40 milliseconds.
85. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
that is either positive or negative in polarity.
86. The implantable cardioverter-defibrillator of claim 60, wherein
the anti-bradycardia pacing energy comprises a monophasic waveform
that is provided at a rate of approximately 20 to approximately 120
stimuli/minute.
87. The implantable cardioverter-defibrillator of claim 86, wherein
the monophasic waveform is provided after a patient's heart rate is
greater than or equal to approximately 20 beats/minute.
88. A method for supplying power for an implantable
cardioverter-defibrillator for subcutaneous positioning between the
third rib and the twelfth rib and using a lead system that does not
directly contact a patient's heart or reside in the intrathorasic
blood vessels and for providing anti-bradycardia pacing energy to
the heart, the method comprising: generating anti-bradycardia
pacing energy; storing the anti-bradycardia pacing energy; and
delivering the anti-bradycardia pacing energy to the patient's
heart.
89. The method of claim 88, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately one milliamp to approximately 250 milliamps.
90. The method of claim 89, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately one milliamp to approximately 50 milliamps.
91. The method of claim 89, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately 50 milliamps to approximately 100 milliamps.
92. The method of claim 89, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately 100 milliamps to approximately 150 milliamps.
93. The method of claim 89, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately 150 milliamps to approximately 200 milliamps.
94. The method of claim 89, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a peak current that is
approximately 200 milliamps to approximately 250 milliamps.
95. The method of claim 88, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 1 millisecond to approximately 40 milliseconds.
96. The method of claim 95, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 1 millisecond to approximately 10 milliseconds.
97. The method of claim 95, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 10 milliseconds to approximately 20 milliseconds.
98. The method of claim 95, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 20 milliseconds to approximately 30 milliseconds.
99. The method of claim 95, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform having a pulse width that is
approximately 30 milliseconds to approximately 40 milliseconds.
100. The method of claim 88, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform further comprising a portion
that is positive in polarity and a portion that is negative in
polarity.
101. The method of claim 88, wherein the anti-bradycardia pacing
energy comprises a biphasic waveform that is provided at a rate of
approximately 20 to approximately 120 stimuli/minute.
102. The method of claim 101, wherein the biphasic waveform is
provided after a patient's heart rate is greater than or equal to
approximately 20 beats/minute.
103. The method of claim 88, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a peak current that
is approximately one milliamp to approximately 250 milliamps.
104. The method of claim 103, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a peak current that
is approximately one milliamp to approximately 50 milliamps.
105. The method of claim 103, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a peak current that
is approximately 50 milliamps to approximately 100 milliamps.
106. The method of claim 103, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a peak current that
is approximately 100 milliamps to approximately 150 milliamps.
107. The method of claim 103, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a peak current that
is approximately 150 milliamps to approximately 200 milliamps.
108. The method of claim 103, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a peak current that
is approximately 200 milliamps to approximately 250 milliamps.
109. The method of claim 88, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a pulse width that is
approximately 1 millisecond to approximately 40 milliseconds.
110. The method of claim 109, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a pulse width that is
approximately 1 millisecond to approximately 10 milliseconds.
111. The method of claim 109, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a pulse width that is
approximately 10 milliseconds to approximately 20 milliseconds.
112. The method of claim 109, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a pulse width that is
approximately 20 milliseconds to approximately 30 milliseconds.
113. The method of claim 109, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform having a pulse width that is
approximately 30 milliseconds to approximately 40 milliseconds.
114. The method of claim 88, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform that is either positive or
negative in polarity.
115. The method of claim 88, wherein the anti-bradycardia pacing
energy comprises a monophasic waveform that is provided at a rate
of approximately 20 to approximately 120 stimuli/minute.
116. The method of claim 115, wherein the monophasic waveform is
provided after a patient's heart rate is greater than or equal to
approximately 20 beats/minute.
117. The method of claim 88, wherein the implantable
cardioverter-defibrillator is subcutaneously positioned between the
third and fourth ribs.
118. The method of claim 88, wherein the implantable
cardioverter-defibrillator is subcutaneously positioned between the
fourth and sixth ribs.
119. The method of claim 88, wherein the implantable
cardioverter-defibrillator is subcutaneously positioned between the
sixth and eighth ribs.
120. The method of claim 88, wherein the implantable
cardioverter-defibrillator is subcutaneously positioned between the
eighth and tenth ribs.
121. The method of claim 88, wherein the implantable
cardioverter-defibrillator is subcutaneously positioned between the
tenth and twelfth ribs.
122. The method of claim 88, wherein the implantable
cardioverter-defibrillator provides anti-bradycardia pacing energy
to the heart for treatment of atrial fibrillation.
123. The method of claim 88, wherein the implantable
cardioverter-defibrillator provides anti-bradycardia pacing energy
to the heart for treatment of ventrical fibrillation.
124. The power supply of claim 1, wherein the battery subsystem and
the capacitor system provide a sufficient voltage to provide an
anti-bradycardia pacing energy comprising an approximately constant
current.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] The present application is a continuation-in-part of U.S.
patent application entitled "SUBCUTANEOUS ONLY IMPLANTABLE
CARDIOVERTER-DEFIBRILLATOR AND OPTIONAL PACER," having Ser. No.
09/663,607, filed Sep. 18, 2000, pending, and U.S. patent
application entitled "UNITARY SUBCUTANEOUS ONLY IMPLANTABLE
CARDIOVERTER-DEFIBRILLATO- R AND OPTIONAL PACER," having Ser. No.
09/663,606, filed Sep. 18, 2000, pending, of which both
applications are assigned to the assignee of the present
application, and the disclosures of both applications are hereby
incorporated by reference.
[0002] In addition, the present application is filed concurrently
herewith U.S. patent application entitled "MONOPHASIC WAVEFORM FOR
ANTI-BRADYCARDIA PACING FOR A SUBCUTANEOUS IMPLANTABLE
CARDIOVERTER-DEFIBRILLATOR," U.S. patent application entitled
"MONOPHASIC WAVEFORM FOR ANTI-TACHYCARDIA PACING FOR A SUBCUTANEOUS
IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR" and U.S. patent application
entitled "CURRENT WAVEFORMS FOR ANTI-TACHYCARDIA PACING FOR A
SUBCUTANEOUS IMPLANTABLE CARDIOVERTER DEFIBRILLATOR," the
disclosures of which applications are hereby incorporated by
reference.
FIELD OF THE INVENTION
[0003] The present invention relates to an apparatus and method for
performing electrical cardioversion/defibrillation and optional
pacing of the heart via a totally subcutaneous non-transvenous
system.
BACKGROUND OF THE INVENTION
[0004] Defibrillation/cardioversion is a technique employed to
counter arrhythmic heart conditions including some tachycardias in
the atria and/or ventricles. Typically, electrodes are employed to
stimulate the heart with electrical impulses or shocks, of a
magnitude substantially greater than pulses used in cardiac pacing.
Shocks used for defibrillation therapy can comprise a biphasic
truncated exponential waveform. As for pacing, a constant current
density is desired to reduce or eliminate variability due to the
electrode/tissue interface.
[0005] Defibrillation/cardioversion systems include body
implantable electrodes that are connected to a hermetically sealed
container housing the electronics, battery supply and capacitors.
The entire system is referred to as implantable
cardioverter/defibrillators (ICDs). The electrodes used in ICDs can
be in the form of patches applied directly to epicardial tissue,
or, more commonly, are on the distal regions of small cylindrical
insulated catheters that typically enter the subclavian venous
system, pass through the superior vena cava and, into one or more
endocardial areas of the heart. Such electrode systems are called
intravascular or transvenous electrodes. U.S. Pat. Nos. 4,603,705,
4,693,253, 4,944,300, 5,105,810, the disclosures of which are all
incorporated herein by reference, disclose intravascular or
transvenous electrodes, employed either alone, in combination with
other intravascular or transvenous electrodes, or in combination
with an epicardial patch or subcutaneous electrodes. Compliant
epicardial defibrillator electrodes are disclosed in U.S. Pat. Nos.
4,567,900 and 5,618,287, the disclosures of which are incorporated
herein by reference. A sensing epicardial electrode configuration
is disclosed in U.S. Pat. No. 5,476,503, the disclosure of which is
incorporated herein by reference.
[0006] In addition to epicardial and transvenous electrodes,
subcutaneous electrode systems have also been developed. For
example, U.S. Pat. Nos. 5,342,407 and 5,603,732, the disclosures of
which are incorporated herein by reference, teach the use of a
pulse monitor/generator surgically implanted into the abdomen and
subcutaneous electrodes implanted in the thorax. This system is far
more complicated to use than current ICD systems using transvenous
lead systems together with an active can electrode and therefore it
has no practical use. It has in fact never been used because of the
surgical difficulty of applying such a device (3 incisions), the
impractical abdominal location of the generator and the
electrically poor sensing and defibrillation aspects of such a
system.
[0007] Recent efforts to improve the efficiency of ICDs have led
manufacturers to produce ICDs which are small enough to be
implanted in the pectoral region. In addition, advances in circuit
design have enabled the housing of the ICD to form a subcutaneous
electrode. Some examples of ICDs in which the housing of the ICD
serves as an optional additional electrode are described in U.S.
Pat. Nos. 5,133,353, 5,261,400, 5,620,477, and 5,658,321 the
disclosures of which are incorporated herein by reference.
[0008] ICDs are now an established therapy for the management of
life threatening cardiac rhythm disorders, primarily ventricular
fibrillation (VFib). ICDs are very effective at treating V-Fib, but
are therapies that still require significant surgery.
[0009] As ICD therapy becomes more prophylactic in nature and used
in progressively less ill individuals, especially children at risk
of cardiac arrest, the requirement of ICD therapy to use
intravenous catheters and transvenous leads is an impediment to
very long term management as most individuals will begin to develop
complications related to lead system malfunction sometime in the
5-10 year time frame, often earlier. In addition, chronic
transvenous lead systems, their reimplantation and removals, can
damage major cardiovascular venous systems and the tricuspid valve,
as well as result in life threatening perforations of the great
vessels and heart. Consequently, use of transvenous lead systems,
despite their many advantages, are not without their chronic
patient management limitations in those with life expectancies of
>5 years. The problem of lead complications is even greater in
children where body growth can substantially alter transvenous lead
function and lead to additional cardiovascular problems and
revisions. Moreover, transvenous ICD systems also increase cost and
require specialized interventional rooms and equipment as well as
special skill for insertion. These systems are typically implanted
by cardiac electrophysiologists who have had a great deal of extra
training.
[0010] In addition to the background related to ICD therapy, the
present invention requires a brief understanding of a related
therapy, the automatic external defibrillator (AED). AEDs employ
the use of cutaneous patch electrodes, rather than implantable lead
systems, to effect defibrillation under the direction of a
bystander user who treats the patient suffering from V-Fib with a
portable device containing the necessary electronics and power
supply that allows defibrillation. AEDs can be nearly as effective
as an ICD for defibrillation if applied to the victim of
ventricular fibrillation promptly, i.e., within 2 to 3 minutes of
the onset of the ventricular fibrillation.
[0011] AED therapy has great appeal as a tool for diminishing the
risk of death in public venues such as in air flight. However, an
AED must be used by another individual, not the person suffering
from the potential fatal rhythm. It is more of a public health tool
than a patient-specific tool like an ICD. Because >75% of
cardiac arrests occur in the home, and over half occur in the
bedroom, patients at risk of cardiac arrest are often alone or
asleep and can not be helped in time with an AED. Moreover, its
success depends to a reasonable degree on an acceptable level of
skill and calm by the bystander user.
[0012] What is needed therefore, especially for children and for
prophylactic long term use for those at risk of cardiac arrest, is
a combination of the two forms of therapy which would provide
prompt and near-certain defibrillation, like an ICD, but without
the long-term adverse sequelae of a transvenous lead system while
simultaneously using most of the simpler and lower cost technology
of an AED. What is also needed is a cardioverter/defibrillator that
is of simple design and can be comfortably implanted in a patient
for many years.
SUMMARY OF THE INVENTION
[0013] A power supply for an implantable cardioverter-defibrillator
for subcutaneous positioning between the third rib and the twelfth
rib and using a lead system that does not directly contact a
patient's heart or reside in the intrathorasic blood vessels and
for providing anti-bradycardia pacing energy to the heart,
comprising a capacitor subsystem for storing the anti-bradycardia
pacing energy for delivery to the patient's heart; and a battery
subsystem electrically coupled to the capacitor subsystem for
providing the anti-bradycardia pacing energy to the capacitor
subsystem.
BRIEF DESCRIPTION OF THE DRAWINGS
[0014] For a better understanding of the invention, reference is
now made to the drawings where like numerals represent similar
objects throughout the figures where:
[0015] FIG. 1 is a schematic view of a Subcutaneous ICD (S-ICD) of
the present invention;
[0016] FIG. 2 is a schematic view of an alternate embodiment of a
subcutaneous electrode of the present invention;
[0017] FIG. 3 is a schematic view of an alternate embodiment of a
subcutaneous electrode of the present invention;
[0018] FIG. 4 is a schematic view of the S-ICD and lead of FIG. 1
subcutaneously implanted in the thorax of a patient;
[0019] FIG. 5 is a schematic view of the S-ICD and lead of FIG. 2
subcutaneously implanted in an alternate location within the thorax
of a patient;
[0020] FIG. 6 is a schematic view of the S-ICD and lead of FIG. 3
subcutaneously implanted in the thorax of a patient;
[0021] FIG. 7 is a schematic view of the method of making a
subcutaneous path from the preferred incision and housing
implantation point to a termination point for locating a
subcutaneous electrode of the present invention;
[0022] FIG. 8 is a schematic view of an introducer set for
performing the method of lead insertion of any of the described
embodiments;
[0023] FIG. 9 is a schematic view of an alternative SICD of the
present invention illustrating a lead subcutaneously and
serpiginously implanted in the thorax of a patient for use
particularly in children;
[0024] FIG. 10 is a schematic view of an alternate embodiment of an
S-ICD of the present invention;
[0025] FIG. 11 is a schematic view of the S-ICD of FIG. 10
subcutaneously implanted in the thorax of a patient;
[0026] FIG. 12 is a schematic view of yet a further embodiment
where the canister of the S-ICD of the present invention is shaped
to be particularly useful in placing subcutaneously adjacent and
parallel to a rib of a patient;
[0027] FIG. 13 is a schematic of a different embodiment where the
canister of the S-ICD of the present invention is shaped to be
particularly useful in placing subcutaneously adjacent and parallel
to a rib of a patient;
[0028] FIG. 14 is a schematic view of a Unitary Subcutaneous ICD
(US-ICD) of the present invention;
[0029] FIG. 15 is a schematic view of the US-ICD subcutaneously
implanted in the thorax of a patient;
[0030] FIG. 16 is a schematic view of the method of making a
subcutaneous path from the preferred incision for implanting the
US-ICD;
[0031] FIG. 17 is a schematic view of an introducer for performing
the method of US-ICD implantation; and
[0032] FIG. 18 is an exploded schematic view of an alternate
embodiment of the present invention with a plug-in portion that
contains operational circuitry and means for generating
cardioversion/defibrillation shock waves;
[0033] FIG. 19 is a graph that shows an example of a biphasic
waveform for use in anti-bradycardia pacing in an embodiment of the
present invention; and
[0034] FIG. 20 is a graph that shows an example of a monophonic
waveform for use in anti-bradycardia pacing in an embodiment of the
present invention.
DETAILED DESCRIPTION
[0035] Turning now to FIG. 1, the S-ICD of the present invention is
illustrated. The S-ICD consists of an electrically active canister
11 and a subcutaneous electrode 13 attached to the canister. The
canister has an electrically active surface 15 that is electrically
insulated from the electrode connector block 17 and the canister
housing 16 via insulating area 14. The canister can be similar to
numerous electrically active canisters commercially available in
that the canister will contain a battery supply, capacitor and
operational circuitry. Alternatively, the canister can be thin and
elongated to conform to the intercostal space. The circuitry will
be able to monitor cardiac rhythms for tachycardia and
fibrillation, and if detected, will initiate charging the capacitor
and then delivering cardioversion/defibrillation energy through the
active surface of the housing and to the subcutaneous electrode.
Examples of such circuitry are described in U.S. Pat. Nos.
4,693,253 and 5,105,810, the entire disclosures of which are herein
incorporated by reference. The canister circuitry can provide
cardioversion/defibrillation energy in different types of
waveforms. In one embodiment, a 100 uF biphasic waveform is used of
approximately 10-20 ms total duration and with the initial phase
containing approximately 2/3 of the energy, however, any type of
waveform can be utilized such as monophasic, biphasic, multiphasic
or alternative waveforms as is known in the art.
[0036] In addition to providing cardioversion/defibrillation
energy, the circuitry can also provide transthoracic cardiac pacing
energy. The optional circuitry will be able to monitor the heart
for bradycardia and/or tachycardia rhythms. Once a bradycardia or
tachycardia rhythm is detected, the circuitry can then deliver
appropriate pacing energy at appropriate intervals through the
active surface and the subcutaneous electrode. Pacing stimuli can
be biphasic in one embodiment and similar in pulse amplitude to
that used for conventional transthoracic pacing.
[0037] This same circuitry can also be used to deliver low
amplitude shocks on the T-wave for induction of ventricular
fibrillation for testing S-ICD performance in treating V-Fib as is
described in U.S. Pat. No. 5,129,392, the entire disclosure of
which is hereby incorporated by reference. Also the circuitry can
be provided with rapid induction of ventricular fibrillation or
ventricular tachycardia using rapid ventricular pacing. Another
optional way for inducing ventricular fibrillation would be to
provide a continuous low voltage, i.e., about 3 volts, across the
heart during the entire cardiac cycle.
[0038] Another optional aspect of the present invention is that the
operational circuitry can detect the presence of atrial
fibrillation as described in Olson, W. et al. "Onset And Stability
For Ventricular Tachyarrhythmia Detection in an Implantable
Cardioverter and Defibrillator," Computers in Cardiology (1986) pp.
167-170. Detection can be provided via R-R Cycle length instability
detection algorithms. Once atrial fibrillation has been detected,
the operational circuitry will then provide QRS synchronized atrial
defibrillation/cardioversion using the same shock energy and
waveshape characteristics used for ventricular
defibrillation/cardioversion.
[0039] The sensing circuitry will utilize the electronic signals
generated from the heart and will primarily detect QRS waves. In
one embodiment, the circuitry will be programmed to detect only
ventricular tachycardias or fibrillations. The detection circuitry
will utilize in its most direct form, a rate detection algorithm
that triggers charging of the capacitor once the ventricular rate
exceeds some predetermined level for a fixed period of time: for
example, if the ventricular rate exceeds 240 bpm on average for
more than 4 seconds. Once the capacitor is charged, a confirmatory
rhythm check would ensure that the rate persists for at least
another 1 second before discharge. Similarly, termination
algorithms could be instituted that ensure that a rhythm less than
240 bpm persisting for at least 4 seconds before the capacitor
charge is drained to an internal resistor. Detection, confirmation
and termination algorithms as are described above and in the art
can be modulated to increase sensitivity and specificity by
examining QRS beat-to-beat uniformity, QRS signal frequency
content, R-R interval stability data, and signal amplitude
characteristics all or part of which can be used to increase or
decrease both sensitivity and specificity of S-ICD arrhythmia
detection function.
[0040] In addition to use of the sense circuitry for detection of
V-Fib or V-Tach by examining the QRS waves, the sense circuitry can
check for the presence or the absence of respiration. The
respiration rate can be detected by monitoring the impedance across
the thorax using subthreshold currents delivered across the active
can and the high voltage subcutaneous lead electrode and monitoring
the frequency in undulation in the waveform that results from the
undulations of transthoracic impedance during the respiratory
cycle. If there is no undulation, then the patent is not respiring
and this lack of respiration can be used to confirm the QRS
findings of cardiac arrest. The same technique can be used to
provide information about the respiratory rate or estimate cardiac
output as described in U.S. Pat. Nos. 6,095,987, 5,423,326,
4,450,527, the entire disclosures of which are incorporated herein
by reference.
[0041] The canister of the present invention can be made out of
titanium alloy or other presently preferred electrically active
canister designs. However, it is contemplated that a malleable
canister that can conform to the curvature of the patient's chest
will be preferred. In this way the patient can have a comfortable
canister that conforms to the shape of the patient's rib cage.
Examples of conforming canisters are provided in U.S. Pat. No.
5,645,586, the entire disclosure of which is herein incorporated by
reference. Therefore, the canister can be made out of numerous
materials such as medical grade plastics, metals, and alloys. In
the preferred embodiment, the canister is smaller than 60 cc volume
having a weight of less than 100 gms for long term wearability,
especially in children. The canister and the lead of the S-ICD can
also use fractal or wrinkled surfaces to increase surface area to
improve defibrillation capability. Because of the primary
prevention role of the therapy and the likely need to reach
energies over 40 Joules, a feature of one embodiment is that the
charge time for the therapy, is intentionally left relatively long
to allow capacitor charging within the limitations of device size.
Examples of small ICD housings are disclosed in U.S. Pat. Nos.
5,597,956 and 5,405,363, the entire disclosures of which are herein
incorporated by reference.
[0042] Different subcutaneous electrodes 13 of the present
invention are illustrated in FIGS. 1-3. Turning to FIG. 1, the lead
21 for the subcutaneous electrode is preferably composed of
silicone or polyurethane insulation. The electrode is connected to
the canister at its proximal end via connection port 19 which is
located on an electrically insulated area 17 of the canister. The
electrode illustrated is a composite electrode with three different
electrodes attached to the lead. In the embodiment illustrated, an
optional anchor segment 52 is attached at the most distal end of
the subcutaneous electrode for anchoring the electrode into soft
tissue such that the electrode does not dislodge after
implantation.
[0043] The most distal electrode on the composite subcutaneous
electrode is a coil electrode 27 that is used for delivering the
high voltage cardioversion/defibrillation energy across the heart.
The coil cardioversion/defibrillation electrode is about 5-10 cm in
length. Proximal to the coil electrode are two sense electrodes, a
first sense electrode 25 is located proximally to the coil
electrode and a second sense electrode 23 is located proximally to
the first sense electrode. The sense electrodes are spaced far
enough apart to be able to have good QRS detection. This spacing
can range from 1 to 10 cm with 4 cm being presently preferred. The
electrodes may or may not be circumferential with the preferred
embodiment. Having the electrodes non-circumferential and
positioned outward, toward the skin surface, is a means to minimize
muscle artifact and enhance QRS signal quality. The sensing
electrodes are electrically isolated from the
cardioversion/defibrillation electrode via insulating areas 29.
Similar types of cardioversion/defibrillation electrodes are
currently commercially available in a transvenous configuration.
For example, U.S. Pat. No. 5,534,022, the entire disclosure of
which is herein incorporated by reference, disclosures a composite
electrode with a coil cardioversion/defibrillation electrode and
sense electrodes. Modifications to this arrangement is contemplated
within the scope of the invention. One such modification is
illustrated in FIG. 2 where the two sensing electrodes 25 and 23
are non-circumferential sensing electrodes and one is located at
the distal end, the other is located proximal thereto with the coil
electrode located in between the two sensing electrodes. In this
embodiment the sense electrodes are spaced about 6 to about 12 cm
apart depending on the length of the coil electrode used. FIG. 3
illustrates yet a further embodiment where the two sensing
electrodes are located at the distal end to the composite electrode
with the coil electrode located proximally thereto. Other
possibilities exist and are contemplated within the present
invention. For example, having only one sensing electrode, either
proximal or distal to the coil cardioversion/defibrillation
electrode with the coil serving as both a sensing electrode and a
cardioversion/defibrillation electrode.
[0044] It is also contemplated within the scope of the invention
that the sensing of QRS waves (and transthoracic impedance) can be
carried out via sense electrodes on the canister housing or in
combination with the cardioversion/defibrillation coil electrode
and/or the subcutaneous lead sensing electrode(s) In this way,
sensing could be performed via the one coil electrode located on
the subcutaneous electrode and the active surface on the canister
housing. Another possibility would be to have only one sense
electrode located on the subcutaneous electrode and the sensing
would be performed by that one electrode and either the coil
electrode on the subcutaneous electrode or by the active surface of
the canister. The use of sensing electrodes on the canister would
eliminate the need for sensing electrodes on the subcutaneous
electrode. It is also contemplated that the subcutaneous electrode
would be provided with at least one sense electrode, the canister
with at least one sense electrode, and if multiple sense electrodes
are used on either the subcutaneous electrode and/or the canister,
that the best QRS wave detection combination will be identified
when the S-ICD is implanted and this combination can be selected,
activating the best sensing arrangement from all the existing
sensing possibilities. Turning again to FIG. 2, two sensing
electrodes 26 and 28 are located on the electrically active surface
15 with electrical insulator rings 30 placed between the sense
electrodes and the active surface. These canister sense electrodes
could be switched off and electrically insulated during and shortly
after defibrillation/cardioversion shock delivery. The canister
sense electrodes may also be placed on the electrically inactive
surface of the canister. In the embodiment of FIG. 2, there are
actually four sensing electrodes, two on the subcutaneous lead and
two on the canister. In the preferred embodiment, the ability to
change which electrodes are used for sensing would be a
programmable feature of the S-ICD to adapt to changes in the
patient physiology and size (in the case of children) over time.
The programming could be done via the use of physical switches on
the canister, or as presently preferred, via the use of a
programming wand or via a wireless connection to program the
circuitry within the canister.
[0045] The canister could be employed as either a cathode or an
anode of the S-ICD cardioversion/defibrillation system. If the
canister is the cathode, then the subcutaneous coil electrode would
be the anode. Likewise, if the canister is the anode, then the
subcutaneous electrode would be the cathode.
[0046] The active canister housing will provide energy and voltage
intermediate to that available with ICDs and most AEDS. The typical
maximum voltage necessary for ICDs using most biphasic waveforms is
approximately 750 Volts with an associated maximum energy of
approximately 40 Joules. The typical maximum voltage necessary for
AEDs is approximately 2000-5000 Volts with an associated maximum
energy of approximately 200-360 Joules depending upon the model and
waveform used. The S-ICD and the US-ICD of the present invention
uses maximum voltages in the range of about 50 to about 3500 Volts
and is associated with energies of about 0.5 to about 350 Joules.
The capacitance of the devices can range from about 25 to about 200
micro farads.
[0047] In another embodiment, the S-ICD and US-ICD devices provide
energy with a pulse width of approximately one millisecond to
approximately 40 milliseconds. The devices can provide pacing
current of approximately one milliamp to approximately 250
milliamps.
[0048] The sense circuitry contained within the canister is highly
sensitive and specific for the presence or absence of life
threatening ventricular arrhythmias. Features of the detection
algorithm are programmable and the algorithm is focused on the
detection of V-FIB and high rate V-TACH (>240 bpm). Although the
S-ICD of the present invention may rarely be used for an actual
life-threatening event, the simplicity of design and implementation
allows it to be employed in large populations of patients at modest
risk with modest cost by non-cardiac electrophysiologists.
Consequently, the S-ICD of the present invention focuses mostly on
the detection and therapy of the most malignant rhythm disorders.
As part of the detection algorithm's applicability to children, the
upper rate range is programmable upward for use in children, known
to have rapid supraventricular tachycardias and more rapid
ventricular fibrillation. Energy levels also are programmable
downward in order to allow treatment of neonates and infants.
[0049] Turning now to FIG. 4, the optimal subcutaneous placement of
the S-ICD of the present invention is illustrated. As would be
evidence to a person skilled in the art, the actual location of the
S-ICD is in a subcutaneous space that is developed during the
implantation process. The heart is not exposed during this process
and the heart is schematically illustrated in the figures only for
help in understanding where the canister and coil electrode are
three dimensionally located in the left mid-clavicular line
approximately at the level of the inframammary crease at
approximately the 5th rib. The lead 21 of the subcutaneous
electrode traverses in a subcutaneous path around the thorax
terminating with its distal electrode end at the posterior axillary
line ideally just lateral to the left scapula. This way the
canister and subcutaneous cardioversion/defibrillation electrode
provide a reasonably good pathway for current delivery to the
majority of the ventricular myocardium.
[0050] FIG. 5 illustrates a different placement of the present
invention. The S-ICD canister with the active housing is located in
the left posterior axillary line approximately lateral to the tip
of the inferior portion of the scapula. This location is especially
useful in children. The lead 21 of the subcutaneous electrode
traverses in a subcutaneous path around the thorax terminating with
its distal electrode end at the anterior precordial region, ideally
in the inframammary crease. FIG. 6 illustrates the embodiment of
FIG. 1 subcutaneously implanted in the thorax with the proximal
sense electrodes 23 and 25 located at approximately the left
axillary line with the cardioversion/defibrillatio- n electrode
just lateral to the tip of the inferior portion of the scapula.
[0051] FIG. 7 schematically illustrates the method for implanting
the S-ICD of the present invention. An incision 31 is made in the
left anterior axillary line approximately at the level of the
cardiac apex. This incision location is distinct from that chosen
for S-ICD placement and is selected specifically to allow both
canister location more medially in the left inframammary crease and
lead positioning more posteriorly via the introducer set (described
below) around to the left posterior axillary line lateral to the
left scapula. That said, the incision can be anywhere on the thorax
deemed reasonably by the implanting physician although in the
preferred embodiment, the S-ICD of the present invention will be
applied in this region. A subcutaneous pathway 33 is then created
medially to the inframmary crease for the canister and posteriorly
to the left posterior axillary line lateral to the left scapula for
the lead.
[0052] The S-ICD canister 11 is then placed subcutaneously at the
location of the incision or medially at the subcutaneous region at
the left inframmary crease. The subcutaneous electrode 13 is placed
with a specially designed curved introducer set 40 (see FIG. 8).
The introducer set comprises a curved trocar 42 and a stiff curved
peel away sheath 44. The peel away sheath is curved to allow for
placement around the rib cage of the patient in the subcutaneous
space created by the trocar. The sheath has to be stiff enough to
allow for the placement of the electrodes without the sheath
collapsing or bending. Preferably the sheath is made out of a
biocompatible plastic material and is perforated along its axial
length to allow for it to split apart into two sections. The trocar
has a proximal handle 41 and a curved shaft 43. The distal end 45
of the trocar is tapered to allow for dissection of a subcutaneous
path 33 in the patient. Preferably, the trocar is cannulated having
a central Lumen 46 and terminating in an opening 48 at the distal
end. Local anesthetic such as lidocaine can be delivered, if
necessary, through the lumen or through a curved and elongated
needle designed to anesthetize the path to be used for trocar
insertion should general anesthesia not be employed. The curved
peel away sheath 44 has a proximal pull tab 49 for breaking the
sheath into two halves along its axial shaft 47. The sheath is
placed over a guidewire inserted through the trocar after the
subcutaneous path has been created. The subcutaneous pathway is
then developed until it terminates subcutaneously at a location
that, if a straight line were drawn from the canister location to
the path termination point the line would intersect a substantial
portion of the left ventricular mass of the patient. The guidewire
is then removed leaving the peel away sheath. The subcutaneous lead
system is then inserted through the sheath until it is in the
proper location. Once the subcutaneous lead system is in the proper
location, the sheath is split in half using the pull tab 49 and
removed. If more than one subcutaneous electrode is being used, a
new curved peel away sheath can be used for each subcutaneous
electrode.
[0053] The S-ICD will have prophylactic use in adults where chronic
transvenous/epicardial ICD lead systems pose excessive risk or have
already resulted in difficulty, such as sepsis or lead fractures.
It is also contemplated that a major use of the S-ICD system of the
present invention will be for prophylactic use in children who are
at risk for having fatal arrhythmias, where chronic transvenous
lead systems pose significant management problems. Additionally,
with the use of standard transvenous ICDs in children, problems
develop during patient growth in that the lead system does not
accommodate the growth. FIG. 9 illustrates the placement of the
S-ICD subcutaneous lead system such that he problem that growth
presents to the lead system is overcome. The distal end of the
subcutaneous electrode is placed in the same location as described
above providing a good location for the coil
cardioversion/defibrillation electrode 27 and the sensing
electrodes 23 and 25. The insulated lead 21, however is no longer
placed in a taught configuration. Instead, the lead is
serpiginously placed with a specially designed introducer trocar
and sheath such that it has numerous waves or bends. As the child
grows, the waves or bends will straighten out lengthening the lead
system while maintaining proper electrode placement. Although it is
expected that fibrous scarring especially around the defibrillation
coil will help anchor it into position to maintain its posterior
position during growth, a lead system with a distal tine or screw
electrode anchoring system 52 can also be incorporated into the
distal tip of the lead to facilitate lead stability (see FIG. 1).
Other anchoring systems can also be used such as hooks, sutures, or
the like.
[0054] FIGS. 10 and 11 illustrate another embodiment of the present
S-ICD invention. In this embodiment there are two subcutaneous
electrodes 13 and 13' of opposite polarity to the canister. The
additional subcutaneous electrode 13' is essentially identical to
the previously described electrode. In this embodiment the
cardioversion/defibrillation energy is delivered between the active
surface of the canister and the two coil electrodes 27 and 27'.
Additionally, provided in the canister is means for selecting the
optimum sensing arrangement between the four sense electrodes 23,
23', 25, and 25'. The two electrodes are subcutaneously placed on
the same side of the heart. As illustrated in FIG. 6, one
subcutaneous electrode 13 is placed inferiorly and the other
electrode 13' is placed superiorly. It is also contemplated with
this dual subcutaneous electrode system that the canister and one
subcutaneous electrode are the same polarity and the other
subcutaneous electrode is the opposite polarity.
[0055] Turning now to FIGS. 12 and 13, further embodiments are
illustrated where the canister 11 of the S-ICD of the present
invention is shaped to be particularly useful in placing
subcutaneously adjacent and parallel to a rib of a patient. The
canister is long, thin, and curved to conform to the shape of the
patient's rib. In the embodiment illustrated in FIG. 12, the
canister has a diameter ranging from about 0.5 cm to about 2 cm
without 1 cm being presently preferred. Alternatively, instead of
having a circular cross sectional area, the canister could have a
rectangular or square cross sectional area as illustrated in FIG.
13 without falling outside of the scope of the present invention.
The length of the canister can vary depending on the size of the
patient's thorax. In an embodiment, the canister is about 5 cm to
about 40 cm long. The canister is curved to conform to the
curvature of the ribs of the thorax. The radius of the curvature
will vary depending on the size of the patient, with smaller
radiuses for smaller patients and larger radiuses for larger
patients. The radius of the curvature can range from about 5 cm to
about 35 cm depending on the size of the patient. Additionally, the
radius of the curvature need not be uniform throughout the canister
such that it can be shaped closer to the shape of the ribs. The
canister has an active surface, 15 that is located on the interior
(concave) portion of the curvature and an inactive surface 16 that
is located on the exterior (convex) portion of the curvature. The
leads of these embodiments, which are not illustrated except for
the attachment port 19 and the proximal end of the lead 21, can be
any of the leads previously described above, with the lead
illustrated in FIG. 1 being presently preferred.
[0056] The circuitry of this canister is similar to the circuitry
described above. Additionally, the canister can optionally have at
least one sense electrode located on either the active surface of
the inactive surface and the circuitry within the canister can be
programmable as described above to allow for the selection of the
best sense electrodes. It is presently preferred that the canister
have two sense electrodes 26 and 28 located on the inactive surface
of the canisters as illustrated, where the electrodes are spaced
from about 1 to about 10 cm apart with a spacing of about 3 cm
being presently preferred. However, the sense electrodes can be
located on the active surface as described above.
[0057] It is envisioned that the embodiment of FIG. 12 will be
subcutaneously implanted adjacent and parallel to the left anterior
5th rib, either between the 4th and 5th ribs or between the 5th and
6th ribs. However other locations can be used.
[0058] Another component of the S-ICD of the present invention is a
cutaneous test electrode system designed to simulate the
subcutaneous high voltage shock electrode system as well as the QRS
cardiac rhythm detection system. This test electrode system is
comprised of a cutaneous patch electrode of similar surface area
and impedance to that of the S-ICD canister itself together with a
cutaneous strip electrode comprising a defibrillation strip as well
as two button electrodes for sensing of the QRS. Several cutaneous
strip electrodes are available to allow for testing various bipole
spacings to optimize signal detection comparable to the implantable
system.
[0059] FIGS. 14 to 18 depict particular US-ICD embodiments of the
present invention. The various sensing, shocking and pacing
circuitry, described in detail above with respect to the S-ICD
embodiments, may additionally be incorporated into the following
US-ICD embodiments. Furthermore, particular aspects of any
individual S-ICD embodiment discussed above, may be incorporated,
in whole or in part, into the US-ICD embodiments depicted in the
following figures.
[0060] Turning now to FIG. 14, the US-ICD of the present invention
is illustrated. The US-ICD consists of a curved housing 1211 with a
first and second end. The first end 1413 is thicker than the second
end 1215. This thicker area houses a battery supply, capacitor and
operational circuitry for the US-ICD. The circuitry will be able to
monitor cardiac rhythms for tachycardia and fibrillation, and if
detected, will initiate charging the capacitor and then delivering
cardioversion/defibrillation energy through the two
cardioversion/defibrillating electrodes 1417 and 1219 located on
the outer surface of the two ends of the housing. The circuitry can
provide cardioversion/defibrillation energy in different types of
waveforms. In one embodiment, a 100 uF biphasic waveform is used of
approximately 10-20 ms total duration and with the initial phase
containing approximately 2/3 of the energy, however, any type of
waveform can be utilized such as monophasic, biphasic, multiphasic
or alternative waveforms as is known in the art.
[0061] The housing of the present invention can be made out of
titanium alloy or other presently preferred ICD designs. It is
contemplated that the housing is also made out of biocompatible
plastic materials that electronically insulate the electrodes from
each other. However, it is contemplated that a malleable canister
that can conform to the curvature of the patient's chest will be
preferred. In this way the patient can have a comfortable canister
that conforms to the unique shape of the patient's rib cage.
Examples of conforming ICD housings are provided in U.S. Pat. No.
5,645,586, the entire disclosure of which is herein incorporated by
reference. In the preferred embodiment, the housing is curved in
the shape of a 5.sup.th rib of a person. Because there are many
different sizes of people, the housing will come in different
incremental sizes to allow a good match between the size of the rib
cage and the size of the US-ICD. The length of the US-ICD will
range from about 15 to about 50 cm. Because of the primary
preventative role of the therapy and the need to reach energies
over 40 Joules, a feature of the preferred embodiment is that the
charge time for the therapy, intentionally be relatively long to
allow capacitor charging within the limitations of device size.
[0062] The thick end of the housing is currently needed to allow
for the placement of the battery supply, operational circuitry, and
capacitors. It is contemplated that the thick end will be about 0.5
cm to about 2 cm wide with about 1 cm being presently preferred. As
microtechnology advances, the thickness of the housing will become
smaller. The two cardioversion/defibrillation electrodes on the
housing are used for delivering the high voltage
cardioversion/defibrillation energy across the heart. In the
preferred embodiment, the cardioversion/defibrillation electrodes
are coil electrodes, however, other cardioversion/defibrillati- on
electrodes could be used such as having electrically isolated
active surfaces or platinum alloy electrodes. The coil
cardioversion/defibrillat- ion electrodes are about 5-10 cm in
length. Located on the housing between the two
cardioversion/defibrillation electrodes are two sense electrodes
1425 and 1427. The sense electrodes are spaced far enough apart to
be able to have good QRS detection. This spacing can range from 1
to 10 cm with 4 cm being presently preferred. The electrodes may or
may not be circumferential with the preferred embodiment. Having
the electrodes non-circumferential and positioned outward, toward
the skin surface, is a means to minimize muscle artifact and
enhance QRS signal quality. The sensing electrodes are electrically
isolated from the cardioversion/defibrillation electrode via
insulating areas 1423. Analogous types of
cardioversion/defibrillation electrodes are currently commercially
available in a transvenous configuration. For example, U.S. Pat.
No. 5,534,022, the entire disclosure of which is herein
incorporated by reference, discloses a composite electrode with a
coil cardioversion/defibrillation electrode and sense electrodes.
Modifications to this arrangement is contemplated within the scope
of the invention. One such modification is to have the sense
electrodes at the two ends of the housing and have the
cardioversion/defibrillation electrodes located in between the
sense electrodes. Another modification is to have three or more
sense electrodes spaced throughout the housing and allow for the
selection of the two best sensing electrodes. If three or more
sensing electrodes are used, then the ability to change which
electrodes are used for sensing would be a programmable feature of
the US-ICD to adapt to changes in the patient physiology and size
over time. The programming could be done via the use of physical
switches on the canister, or as presently preferred, via the use of
a programming wand or via a wireless connection to program the
circuitry within the canister.
[0063] Turning now to FIG. 15, the optimal subcutaneous placement
of the US-ICD of the present invention is illustrated. As would be
evident to a person skilled in the art, the actual location of the
US-ICD is in a subcutaneous space that is developed during the
implantation process. The heart is not exposed during this process
and the heart is schematically illustrated in the figures only for
help in understanding where the device and its various electrodes
are three dimensionally located in the thorax of the patient. The
US-ICD is located between the left mid-clavicular line
approximately at the level of the inframammary crease at
approximately the 5.sup.th rib and the posterior axillary line,
ideally just lateral to the left scapula. This way the US-ICD
provides a reasonably good pathway for current delivery to the
majority of the ventricular myocardium.
[0064] FIG. 16 schematically illustrates the method for implanting
the US-ICD of the present invention. An incision 1631 is made in
the left anterior axillary line approximately at the level of the
cardiac apex. A subcutaneous pathway is then created that extends
posteriorly to allow placement of the US-ICD. The incision can be
anywhere on the thorax deemed reasonable by the implanting
physician although in the preferred embodiment, the US-ICD of the
present invention will be applied in this region. The subcutaneous
pathway is created medially to the inframammary crease and extends
posteriorly to the left posterior axillary line. The pathway is
developed with a specially designed curved introducer 1742 (see
FIG. 17). The trocar has a proximal handle 1641 and a curved shaft
1643. The distal end 1745 of the trocar is tapered to allow for
dissection of a subcutaneous path in the patient. Preferably, the
trocar is cannulated having a central lumen 1746 and terminating in
an opening 1748 at the distal end. Local anesthetic such as
lidocaine can be delivered, if necessary, through the lumen or
through a curved and elongated needle designed to anesthetize the
path to be used for trocar insertion should general anesthesia not
be employed. Once the subcutaneous pathway is developed, the US-ICD
is implanted in the subcutaneous space, the skin incision is closed
using standard techniques.
[0065] As described previously, the US-ICDs of the present
invention vary in length and curvature. The US-ICDs are provided in
incremental sizes for subcutaneous implantation in different sized
patients. Turning now to FIG. 18, a different embodiment is
schematically illustrated in exploded view which provides different
sized US-ICDs that are easier to manufacture. The different sized
US-ICDs will all have the same sized and shaped thick end 1413. The
thick end is hollow inside allowing for the insertion of a core
operational member 1853. The core member comprises a housing 1857
which contains the battery supply, capacitor and operational
circuitry for the US-ICD. The proximal end of the core member has a
plurality of electronic plug connectors. Plug connectors 1861 and
1863 are electronically connected to the sense electrodes via
pressure fit connectors (not illustrated) inside the thick end
which are standard in the art. Plug connectors 1865 and 1867 are
also electronically connected to the cardioverter/defibrillator
electrodes via pressure fit connectors inside the thick end. The
distal end of the core member comprises an end cap 1855, and a
ribbed fitting 1859 which creates a water-tight seal when the core
member is inserted into opening 1851 of the thick end of the
US-ICD.
[0066] The S-ICD and US-ICD, in alternative embodiments, have the
ability to detect and treat atrial rhythm disorders, including
atrial fibrillation. The S-ICD and US-ICD have two or more
electrodes that provide a far-field view of cardiac electrical
activity that includes the ability to record the P-wave of the
electrocardiogram as well as the QRS. One can detect the onset and
offset of atrial fibrillation by referencing to the P-wave recorded
during normal sinus rhythm and monitoring for its change in rate,
morphology, amplitude and frequency content. For example, a
well-defined P-wave that abruptly disappeared and was replaced by a
low-amplitude, variable morphology signal would be a strong
indication of the absence of sinus rhythm and the onset of atrial
fibrillation. In an alternative embodiment of a detection
algorithm, the ventricular detection rate could be monitored for
stability of the R-R coupling interval. In the examination of the
R-R interval sequence, atrial fibrillation can be recognized by
providing a near constant irregularly irregular coupling interval
on a beat-by-beat basis. A R-R interval plot during AF appears
"cloudlike" in appearance when several hundred or thousands of R-R
intervals are plotted over time when compared to sinus rhythm or
other supraventricular arrhythmias. Moreover, a distinguishing
feature compared to other rhythms that are irregularly irregular,
is that the QRS morphology is similar on a beat-by-beat basis
despite the irregularity in the R-R coupling interval. This is a
distinguishing feature of atrial fibrillation compared to
ventricular fibrillation where the QRS morphology varies on a
beat-by-beat basis. In yet another embodiment, atrial fibrillation
may be detected by seeking to compare the timing and amplitude
relationship of the detected P-wave of the electrocardiogram to the
detected QRS (R-wave) of the electrocardiogram. Normal sinus rhythm
has a fixed relationship that can be placed into a template
matching algorithm that can be used as a reference point should the
relationship change.
[0067] In other aspects of the atrial fibrillation detection
process, one may include alternative electrodes that may be brought
to bear in the S-ICD or US-ICD systems either by placing them in
the detection algorithm circuitry through a programming maneuver or
by manually adding such additional electrode systems to the S-ICD
or US-ICD at the time of implant or at the time of follow-up
evaluation. One may also use electrodes for the detection of atrial
fibrillation that may or may not also be used for the detection of
ventricular arrhythmias given the different anatomic locations of
the atria and ventricles with respect to the S-ICD or US-ICD
housing and surgical implant sites.
[0068] Once atrial fibrillation is detected, the arrhythmia can be
treated by delivery of a synchronized shock using energy levels up
to the maximum output of the device therapy for terminating atrial
fibrillation or for other supraventricular arrhythmias. The S-ICD
or US-ICD electrode system can be used to treat both atrial and
ventricular arrhythmias not only with shock therapy but also with
pacing therapy. In a further embodiment of the treatment of atrial
fibrillation or other atrial arrhythmias, one may be able to use
different electrode systems than what is used to treat ventricular
arrhythmias. Another embodiment, would be to allow for different
types of therapies (amplitude, waveform, capacitance, etc.) for
atrial arrhythmias compared to ventricular arrhythmias.
[0069] The core member of the different sized and shaped US-ICD
will all be the same size and shape. That way, during an
implantation procedures, multiple sized US-ICDs can be available
for implantation, each one without a core member. Once the
implantation procedure is being performed, then the correct sized
US-ICD can be selected and the core member can be inserted into the
US-ICD and then programmed as described above. Another advantage of
this configuration is when the battery within the core member needs
replacing it can be done without removing the entire US-ICD.
[0070] Post-shock bradycardia is a common after-effect of shocking
the heart for cardioversion/defibrillation therapy. Symptoms
related to low blood pressure may result from post-shock
bradycardia whenever the heart rate falls below approximately 30 to
approximately 50 beats per minute. Accordingly, it is often
desirable to provide anti-bradycardia pacing to correct the
symptoms resulting from bradycardia.
[0071] To ensure adequate pacing capture of the heart through a
subcutaneous only lead system, pacing therapy can be considerably
enhanced (i.e., require less energy and voltage) by using either a
monophasic or a biphasic waveform for pacing.
[0072] FIG. 19 is a graph that shows an embodiment of the example
of a biphasic waveform for use in anti-bradycardia pacing
applications in subcutaneous implantable
cardioverter-defibrillators ("S-ICD") in an embodiment of the
present invention. As shown in FIG. 19, the biphasic waveform is
plotted as a function of current versus time.
[0073] In an embodiment, the biphasic waveform 1902 comprises a
positive portion 1904, a negative portion 1906 and a transition
portion 1908. In an embodiment, both the positive portion 1904 and
the negative portion 1906 are substantially rectangular in shape.
The positive portion 1904 of the biphasic waveform 1902 comprises
an initial positive current 1910, a positive fixed current 1912 and
a final positive current 1914. The negative portion 1906 of the
biphasic waveform 1902 comprises an initial negative current 1916,
a negative fixed current 1918 and a final negative current 1920. In
an embodiment, the polarities of the biphasic waveform 1902 can be
reversed such that the negative portion 1906 precedes the positive
portion 1904 in time.
[0074] As shown in FIG. 19, the biphasic waveform 1902 is initially
at zero current. Upon commencement of the anti-bradycardia pacing,
a current of positive polarity is provided and the biphasic
waveform 1902 rises to the initial positive current 1910. Next, the
current of the biphasic waveform 1902 remains at a constant level
along the positive fixed current 1912. The positive portion 1904 of
the biphasic waveform 1902 is then truncated and a negative current
is provided. The biphasic waveform 1902 then undergoes a relatively
short transition portion 1908 where the current is approximately
zero. Next, the biphasic waveform 1902 is increased (in absolute
value) in the opposite (negative) polarity to the initial negative
current 1916. After reaching its maximum negative current (in
absolute value), the current of the biphasic waveform 1902 remains
at a constant level along the negative fixed current 1918. After
the negative portion 1906 of the biphasic waveform 1902 is
truncated at the final negative current 1914, the biphasic waveform
1902 returns to zero.
[0075] The total amount of time that the biphasic waveform 1902
comprises is known as the "pulse width." In an embodiment, the
pulse width of the biphasic waveform can range from approximately 1
millisecond to approximately 40 milliseconds. The total amount of
energy delivered is a function of the pulse width and the absolute
value of the current.
[0076] An example of one embodiment of the biphasic waveform 1902
will now be described. In this embodiment, the amplitude of the
initial positive current 1910 can range from approximately one to
approximately 250 milliamps. Similarly, the amplitude of the
initial negative current 1916 can range from approximately one to
approximately 250 milliamps.
[0077] In the example, the pulse width of the biphasic waveform
1902 can range from approximately 1 millisecond to approximately 40
milliseconds. In addition, the implantable
cardioverter-defibrillator employs biphasic anti-bradycardia pacing
at rates of approximately 20 to approximately 120 stimuli/minute
for severe bradycardia episodes although programming of higher
pacing rates up to 120 stimuli/minute is also possible.
[0078] FIG. 20 is a graph that shows an embodiment of the example
of a monophasic waveform for use in anti-bradycardia pacing
applications in subcutaneous implantable
cardioverter-defibrillators ("S-ICD") in an embodiment of the
present invention. As shown in FIG. 20, the monophasic waveform is
plotted as a function of current versus time.
[0079] In an embodiment, the monophasic waveform 2002 comprises an
initial positive current 2004, a positive fixed current 2006 and a
final positive current 2008. In an embodiment, the monophasic
waveform 2002 is substantially rectangular in shape. In an
embodiment, the polarities of the monophasic waveform 2002 can be
reversed such that the waveform 2002 is negative in polarity.
[0080] As shown in FIG. 20, the monophasic waveform 2002 is
initially at zero current. Upon commencement of the
anti-bradycardia pacing, a current of positive polarity is provided
and the monophasic waveform 2002 rises to the initial positive
current 2004. Next, the current of the monophasic waveform 2002
remains at a constant level along the positive fixed current 1906.
The monophasic waveform 2002 is then truncated.
[0081] The total amount of time that the monophasic waveform 2002
comprises is known as the "pulse width." In an embodiment, the
pulse width of the monophasic waveform can range from approximately
1 millisecond to approximately 40 milliseconds. The total amount of
energy delivered is a function of the pulse width and the absolute
value of the current.
[0082] An example of one embodiment of the monophasic waveform 2002
will now be described. In this embodiment, the amplitude of the
initial positive current 2004 can range from approximately one to
approximately 250 milliamps.
[0083] In the example, the pulse width of the monophasic waveform
2002 can range from approximately 1 millisecond to approximately 40
milliseconds. In addition, the implantable
cardioverter-defibrillator employs monophasic anti-bradycardia
pacing at rates of approximately 20 to approximately 120
stimuli/minute for severe bradycardia episodes although programming
of higher pacing rates up to 120 stimuli/minute is also possible.
In order to maintain these rates, in one embodiment of the
invention, the power supply continues to operate to maintain a
sufficient voltage to deliver a constant current.
[0084] Although it possible for the present invention to provide
standard VVI pacing at predetermined or preprogrammed rates, one
embodiment provides anti-bradycardia pacing only for bradycardia or
post-shock bradycardia. To avoid frequent anti-bradycardia pacing
at 50 stimuli/minute but to provide this rate in case of
emergencies, a hysteresis detection trigger can be employed at
lower rates, typically in the range of approximately 20 to
approximately 40 stimuli/minute. For example, a default setting may
be set at approximately 20 stimuli/minute (i.e., the equivalent of
a 3 second pause), and the invention providing VVI pacing at a rate
of approximately 50 stimuli/minute only when such a pause occurs.
In another embodiment, the invention can provide physiologic pacing
in a VVIR mode of operation in response to a certain activity,
respiration, pressure or oxygenation sensor.
[0085] The S-ICD and US-ICD devices and methods of the present
invention may be embodied in other specific forms without departing
from the teachings or essential characteristics of the invention.
The described embodiments are therefore to be considered in all
respects as illustrative and not restrictive, the scope of the
invention being indicated by the appended claims rather than by the
foregoing description, and all changes which come within the
meaning and range of equivalency of the claims are therefore to be
embraced therein.
* * * * *