U.S. patent number 3,877,438 [Application Number 05/440,621] was granted by the patent office on 1975-04-15 for pacer with self-adjusting output.
This patent grant is currently assigned to American Optical Corporation. Invention is credited to Robert L. Cannon.
United States Patent |
3,877,438 |
Cannon |
April 15, 1975 |
PACER WITH SELF-ADJUSTING OUTPUT
Abstract
There is disclosed an implantable pacer, the characteristics of
whose output pulses change automatically after the pacer has
generated a predetermined number of pulses. The pacer includes a
charge-dependent resistor whose impedance increases in accordance
with the total current flow through it. After a predetermined
number of pulses have been generated, the impedance increases
relatively abruptly. The increase in impedance controls a decrease
in the amplitude and/or decrease in the width of subsequent
pulses.
Inventors: |
Cannon; Robert L. (Waltham,
MA) |
Assignee: |
American Optical Corporation
(Southbridge, MA)
|
Family
ID: |
23749498 |
Appl.
No.: |
05/440,621 |
Filed: |
February 7, 1974 |
Current U.S.
Class: |
607/11 |
Current CPC
Class: |
A61N
1/365 (20130101) |
Current International
Class: |
A61N
1/365 (20060101); A61n 001/36 () |
Field of
Search: |
;128/419P,421,422,2.6R
;323/25 |
References Cited
[Referenced By]
U.S. Patent Documents
Primary Examiner: Kamm; William E.
Attorney, Agent or Firm: Wall; Joel Nealon; W. C.
Berkenstock, Jr.; Howard R.
Claims
What I claim is:
1. A heart pacer comprising electrode means for connection to a
patient's heart, pulser means for generating and applying
stimulating pulses to said electrode means, timing means for
controlling the generation of stimulating pulses by said pulser
means in timed sequence, means for measuring the number of
stimulating pulses generated by said pulser means, means responsive
to said measuring means for controlling said pulser means to change
a characteristic of subsequently generated pulses, said measuring
means including a coulometer device having a characteristic which
is a function of the total current which flowed through it, means
for causing a current to flow through said coulometer device
whenever said pulser means generates a stimulating pulse, said
pulser means comprising two capacitors connected in parallel for
furnishing a current pulse to said electrode means, said coulometer
device being connected in series with one of said capacitors, and
said measuring means including means for allowing a current flow in
only one direction through said coulometer device.
2. A heart pacer in accordance with claim 1 wherein said coulometer
device includes means for inhibiting current by said one capacitor
to said electrode means after a predetermined total current has
flowed therethrough.
3. A heart pacer in accordance with claim 2 wherein said
controlling means includes means for causing the amplitude of the
stimulating pulses generated by said pulser means to decrease as
the total number of stimulating pulses generated by said pulser
means increases, until the amplitude reaches a predetermined
magnitude.
4. A heart pacer in accordance with claim 3 wherein said
controlling means includes further means for decreasing the width
of the stimulating pulses generated by said pulser means as the
total number of stimulating pulses generated by said pulser means
increases.
5. A heart pacer in accordance with claim 1 wherein said
controlling means includes means for causing the amplitude of the
stimulating pulses generated by said pulser means to decrease as
the total number of stimulating pulses generated by said pulser
means increases, until the amplitude reaches a predetermined
magnitude.
6. A heart pacer in accordance with claim 5 wherein said
controlling means includes further means for decreasing the width
of the stimulating pulses generated by said pulser means as the
total number of stimulating pulses generated by said pulser means
increases.
7. A heart pacer in accordance with claim 1 wherein said
controlling means includes further means for decreasing the width
of the stimulating pulses generated by said pulser means as the
total number of stimulating pulses generated by said pulser means
increases.
Description
This invention relates to implantable pacers, and more particularly
to a pacer whose output pulse characteristics change automatically
shortly after the pacer is implanted in a patient.
It has been established that the stimulus required from a heart
pacer is greatest during approximately the second week following
implantation. The excitation threshold (the current magnitude
required to stimulate the patient's heart) increases during the
first week, remains relatively constant during the second week and
then drops during the third week. The excitation threshold after 3
or 4 weeks is only approximately 25% of the maximum value. Prior
art pacers are designed to stimulate at the level required during
the interval of minimum excitability.
There are several disadvantages in providing stimulating pulses of
excess magnitude after approximately the first 3 or 4 weeks of
pacer operation. Not only is there more tissue damage at the site
of stimulation than would otherwise be necessary, but the increased
power consumption necessarily decreases the pacer life. Also, in
the case of a pacer which is operated in the continuous mode (or in
the case of a demand pacer in which the sensing amplifier has
failed), that is, where stimulating pulses are generated at
periodic intervals regardless of whether spontaneous beats are
occurring, there is a greater possibility of competition between
natural heartbeats and pacerstimulated heartbeats than there would
be were the pacer pulses of smaller magnitude; this, in turn,
increases the possibility of ventricular fibrillation.
It is a general object of my invention to provide a pacer in which
the pulse characteristics change automatically at some time
following implantation. More specifically, it is an object of my
invention to provide a pacer in which the magnitude of the pacer
pulses and/or the width of the pacer pulses decrease automatically
following the generation of the predetermined number of such
pulses.
Briefly, in accordance with the principles of my invention, I
provide a coulometer device such as an "E-cell" whose impedance
changes in accordance with the total current which flows through
it. The current which flows through the coulometer device
incorporated in the pacer of my invention equals the sum of a fixed
fraction of the current pulses delivered to the patient's heart. As
more and more current flows through the device, eventually there is
a relatively abrupt change in impedance. This change in impedance
is used to control a decrease in the magnitude of the pacer pulse.
The change in impedance can also be used to control other
characteristics of the pacer or the pacer pulses, e.g., a decrease
in the pacer pulse width since a narrower pulse can usually be
tolerated after the pacer has been implanted for several weeks.
Further objects, features and advantages of my invention will
become apparent upon consideration of the following detailed
description in conjunction with the drawing, in which:
FIG. 1 depicts a prior art pacer circuit;
FIG. 2 depicts the manner in which the pacer of FIG. 1 is modified
in accordance with the principles of my invention;
FIG. 3 is a plot of the heart pacing threshold current as a
function of time; and
FIG. 4 is a plot of the pacer pulse amplitude as a function of time
for the pacer of FIG. 2.
FIG. 1 depicts a conventional prior art demand pacer of the type
which can be modified in accordance with the principles of my
invention. Only those parts of the pacer circuit which are required
for an understanding of the present invention are shown in detail.
A pacer of this type is disclosed in detail, for example, in
Berkovits application Ser. No. 214,218 filed on Dec. 30, 1971, and
issued on Sept. 11, 1973 as U.S. Pat. No. 3,757,791, and entitled
"Synchronized Atrial And Ventricular Pacer." (Although the pacer
disclosed in the Berkovits application provides a atrial
stimulation as well as ventricular stimulation, if the circuitry
required for atrial stimulation is omitted, what is left is a
demand pacer for ventricular stimulation of the type depicted in
FIG. 1.) Although the invention is described in the context of a
demand pacer, it will be apparent that the invention is equally
applicable to a pacer of the continuous type.
The pacer is powered by a power source 14 (typically, 5 cells
connected in series). Following the generation of a pacer pulse,
current flows from the source through resistor 32, capacitor 38,
electrode E1, the patient's heart, and electrode E2 to "ground"
conductor 18. The current is low in magnitude and has no effect on
the heart. Current flows only until capacitor 38 has fully charged.
In order to generate a pacer pulse, transistor T4 is turned on, as
will be described below. At this time, capacitor 38 discharges
through the transistor, the two electrodes and the patient's heart
in order to stimulate a ventricular beat. When transistor T4 turn
off, the capacitor charges once again in preparation for another
cycle.
Capacitor 24 controls the timing of the pacer pulses. Current flows
from the source through resistors 28 and 26, the capacitor, and
resistors 34 and 36. Transistors T2 and T3 are arranged in a
standard configuration, with the base of transistor T2 being
connected to a reference voltage. The reference voltage is shown as
being derived from a reference source 30; the details of the
reference source are not important for the purposes of the present
invention. When capacitor 24 has charged to a level sufficient to
control conduction in transistors T2 and T3, these transistors turn
on and the capacitor discharges through the transistors and
resistor 26. The transistors turn off as soon as the capacitor has
discharged. While the transistors remain on, current flows from
source 14 through resistor 28, transistors T2 and T3, and resistors
34 and 36. The positive potential developed across resistor 36
causes transistor T4 to turn on so that a stimulating pulse can be
generated.
In the absence of the turning on of transistor T1, capacitor 24
charges and discharges continuously, with pacer pulses being
generated at a fixed rate. The inter-pulse interval is controlled
by the resistors in the charging current path. Frequently, resistor
28 is a variable impedance which is set prior to implantation. As
the impedance of this resistor is increased, it takes longer for
capacitor 24 to charge to the firing level of transistors T2 and
T3, and consequently pacer pulses are generated at a slower rate.
Since capacitor 24 discharges through resistor 26 and transistors
T2 and T3, and transistor T4 remains on only while transistors T2
and T3 conduct, it is apparent that the width of each pacer pulse
depends upon the magnitude of resistor 26. Frequently, resistor 26
is also a variable impedance which is set prior to implantation to
control the pacer pulse width.
Electrodes E1 and E2 are coupled via conductors 18 and 20 to QRS
detector 10. This unit, as well as interference rejection circuit
12, is powered by potential source 14. The QRS detector detects an
electrical signal on the electrodes during the spontaneous beating
of the patient's heart. When such a condition is detected, a pulse
is extended to the input of interference rejection circuit 12.
Normally, this circuit simply passes the pulse on to the base of
transistor T1, the pulse appearing across bias resistor 22. The
pulse causes transistor T1 to turn on, at which time capacitor 24
discharges through it. Since the capacitor discharges, the next
stimulating pulse which would otherwise have been generated is
inhibited, and a new timing cycle begins as soon as transistor T1
turns off and capacitor 24 starts to charge once again. The
function of interference rejection circuit 12 is to prevent the
detected pulses from being transmitted to the base of transistor T1
if such pulses occur at too fast a rate. If they do, it is an
indication that what is being detected is some kind of "noise,"
such as stray 60 Hz, in which case pacer pulses should not be
inhibited. As long as such noise is detected, transistor T1 is not
turned on and the pacer operates in a continuous mode.
FIG. 3 depicts a plot of the heart pacing threshold current (in
milliamperes) as a function of time -- with the time axis not being
drawn to scale. As is apparent from the plot, the minimum current
required to stimulate a ventricular beat increases immediately
following implantation, remains approximately constant during the
second week, and then decreases to a minimum level. The minimum
level is approximately 25% of the maximum level. The plot varies
from patient to patient, but it is clear that after approximately 4
weeks the current threshold drops to the minimum value.
FIG. 4 depicts the amplitude of the current pulses generated in
accordance with the principles of my invention as a function of
time -- in the case of continuous pacing. The initial current level
is approximately 15 milliamperes but after approximately 4 weeks of
continuous pacing, the current level drops to approximately 4
milliamperes. The fact that current pulses with magnitudes greater
than necessary are generated during the first week of pacer
operation is of little concern; during only one week of operation,
there can be little tissue damage and little needless power
consumption. What is important, of course, is that after
approximately 4 weeks of continuous pacing, the current amplitude
decreases and remains at the lower level during the succeeding
years of operation. Also, it should be noted that the plot of FIG.
4 is based on the case of continuous pacing. As will become
apparent when the circuit of FIG. 2 is considered, the switching in
current level is dependent upon the total number of pulses which
are generated following implantation. If it is assumed that there
are approximately 100,000 pulses/day in the case of continuous
pacing, then the pacer is designed such that after approximately
2,800,000 pulses, the lower current level is achieved. In the case
of demand pacing, 2,800,000 pulses may not be generated until after
more than 4 weeks have gone by, but while the switch-over may occur
later, it still occurs after the same number of pulses have been
generated and all of the advantages of the invention are still
achieved. It should also be noted that the plot of FIGS. 3 and 4
are only approximate. To be on the safe side, the pacer may be
designed to switch current levels after approximately 3,500,000
pulses have been generated, and the minimum current level may be
greater than 25% of the maximum current level, e.g., 35% of it.
The prior art pacer of FIG. 1 is modified as shown in FIG. 2 in the
following respects. First, instead of providing a single capacitor
38, two capacitors 38-1 and 38-2 are provided. Capacitor 38-2 is
connected in series with diode 44, and these two elements are in
parallel with capacitor 38-1. In parallel with diode 44 is another
oppositely-poled diode 42 and an E-cell 40. Also, instead of
providing a single resistor 26 for determining the pulse width, two
such resistors 26-1 and 26-2 are provided. Resistor 26-1 is
connected across an additional transistor T5 whose base terminal is
coupled to the junction of diode 42 and E-cell 40.
It will be recalled that in the circuit of FIG. 1 capacitor 38 is
charged by current which flows through resistor 32, the two
electrodes and the patient's heart. In the circuit of FIG. 2,
capacitor 38-1 charges in the same way. But capacitor 38-2 also
charges at the same time, with current flowing through this
capacitor and diode 44 in parallel with the current flow through
capacitor 38-1.
Referring back to FIG. 1, it will be recalled that when transistor
T4 is turned on, capacitor 38 discharges through the transistor,
the two electrodes and the patient's heart. When transistor T4 is
turned on in the circuit of FIG. 2, capacitor 38-1 discharges in
the same way. But now capacitor 38-2 discharges as well, the
current flowing through the transistor, the two electrodes and the
patient's heart, diode 42 and E-cell 40. A fixed fraction of the
sum of the pacer pulses thus flows through the E-cell.
The E-cell is a coulometer device; one of its characteristics
changes in accordance with the total charge (current) which flows
through it. In the case of an E-cell, the total current which flows
through the cell is "remembered," and after a predetermined total
current has passed through the cell, the cell impedance changes.
The change is more or less abrupt, but even if the change is
gradual, that has little effect on the circuit operation. As the
impedance builds up (e.g., from a few ohms to a few hundred
thousand ohms), capacitor 38-2 discharges to a lesser extent
whenever a stimulating pulse is generated, because the time
constant of the discharge path for capacitor 38-2 includes the
E-cell. Eventually, the impedance of this device increases to a
level for which capacitor 38-2 cannot discharge to any appreciable
extent during the time that transistor T4 is on. Consequently, when
the pacer is first implanted, both capacitors discharge through the
transistor and a large-magnitude current pulse is achieved. As more
and more pulses are generated, capacitor 38-2 is eventually taken
out of the circuit operation.
The reason for providing two diodes 42 and 44 should be noted. If
the E-cell is simply placed in series with capacitor 38-2, equal
currents would flow through the E-cell during each complete
charging/discharging cycle of capacitor 38-2. Since an E-cell is
"reversible" and functions to subtract charge as well as to add it,
the net effect would be that the characteristics of the cell would
not change. If is for this reason that separate charging and
discharging paths are provided; the two diodes steer the charging
and discharging currents along two different paths. It is only when
capacitor 38-2 discharges that any current flows through the
E-cell.
It would be possible to include the E-cell in series with diode 44
rather than diode 42, in which case the E-cell characteristics
would be changed in accordance with the charging current. However,
this is not the preferred position for the cell because even when
the cell has a very large magnitude, capacitor 38-2 would still
eventually charge -- albeit at a very slow rate. This, in turn,
would result in some of the pacer pulses being excessively large
since capacitor 38-2 would discharge through transistor T4 and
diode 42 occasionally. In order to prevent occasional large pulses,
it is preferable to place the E-cell in series with diode 42; even
though capacitor 38-2 can charge rapidly through diode 44, the
capacitor cannot discharge to any significant extent during the
short time interval (typically 0.5-4 milliseconds) that transistor
T4 conducts.
In the actual manufacture of a pacer, a value for capacitor 38-1
should be selected which provides the proper level pulses after the
coulometer device has changed state. Capacitor 38-2 should then be
chosen so that the additional current provided by it insures that
the maximum level pulses are achieved during the first few weeks of
pacing. It is important that the E-cell not change state before
approximately 2,800,000 pulses have been generated. Rather than to
rely on published specifications for coulometer devices, it is
preferable to charge the E-cell until it is in a state of high
impedance. Thereafter, pulses from a capacitor equivalent to
capacitor 38-2 can be passed through the E-cell in a direction
opposite to that in which diode 42 is poled. This can be
accomplished by placing a pulsing source directly across the
E-cell. Each such pulse subtracts from the total charge
accumulation in the cell, and after 2,800,000 pulses have been
generated, 2,800,000 pacer pulses will have to be generated before
the E-cell switches from the low impedance state to the high
impedance state. This, however, is merely a preferred manufacturing
technique, and is not essential to the method of making pacers.
The combined impedance of resistors 26-1 and 26-2 equals the
impedance of resistor 26 in the circuit of FIG. 1. Initially,
transistor T5 is held off and capacitor 24 discharges through the
two resistors in series. Thus, the initial pacer pulse width in the
circuit of FIG. 2 is the same as the pacer pulse width in the
circuit of FIG. 1. The gate of transistor T5 is connected to the
junction of the E-cell and diode 42, and since initially the E-cell
has no voltage across it, transistor T5 remains off.
But as pacer pulses are generated and the charge on the E-cell
accumulates, the voltage across the cell rises. The voltage reaches
the maximum level when the E-cell reaches the high impedance state.
At this time, the increased potential on the gate of transistor T5
causes this transistor to turn on. Consequently, the pacer pulse
width is determined solely by the magnitude of resistor 26-2, and
since this resistor is lower in magnitude than the magnitude of the
two resistors in series, the pacer pulse width is shortened. If the
magnitude of resistor 26-1 is several times greater than the
magnitude of resistor 26-2, the pacer pulse width may be decreased,
for example, from 2 milliseconds to 0.5 milliseconds. The use of
the coulometer device to decrease the pacer pulse width, at the
same time that the pulse current level is reduced, is only one
example of the manner in which a pacer characteristic may be
changed automatically after a predetermined number of pulses have
been generated or after a predetermined time period has elapsed
following implantation.
Although the invention has been described with reference to a
particular embodiment, it is to be understood that this embodiment
is only illustrative of the application of the principles of the
invention. For example, pacer pulse width shortening may be
provided without significant amplitude reduction by making
capacitor 38-2 much smaller than capacitor 38-1. Thus it is to be
understood that numerous modifications may be made in the
illustrative embodiment of the invention and other arrangements may
be devised without departing from the spirit and scope of the
invention.
* * * * *