Half a century of continuous pacing: a living witness to the evolution of a technology

To chart the development of pacing technology and its pitfalls we present the experience of a patient who has benefitted from it but also suffered as a result of it from its earliest days. A 53-year-old physician was referred to us with obstruction of the superior and inferior vena cava on a background of more than 50 years of continuous ventricular pacing and 24 previous pacemaker-related interventions. In a single surgical procedure, his existing pacing system and redundant leads were extracted, the superior vena cava was reconstructed, and a new biventricular pacing system with epicardial leads was implanted. Pacemakers can maintain life and preserve the quality of life for many decades. The quality of this therapy has improved due to advances in the technology and in techniques. Maintaining safe pacing in the very long term requires labour, patience, and ingenuity.

Cardiopulmonary resuscitation: from the beginning to the present day

Cardiac arrest represents a dramatic event that can occur suddenly and often without premonitory signs, characterized by sudden loss of consciousness and breathing after cardiac output ceases and both coronary and cerebral blood flows stop. Restarting of the blood flow by cardiopulmonary resuscitation potentially re-establishes some cardiac output and organ blood flows. This article summarizes the major events that encompass the history of cardiopulmonary resuscitation, beginning with ancient history and evolving into the current American Heart Association's commitment to save hearts.

Past and future aspects of clinical electrophysiology

The diagnosis and treatment of clinical electrophysiology has a long and fascinating history. From the earliest time, no clinical symptom impressed the patient (and the physician) more than an irregular heart beat. Although ancient Chinese pulse theory laid the foundation for the study of arrhythmias and clinical electrophysiology in the 5th century BC, the most significant breakthrough in the identification and treatment of cardiac arrhythmias first occurred in this century. In the last decades, our knowledge of electrophysiology and pharmacology has increased exponentially. The enormous clinical significance of cardiac rhythm disturbances has favoured these advances. On the one hand, patients live longer and thus are more likely to experience arrhythmias. On the other hand, circulatory problems of the cardiac vessels have increased enormously, and this has been identified as the primary cause of cardiac rhythm disorders. Coronary heart disease has become not just the most significant disease of all, based on the statistics for cause of death. Arrhythmias are the main complication of ischemic heart disease, and they have been directly linked to the frequent arrhythmogenic sudden death syndrome, which is now presumed to be an avoidable "electrical accident" of the heart. A retrospective look--often charming in its own right--may not only make it easier to sort through the copious details of this field and so become oriented in this universe of important and less important facts; it may also assist the observer in a chronological vantage point of the subject. The study of clinical electrophysiology is no dry compendium of facts and figures, but rather a dynamic field of study evolving out of the competition between various ideas, intentions and theories.

Electricity and the heart

Understanding of cardiac rhythm requires application of physical principles governing electricity. Over a period of more than 100 years, application of the knowledge of electric current led to the gradual evolution of electrocardiogram, pacemaker, defibrillator, and ultimately electrophysiology. The discovery of electrocardiogram (ECG) by Einthoven in 1902 and that of pacing by Zoll in 1952 were two landmarks in this field.

[Pacemaking in Cracow in years 1966-1980]

Permanent pacemaking, a new and effective bradycardia--treatment method, has appeared in the sixties. In Cracow the first emergency temporary stimulation by means of transvenously inserted intracardiac electrode was performed in 1966. Permanent technique of artificial pacing was introduced soon after. The number of pacemaker implantations grew successfully, obtaining 750 of the end of the seventies when the Institute of Cardiology of Nicolaus Copernicus Medical Academy was established. Assortment of implantable devices also became wider, including such rare constructions like nuclear pacemakers and an inductive coupled pacemaker.

History of cardiac rhythm disorders

The history of cardiac rhythm disorders including antiarrhythmic drugs and electrotherapeutical tools is long and fascinating. In the beginning, there was not simply the anatomy and physiology of the heart, but also analysis of the pulse, which indicates the activity of the heart. Thus, like any other field of medicine, the study of arrhythmias has a distinctive past. Our current level of knowledge is not the result of a straight, linear progression any more than there is a static, established, monolithic body of thought dominating this field. Instead, our knowledge of arrhythmias today is the result of many competitive, sometimes serendipitous, scientific realizations, of which a few proved useful enough to pursue and eventually led to real advancements. Looking at the worldwide development of rhythmology it can be said that considerable contributions came from Germany in the last few centuries. Arrhythmology--past, present and future--includes clearly German investigators as pioneers of the field. The growing clinical importance of electric cardiac stimulation has been recognized and renewed as Zoll in 1952 described a successful resuscitation in cardiac standstill by external stimulation. The concept of a fully automatic implantable cardioverter-defibrillator system for recognition and treatment of ventricular flutter/fibrillation was first suggested in 1970. The first implantation of the device in a human being was performed in February 1980. By early 1997, 17 years after the first human implantation more than 100,000 ICD systems had been implanted worldwide. Further developments concern new pharmacological compounds, modern cardioverter-defibrillators, radiofrequency ablation, particularly pulmonary vein ablation in atrial fibrillation, innovative pacemakers including preventive pacing techniques, probably laser therapy and perhaps the automatic implantable pharmacological defibrillator. The advances in the field of therapeutic application of pharmacologic and electrical means as well as alternative methods will continue as rapidly as before in order to give us further significant aid in taking care of the patient.

Are engineers unsung heroes of medical progress?: the historic bond between physics, engineering, and medicine

This review traces the heretofore unsung hero role of engineering in the evolution of today's healthcare and the growing bond between physics, engineering, and medicine. It recognizes the debt owed to the various specialties of healthcare engineering, especially the bioengineers who contribute not only to a better understanding of basic physiologic and pathologic processes but also to the development and application of technology and the adaptation of new engineering discoveries to medicine. In the past half-millennium, the fields of physics, engineering, and medicine have made a large number of seminal contributions to each other, resulting in ever-advancing healthcare methodologies, although only a precious few remain identified by the originators' names. In this review, 3 engineers are cited in detail for their milestone contributions to medical progress: Roentgen in radiology, Bovie in electrosurgery, and, more recently, Greatbatch in implantable cardiac pacemakers. Future horizons in medicine appear to be ever more attainable because of the synergism between the physical and biological sciences.

Present status of cardiac pacing: a nursing perspective

In this article, we focus on the nurse's role as caregiver and patient advocate for individuals requiring cardiac pacing. The history of cardiac pacing, new trends, indications for pacing, pacemaker dysfunction and complications, types of pacing, and nursing considerations will be discussed.

Pacing and ICD therapy in Germany (West and East) before and after reunification in 1989

In 1989 the two German countries, FRG and GDR, were reunited after 50 years of political separation. During this time, these countries underwent independent, and in parts quite different, developments. While the reunification has had less effect on the overall situation in the Western part of the country, the Eastern part has experienced considerable changes, including the health service. In the field of pacing and ICD therapy, this study finds that 8 years after the reunification, the German federal states of both parts of the country have converged in the field of pacing and ICD therapy.

Antitachycardia pacing: an overview

Ventricular tachycardia is the most common life-threatening tachyarrhythmia seen in patients with structural heart disease. In the past 10 years, many thousands of lives have been saved by the addition of the implantable cardioverter-defibrillator to the armamentarium of treatment options. Yet, despite the success of these devices in the prevention of sudden cardiac death, many patients felt that the psychological cost was too high. Loss or restriction of some of the most basic activities such as driving and working and not knowing when they would receive the life-saving but painful shock took a toll on patients' perceptions of the quality of their lives. When antitachycardia pacing was demonstrated to provide about half of these patients a life-saving, yet comfortable, means of controlling episodes of ventricular tachycardia, physicians and patients were eager to try it. None of the many ways to provide antitachycardia pacing has proved overwhelmingly more effective than the others. This paper describes and illustrates each type of antitachycardia pacing and demonstrates their programmed parameters. Several clinical case illustrations are included.

Two unsung heroes of closed-chest cardiac pacing: Green and McWilliam

In the latter half of the last century, cardiorespiratory arrest was not uncommon due to the anesthetic used (chloroform). Animal studies showed that the heart could be paced. One physician (Green) resuscitated 5 of 7 cardiac arrest patients with single stimuli applied to body surface electrodes. Another (McWilliam) issued a proposal for adoption of closed-chest pacing and provided information on the procedure. The following historical footnote describes these pioneering events in the history of cardiac pacing.

A brief history of cardiac pacing

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The next step in cardiac pacing: the view from 1958

At a 1-day conference sponsored by the Rockefeller Institute in September 1958, physicians and engineers held a confused debate over future directions for the young field of cardiac pacing. Many of the existing impediments to long-term pacing for chronic illness received little attention; the participants focused instead on whether atrial synchrony would be a requirement for long-term pacing. The Rockefeller conference illustrates the observation that cardiac pacing has undergone several major redefinitions. This process is rarely a smooth one but involves uncertainty, intense debate, and explicit choice.

Artificial cardiac pacemakers

Artificial pacemakers are electronic devices used primarily to control cardiac rate in patients in whom the intrinsic heart rate is inadequate for a normal life style. These devices automatically and rhythmically provide electrical impulses to stimulate the heart. Electrical stimulation of various organs of the human body was already in practice more than two centuries ago. These applications, however, were in experimental stages until recently when electrical stimulation of the heart has emerged as a new therapy. In view of the astonishing progress made in the field of pacemaker technology and the current indications for the specific types of pacing systems, it behooves physicians caring for patients with heart disease to become familiar with the use of cardiac pacemakers and the not infrequent problems associated with their use. The primary purpose of this review is to present fundamental knowledge in the electrical stimulation of the heart and the various pacing systems available.

Transvenous pacing: a seminal transition from the research laboratory

In the late 1950s, nonsurgical catheter therapies for the treatment of various disorders did not exist, although surgery was at its highest level of development in the classic sense: extirpation of organs, incision and drainage, diagnostic biopsy. Today we live in an era of diagnostic and therapeutic methods based on catheters: observation, aspiration, drainage, stretching, and manipulation by means of relatively atraumatic tubes. The development of catheter techniques has spawned undreamed-of specialties, industries, and professional societies. Although catheters had been used before then in research laboratories, Furman's clinical application of electrode-tipped venous catheters in treating patients with complete heart block and Stokes-Adams seizures represents a turning point. This advance may be regarded as the catalytic and seminal event for the growth of catheter technologies, which are so prominent in the world of medicine today, and their application to many fields of medicine and surgery.

Transesophageal pacing and electrocardiography in the neonate: diagnostic and therapeutic uses

Transesophageal pacing and electrocardiography have important diagnostic and therapeutic uses in the neonate. Electrode placement is simple, and transesophageal ECG recording may be accomplished using available ECG recorders. Transesophageal pacing requires a special stimulator to administer stimulus pulses of 10 msec duration. Transesophageal ECG aids in establishing specific electrophysiologic Transesophageal ECG aids in establishing specific electrophysiologic diagnosis in neonates with rhythm disturbances. Transesophageal pacing is useful for treatment of atrial bradycardia as well as for cardioversion of a variety of tachycardias. There have been no serious long-term complications reported from use of transesophageal pacing and electrocardiography.

25 years of implanted intracardiac pacers

In 1962, a simplified method of transvenously inserting an intracardiac electrode and implanting the whole pacemaker system under local anaesthesia was reported from the Karolinska Hospital in Stockholm. This simplified method has been universally adopted and pacemakers are now probably implanted too freely in many places. In the Stockholm area pacemakers are implanted half as frequently as in the rest of Sweden and as often as in the United Kingdom.

[20-year experience with continuous endocardial stimulation of the heart]

Twenty years' experience with continuous endocardial stimulation of the heart is summed up. The bulk of the reviewed data falls to the period of 1980 through 1985, when 1776 primary implantations were performed, whereas more than 3,000 implantations have been performed in the past 6 years. Opinions are voiced on many aspects related to endocardial stimulation. Endocardial application of electrodes is believed to be the principal method, while myocardial stimulation should only be done simultaneously with heart surgery. Electrode application via puncture is discussed with special reference to its advantages (possible application of two electrodes at once, small cosmetic defect) and possible side effects. The results obtained with a borer electrode, designed by the authors, are reported (130 cases). Complications associated with developing rhythm competition are discussed. It is proposed that the manufacture of asynchronous pacemakers be limited considerably, and that they should mostly be implanted in cases of clinically manifest myopotential inhibition.