Preface

Clinical usage of artificial pacing with the aid of implantable devices dates back to 1958, when battery-powered cardiac pacemakers became available. Modern implantable pacemakers are complex self-controlled electronic devices operating 10–12 years continuously without battery exchange. Although the design of devices is not a primary topic of this book, their development has been addressed through a historical overview from the late 1950s up until the variety of modern-day equipment.

Most attention is paid to the selection of pacing and monitoring devices for implementation in different medical situations. The discussion is oriented toward specifying the clinical indications for implanting the most appropriate cardiac device from the selection of suitable equipment.

Indications for using the most appropriate models of cardiac pacemakers, cardiac resynchronization therapy devices, and implantable cardioverter defibrillators (ICDs) are of interest, paying special attention to the leadless versions of the devices. The contraindications of patients' different health conditions are taken into account carefully. Placing of leads and pacing electrodes has been treated soundly, but particular attention is paid to using leadless devices. For example, the subcutaneous ICD obviates the need for trouble-making transvenous leads and leadless pacemakers are entirely implantable into the right ventricle. Finally, applications of user-friendly wearable devices for the detection and analyses of atrial arrhythmia are discussed.

The authors have derived useful information from both their own clinical practice and the experiences of their close colleagues. Practical knowledge and scientific basics related to pragmatic issues are the most valuable assets of this book.

> **Mart Min** Tallinn University of Technology, Estonia

**1**

**Chapter 1**

*Mart Min*

**1. Early pacemakers**

Developments

Introductory Chapter: From

Basic Foundations to Future

than 20 pacemakers in the 43 years following the first implantation.

inductively by a 150 kHz radio frequency current generated externally.

from Kiwi with a diameter 55 mm and thickness of 16 mm as a mold.

(later founder of the company CCC del Uruguay, now Integer) implanted a pacemaker designed by Dr. Rune Elmqvist and produced by Elema-Schönander (Sweden), in Uruguay on February 2, 1960, together with Dr. Roberto Rubio. In parallel, Earl E. Bakken (1914–2018), an electrical engineer and co-founder of the company Medtronic in 1949 in Minneapolis, USA, made a transistor-based blocking oscillator for the first battery-operated wearable pacemaker (1957). Famous doctor C. Walton Lillehei (1918–1999) from the University of Minnesota, "the father of open chest surgery," took the device into medical use in 1958. This pacemaker became known as the Medtronic Cardiac Pacemaker 5800 (produced in 1958). The chosen pacemaker output was a 2 ms square wave, variable in amplitude from 1 to 20 mA into a 1000 Ω load, which gives from 1 to 20 V. The pacing rate was variable from 60 to 180 pulses per minute. Meanwhile, Dr. Lillehei and his co-workers developed the myocardial wire (1957) for the implanting of pacemakers:

Dr. Rune Elmqvist (1906–1996), a physician working for the Swedish company Elema-Schönander (later a part of Siemens) as an engineer, developed the first implantable pacemaker. Dr. Elmqvist developed the device in cooperation with Åke Senning (1915–2000), a senior physician and cardiac surgeon at the Hospital of Karolinska Institute in Solna near Stockholm [1]. Their first patient, Arne Larsson (1915–2001), underwent secret emergency surgery to implant his first pacemaker on October 8, 1958, just in the middle of his lifetime. The role of his wife Else-Marie was important. She persuaded the scientists to make the surgery, though they strongly refused, initially. Finally, it was an officially unacceptable prank, made under the pressure of female power! Later Arne Larsson went on to receive more

The pacemaker contained a single transistor-based blocking pulse oscillator which delivered pacing impulses at an amplitude of 2 V and a pulse width of 1.5 ms through a transistor buffer. The frequency of pulse sequence was set to have a constant rate pacing of 70 beats per minute. The energy utilized by a totally twotransistor electronic circuit from a nickel-cadmium battery was minimal since Elmqvist managed to obtain a few of the first silicon transistors produced by Texas Instruments, USA. Recharging of the battery once a week for 12 h was accomplished

Dr. Elmqvist produced two of such handmade units encapsulated in a new epoxy resin (Araldite), which had excellent biocompatibility. He used a shoe polish can

After being a young trainee of Dr. Åke Senning in Sweden, Dr. Orestes Fiandra

#### **Chapter 1**
