Physiologically responsive pacemaker and method of adjusting the pacing interval thereof

• US 4,712,555 A
• Filed: 03/27/1985
• Issued: 12/15/1987
• Est. Priority Date: 10/19/1984
• Status: Expired due to Term

• Current Assignee: Pacesetter AB
• Original Assignee: Siemens-Elema AB (Siemens AG)
• Inventors: Sholder, Jason A., Thornander, Hans T., Thacker, James R., Poore, John W., Amundson, David C.
• Primary Examiner(s): Kamm, William E.
• Application Number:
  US06/716,831
• Time in Patent Office: 993 Days
• Field of Search: 128/419 PG, 128/419 PT
• US Class Current: 607/17
• CPC Class Codes: A61N 1/365 controlled by a physiological parameter, e.g. heart potential evoked response A61N1/371
• CPC Class Codes: A61N 1/368 comprising more than one electrode co-operating with different heart regions A61N1/3622, A61N1/3627 take precedence
• CPC Class Codes: A61N 1/3712 Auto-capture, i.e. automatic adjustment of the stimulation threshold
• CPC Class Codes: A61N 1/3714 Atrial capture
• CPC Class Codes: A61N 1/3716 with reduction of residual polarisation effects

Abstract

A pacemaker and physiological sensor for use therewith that allows the rate at which the pacemaker delivers electrical stimulation pulses to the heart, or the escape interval during which a natural heart event must occur before an electrical stimulation pulse is delivered, to be adjusted as needed in order to satisfy the body'"'"'s physiological needs. The sensor measures the depolarization time interval between an atrial stimulation pulse, A, and the responsive atrial or ventricle depolarization, P or R respectively, as an indication of the physiological demands placed on the heart. The time interval between a ventricular stimulation pulse, V, and the responsive ventricular depolarization, R, may also be measured and used as an indication of physiological need, and hence as an alternative criteria for rate control. Atrial depolarization is sensed by detecting a P-wave, and ventricular depolarization is preferably sensed by detecting an R-wave. A method of measuring A-P, A-R, or V-R intervals is used to ascertain if these intervals are increasing or decreasing. If, over several heart cycles or beats, an increase or decrease in these measurements is detected, the pacing interval set by the pacemaker is adjusted in an appropriate direction in order to adjust the heart stimulation rate accordingly.

Claims

1. A cardiac pacemaker for controlling the rate at which a heart beats as a function of physiological need, said heart beat rate defining a cardiac cycle during which atrial and ventricular events occur, said pacemaker comprising:

means for generating an atrial stimulation pulse (A);

means for delivering said atrial stimulation pulse to an atrium of the heart in order to trigger atrial depolarization (P);

means for sensing the occurrence of said triggered atrial depolarization;

means for measuring the time interval between the generation of said atrial stimulation pulse and said triggered atrial depolarization, said atrial depolarization time interval being referred to as an A-P interval, said A-P interval varying as a function of physiological need; and

means for adjusting the pacemaker-controlled rate as a function of the measured A-P interval;

whereby the pacemaker-controlled rate is adjusted as a function of physiological need as sensed by measuring said depolarization time interval.

2. The cardiac pacemaker of claim 1 wherein said means for adjusting the pacemaker-controlled rate as a function of the measured A-P interval includes

means for counting the number of atrial stimulation pulses generated by said atrial stimulation pulse generation means;

means for counting the occurrence of cardiac cycles; and

means for enabling the pacemaker-controlled rate adjustment means only when a prescribed number of atrial stimulation pulses, as counted by said pulse counting means, have been previously generated within a prescribed number of previous consecutive cardiac cycles, as counted by said cardiac cycle counting means.

3. The cardiac pacemaker of claim 1 wherein said triggered atrial depolarization is manifest by the occurrence of a P-wave, and wherein said sensing means includes means for sensing the occurrence of said P-wave, said P-wave having a specified detection point thereon that is used by said sensing means to sense its occurrence.

4. The cardiac pacemaker of claim 3 wherein the detection point of the P-wave comprises the trailing edge of the P-wave, the measured A-P interval therefore including the time from the generation of the atrial stimulation pulse to the trailing edge of the P-wave.

5. The cardiac pacemaker of claim 3 wherein the detection point of the P-wave comprises the peak of the P-wave, the measured A-P interval therefore including the time from the generation of the atrial stimulation pulse to the peak of the P-wave.

6. The cardiac pacemaker of claim 3 wherein the detection point of the P-wave comprises the leading edge of the P-wave, the measured A-P interval therefore including the time from the generation of the atrial stimulation pulse to the leading edge of the P-wave.

7. A cardiac pacemaker having means for generating a stimulation pulse, means for generating a pacing interval, means for controllably delivering said stimulation pulse to a heart at the conclusion of said pacing interval, and means for sensing the physiological need of the heart to be paced at a faster or slower rate, said physiological sensing means comprising:

sensing means for sensing the occurrence of a cardiac depolarization event, referred to as X, which depolarization event follows the delivery of an atrial stimulation pulse, referred to as A, to the atrium of said heart;

timing means for measuring the A-X time interval between the delivery of the stimulation pulse A to the atrium of the heart and the occurrence of the sensed cardiac depolarization event X, said A-X time interval thereby comprising the time it takes the heart to depolarize as measured from the time the stimulation pulse is delivered to the heart, said A-X time interval further representing a measured parameter that varies as a function of the physiological need of the heart to beat at a faster or slower rate; and

means for controllably adjusting the pacing interval of the pacemaker as a function of the A-X time interval measured by said timing means, whereby stimulation pulses are controllably delivered to the heart at a rate that corresponds to the physiological need of the heart to beat at a faster or slower rate.

8. The cardiac pacemaker of claim 7 wherein said means for controllably adjusting the pacing interval of the pacemaker comprises:

trend identifying means for identifying a trend in the lengthening or shortening of said measured A-X time intervals;

selection means responsive to the identification of the trend identified by said trend identifying means for generating a reference A-X interval; and

conversion means for converting said reference A-X time interval to at least one control parameter for adjusting the value of the pacing interval of the pacemaker.

9. The cardiac pacemaker of claim 7 wherein the cardiac event X sensed by said sensing means comprises the depolarization of the atrium of the heart.

10. The cardiac pacemaker of claim 7 wherein the cardiac depolarization event X sensed by said sensing means comprises the occurrence of a P-wave, the time interval measured by said timing means thus comprising the interval between the generation of the atrial stimulation pulse and the sensing of the P-wave, which time interval is defined as an A-P interval.

11. The cardiac pacemaker of claim 10 wherein said means for controllably adjusting the pacing interval includes response means for sensing and responding to a lengthening of the measured A-P interval by decreasing the pacing interval, thereby increasing the rate at which stimulating pulses are controllably delivered to the heart.

12. The cardiac pacemaker of claim 10 wherein said means for controllably adjusting the pacing interval includes response means for sensing and responding to a lengthening of the measured A-P interval by increasing the pacing interval, thereby decreasing the rate at which stimulating pulses are controllably delivered to the heart.

13. The cardiac pacemaker of claim 7 wherein the cardiac depolarization event X sensed by said sensing means comprises the depolarization, or contraction, of the ventricle of the heart.

14. The cardiac pacemaker of claim 7 wherein the cardiac depolarization event X sensed by said sensing means comprises the occurrence of an R-wave, the time interval measured by said timing means thus comprising the interval between the generation of the atrial stimulation pulse and the sensing of the R-wave, which time interval is defined as an A-R interval.

15. A physiologically-controlled, rate-responsive, demand pacemaker having a pulse generator for selectively generating pacing pulses for delivery to a heart;

distribution means for selectively controlling the delivery of the pacing pulses to the heart; and

physiological rate adjustment means for adjusting the rate at which the pacing pulses are delivered to the heart as a function of physiological need, said physiological rate adjusting means comprising;

timing means for measuring the depolarization time interval between the generation of a given pacing pulse and the subsequent depolarization or contraction of said heart, said depolarization time interval being a parameter that changes as a function of physiological need; and

means for automatically adjusting the rate at which the pacing pulses are delivered to the heart by said physiological rate adjustment means as a function of the measured depolarization time interval.

16. The pacemaker of claim 15 wherein said automatic pacing pulse rate adjusting means comprises:

cardiac cycle sensing means for sensing the occurrence of a prescribed number of cardiac cycles;

processing means responsive to said cardiac cycle sensing means for generating a reference time interval value derived from the measured time intervals from said prescribed number of prior cardiac cycles; and

rate changing means for changing the rate at which the pacing pulses are delivered to the heart as a function of said reference time interval value.

17. The pacemaker of claim 16 wherein said processing means comprises means for averaging the measured time intervals derived from said prescribed number of cardiac cycles, said reference time interval value thereby comprising an average time interval of the time intervals measured during said prescribed number of cardiac cycles, said rate changing means including means for changing the pacing pulse delivery rate as a function of said average time interval.

18. The pacemaker of claim 16 wherein said processing means includes trend-identification means for identifying trend changes in the time intervals measured during said prescribed number of cardiac cycles, said rate changing means including means for changing the rate at which pacing pulses are delivered to the heart only when there is an identified trend change in said measured time intervals.

19. The pacemaker of claim 18 wherein said trend identification means includes means for determining whether said timing means has successfully measured said time interval for three consecutive cardiac cycles and all three of the corresponding time interval measurements are greater than or less than the reference time interval value from a prior processed group of time interval measurements.

20. The pacemaker of claim 15 wherein the depolarization time interval measured by said timing means comprises the time interval between the delivery of an atrial pacing pulse and the subsequent depolarization of the atrium.

21. The pacemaker of claim 15 wherein the depolarization time interval measured by said timing means comprises the time interval between the delivery of an atrial pacing pulse and the subsequent depolarization of the ventricle.

22. A pacemaker having sensing and stimulating means coupled to the ventricle of a heart, said pacemaker comprising

means for generating a ventricular stimulation pulse and delivering said pulse to the ventricle through said stimulating means;

means for measuring the depolarization time of the ventricle, said depolarization time comprising a V-R time interval that equals the time between the delivery of said ventricular stimulation pulse to the ventricle and the sensing, by said sensing means, of an R-wave;

means for generating a control signal as a function of said measured V-R time interval; and

means for adjusting a pacing rate of said pacemaker as a function of said control signal, said pacing rate controlling the rate a which said heart beats.

23. The pacemaker of claim 22 wherein said means for measuring the V-R time interval includes processing means for processing the measured V-R time interval over a plurality of previous cardiac cycles and for generating a reference V-R measurement as a result of said processing, said control signal generating means including means responsive to said reference V-R measurement for adjusting the value of said control signal.

24. The pacemaker of claim 23 wherein said processing means includes smoothing means for controlling the rate at which said reference V-R measurement is allowed to change.

25. The pacemaker of claim 23 wherein said processing means includes means for averaging the measured V-R time intervals and for generating an average V-R time interval value as a result of said averaging and for affecting the value of said reference V-R measurement as a function of said average V-R time interval value.

26. The pacemaker of claim 23 wherein said processing means includes trend-identification means for identifying trend changes in the measured V-R time intervals and for generating an acceptable trend signal, said acceptable trend signal indicating that the V-R time intervals are changing in the same direction, said pacing rate adjustment means including means responsive to said acceptable trend signal for adjusting said pacing rate.

27. The pacemaker of claim 26 wherein said trend-identification means includes means for generating said acceptable trend signal when the measured V-R intervals from at least the previous three consecutive cardiac cycles are all greater than or less than a most recently generated reference V-R measurement.

28. A method for physiologically adjusting the pacing interval of a pacemaker, said pacemaker including means for generating an atrial pacing pulse, means for delivering the atrial pacing pulse to the atrium of a heart, and means for sensing the depolarization of the atrium in response to the delivered atrial pacing pulse, said method comprising the steps of:

(a) generating an atrial pacing pulse and delivering said atrial pacing pulse to the atrium of the heart;

(b) sensing the depolarization of the atrium resulting from the delivered atrial pacing pulse;

(c) measuring the time interval between the generation of the atrial pacing pulse and the occurrence of the atrial depolarization, said time interval comprising an atrial depolarization time interval; and

(d) using the atrial depolarization time interval as a control parameter to adjust the pacing interval of the pacemaker.

29. The method of claim 28 wherein step (d) comprises processing the depolarization time intervals measured in step (c) over a plurality of prior cardiac cycles, and generating a reference depolarization time interval that is representative of a trend in the lengthening or shortening of the processed depolarization time interval measurements.

30. A method for physiologically adjusting the pacing interval of a pacemaker, said pacemaker including means for generating a ventricular pacing pulse, means for delivering the ventricular pacing pulse to the ventricle of a heart, and means for sensing the depolarization of the ventricle in response to the delivered ventricular pacing pulse, said method comprising the steps of:

(a) generating a ventricular pacing pulse and delivering said ventricular pacing pulse to the ventricle of the heart;

(b) sensing the depolarization of the ventricle resulting from the delivered ventricular pacing pulse;

(c) measuring the time interval between the generation of the ventricular pacing pulse and the occurrence of the ventricular depolarization, said time interval comprising a ventricular depolarization time interval; and

(d) using the ventricular depolarization time interval as a control parameter to adjust the pacing interval of the pacemaker.

31. The method of claim 30 wherein step (d) comprises processing the depolarization time intervals measured in step (c) over a plurality of prior cardiac cycles, and generating a reference depolarization time interval that is representative of a trend in the lengthening or shortening of the processed depolarization time interval measurements.

32. A method for physiologically adjusting the pacing interval of a pacemaker, said pacemaker including means for generating an atrial pacing pulse, means for delivering the atrial pacing pulse so the atrium of the heart, means for sensing the depolarization of the atrium in response to the delivered atrial pacing pulse, and means for sensing the depolarization of the ventricle following the atrial depolarization, said method comprising the steps of:

(a) generating an atrial pacing pulse and delivering said atrial pacing pulse to the atrium of the heart;

(b) sensing the depolarization of the atrium resulting from the delivered atrial pacing pulse;

(c) sensing the depolarization of the ventricle following the atrial depolarization sensed in step (b);

(d) measuring the time interval between the generation of the atrial pacing pulse and the atrial depolarization sensed in step (b);

(e) measuring the time interval between the generation of the atrial pacing pulse and the ventricular depolarization sensed in step (c); and

(f) adjusting the pacing interval of the pacemaker as a function of a specified one of the time intervals measured in step (d) or (e).

33. The method of claim 32 wherein the specified time interval comprises the atrial-pacing-pulse-to-atrial-depolarization time interval measured in step (d).

34. The method of claim 32 wherein the specified time interval comprises the atrial-pacing-pulse-to-ventricular-depolarization time interval measured in step (e).

35. The method of claim 32 wherein step (f) comprises processing the specified time intervals measured in steps (d) or (e) over a plurality of prior cardiac cycles, and generating a reference time interval from said processing that is representative of a trend in the lengthening or shortening of these time interval measurements, said reference time interval being used as said control parameter to adjust the pacing interval of the pacemaker.

36. A method for physiologically adjusting the pacing interval of a pacemaker, said pacemaker including means for generating an atrial pacing pulse, means for delivering the atrial pacing pulse to the atrium of the heart, means for sensing the depolarization of the atrium in response to the delivered atrial pacing pulse, means for generating a ventricular pacing pulse, means for delivering the ventricular pacing pulse to the ventricle of the heart, and means for sensing the depolarization of the ventricle, said method comprising the steps of:

(a) generating one of said atrial or ventricular pacing pulses and delivering said pacing pulse to the appropriate chamber of the heart;

(b) sensing the depolarization of the heart chamber to which the pacing pulse is delivered;

(c) measuring the time interval between the generation of the specified pacing pulse and a specified sensed depolarization, said time interval comprising a depolarization time interval; and

(d) adjusting the pacing interval of the pacemaker as a function of the time interval measured in step (c).

37. The method of claim 36 wherein the specified pacing pulse comprises the ventricular pacing pulse and the specified depolarization comprises the ventricular depolarization that occurs in response to the delivery of the ventricular pacing pulse.

38. The method of claim 36 wherein the specified pacing pulse comprises the atrial pacing pulse and the specified depolarization comprises the atrial depolarization that occurs in response to the delivery of the atrial pacing pulse.

39. The method of claim 36 wherein the specified pacing pulse comprises the atrial pacing pulse and the specified depolarization comprises the ventricular depolarization that follows the atrial depolarization occurring in response to the delivery of the atrial pacing pulse.

40. A method for measuring the atrial depolarization time of a heart, said atrial depolarization time being referred to as an A-P interval, said heart being stimulated by an atrial stimulation pulse delivered to the atrium of the heart from a pacemaker through an atrial lead, said atrial lead having first and second spaced-apart electrodes in contact with the atrium, said atrial lead providing electrical contact between an atrial stimulation pulse generator within said pacemaker and said first electrode, and said atrial lead further providing electrical contact between a P-wave sensing amplifier within said pacemaker and said second electrode, said measured A-P interval being usable by said pacemaker as a parameter indicative of physiological need, said method comprising the steps of:

(a) stimulating the atrium with pulses generated by said atrial stimulation pulse generator;

(b) monitoring the output of said P-wave sensing amplifier to detect the occurrence of a P-wave in response to the pulse provided in step (a); and

(c) measuring the time interval between the occurrence of one of said pulses generated by said atrial stimulation pulse generator and the detection of a P-wave as sensed at the output of said P-wave sensing amplifier in step (b);

the time interval measured in step (c) providing a measure of the atrial depolarization time, said atrial depolarization time providing, in turn, a relative measure of physiological need at the time the measurement is made.

41. The method of claim 40 further including the step of:

(d) processing the time interval measured in step (c) over a plurality of consecutive occurrences thereof in order to produce a reference time interval measurement that represents all of the time interval measurements from said previous plurality of consecutive occurrences, said reference time interval measurement comprising a measure of the atrial depolarization time over time, said reference time interval measurement thereby providing a measure of physiological need over time.

42. The method of claim 40 further including the steps of:

(d) processing the time interval measured in step (c) over a plurality of consecutive occurrences thereof in order to determine if said time interval measurements are changing in the same direction;

(e) generating a trend signal in response to a finding in step (d) that the time interval measurements are changing in the same direction, said trend signal providing an indication that physiological need is changing in the same direction, whereby an indication is provided as to whether the heart needs to beat faster or slower.

43. The method of claim 42 further including the step of:

(f) generating a reference time interval that reflects the unidirectional changes in said time interval measurements as determined in step (d), said reference time interval providing an indication of the amount of change in physiological need.

44. A method for measuring the ventricular depolarization time of a heart, said ventricular depolarization time being referred to as a V-R interval, said heart being stimulated by a ventricular stimulation pulse delivered to the ventricle of the heart from a pacemaker through a ventricular lead, said ventricular lead having first and second spaced-apart electrodes in contact with the ventricle, said ventricular lead providing electrical contact between a ventricular stimulation pulse generator within said pacemaker and said first electrode, and said ventricular lead further providing electrical contact between an R-wave sensing amplifier within said pacemaker and said second electrode, said measured V-R interval being usable by said pacemaker as a parameter indicative of physiological need, said method comprising the steps of:

(a) stimulating the ventricle with pulses generated by said ventricular stimulation pulse generator;

(b) monitoring the output of said R-wave sensing amplifier to detect the occurrence of an R-wave in response to the pulse provided in step (a); and

(c) measuring the time interval between the occurrence of one of said pulses generated by said ventricular stimulation pulse generator and the detection of an R-wave as sensed at the output of said R-wave sensing amplifier in step (b);

the time interval measured in step (c) providing a measure of the ventricular depolarization time, said ventricular depolarization time providing, in turn, a relative measure of physiological need at the time the measurement is made.

45. The method of claim 44 further including the step of:

(d) processing the time interval measured in step (c) over a plurality of consecutive occurrences thereof in order to produce a reference time interval measurement that represents all of the time interval measurements from said previous plurality of consecutive occurrences, said reference time interval measurement comprising a measure of the ventricular depolarization time over time, said reference time interval measurement thereby providing a measure of physiological need over time.

46. The method of claim 44 further including the steps of:

(d) processing the time interval measured in step (c) over a plurality of consecutive occurrences thereof in order to determine if said time interval measurements are changing in the same direction;

(e) generating a trend signal in response to a finding in step (d) that the time interval measurements are changing in the same direction, said trend signal providing an indication that physiologial need is changing in the same direction, whereby an indication is provided as to whether the heart needs to beat faster or slower.

47. The method of claim 46 further including the step of:

(f) generating a reference time interval that reflects the unidirectional changes in said time interval measurements as determined in step (d), said reference time interval providing an indication of the amount of change in physiological need.