Pacemaker Batteries

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Technical Series

Trends in Cardiac Pacemaker Batteries

Venkateswara Sarma Mallela*, V. Ilankumaran*, and N.Srinivasa Rao†

*Dept. of le!troni! and "omputer ngineering, "aledonian "ollege of ngineering, #affiliated

to $lasgow "aledonian %niversit&, %'(, Sultanate of )man†Dept. of le!troni!s and "ommuni!ations ngineering, +oj Redd& ngineering "ollege for

omen,#affiliate to -awa+arlal Ne+ru e!+nologi!al %niversis&(, /&dera0ad, India.

1ddress for !orresponden!e2 Dr Venkateswara Sarma Mallela, Dept. of le!troni! and"omputer ngineering, "aledonian "ollege of ngineering #affiliated to $lasgow "aledonian

%niversit&, %'(, 3.) o42 5655, "3) See07888, Sultanate of )man. mail2

venkates9!aledonian.edu.om

Abstract

atteries used in Implanta0le !ardia! pa!emakers7present uni:ue !+allenges to t+eir

developers and manufa!turers in terms of +ig+ levels of safet& and relia0ilit&. In addition, t+e

0atteries must +ave longevit& to avoid fre:uent repla!ements. e!+nologi!al advan!es in

leads;ele!trodes +ave redu!ed energ& re:uirements 0& two orders of magnitude. Mi!ro7

ele!troni!s advan!es s+arpl& redu!e internal !urrent drain !on!urrentl& de!reasing si>,>>> pa!emakersare implanted ea!+ &ear worldwide and t+e total num0er of people wit+ various t&pes of

implanted pa!emaker +as alread& !rossed 6 million. 1 !ardia! pa!emaker uses +alf of its 0atter&

power for !ardia! stimulation and t+e ot+er +alf for +ousekeeping tasks su!+ as monitoring and

data logging. +e first implanted !ardia! pa!emaker used ni!kel7!admium re!+argea0le 0atter&,

later on &ears and even toda&

is t+e power sour!e for man& manufa!turers of !ardia! pa!emakers. +is paper 0riefl& reviews

various developments of 0atter& te!+nologies sin!e t+e in!eption of !ardia! pa!emaker and

presents t+e alternative to lit+ium iodine 0atter& for t+e near future.

Introduction

Cardiac Pacemaker

+e pa!emaker unit delivers an ele!tri!al pulse wit+ t+e proper intensit& to t+e proper

lo!ation to stimulate t+e +eart at a desired rate. +e !ardia! pa!emaker !omprises of a pulse

generator and a lead s&stem. +e pulse generator +ouses ele!tri!al !omponents responsi0le for

generating t+e pulse #via output !ir!uits( at t+e proper time #via timing and !ontrol !ir!uits( 0ased on events sensed #via sensing !ir!uits(. It also !ontains a power suppl& #0atter&( and ma&

in!lude ot+er elements su!+ as telemetr& for testa0ilit& and programma0ilit& and memor& #R)M

or R1M( to store data for diagnosti! purposes8.Impulses are transmitted to t+e +eart 0& means of a lead, w+i!+ is atta!+ed to t+e pulse

generator via t+e !onne!tor 0lo!k. 1 lead is eit+er unipolar or 0ipolarB a unipolar lead !ontains

Indian Pacing and Electrophysiology ournal !ISS" 0#$2%&2#2'( )!)'* 201%212 !200)'


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+enkates,ara Sarma -allela( +. Ilankumaran and ".Srini/asa ao( 202“Trends in Cardiac Pacemaker Batteries ”

one insulated !oil, w+ereas a 0ipolar lead !ontains two !oils, separated 0& an inner insulation.

1n outer insulation s+ields a lead from t+e environment. +e tip of a lead, w+i!+ !ontains an

ele!trode, is implanted into t+e inner, endo!ardial surfa!e of t+e +eart, t+e a!tual lo!ation

depends on t+e t&pe of pa!emaker. +e pa!emaker unit is usuall& implanted in t+e pe!toral

region, wit+ t+e lead running t+roug+ t+e rig+t su0!lavian vein to t+e internal surfa!e of t+e

+eart. 1 pa!emaker is programmed 0& means of a programmer, a !omputer wit+ a spe!ial user interfa!e for data entr& and displa&, and wit+ spe!ial software to !ommuni!ate wit+ t+e

pa!emaker. +e telemetr& +ead is pla!ed a0ove t+e lo!ation of t+e pa!emakerB information from

t+e programmer to t+e pa!emaker, and 0a!k, is transmitted 0& means of telemetr&.

+e !asing of t+e pulse generator fun!tions as +ousing for t+e 0atter& and all ot+er

ele!troni! and ele!tri!al !ir!uits. 1 !onne!tor 0lo!k, made of pol&uret+ane, #glass materials

were used to !omprise t+e !onne!tor 0lo!k in earlier models( is lo!ated at t+e top of t+e

pa!emaker. It serves to atta!+ t+e pa!emaker to t+e pa!emaker lead#s(. +e present da& pulsegenerator !ase is made of titanium, a metal t+at is ten times as strong as steel, 0ut mu!+ lig+ter.

itanium and two of its allo&s, nio0ium and tantalum, are 0io!ompati0le, t+e& e4+i0it p+&si!al

and me!+ani!al properties superior to man& ot+er metals. +e modulus of elasti!it& #measure of

stiffness( of titanium and its allo&s range 0etween 8>>785>$3a. 4treme resistan!e to !orrosionand dura0ilit& make titanium and its allo&s ideal materials for +ermeti!all& sealed pulse

generator !ases for !ardia! pa!emakers. itanium repla!ed !erami!s and epo4& resin wit+ sili!one ru00er, w+i!+ were used for

en!apsulation of some pa!emakers in t+e past. o assem0le t+e pulse generator, t+e +&0rid

!ir!uits and t+e 0atter& are pla!ed in t+e titanium !ase #1SM $rade 8( in a spe!iall& designed

!lean room t+at +as no stati! !+arge #less t+an 8C moisture( and no dust in it. )n!e t+e +&0rid

!ir!uits and t+e 0atter& are in t+e !asing, t+e !asing is welded s+ut wit+ a +ig+7powered laser

0eam. +is laser 0eam gives t+e pulse generator a +ermeti! seal, w+i!+ means t+at t+e devi!e is

airtig+t and li:uid7tig+t. 1fter welding, t+e top, or +eader of t+e pa!emaker is atta!+ed and t+eentire devi!e is !overed in a t+in la&er of plasti! #epo4& plasti!(. +is plasti! !oating furt+er

seals t+e pa!emaker. +e !asing is a given a kind of ellipti!al s+ape and a t&pi!al pa!emaker diagram is

s+own in igure 1. +is upgrade to titanium allowed patients to safel& use applian!es su!+ as

mi!rowave ovens 0e!ause titanium +elps to s+ield t+e internal !omponents and redu!e t+e

e4ternal ele!tromagneti! interferen!e. In addition, titanium !asing s+ields from ground level

!osmi! radiation.

igure 1* &pi!al 3a!emaker Diagram

Batteries for Cardiac Pacemakers

In 8@E, 1ke Senning, a t+ora!i! surgeon at t+e 'arolinska /ospital in Sto!k+olm,

implanted m&o!ardial ele!trodes and a pulse generator wit+ a re!+argea0le ni!kel7!admium

0atter& in a F>7&ear7old patient. Senning and +is asso!iate, Rune lm:uist, an engineer wit+ t+e



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+enkates,ara Sarma -allela( +. Ilankumaran and ".Srini/asa ao( 20)“Trends in Cardiac Pacemaker Batteries ”

Early Developments

Re!+argea0le #se!ondar& 0atteries( nickel-cadmium batteries were used in t+e 0eginning

#in 8@E( of pa!emaker implants in +uman 0eings. +e& were indu!tivel& re!+arged 0& t+e

transmission of energ& to t+e implanted re!eiver. +e !ell voltage was 8.5 V and t+e !apa!it&was 8@> m1+. +e major pro0lems were two fold, t+e first 0eing ver& s+ort life time and t+e

se!ond was to pla!e t+e responsi0ilit& for re!+arging in t+e +ands of patients, w+i!+ is not agood medi!al pra!ti!e. It was well known t+at primar& or non7re!+argea0le 0atteries would give

longer lifetime !ompared to se!ondar& 0atteries. +ere are still some re!+argea0le pa!emakers

in use t+oug+ not sold an& more.

Some of t+e earl& pulse generators !onstru!ted mainl& from dis!rete !omponents were

powered 0& series7wired mer!ur&7s(. Su!+ mer!ur&7s to manufa!ture pra!ti!al 0atteries. e!ause lit+ium rea!ts violentl& wit+ water, non7

a:ueous ele!trol&tes must 0e used. )rgani! solvents su!+ as a!etonitrile and prop&lene

!ar0onate, plus inorgani! solvents su!+ as t+ion&l !+loride #S)"l5( are t&pi!al, wit+ a

!ompati0le solute to provide !ondu!tivit&. Man& different materials su!+ as sulfur di, t+ion&l

!+loride, manganese dio4ide, and !ar0on monofluoride, are used for t+e a!tive !at+ode material.



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+enkates,ara Sarma -allela +. Ilankumaran and ".Srini/asa ao( 204“Trends in Cardiac Pacemaker Batteries ”

Introduction

Introdu!tion of a lit+ium iodine 0atter& in 8@A greatl& e4tended t+e pa!emaker 0atter&

life #more t+an 8> &ears for some models( and repla!ed t+e mer!ur&7C loss of !apa!it& over five &ears8. +is !ompares wit+ a similar loss for

alkaline !ells over onl& one &ear. +e long s+elf life of lit+ium 0atteries arises from t+e lit+ium

metal surfa!e 0e!oming passivated 0& rea!tion wit+ t+e ele!trol&te. 1ll lit+ium s&stems are saidto 0e t+ermod&nami!all& unsta0le 0ut kineti!all& sta0le. +e& produ!e no gas and +en!e t+e&

!an 0e +ermeti!all& sealed. In addition, t+e terminal voltage de!a& !+ara!teristi! is well

0e+aved, falling slowl& enoug+ for 0atter& end7of7life#)?( to 0e anti!ipated in routine follow

up.

?it+ium 0atteries are !ategori


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+enkates,ara Sarma -allela( +. Ilankumaran and ".Srini/asa ao( 20&“Trends in Cardiac Pacemaker Batteries ”

of a parti!ular fre:uen!&( of t+e lit+ium iodine !ell is an important fa!tor in 0atter&

performan!e. +e greater t+e impedan!e, t+e more diffi!ult it is to pass !urrent t+roug+ t+e !ell.

In!reased !ell impedan!e !orresponds to a de!reased power sour!e at t+e !ell terminals. +e

0eginning7of7life #)?( impedan!e ranges from > to 8>> )+ms. +e impedan!e in!reases

during servi!e to values from 5>,>>> to 6>,>>> )+ms during t+e a!!umulation of dis!+arge

produ!tE

.

Lithium Iodine Battery for Cardiac Pacemaker

+e lit+ium ; iodine7pol&vin&lp&ridine 0atter&, first implanted in 8@A5 +as 0e!ome t+e power sour!e of !+oi!e for !ardia! pa!emaker. Sin!e t+en, improvements in !ell !+emistr&, !ell

design, and modeling of !ell performan!e +ave 0een made8>. "ells toda& e4+i0it an energ&

densit& over t+ree to four times as great as !ells produ!ed in 8@A5. ell over 6 million

pa!emakers +ave 0een implanted wit+ t+is !+emistr&, and t+e s&stem +as e4+i0ited e4!ellentrelia0ilit&. +e 0atter& !+emistr& provides a long s+elf life and +ig+ energ& densit&. ?it+ium

!upri! sulfide was used in some pa!emakers5 manufa!tured 0& t+e "ordis "orporation due to its

e4!ellent energ& densit&. /owever, due to t+e !orrosive nature of t+is !ompound man& a0rupt pa!emaker failures o!!urred w+en t+e 0atter& !+emi!als ate t+roug+ t+eir !ontainment. It is still

present in some of t+e alread& implanted pa!emakers 0ut lit+ium !upri! sulfide is no longer used.

?it+ium Iodine +as two !+ara!teristi!s t+at make it an e4!ellent power sour!e for !ardia!

pa!emaker appli!ations. +e self7dis!+arge rate is ver& low resulting in a long s+elf life. It +as a

sta0le voltage t+roug+ mu!+ of t+e useful life t+en tapers down in a gradual and predi!ta0le

manner. +is makes predi!ting t+e ele!tive repla!ement time safe and eas&.

+e !at+ode is a !omple4 of iodine and pol&757vin&l p&ridine #35V3(. Neit+er !ondu!ts

ele!tri!it&, 0ut w+en mi4ed and +eated at 8F@" for 6 da&s, t+e& rea!t into a 0la!k vis!ous pastet+at !ondu!ts ele!tri!it&. +is is poured into t+e 0atter& w+en molten and !ools to form a solid.

+en t+is paste !onta!ts metalli! lit+ium, a monomole!ular la&er of !r&stalline lit+ium iodineforms. It is a mole!ular semi!ondu!tor t+at passes lit+ium ions, as re:uired for !urrent flow, 0ut

not iodine mole!ules8

Chemical eactions

"onventional !urrent flows t+roug+ a devi!e from anode to !at+ode. Gor a 0atter&, t+e!urrent flows from t+e negative anode, t+roug+ t+e 0atter&, to t+e positive !at+ode. )4idation of

metal o!!urs at t+e anode, Li --> Li+ + e- and redu!tion of +alide o!!urs at t+e !at+ode, I 2

+ !e- --> ! I -. +e !om0ined rea!tion is, ! Li + I 2 77O ! LiI . "onventional !urrent flows from

anode to !at+ode. +e lit+ium rea!ts wit+ iodine to form lit+ium7iodide, w+i!+ grows in volumeand in!reases t+e resistan!e.

Internal esistance

+e internal !ell resistan!e #Rd!, +e resistan!e to flow of an ele!tri! !urrent wit+in a

!ellB t+e sum of t+e ioni! and ele!troni! resistan!e of t+e !ell !omponents( as a fun!tion of

!apa!it& for 3V37 !oated and un!oated #see 0elow( lit+ium anode are s+own in igure 2. +e

open !ir!uit voltage #)"V( and voltage at 5> 1 load !+ara!teristi!s are s+own in igure . Itis seen t+at t+e voltage a0ove 5.5V #re:uired minimum 0& t+e pa!emaker ele!troni!s( is well

maintained until t+e 5. 1+ rating of t+e 0atter&.



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+enkates,ara Sarma -allela( +. Ilankumaran and ".Srini/asa ao( 20$“Trends in Cardiac Pacemaker Batteries ”

igure 2* "apa!it& vs Internal resistan!e

igure * Run down !+ara!teristi!s

"anufacturin#

?it+ium is easil& formed into s+eets t+at !an 0e !ut to t+e re:uired si


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+e !omple4 of iodine and pol&757vin&l p&ridine #35V3( is poured into t+e !at+ode !ase and

allowed to !ool88.

Testin#

o maintain +ig+ relia0ilit& #of t+e order of >.>> C failures per mont+(, !ells aredesigned !onservativel&. +e& are manufa!tured under stringent :ualit& !ontrols, as demanded

0& t+e $ood Manufa!turing 3ra!ti!es #$M3( issued 0& t+e Good and Drug 1dministration

#GD1(, %S1. +e :ualifi!ation testing is performed under a!!elerated test !onditions spe!ified

for ?i;I573V3 !ells88. +e list in!ludes Non7destru!tive e4aminations, t+ermal !&!ling, +ig+ pressure, me!+ani!al vi0ration, temperature ; +umidit&, me!+ani!al s+o!k, voltage ;

temperature, seal terminal strengt+, elevated temperature dis!+arge, destru!tive anal&sis, and

solvent resistan!e.

Lon#evity and Battery life estimation

Longevity

+e pa!emaker 0atter& provides energ& re:uired for t+e operation of t+e !ir!uitr& of a

pa!emaker, w+i!+ in!ludes t+e !ontrol, sensing and pulse7generating units. 1 major !on!ern in

using 0atter& is its longevit&. ?ongevit& of a 0atter& !an 0e determined knowing 0atter& !apa!it&#1+( and !urrent drain #mi!roamperes(. +e !urrent drain is dependent on t+e t&pe of ele!trode

as well as t+e !ir!uitr& and t&pe of pulse generation of t+e pa!emaker.

Lie !stimation

Sin!e t+e longevit& of a !ardia! pa!emaker means its 0atter& life, it is essential to +ave

t+e !ir!uitr& to identif& t+e remaining useful life of 0atter& in a simple and relia0le manner.Monitoring of internal resistan!e is a !onvenient tool for estimation of dis!+arge level and for

predi!ting t+e approa!+ing end7of7servi!e.

In man& pa!emaker s&stems, !ir!uits are provided to measure t+e internal resistan!e of

t+e 0atter& to dedu!e t+e remaining life. it+ t+is !ir!uit8, t+e pa!emaker is first swit!+ed toPtest modeQ and a resistive load is applied to t+e 0atter& to measure t+e voltage drop. +e status

of t+e 0atter& is indi!ated 0& generating a series of test pulses. Depending on t+e internal voltage

drop, and t+us t+e internal resistan!e, t+e fre:uen!& of t+e stimulation pulse is !+anged, w+i!+ is

measured e4ternall&. /owever, t+is !ir!uit !an onl& 0e used for 0atteries wit+ in!reasing internal

resistan!e as t+e 0atter& dis!+arges.

o over!ome t+e limitations of t+e a0ove te!+ni:ue and to measure t+e life e4pe!tan!&

of a 0atter& wit+ !onstant internal resistan!e, anot+er te!+ni:ue was proposed8. +e 0atter& test!ir!uit is provided wit+ a pulse !ounter and input logi! to measure t+e !onsumed !+arge from

t+e operating parameters of t+e pa!emaker and t+e num0er of pulses delivered over a period of

time. During ea!+ test, t+e !+arge delivered sin!e t+e last 0atter& test is !al!ulated 0ased on t+e

!ount in t+e pulse !ounter, w+i!+ is t+en summed to t+e !ontents of t+e !+arge !ounter inmemor&. +e !ontent of t+e !+arge !ounter is a measure of t+e total !+arge !onsumed and

provides information a0out t+e remaining life of t+e 0atter&85.

+e7!ir!uit is implemented internall& in t+e pa!emaker unit and a means is provided to

report t+e value of t+e !+arge !ounter w+en interrogated 0& telemetri! met+ods. +e advantage

of t+is met+od is t+at t+ere is no need to alter t+e fre:uen!& of stimulation pulses w+ile testingt+e 0atter&.

In some models7of pa!emakers, appro4imatel& twi!e per da& t+e devi!e evaluates t+e

0atter& status, w+i!+ is reported during follow7upB w+ere as in some ot+er models, 0atter& status

is automati!all& evaluated ever& 88 +ours. atter& status ma& 0e displa&ed in t+e form of a



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+enkates,ara Sarma -allela( +. Ilankumaran and ".Srini/asa ao( 20#“Trends in Cardiac Pacemaker Batteries ”

gauge #s+owing )?, R, and )?( and longevit& remaining #O &ears to >. &ears in >.

&ear in!rements( at 8>>C pa!ing86.

$pecifications

+e 0atter& s+ould meet t+e pa!emaker pulse re:uirements in t+e range of 5 -, a ver&small power #!ompared to 87F> - for Implanta0le "ardioverter Defi0rillators(. +e following

are 0road spe!ifi!ations.

)pen "ir!uit Voltage2 5.E Volt

"ontrol "ir!uit minimal voltage2 5.5 Volt"ontrol "ir!uit !urrent drain2 8> 1

)? 0atter& resistan!e2 8> k )+ms

"hold

2 8> G

Dis!+arge times2 8 ms, ms

)s!illator fre:uen!&2 8=A /<

Dut& "&!leB 8=.A C

1+ rating2 5 1+ #t&pi!al rating(Relia0ilit&2 @@.=C pro0a0ilit& of survival 0e&ond E &ears

Gailure Rate2 >.>> C failures;mont+.

%ei#ht& 'olume& $hape and $i(e

"eight

/alf of t+e o!!upied spa!e is !onsumed 0& t+e internal 0atter&8F in !ardia! pa!emaker.

+erefore t+e energ& densit& #energ&;volume( and spe!ifi! energ& #energ&;mass( are important

!onsiderations for implanta0le 0atteries. "ompared wit+ lead, t+e same volume of lit+ium provides eig+t times as mu!+ ele!tri!it&, at one7t+irtiet+ t+e weig+t. +e weig+t of a lit+ium7

iodine 0atter& varies from a0out 85. grams to 8. grams for different manufa!turers,86,8,8= of

t+e pa!emaker unit. +e variation in weig+t is primaril& due to t+e longevit& and !urrent drain

!apa0ilities of t+e 0atter&.

#olume

+e volume o!!upied 0& t+e 0atter& in a pa!emaker #pulse generator unit( is also a0out

+alf t+e total volume. +is varies from to E !! for t+e units manufa!tured 0& different

manufa!turers ,86,8,8=.

Sha$e

Most of t+e !ardia! pa!emakers are s+aped as variations on !ir!ular or ellipti!al o0je!ts8

to avoid +aving s+arp !orners t+at mig+t penetrate t+e skin or damage surrounding tissues.

+erefore, t+e 0atteries in t+ese devi!es are s+aped to !onform to t+e overall devi!e geometr&,

and often appro4imate a semi!ir!le wit+ a radius of a0out 6!m and a dept+ of = to Emm.

Si%e

&pi!al dimensions of an implanta0le !ardia! pa!emaker are in t+e range of F@ mm 4 F=mm 4 = mm ; FA mm 4 F8 mm 4 A mm ; F mm 4 5 mm 4 A mm ; FF mm 4 F5 mm 4 E mm ;

F8 mm 4 > mm 4A mm,86,8,8=. +e dimensions var& from one model to an anot+er as well as



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from one manufa!turer to an anot+er. +e 0atter& o!!upies a0out +alf of t+e si m1,

w+i!+ is slig+tl& 0etter t+an toda&s !ompeting 0atteries8E,8@. Su!+ innovations will 0e ne!essar&, parti!ularl& if )M visions of patient management !ome to fruition. Medtroni!, for e4ample,

+as alread& em0arked on a de!ade7long program, known as Vision 5>8>, w+i!+ !alls for far7

rea!+ing use of devi!e !onne!tivit&. %ltimatel&, engineers sa& t+e& !an foresee a da& w+en an

implanted +eart monitor will dete!t a pro0lem and !all an am0ulan!eB all w+ile t+e patient lies

sleeping.

3ithium 6 carbon mono7luoride !3i 6 C8'* a ne, pacemaker battery

+e redu!tion in pa!emaker siCredu!tion in weig+t over t+e same si


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suita0le for t+is anal&sis, 0ut it is a mu!+ more sop+isti!ated and e4pensive te!+ni:ue. )f

interest, is a simple met+od of gamma70ut&rola!tone dete!tion t+at was developed 58.

Ackno,ledgements

+e aut+ors a!knowledge wit+ t+anks t+e e4e!utives of "aledonian "ollege of ngineering #affiliated to $lasgow "aledonian %niversit&, %'(, Sultanate of )man, for t+eir

support, en!ouragement, and for providing resear!+ environment in t+e !ollege.

e7erences

1. e0ster, -.$. #ed.( PDesign of "ardia! 3a!emakersQ, 3is!atawa&, N-, I 3ress, 8@@

2. $reat0at!+ , P )rigins of Implanta0le "ardia! 3a!emakerQ, - "ardiaovas! Nurs 8@@8 1pr

2E>7E

. lmovist, /.8@EF, PImplanta0le +eart pa!emakerQ, %S patent F,F=6,A>=

). +ttp2;;www.powerstream.!om;0atter&, a!!essed 5 -an 5>>F

4. %rugua& ".".", +ttp2;;www.naspe.org;ep7+istor&;topi!sTinTdept+, a!!essed 5F -an 5>>F

&. ernstein, 1lan D. P"lassifi!ation of "ardia! 3a!emakersQ, "ardia! 3a!ing and

le!trop+&siolog&. Rds. Na0il l7S+erif and 3+ilip Samet, 3+iladelp+ia2 .. Saunders

"ompan&, 8@@8, F@F7>6

$. "+arles -. ?oveQ /and0ook of "ardia! 3a!ingQ, ?andes ios!ien!e, 8@@@, Viva ooks 3vt?td

5. "urtis G. /olmes, P +e Role of "+emi!al 3ower Sour!es in Modern /ealt+ "areQ+e le!tro!+emi!al So!iet& Interfa!e U Gall 8@@@, pp265

#. e0ster, -.$.,ed. n!&!lopedia of Medi!al Devi!es and Instrumentation, F vol, Vol F. New

ork2 -o+n ile& W Sons, In!., 8@EE, 58A755>6

10. $raet0at!+ , /olmes "G, 31", 8@@5 Nov 825>6F7=

11. S!+alda!+ M, le!trot+erap& of t+e +eart Springer7verlag, 8@@5.

12. Mo0erg, ?. 8@EA, Patter& est "ir!uits for a +eart pa!emakerQ, %.S patent F,A8,6E886

1. +ttp2;;www.guidant.!om;produ!ts;3rodu!templates;"RM;pulsarTma45.s+tml, a!!essed 5

-an 5>>F

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