CH13

THERAPEUTIC AND
PROSTHETIC DEVICES
13.1 CARDIAC PACEMAKERS AND OTHER ELECTRIC STIMULATORS
13.2 DEFIBRILLATORS AND CARDIOVERTERS
13.3 MECHANICAL CARDIOVASCULAR ORTHOTIC AND PROSTHETIC DEVICES

13.4 HEMODIALYSIS
13.5 LITHOTRIPSY
13.6 VENTILATORS
13.7 INFANT INCUBATORS
13.8 DRUG DELIVERY DEVICES
13.9 SURGICAL INTRUMENTS
13.10 THERAPEUTIC APPLICATIONS OF THE LASER

Content of this chapter

Previous chapters

diagnostic instruments

This chapter

therapeutical instrument, stimulator, prosthesis

(, , ), incubator, ventilator, heartlung machine, artificial kidney, diathermy
device, electrosurgical instrument

13.1 Cardiac Pacemaker

Targets of stimulation:
Epicardium

Myocardium
Endocardium

What to cure:
Pathalogical condition: heart block

asynchronous cardiac pacemaker

Provides a train of stimulus pulses at a constant rate.

The output circuit:

A free-running
oscillator

Constant current
Constant voltage

Figure 13.1 Block diagram of an asynchronous

cardiac pacemaker
Epicardial electrode
Good conductor
Mechanically strong
Good insulation

Intramyocardial electrode

Endocardial or intraluminal electrode

Package design:
(1) Compatible, tolerated by the body
(2) To protect the circuit
(3)Comfortability

Electrode (and lead wire) materials:

Platinum,

Stainless steel,
Carbon,
titanium,
Alloys (Elgiloy, MP35N)

Figure 13.2

To place a pacemaker, a lead wire is inserted into the cephalic vein of the
shoulder and fed into the heart chambers (B). An electrode is implanted in the
heart muscle of the lower chamber, and the device is attached (C).
www.surgeryencyclopedia.com/La-Pa/Pacemakers.html

Synchronous pacemakers
SA node
(spontaneous)
Artificial pacemaker

Reason of using sync. Instead of async. Pacemakers:

Often the patient requires pacing only intermittently.
Continuous stimulation may result in serious complications.

(1) Demand pacemaker

(2) Atrial-synchronous pacemaker

ECG
Timing

(counter)
Out
Reset
Figure 13.3 A demand-type synchronous pacemaker Electrodes serve as a means of both
applying the stimulus pulse and detecting the electric signal from spontaneously occurring
ventricular contractions that are used to inhibit the pacemaker's timing circuit.

For normal atrium and abnormal ventricle

V 1g

V 1g
V1

V2
V3
V4
OUT
ECG
Figure 13.4 An atrial-synchronous cardiac pacemaker, which detects electric signals corresponding to the
contraction of the atria and uses appropriate delays to activate a stimulus pulse to the ventricles. Figure 13.5
shows the waveforms corresponding to the voltages noted.

Rate-responsive pacemaker
Physioogical variable

Sensor

Blood temperature (in right ventricle)

Stimulus-to-T-wave interval (in ECG)
R-wave area (in ECG)
Blood pH
Rate of pressure change (of right ventricle)
Blood oxygen saturation (in vein)
Intracardiac volume changes
Respiratory rate and/or volume
Body vibration

Thermister
ECG electrodes
ECG electrodes
Electrochemical pH electrode
Semiconductor strain-gage pressure sensor
Optical oximeter
Electric-impedance plethysmography (intracardiac)
Electric-impedance plethysmography (thoracic)
Accelerometer

Figure 13.5 Block diagram of a rate-responsive pacemaker

Figure 13.5

Figure 13.6

Example 13.1

Bladder
Detrusor (:).
Mucosal
Orifice
Prostatic
Seminal vesicle ;
Sphincter
Trigone
Ureter
Urethra

Urinary incontenence
Unable to pass the urine (empty the bladder)
Source: http://sci.rutgers.edu/forum/showthread.php?t=130246

(ages female)
(aged male)

Bladder stimulator

13.2 Defibrilators and Cardioverters

The disease

Cardiac fibrilation:
Individual myocardial cells contract asynchronously with only very local
patterns.
Cardiac output 0

Risk: Irreversible brain demage; death

How to resuscitate?

Reestablish a normal cardiac rhythm with electric shock to the heart

What to use?
Defibrillators

13.2 Defibrilators and Cardioverters

http://www.britsattheirbest.com/ingenious/ii
_20th_century_1950_1970.htm

(cont.)

http://www.sciencemuseum.org.uk/images/I050/10319037.aspx?key
words=pack

Japanese
English
Simp. Chinese
Korean

2010.06.24
Hase-dera Temple, Kamakura City, Kanagawa, Japan

13.2 Defibrilators and Cardioverters

(cont.)

Capacitive-discharge dc dfibrillator

Why is this not desired?

Why is this desired?
What is the function of L?
Ans:
What will be the waveform of vp without L?
Ans:

Figure 13.9 (a) Basic circuit diagram for a capacitivedischarge type of cardiac defibrillator. (b) A typical waveform of the
discharge pulse. The actual waveshape is strongly dependent on the values of L, C, and the torso resistance RL.

13.2 Defibrilators and Cardioverters

(cont.)

Designing the step-up transformer

The energy level required for defibrillation = 400 J. The power source is 100 V.
C = 10 to 200 F. How high is the voltage across C?
Ans:
E = Cv2/2
v = (2E/C) = [2 400/(10 10-6)] = 8944.272 V
v = (2E/C) = [2 400/(200 10-6)] = 2000 V

Primary
100 V
10 A
1000 W

10
turns

200
turns

Secondary
2000 V
0.5 A
1000 W

13.2
Defibrillation is a process in which an electronic device, called an
automated external defibrillator (AED), helps reestablish
normal contraction rhythms in a heart that's not beating properly.
It does this by delivering an electric shock to the heart.
All emergency personnel should be trained and allowed to use a
properly maintained defibrillator if their job requires them to
respond to people having cardiac arrest.
This includes all first-responding emergency personnel,
both hospital and non-hospital.
CAPACITIVE-DISCHARGE dc DEFIBRILLATORS
RECTANGULAR-WAVE DEFIBRILLATORS
DEFIBRILLATORS ELECTRODES
CARIOVERTERS
IMPLANTABLE AUTOMATIC DEFIBRILLATORS

What is ventricular fibrillation?

The heart beats when electrical signals move through it.
Ventricular fibrillation (V fib) is a condition in which the heart's electrical activity
becomes disordered.
When this happens, the heart's lower (pumping) chambers contract in a rapid,
unsynchronized way. (The ventricles twitch" rather than beat.)
The heart pumps little or no blood.
http://www.americanheart.org/presenter.jhtml?identifier=4784
AHA Scientific Position (Abnormal Heart Rhythms )
Ventricular fibrillation is very serious. Collapse and sudden cardiac death
will follow in minutes unless medical help is provided immediately.
If treated in time, V fib and ventricular tachycardia (extremely rapid heartbeat)
can be converted into normal rhythm.
This requires shocking the heart with a device called a defibrillator.
Today one effective way to correct life-threatening rhythms is by using an
electronic device called an implantable cardioverter-defibrillator.
This device shocks the heart to normalize the heartbeat if the heart's own
electrical signals become disordered

Cardioverter = a defibrillator + a cardiac monitor

A stimulus possibly leads to

fibrillation if it occurs in the
interval of T wave

This is the reason why the

cardioverter is used.

QRS complex
R

0.1 mV
PR segment

ST segment
0.04 ms

T
P
U

ST interval
S

PR interval

QT interval

Fig. 13-11

Figure 13.12 A cardioverter The defibrillation pulse in this case must be synchronized
with the R wave of the ECG so that it is applied to a patient shortly after the occurrence
of the R wave.

Implantable automatic defibrillators

Implantable
defibrillator
Artificial
pacemaker

Tachyarrhythmia (fibrillation)
Bradyarrhythmia

13.3 Mechanical Cardiovascular Orthotic and Prosthetic Devices

cardiovascular
orthotics
prosthetic
.

Cardiac-assist devices
To aid the failing heart after acute traumatic insults such as
myocardial infarction or cardiac surgery

CO2 is used instead of O2. Why?

CO2: more soluble in blood
O2: fatal gas embolism

US Patent 3,769,960 (1973) Intra-aortic system

The balloon does much of the

work normally done by the left
ventricle in causing the blood to
circulate to the periphery.

embolism
trauma
traumatic
myocardial infarction

Example 13.3
An intra-aortic balloon pump device is being applied to a patient in cardiovascular shock. The patient's blood
pressure is 80/60, and his heart rate is 85 beats per min. The patient's cardiac output has been determined
to be 2.5 liters/min. Once the balloon cardiac-assist device has been started, the patient's systolic blood
pressure at the heart drops to 65 mm Hg; the heart rate and cardiac output remain the same. After several
hours on the balloon, the systolic pressure is back to 80 mm Hg, the heart rate has dropped to 78
beats/min, and the cardiac output has risen to 3.4 liters/min. Estimate the work done by the heart per beat
and per minute before and after the balloon pump was started, as well as several hours later. If the balloon
pumps against an average diastolic pressure of 60 mm Hg, how much work is it doing?
-1- (Before a balloon is used)
BP = 80/60 mmHg, HR = 85 bpm, CO = 2.5 L/min
-2- (Once the balloon cardiac-assist device has been started)
BP = 65/-- mmHg, HR = 85 bpm, CO = 2.5 L/min
-3- (After several hours on the balloon)
BP = 80/-- mmHg, HR = 78 bpm, CO = 3.4 L/min
Q: The work done by the heart = ? in -1-, -2-, and -3-.
Q: The work done by the balloon to pump against 60 mmHg = ?

Pump Oxygenator
Blood and oxygen are in direct
contact. This can denature some
of the protein components of the
blood, which can lead to formation
of clots and emboli.

1.
2.

Used during certain procedures of

a cardiac surgery
Used to allow the diseased lung
of an infant to rest for several days

pump-oxygenator:
,(,).
Figure 13.13 Connection of a pump oxygenator to bypass the heart
A disk-type oxygenator is used with a roller pump. Venous blood is taken
from a cannula in the right atrium, and oxygenated blood is returned
through a cannula in the femoral artery.

cannula
venous
femoral

Total Artificial Heart

AbioCor
Jaarvic 7

13.4 Hemodialysis ()

Renal replacement therapies:

(1)renal transplant
(2)Hemodialysis
(3)peritoneal dialysis

renal
peritoneal
dialysis

13.4 Hemodialysis ()
Dialysate = water + various solutions

Types of exchangers:
(1) The coil-dialyzer
(2) The parallel-plate dialyzer
(3) The hollow-fiber kidney
10,000-15,000 parallel hollow fibers with 0.2-mm in diameter
and 150 mm in length
dialysate

Figure 13.14 An artificial kidney The dialysate

delivery system in this unit mixes dialysate from a
concentrate before pumping it through the
exchange chamber.

Measuring the gross concentration of electrolytes of the dialysate:

(1) By impedimetric method
Detection of blood leakage:
(1) By colorimetric or optical density change
(2) By pressure change
The semipermeable allows the waste
components in the blood to diffuse
through to the dialysate.

Detection of bubbles in the blood:

(to prevent emboli)

Example 13.4
The electric conductivity (S/cm) of an electrolytic solution such as a dialysate can be
approximated by

N i qi i

(E13 .19 )

Where Ni = number of ions of i per cm3, qi = charge on ions of i, i = mobility of ions of i in

solution, cm2/Vs.
The equation is summed for all ionic species present in the solution. Assume that the
dialysate is made up of 0.9 g equivalents of cations having a single electronic charge per ion and
a mean mobility of 0.623 cm2/(Vs) and that the same amount of oppositely charged anions
having a mobility of 0.986 cm2/(Vs). (A) Determine the conductivity of the dialysate solution. (B)
How much will it change if 0.05 g equivalents of an anions are added to the solution?

(A) The conductivity of the dialysate solution is

N i qi i
(E13.19)
i

0.9 6.023 1023 / L 103 L / cm3 1.6 1019 C 0.623 0.986cm 2 / V s

139.6 S / cm
(B) The conductivity of the dialysate solution will become

0.95 6.0231023 / L 103 L / cm3 1.6 1019 C 0.623 0.986cm2 / V s

0.95 / 0.9 139.6 S / cm 1147.4 S / cm

13.7 Infant Incubator ()

amazing medical co.,Ltd
Product ID: YP-910
infant incubator
Brief introduction:
servo-controlled by micro-computer; quite
operation windows can reduce the disturbance to
the baby during nursing; inclination of the bassinet
can be adjusted, touch switch panel with LED
digital display, set-temp, real-temp and auxiliary
temperature are displayed separately; multiply selfchecking alarms with audible and visible; heating
power rate indicates 0-100%; whole aluminum
water tank, and it can be filled with water or
discharge; RS 232 connector, data output.
Standard configure:
Hood, infant bed, temperature controller, skin
temperature sensor, water tank, air filter, Guardrail,
I.V. Pole, cabinet.

http://www.allproducts.com/manufacture97/sunglowltd/product5.html

amazing medical co.,Ltd

Product ID: YP-910

infant incubator

Technical specification:
Power supply : AC220V50HZ
Power input: 600VA
Air Temperature control range25~37
Skin Temperature control range34~37
Sensor precision: 0.3
Changing of temperature: 0.5
Uniformity of temperature: 0.8
Temperature rising time: 30min
Noise level: 55dBA
Inclination of bassinet: 0~5
Alarming:
audible and visible alarm indication, and it can indicate the real temperature and cut off the power supply of heater
(except for the low deviation alarm), meanwhile, the skin temperature indication window can indicate the alarm code. For
the alarm 1-6, the relevant light is on, and for the alarm 7, all alarming lights are on; all alarm sound can be cancelled
except for the power failure alarm and the system alarm.
Over-temp alarm: when the air temperature control 38, skin temperature control40
Upper Deviation alarm: air temperature control +3.0, skin temperature control +1.0
Lower Deviation alarm: air temperature control -3.0, skin temperature control -1.0
Sensor alarm: when the sensor is disconnected, open circuit, short circuit or put on the wrong place;
Fan alarm: when the fan is blocked, speed 1000rpm or stop working;
Power failure alarm: when there is no power or the power cord is disconnected.
System alarm: when there is E2ROM malfunction inside of temperature controller.
Package
Gross Weight66Kg
Net Weight 55Kg
Measurement1085mm640mm915mm
Notice
Some technical data of this model can be changed properly in standard permission range according to the standard and
users requirement like infant scale, tray. If the technical specification of above product changes, please refer to the
standard at selling time.
http://www.allproducts.com/manufacture97/sunglowltd/product5.html

United States Patent 6679830

Infant incubator with non-contact sensing
and monitoring
An infant care unit of the type comprising means for
controlling the environment in which the infant
resides includes one or more sensors spaced apart
from the infant to sense a physiological parameter
and provide a sensor output, the controlling means
being responsive to the sensor output to change the
environment or provide an alarm or other indication
of the parameter. The sensors include one or more
of an infrared sensor for sensing the infant's
temperature, cameras coupled to video processing
software for sensing respiration rate, heart rate or
skin perfusion, microphones coupled to audio
processing software for sensing respiration rate,
breathing difficulty, or infant distress. Speakers are
provided for cancelling noise or providing audio
signals to the infant. The camera, microphone and
speakers are capable of being coupled to a
computer network for remote monitoring of the infant.

http://www.freepatentsonline.com/6679830.html

Figure 13.16 Block diagram of a proportional temperature controller used to maintain the
temperature of air inside an infant incubator.
Thermistor

Bridge

Power
line

Amplifier

Comparator

Set-point
resistor

1-Hz
sawtooth
generator

Gate
4
pulse
generator

Siliconcontrolled
switch
5

Heater

13.9 Surgical Instruments

Electrosurgical unit

http://www.ihe-online.com/products/surgicalor/electrosurgery-accessories/hospitalequipment/electrosurgical-units1/index.html?tx_ttproducts_pi1%5BbackPID%5D=
1334&cHash=2e28600aef

http://yesng.english.eyp.com.tw/eyp/front/bin/
ptdetail.phtml?Category=4206&Part=Access
ories-3

Figure 13.20 (a) Block diagram for an

electrosurgical unit. High-power, highfrequency oscillating currents are
generated and coupled to electrodes to
incise and coagulate tissue. (b) Three
different electric voltage waveforms
available at the output of electrosurgical
units for carrying out different functions.

coagulate

comment