Project Title Temporary Pacemaker Training Simulator

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1 Project Title Temporary Pacemaker Training Simulator Project Description Problem: There is no available training device for temporary pacemakers (pacemakers). A training device will have to essentially replace of the patient s heart (#2 below in background information) and interface with the monitor and the pacemaker to be realistic. Development of such a device would allow trainees (students, nurses, residents, fellows) to learn pacemaker function without using a real patient and exposing patients to the risk of adverse events. Background: Patients are at high risk for developing abnormal cardiac rhythms in the post-operative period after cardiac surgery. Pacemakers are commonly used after cardiac surgery to provide therapy for some of these post-operative abnormal rhythms. In addition, continuous electrocardiogram (ECG) monitoring is used in the post-operative period to monitor the patient s electrical cardiac activity and also to monitor the patients response to the pacemaker, if the pacemaker is used. Our aim is to design and develop a simulation device that would interact with a monitor and pacemaker in the same manner as a patient s heart. The input and output relationship between the three systems is demonstrated in the following figure and text: Figure Monitor. Input: Receives electrical input from the patient s heart, including how the pacemaker electrical activity is transmitted to the patient and how the patient heart responds to the pacemaker. The interface is through 3 leads

2 placed on the patient s skin (right and left shoulders, left hip). The electrical activity of the heart and pacemaker are represented by an ECG waveform on the monitor and results in a P wave (atrial conduction), QRS wave (ventricular conduction), and T wave (repolarization of the heart)(figure 2). Pacemaker activity, or output, is typically displayed as a single line or deflection spike on the monitor since the pulse interval is very short (Figure 3). Output: None to the patient or pacemaker. Figure 2 Typical heart rhythm produced by a patient not requiring a pacer. Cardiachealth.org ecg-educator.blogspot.com Figure 3 Examples of a heart rhythm produced when both the atrial and ventricular waves are stimulated by a pacemaker (pacing spikes indicated by arrows): qureshiuniversity.com pic2fly.com 2. Patient heart (and proposed device). Input: The heart receives pacemaker output through epicardial leads (or wires) on the surface of the heart. The epicardial leads consist of 2 atrial and 2 ventricular wires. The other end of the pacing wires connect to a cable (atrial and ventricular cables) which insert into the pacemaker. The heart will respond with intrinsic heart activity if the pacemaker output is sufficient. The response will be a P wave (from pacemaker atrial output), a QRS wave (from pacemaker ventricular output), or both, depending on the

3 pacemaker settings (Figure 3) Output: The intrinsic (Figure 2) or pacemaker stimulated (Figure 3) electrical cardiac activity of the heart is measured by the monitor (1) and the pacemaker (3). Cardiac electrical activity is displayed as an ECG waveform on the monitor (described above) for each heart beat. The electrical output is also transmitted via the epicardial leads to the pacemaker. The pacemaker senses the cardiac electrical activity in millivolts (mv). 3. Pacemaker. Input: The input and output of the pacer is through two cables, inserted into the pacemaker, which in turn are attached to 2 atrial epicardial and 2 ventricular epicardial leads placed on the outer surface of the heart. The pacemaker receives input from the patient s heart and senses the millivolts (mv) that the atrium and ventricle produce during each heartbeat. The range, or lower limit, of mv that the pacer senses can be adjusted from mv (atrial) and mv (ventricle). When the pacer senses atrial or ventricular output from the heart at or above the sensing voltage it will not pace the heart for that time interval (Inhibition or negative feedback loop). Output: The pacemaker has an output function that will send an electric current to pace the heart if it does not sense atrial or ventricular output for a given time interval (Trigger or positive feedback loop). The output of the pacer is measured in milliamps (ma). The output range can be adjusted from ma (atrial) and ma (ventricle). The output also can be adjusted for frequency or rate of output from per minute. There are rhythm generators on the market that can produce a waveform on a monitor (see Simulaids and Laerdal websites below for examples). However, there are no simulators that interface between the monitor and a pacer, which is our request. We have developed a tablet based computer software program that will generate rhythms to simulate cardiac activity. The program allows for creation of cardiac rhythms and individual output (morphology and amplitude) for P waves, QRS waves, T waves and the intervals between the waves (Figure 2 above and Figure 4 below). The program allows for at least six inputs from the instructor including: 1. Adjustable heart rate 2. Heart rhythms (In addition to a normal rhythm, we have developed the most common 5-6 rhythms we expect post-operatively and that we can treat with a pacer) 3. Atrial output (mv) to the pacer 4. Atrial sensitivity (ma), response to the pacers output 5. Ventricular output (mv) to the pacer 6. Ventricular sensitivity (ma), response to the pacers output

4 Figure 4 Requested submission: Develop an interface (simulated heart) between the tablet program (1), pacemaker (2) and monitor (3) that replicates the electrical conduction system of the heart, specifically the hearts electrical output and its electrical response to the pacemaker. An example using an Arduino Microcontroller is shown in Figure 4. The interface would ideally be hardwired to the pacemaker and monitor, and use wireless technology to the tablet. The interested team would work closely with the developer of the tablet software to ensure inputs from the operator (instructor) from the tablet is successfully transmitted to the monitor and pacemaker, and that pacemaker output is successfully transmitted to the monitor and tablet. The simulated heart would have to respond with an electrical heartbeat (P, QRS, and T waves) when the pacer output (ma) exceeds the atrial and/or ventricular sensitivity threshold of the simulated heart. Material/Supplies Available Temporary Pacemaker, cables and wires, tablet, electrocardiogram monitor, cables and leads. Relevant Journal Articles/Websites No pubmed articles found related to temporary pacemaker, training, and/or simulation were found except the following: Ahlfeldt H, et al. Computer simulation of cardiac pacing. Pacing Clin Electrophysiol Feb;11(2): The temporary pacemaker we use is the Medtronic Dual Chamber External Pacemaker Model 5388 and is at the following website:

5 Examples of ECG can be found at the following website: Rhythms we would be interested in include normal sinus rhythm, junctional rhythm, third degree AV block and supraventricular tachycardia. We would want to be able to vary the rate of these rhythms. There are many companies that have created rhythm generators including Laerdal and Simulaids. We have both available to us at UWHC and AFCH. Skills Needed Electronics Software Budget $500 Contact Information: Dr. Scott A. Hagen, MD Division of Critical Care Medicine Department of Pediatrics University of Wisconsin School of Medicine and Public Health (608) or (608) Alternate Contact Information: Glenda Zemlicka (608)

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