Table of Contents
Significant Events in the 1950s:
- 1955: Open-heart surgery to correct Tetralogy of Fallot with use of heart-lung bypass (C. Walton Lillehei, University of Minnesota)
- 1958: Commercial passenger jet service introduced in the U.S.
- 1959: Simultaneous invention of the integrated circuit at Texas Instruments and Fairchild Semiconductor.
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Long Term Ambulatory Exteriorized Transvenous Pacing HN, a 67-year-old man with 2:1 and complete heart block had had syncopal episodes for several years. He underwent insertion of a transvenous lead via cephalic vein cut down, on May 19, 1959, was hospital discharged on June 23, 1959 and lived at home as an ambulatory outpatient until November 1962. During that time he was paced with the newly available, battery operated model 902M (Atronic Products, Inc. Bala Cynwyd, PA, USA). The unit was capable of sensing spontaneous cardiac activity (but not of output inhibition in response to such sensing), of variation in output and stimulation rate and general evaluation of the impedance of the electrode system. A small meter indicated emission of stimuli or sensed events. A permanently attached cable delivered output to the electrodes. An audio output plug connector was available. Because the endocardial lead exited through the skin, it was fastened in place with stainless steel sutures which required frequent renewal. Though systemic infection did not occur the entry wound was frequently superficially infected, requiring cleansing and redressing. On November 8, 1962, after 41 months of such pacing he underwent thoracotomy for implantation of a pacemaker system, as a matter of potential convenience rather than to resolve pacing problems. He never fully recovered from surgery and died twenty days later.
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| Atronic Products Model 902M | New York Mirror June 23, 1959 |
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| New York Daily News June 23, 1959 | New York Times June 23, 1959 |
Schwedel JB, Furman S, Escher DJW. Use of an Intracardiac Pacemaker in the treatment of Stokes-Adams Seizures. Prog Cardiovasc Dis 1960;3:170-177.
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| First Working Pacemaker Implant On October 27, 1956, I was asked to see a 37-year-old lawyer. She had experienced her first Adams-Stokes episode. The physical examination was normal except for a regular bradycardia. The ECG showed complete heart block. Drugs were unavailing and she continued to experience Adams-Stokes attacks, sometimes as many as three a day. Between the attacks she recovered completely and continued her professional activities. | 
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| More Photos |
In 1959, the frequency of syncope increased so that I considered the possibility of pacemaker implantation. The small generator, implanted by Dr. Ake Senning on October 8, 1958 had not worked as expected. Large external pacemakers "…connected to the general current supply…" were still in use in Sweden for the treatment of AV block. I wrote directly to Elmqvist suggesting consideration of recent technological advances, i.e., the silicone transistor which seemed more suitable for an implantable pacemaker than the germanium transistor, and a new epoxy resin (Araldit) produced by Ciba, which had excellent biocompatibility for pulse generator encapsulation.
Dr. Elmqvist was able to provide an implantable pulse generator powered by two rechargeable nickel-cadmium batteries, each delivering 50 microampere/hours. Recharging was accomplished by a 150 kHz current generated by an external 220 volt unit. The current was transmitted by induction from an external flexible coil 25 cm in diameter placed on the skin over the pacemaker, to a coil 50 mm in diameter within the implanted generator. The pacemaker required charging once a week for 12 hours.
The cylindrical unipolar asynchronous implantable generator consisted of the nickel-cadmium batteries, the electronic circuit and the recharging antenna, all encapsulated in epoxy. It was 52.5 mm in diameter, 17.5 mm thick and weighed 64.3 grams. The lead had a braided nylon core surrounded by four flat stainless steel bands insulated by a polyethylene coating. The stimulating electrode was a platinum disc 9 mm in diameter, to be sutured to the epicardium through two small holes. The cathodal stimulating surface area was 63.6 square mm, the anode was a metal ring 10 mm wide on the pacemaker's edge. The ring was not completely circumferential to avoid interruption of the magnetic field created by the charging current.
Dr. Robert Rubio implanted this unit on February 3, 1960 at the CASMU Clinic of Montevideo, Uruguay. The epicardial electrode was sutured to the left ventricular surface and the pulse generator was placed in the abdominal wall. Her early course was of an increased exercise tolerance and the absence of Adams-Stokes seizures. Infection developed in the thoracic incision and she died of sepsis on October 20, 1960, 9 1/2 months after pacemaker implantation.
Learn more about the first working implantable pacemaker and see more photos of the device by visiting Centro de Construccion de Cardioestimuladores del Uruguay in Topics in Depth
Fiandra O. The First Pacemaker Implant in America. PACE 1988;11:1234-1238
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Radiofrequency Epicardial Pacing
Soon after the introduction of cardiac pacing with exteriorized myocardial electrodes it was apparent that peri-electrode infections would limit long-term pacing. To avoid this complication there was developed and introduced clinically in 1958-59 a totally implantable battery-powered pacemaker and a radiofrequency (RF) stimulator inductively coupled through intact skin (Mauro's technique) to pace the heart. After several years, the addition of a long-lasting lithium battery and the ability to externally program the pacing parameters favored the sole use of a totally implantable cardiac pacemaker. The use of the rf induction method for stimulating excitable tissue was expanded to pace the diaphragm, contract the paralyzed urinary bladder and muscle sphincters, and enhance hearing (cochlear implant).
Glenn WWL, Mauro A, Longo E, Lavietes PH, MacKay FJ The Radiofrequency Cardiac Pacemaker. Remote stimulation of the heart by radiofrequency transmission. Clinical application to a patient with Stoke-Adams Syndrome. New Engl J Med 1959:262;948-951
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Treatment of Unexpected Cardiac Arrest by External Electric Stimulation of the Heart
Cardiac arrest may occur unexpectedly during various diagnostic and therapeutic procedures, particularly under anesthesia. Though infrequent (1 in every 500 to 5000 operations), each accident is a catastrophe. Current therapy is too often unsuccessful. The commonly recognized mechanisms of cardiac arrest are ventricular standstill and ventricular fibrillation; standstill is the usual cause. In a compilation of 1200 cases of cardiac arrest, the occurrence of standstill was 88 percent. Eight successful cases of cardiac resuscitation from unexpected arrest by electric stimulation of the heart are reported here. The cases occurred during various procedures - 7 during surgery, and 1 during pericardiocentesis. The cardiac arrest was terminated in each case by the electric pacemaker so that thoracotomy and cardiac massage were not necessary. Five patients recovered completely; 2 died of unsuccessful cardiac surgery, and 1 died eight hours after operation. A practical monitoring device to signal immediately the cessation of the heartbeat would obviate crucial delay in recognizing the onset of arrest. Ideally, such an alarm system should register the electric activity of the ventricles by an audible signal of each heart beat and sound analarm upon the onset of cardiac arrest. In I well documented case with such a monitor, thoracotomy was performed and cardiac massage begun eighteen seconds after the onset of arrest. The routine application of a cardiac monitor to all patients under anesthesia would give greatest assurance of immediate recognition of cardiac arrest. Ventricular standstill may persist despite effective massage, may recur after massage or may follow defibrillation. Electric stimulation may then be applied directly to the heart, preferably by needle electrodes a few millimeters apart. Epinephrine hydrochloride (0.2 ml. if 1:1000 aqueous solution) or calcium gluconate (4 ml. of a 10 per cent aqueous solution) may be injected into a cardiac chamber.
Zoll PM, Linenthal AJ, Norman LR, Paul MH, Gibson W. Treatment of Unexpected Cardiac Arrest by External Electric Stimulation of the Heart. New Eng J Med 1956; 254:541-546.
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Early Pacemaker Development
In 1958, in Sweden, the first attempts at pacing with an implantable pacemaker were made. Because cardiac stimulation through external wires presented risk of infection, I developed a pacemaker, at the initiative of Dr. Senning, that was small enough to implant subcutaneously in the epigastrium.
At that time it was thought that the pulse generator should deliver impulses of about 2 volts and an impulse period of about 1.5 ms at a rate of 70-80 per minute, using as little energy as possible. Fortunately, ...silicon transistors had just appeared on the market.
Among the many types of primary cells, the Ruben-Mallory cells with zinc as the anode and mercuric-oxide as the depolarizer were a possible choice. I had already had experience with the mercury cells … their lifetime was short. Besides, I did not know what effect the hydrogen gas development at the zinc anode would have on a cell encapsulated in plastic. For that reason, nickel-cadmium rechargeable cells were then chosen. Two cells of 60 mAh each were connected in series.
A coil with a diameter of about 50 mm was connected to the cells via a silicon diode. The charging current came from a line-connected vacuum tube radiofrequency generator with a frequency of 150 kHz. A large flexible coil in the output circuit of the generator could be attached to the patient's abdomen with adhesive tape. Recharging was done overnight … about once a month. The whole apparatus was encapsulated in epoxy resin. The diameter was about 55 mm and the thickness about 16 mm.
The first apparatus had two electrode wires, each consisting of a twined, stainless suture wire with polyethylene insulation sewn in the myocardium … It soon appeared that the wire was unsuitable as an electrode. The stimulation threshold increased and after only a few weeks, the unit ceased to stimulate. The patient again went into heart block, but the Adams-Stokes attacks did not recur.
American manufacturers were predicting a five year lifetime for pacemakers with mercury-zinc batteries, and since we felt that rechargeable units were cumbersome for patients, we also began to use mercury-zinc cells. I am not convinced that it was right to give up the rechargeable cells since, at that time, the quality of mercury cells was not high enough.
I must admit that I had regarded the pacemaker more or less as a technical curiosity. It has, therefore, been gratifying for me to follow its enormous success, and to have taken part in its development.
| Rechargable Pacer Elmqvist-Senning Implants | | DATE | LOCATION | DURATION | | 10/8/58 | STOCKHOLM | 8 HRS | | 10/9/58 | STOCKHOLM | 1 WK | | 2/3/60 | MONTEVIDEO | 9 MOS | | 3/31/60 | LONDON | 11 MOS | | ?????? | LONDON | 22 HRS | | PROBABLY OTHERS | | | | | A. H. W. Larsson Pacemaker History | | OCT. 8, 1958 | PM # 1 | NiCd | | OCT. 8, 1958 | PM # 2 | NiCd | | PM # 2 REMOVED AFTER ONE WEEK | | NOV. 19, 1961 | PM # 3 | HgZn | | JAN. 29, 1993 | PM # 26 | LiI | | |
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Elmqvist R. Review of Early Pacemaker Development. PACE 1978; 1:535-536.
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Congenital Deaf-Mutism, Functional Heart Disease, with Prolongation of the Q-T Interval and Sudden Death
A combination of deaf-mutism and a peculiar heart disease has been observed in 4 children in a family of 6. The parents were not related and were, as the other two children, quite healthy and had normal hearing. The deaf-mute children, who otherwise seemed quite healthy, suffered from "fainting attacks" occurring from the age of 3 to 5 years. By clinical and roentgen examination, which was performed in 3 of the children, no signs of heart disease could be discovered. The electrocardiograms, however, revealed a pronounced prolongation of the Q-T interval in all cases.
Three of the deaf-mute children died suddenly at ages of 4, 5 and 9 years, respectively.
Jervel A. Lange-Neilson F. Congenital deaf-mutism, functional heart disease with prolongation of the Q-T interval, and sudden death. AM Heart J 1957; 54:59-68.
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Transvenous Cardiac Pacing
On July 16, 1958 the transvenous catheter electrode was introduced, with fluoroscopy, via the basilic vein into the right ventricular outflow tract, in a patient with fixed complete heart block who required colon resection because of a malignancy. The simultaneous femoral artery tracing of the initial idioventricular rhythm (above) demonstrates the more rapid atrial rate and the dissociated, idioventricular brachycardia. In the lower strip the effectiveness of stimulation and the ability to control the cardiac rate and rhythm are clearly seen. Pacing was continued for two hours, during the operative procedure, and ended with slowing of the stimulation rate until an unpaced idioventricular rhythm developed. The catheter was removed without complication and the patient resumed the idiventricular bradycardia.
Furman S, Schwedel JB: An intracardiac pacemaker for Stokes-Adams Seizures. N Eng J Med 1959; 261:943-948
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