Source: https://patents.google.com/patent/DE69807986T3/en
Timestamp: 2020-01-20 09:01:04
Document Index: 588136336

Matched Legal Cases: ['art 4', 'art 4', 'art 4', 'art 4', 'art 4', 'art 4', 'art 4', 'art 4', 'art 4', 'art 4', 'art 4', 'art 4', 'art 4']

DE69807986T3 - Pacemaker - Google Patents
DE69807986T3
DE69807986T3 DE1998607986 DE69807986T DE69807986T3 DE 69807986 T3 DE69807986 T3 DE 69807986T3 DE 1998607986 DE1998607986 DE 1998607986 DE 69807986 T DE69807986 T DE 69807986T DE 69807986 T3 DE69807986 T3 DE 69807986T3
DE1998607986
DE69807986D1 (en
DE69807986T2 (en
1997-06-06 Priority to US870935 priority
1998-06-03 Application filed by St Jude Medical AB filed Critical St Jude Medical AB
2002-10-24 Publication of DE69807986D1 publication Critical patent/DE69807986D1/en
2003-05-22 Publication of DE69807986T2 publication Critical patent/DE69807986T2/en
2003-06-17 First worldwide family litigation filed litigation Critical https://patents.darts-ip.com/?family=25356365&utm_source=google_patent&utm_medium=platform_link&utm_campaign=public_patent_search&patent=DE69807986(T3) "Global patent litigation dataset” by Darts-ip is licensed under a Creative Commons Attribution 4.0 International License.
2009-03-19 Publication of DE69807986T3 publication Critical patent/DE69807986T3/en
The The present invention is directed to a cardiac assist device, such as a Pacemaker, defibrillator or cardioverter, of the type directed a unipolar atrial lead and a unipolar ventricular lead and in particular to an arrangement in such Device for analyzing the differential signal between the Unipolar leads around different types of cardiac events and cardiac activities identify that generated the differential signal.
On implantable cardiac assist devices such as pacemakers, Defibrillators and cardioverters it is known to use leads which are implanted in or around the heart to receive electrical signals to get that for cardiac events and / or cardiac activity in the heart representative are. There are various types of sensor or sensing arrangements for this Purpose known. For example, unipolar, atrial sensing occurs using the tip electrode on the electrode lead, which also for the delivery of stimulation pulses to the atrium is used, where the feeling takes place between the tip electrode, which acts as an active sensing electrode and the metallic pacemaker housing called the indifferent Electrode acts. In a similar way can be a unipolar ventricular sensing can be achieved using the acting as a sensing electrode tip electrode an electrode cable placed in the ventricle and the indifferent electrode acting metallic pacemaker housing. Such a unipolar one sensing has the advantage that within the special electrode cable which used, only one electrical conductor must be included, whereby the diameter of the cable is minimized and a simplified cable construction possible is because the same electrode (the tip electrode) to stimulate and used for feeling becomes.
A another common form to feel cardiac activity, which are used in implanted cardiac assist devices is bipolar sensing. For bipolar sensing indicates the particular lead being used (i.e., the atrial Lead, the ventri kular Line or both of these lines), in addition to the tip electrode one Ring electrode, which is spaced from the tip electrode is where the feeling is between the tip electrode and this ring electrode takes place. Because the signal path in bipolar sensing between the two electrodes is much shorter than in the case of a unipolar sensing, is the sensed Signal less with interference signals compared to a unipolar signal Afflicted, since the relatively large Amount of lying between the unipolar electrode and the pacer housing Tissue opportunity for there are different types of interfering signals, that caused by the cardiac event or cardiac activity superimposed on the current signal becomes. However, such known bipolar sensing has the disadvantage on that there are two electrical conductors and the associated insulation, to isolate the two conductors from each other, which must be contained within the implanted lead, thereby the cable diameter is increased.
A relatively recent suggestion for sensing other than known unipolar sensing and bipolar sensing is differential sensing, sometimes referred to as "bipolar" sensing. In this type of sensing, a unipolar lead is placed in the ventricle and a unipolar lead into the atrium and sensing occurs between the corresponding tip electrodes of these two unipolar leads. Between these two lines, a differential signal is generated. A feeling of this kind is in the U.S. Patent No. 5,571,143 described. The atrial activity is sensed between the atrial tip electrode and the ventricular electrode while the ventricular electrical activity is sensed between the tip electrode in the ventricle and the metallic housing of the pacemaker. Such a differential sensing arrangement avoids interference, for example, from muscle activity, particularly in the case of conventional unipolar atrial sensing, because the atrial signal is a much weaker signal than the ventricular signal, but there is no need for a bipolar electrode in the atrium use.
Since the signals obtained in differential sensing may represent both the activity arising in the atrium and the activity arising in the ventricle, in order to analyze such a differential signal, a way must be provided to identify which chamber has generated the electrical activity that represents itself in an incoming differential signal. One possibility is in the U.S. Patent No. 5,607,457 described in which the incoming electrical signals between the unipolar atrial electrode and the unipolar ventricular electrode are differentially sensed and the sensed signal is additionally subjected to a correlation detection to identify which electrode is the source of the incoming signal.
in the Trap of conventional (i.e., non-differential) unipolar sensing is a large number just as in the case of conventional bipolar sensing of analysis techniques and algorithms known for analyzing the sensed Signals and identifying the type of cardiac event or cardiac activity, that caused the signal, for classification purposes the incoming signal. Such a classification can turn be used for a number of different purposes, such as determining whether the signal a normal (or desired) cardiac activity represents the no change in the cardiac support treatment, as the stimulation treatment, as well as for the identification, whether a kind of setting in electrical therapy, by the cardiac assist device is administered, needed For example, as by increasing the pulse amplitude when in the sensed Signal, for example, an evoked response to an emitted Stimulation pulse is not detected. Such a classification can also be used to identify critical cardiac events the immediate attention by the cardiac support device need, such as the presence of tachycardia and / or fibrillation.
One such known technique used in conventional unipolar sensing and conventional bipolar sensing is a pattern recognition or waveform morphology technique. A variety of different versions of this technique is known. In general, however, the technique involves identifying a pattern or waveform throughout or part of the incoming signal representing a cardiac cycle, and comparing that pattern or morphology with a number of stored patterns, each indicative of a different type of cardiac event or cardiac activity. The incoming signal is then classified according to the event or activity represented by the stored signal, which is as close as possible to the pattern or morphology in the incoming signal. The pattern may be characterized in the stored form by one of a variety of different ways, such as by the appearance and / or amplitude of peaks, the slope of various portions of the signal as represented by a first differentiation of the signal or changes therein Inclination, as they are represented by a second differentiation of the signal. Various combinations of these characteristics can also be used to further define the pattern. Examples of these types of techniques, as used in conventional unipolar and / or bipolar sensing, are described in U.S. Patent Nos. 4,917,259, 4,348,074 U.S. Patent No. 4,905,708 and in the article "Detection of Pathological Tachycardia by Analysis of Electrogram Morphology," Davis et al., PACE, Vol. 9, March-April 1986, pages 200 to 208.
The EP-A-0646390 discloses a heart stimulator including an atrial electrode in an atrium of a heart and a ventricular electrode in the ventricle of the heart. To sense paced events in the heart, a detector is connected between the atrial and ventricular electrodes.
The US-A-4535776 discloses a dual-chamber pulse generator having an electrode in an atrium and an electrode in a ventricle of a heart and an indifferent electrode. The unipolar atrial signal and the unipolar ventricular signal as well as the difference signal between the atrial and ventricular leads are fed to three Schmitt trigger comparators. The output signals of the Schmitt trigger comparators are analyzed in a signal processing unit to determine the type of detected signal.
The WO-A-921740 discloses a method and apparatus for providing improved ability to detect and collect electrical cardiac signals via a series of relatively closely spaced subcutaneous electrodes that may be disposed on the body of the implanted device.
It An object of the present invention is an arrangement in one cardiac assist device with a unipolar atrial lead and a unipolar ventricular lead available to do that uses a differential sensing to a cardiac activity to identify and classify in which the identification and classification of cardiac activity is improved.
This object is achieved in a cardiac assist device such as a pacemaker as defined in claim 1. In the cardiac assist device as described herein, the signal obtained between the atrial tip electrode and the ventricular tip electrode may be evaluated, if necessary, by a morphology analysis method or algorithm which discriminates between P-waves, PAC (premature atrial contractions). , atrial fibrillation, R-waves, PVC (premature ventricular contractions) and ventricular tachycardia. The inventors have recognized that there is a significant difference in the morphology between the differential signals that are generated when these different types of cardiac activity are present and that the recognition of these ver different types of differential signals and thus the classification of the cardiac activity represented in those signals can be reliably and relatively easily achieved.
The Morphology analysis, if done, is done in a microprocessor executed in the decision logic of the implanted device. There the morphology analysis, as through pattern recognition, is a bit complicated Processing may be a factor that may be required to an increased Energy consumption contributes.
If no extraordinary States, like a fibrillation, present in the heart and therefore a relatively normal differential signal is present, this indicates normal signal Components that can be used to relatively simply the Source of the signal (i.e., atrium or ventricle), without having to use the morphology analysis. This is achieved by Analyze the energy content of the signal or analyze it the slew rate of different parts of the signal. The The morphology analysis to be performed may be of the kind that they are in the above-mentioned article by Davis et al. is described.
One another solution It is a neural network for analyzing the differential Signal using the neural network appropriately weighted Neurons to make appropriate choices for classifying the To hit signals under a variety of learned conditions. in the In the case of a morphology analysis, the classification takes place accordingly the stored pattern takes place in the memory of the pacemaker must be programmed. These patterns are, at least initially, patterns that have been obtained are from a suitable patient population and those known for it are that they are fairly representative of specific types of cardiac activity are. After the cardiac support device for a while implanted in a subject, however, is a sufficiently large database your own cardiac activity of the subject has been created so that it is possible to enter the originally entered Replace patterns with patterns or bring them up to date with greater accuracy representative of the subject in which the cardiac assist device is implanted is. In a neural network, the network learns the story cardiac activity of the subject over time by appropriately adjusting the neutron weighting. Furthermore For example, the neural network itself may use fuzzy logic or can be connected to a fuzzy logic processing electronics, to make decisions according to the principles of fuzzy logic to meet.
at the identification of the particular type of cardiac activity present in represents an incoming differential signal, the therapy, administered by the cardiac assist device will be adjusted if necessary, or it may be immediate Emergency steps are taken, such as by initiating Defibrillation or initiation of an anti-Tachyarithmie routine, if desired is.
1 illustrates in a known construction the connection of a pacemaker with a heart for differential sensing.
2 Figure 12 is a block circuit diagram of the basic components of a cardiac assist device, in the form of a pacemaker, constructed in accordance with the principles of the present invention.
3 FIG. 12 shows a first normal atrial activity waveform obtained by differential sensing used in the cardiac assist device of FIG 2 to undergo a morphology analysis.
4 FIG. 12 shows a differential waveform arising in the atrium representative of atrial fibrillation and in the cardiac assist device of FIG 2 to undergo a morphology analysis.
5 is a block diagram showing the details of the differential detector and the decision logic in the in 2 illustrated cardiac support device shows.
6 Figure 5 is a simplified illustration of a differential signal for explaining various classification techniques according to this invention.
7 shows a waveform for a respiratory rate signal that as a differential signal in the in 2 shown cardiac support device can be obtained.
1 represents an implantable pacemaker 1 for stimulating and sensing cardiac activity in vivo in a (schematically) illustrated heart 4 dar. The pacemaker 1 is by means of a unipolar atrial lead 2 and a unipolar ventricular lead 5 in electrical connection with the heart 4 , The atrial line 2 ends in an electrode 3 placed in a suitable place in the right atrium of the heart 4 is arranged and the ventriku line 5 ends in an electrode 6 placed in a suitable place in the right ventricle of the heart 4 is arranged. The respective, in 1 illustrated positions of the electrodes 3 and 6 within the heart 4 are only examples. The electrodes 3 and 6 may be located at any suitable location in the right atrium and right ventricle, respectively, according to physiology and pacing therapy for a particular patient. In addition, in the case of a single-chamber stimulation, only one lead and electrode can be used (active), ie only the atrial electrode 3 or only the ventricular electrode 6 although both lines and electrodes are still present.
The basic components of the implantable pacemaker 1 according to the principles of the present invention are in 2 shown. The pacemaker 1 has a metallic pacemaker housing 7 with which the wires 2 and 5 in a known manner (not shown in detail) are mechanically and electrically connected. Electrical impulses to artificially stimulate the atrium of the heart 4 be through an atrial stimulation pulse generator 8th generated with the atrial lead 2 connected, and over the line 2 and the electrode 3 delivered to the right atrium. Similarly, ventricular pacing pulses are delivered by a ventricular stimulation pulse generator 9 generated and via the ventricular lead 5 and the electrode 6 the right ventricle of the heart 4 fed. The duration, energy content, frequency, and other standard features of the atrial and ventricular pacing pulses are determined by stimulation logic and control unit 10 adjusted with the atrial stimulation pulse generator 8th and the ventricular stimulation pulse generator 9 connected is. The stimulation logic and control unit 10 includes all necessary known electronics, which may include a microprocessor and a memory, for operating a programmable implanted pacemaker.
The detection of atrial and ventricular cardiac events also occurs via the unipolar leads 2 and 5 instead of. For this purpose, the atrial lead 2 with a differential detector 11 connected. The ventricular lead 5 is also with the differential detector 11 connected. Therefore, the detection always takes place in the differential detector 11 between the atrial electrode 3 and the ventricular electrode 6 instead of.
The output signal of the differential detector 11 becomes the decision logic 14 fed. The decision logic 14 uses a morphology analysis of a suitable type, such as that described in the above-mentioned Davis et al. is described by each of the differential detector 14 to evaluate and classify generated signals. Based on this morphology assessment, the decision logic leads 14 the stimulation logic and control unit 10 a signal indicating whether any healing steps should be taken to stop the stimulation treatment.
Although in 2 not shown, the in 2 The pacing components shown may also be employed in a defibrillator or cardioverter, which also has the ability to store sufficient energy to cause cardioversion or defibrillation of a heart in need of such therapy. If the in 2 components used in such an implanted device, the output of the decision logic 14 can also be used to initiate cardioversion or defibrillation, if desired. In addition to providing support for artificially maintaining a normal sinus rhythm through ventricular and / or atrial pacing, it is known in the pacing logic and control unit 10 to store an anti-tachyarrhythmia routine and such a routine may be initiated for identification in the decision logic 14 that such activity exists.
All components in 2 be through a in the pacemaker housing 7 included battery 24 energized. The electrical connections from the battery 24 to the respective components are not shown separately, these are well known to those skilled in the art. The stimulation logic and control unit 10 contains a standard circuit for adjusting the energy content of the atrial and ventricular pulses generated by the pulse generators 8th and 9 be generated so that they are just sufficient to deliver these pulses to the heart 4 to cause an appropriate response or response, which causes the energy of the battery 24 is handled sparingly. The stimulation logic and control unit 10 Also includes a suitable demand circuit so that the pulses are caused by the pulse generators 8th and 9 only in the absence of natural or spontaneous atrial and / or ventricular activity. The stimulation logic and control unit 10 can by programmed instructions the pulse generators 8th and or 9 operate for single chamber or dual chamber pacing.
The stimulation logic and control unit 10 is also in a two-way connection with a telemetry unit 15 , The telemetry unit 15 in turn, is in duplex connection with an extracorporeal programming unit 16 like an RF connection. The programming unit 16 becomes not only used to the operation of the pacemaker 1 but also with new or updated parameters in the pacing logic and control unit 10 for use in the operating program. The programming unit 16 is also used to periodically accumulated, stored historical information that controls the operation of the pacemaker 1 and the state of the heart 4 to be downloaded over an extended period of time.
Exemplary waveforms of the type at the output of the differential detector 11 appears in the 3 and 4 shown. 3 represents a differential signal indicative of normal cardiac activity. This signal would be at the output of the differential detector 11 appear when the heart 4 works normally.
4 shows the type of signal that is at the output of the differential detector 11 occurs when the heart 4 undergoes atrial fibrillation.
If the heart 4 If the types of activities in question are experiencing these signals, they will be in the above-mentioned analysis in the decision logic 14 subjected. In the case of in 3 represented signal would be the output of the decision logic 14 the stimulation logic and control unit 10 to maintain the current status, ie no changes in the delivery of pacing therapy are required. In the case of in 4 represented signal, the decision logic 14 is fed, the decision logic 14 through a morphology analysis identify the fact that atrial fibrillation occurs and would respond to the pacing logic and control unit 10 provide a signal that identifies the presence of this type of activity. According to the stored routines, then the stimulation logic and control unit 10 to adjust the amplitude and / or frequency pulses supplied to the atrium to try to correct for this abnormality. If and when the heart 4 If the atrial fibrillation is freed (this is usually not a life-threatening event), the decision logic becomes 14 again the presence of a waveform of in 3 The type shown and recognizes the stimulation logic and control circuit 10 inform that she should return to a "normal" stimulation treatment.
Although it is for the decision logic 14 is possible for a classification of the differential detector 14 In order to rely solely on morphology analysis, such morphology analysis, such as pattern recognition, involves an increased amount of processing time when the morphology analysis is performed in a microprocessor. This has with the battery 24 an increased energy withdrawal result. In the context of most implanted cardiac assist devices, it is desirable to keep the energy drain of the battery as low as possible. Therefore, as in 6 4, the cardiac assist device constructed and operative in accordance with the invention uses a simplified classification technique that is less computationally intensive than the morphology analysis in situations where the differential signal is relatively straightforward. In most "normal" situations, the differential signal appears as in 6 and it is therefore not necessary to resort to the morphology analysis to classify such a signal, ie, to determine if the signal originated in the atrium or ventricle. Only when more severe waveforms occur, such as those arising in the case of a fibrillating heart, in cases where the simpler techniques would not provide a definite result, would the microprocessor resort to the application of morphology analysis.
Therefore contains at the in 5 illustrated embodiment of the differential detector 11 one with the unipolar leads 2 and 5 connected differential amplifier 17 , as well as an analog / digital converter 18 with which the unipolar leads 2 and 5 also connected to the analog input side. The differential amplifier 17 represents the difference between the on the corresponding unipolar leads 2 and 5 resulting signals and supplies as a control signal to the converter 18 an output signal. If the difference between the signals on the corresponding unipolar lines 2 and 5 exceeds a predetermined value, the differential amplifier outputs 17 an output signal which is a sample of the analogue side of the converter 18 initiates supplied signals. If the difference between the relevant signals on the unipolar lines 2 and 5 is below the said predetermined value, it is assumed that unambiguous classification of the differential signal using simpler techniques is not possible, in which case a morphology analysis is then used to classify the incoming signal.
Assuming that through the differential amplifier 17 outputting an output signal, a sample representation of the differential signal in digital form becomes the decision logic 14 fed. The decision logic 14 contains a latch 19 in conjunction with a microprocessor 20 and a parameter memory 21 , also in connection with the microprocessor 20 , Successive samples of the converter 18 supplied differential signal are in Sig nalspeicher 19 stored so that a complete signal or representation thereof in the latch 19 is stored. Assuming that the morphology analysis is not needed, the microprocessor can 20 then analyze this memory signal based on a selected parameter thereof. Two options for the microprocessor 20 to analyze, the slew rate of the stored signal or the energy content of the stored signal.
How out 6 As can be seen, the portion of the differential signal originating in the atrium has a negative slew rate and the portion of the signal originating from the ventricle has a positive slew rate. By analyzing the slew rate only to determine if it is positive or negative, then an identification can be made as to whether the differential signal has arisen in the atrium or ventricle. The parameter memory 21 stores the slew rate parameters, ie a first slew rate (negative) for atrial signals and a second slew rate (negative) for ventricular signals.
The energy content of the signal can be used as an indicator to identify the origin of the differential signal. The energy content is expressed as the time integral of the squared signal voltage (amplitude). For this purpose, the signal is in the latch 19 squared and the integration is in the microprocessor 20 started when the signal exceeds a predetermined level, such as 0.2 mV. The integration is performed until further integration adds no significant amount, such as a given increment or percentage increment, to the current result. However, it must be ensured that the integration is terminated before the T-wave occurs, otherwise the result of the analysis will take too long to analyze. The integration period typically lasts approximately 10 to 25 ms for atrial-derived signals and approximately 100 ms for ventricular-derived signals. These integration areas are stored in the parameter memory 21 stored respectively for atrial signals and ventricular signals as energy content (integration time) parameters. The microprocessor 20 compares the integration time of the current differential signal with these stored parameters to determine if the current signal has its origin in the atrium or ventricle.
Depending on the result of the above analysis, the microprocessor gives 20 on the line 22 a signal indicating that the current differential signal has its origin in the atrium or there is on the line 23 a signal indicating that the current differential signal has its origin in the ventricle or, if the morphology analysis is being used, giving a signal on the lead 24 indicating that there is some type of abnormal cardiac condition, such as fibrillation.
Another application of the invention is to detect the respiratory rate of the subject in which the cardiac assist device operating in accordance with this invention is implanted. The ventricular lead tip 6 is located in the apex in the ventricle in most cases. This position is very close to the diaphragmatic muscle that controls respiration. In order to reliably detect the respiration, an electrode is needed that is close to the diaphragm, along with an indifferent electrode that is not too close to the breath sensing electrode but is not exposed to significant myopotential disturbances. One possibility, therefore, is the unipolar line 5 with the tip located in the apex 6 to use, with the top 3 the unipolar line 2 serves as an indifferent electrode. Respiration detection criteria are a low amplitude signal with a burst characteristic, where the burst frequency is in the range of 10 to 25 Hz and the repetition rate of the burst is similar to the expected human respiratory rate. An example of such a signal is in 7 shown. Typically, a signal with the in 7 As shown above, the waveform within the burst has a frequency of 10 to 25 Hz. To qualify a signal as a respiratory rate signal, respiration must be at least 200 ms for at least 200 ms contain five tips.
To get a breathing signal of in 7 To detect the type shown, the differential detector 11 can be set to a relatively high sensitivity and so many non-respiratory artifacts can be present in the signal. Therefore, an algorithm identifying the respiratory rate signal must take into account factors other than the aforementioned criteria to reliably identify the respiratory rate. Examples of these or other factors are amplitude stability, repetition frequency and burst duration. If the differential signal shows a high variability in the amplitude and burst duration of burst to burst, then the source of the signal is most likely not respiration. However, over time, slow changes in such a signal related to changes in physical activity become even more significant. The respiratory rate signal is then used in a known manner to control the pacing rate.
Although those skilled in the art may be attracted to modifications and alterations, it is the intention of the inventors to incorporate all changes and modifications within the granted patent, supra far as they are considered to be reasonable and appropriate, lie within the contribution of the inventors to this technique.
A heart stimulator comprising: a metal housing implantable in a subject ( 7 ); a pulse generator device contained in the housing ( 8th . 9 ) for emitting stimulation pulses; a first unipolar electrical line ( 2 ) electrically connected to the pulse generator device for receiving the stimulation pulses therefrom and in an atrial electrode (Fig. 3 ) that is placeable in an atrium of a heart of the subject; a second unipolar electrical line ( 5 ) electrically connected to the pulse generator device for receiving the stimulation pulses therefrom and in a ventricular electrode (Fig. 6 ) that is placeable in a ventricle of the heart; a control device ( 10 ) in the housing for controlling the pulse generator means for adjusting the amplitude and frequency of the stimulation pulses and for causing the stimulation pulses to be delivered to at least one of the atrial and ventricular elements; a differential detector device ( 11 ) in the housing connected to the first and second electrical leads for differential detection of cardiac activity between the atrial electrode and the ventricular electrode and for generating a differential electrical activity signal corresponding to cardiac activity; and decision logic ( 14 ) containing a morphology analyzer to which the differential signal is applied to analyze the same and to classify cardiac activity among a plurality of different types of cardiac activity and to provide a signal to the controller to cause it to alter the stimulation pulses as necessary; characterized in that the morphology analyzer includes means for one or more of the following criteria; Determining an energy content in the differential signal or; Determining a slew rate in the differential signal to identify the origin of cardiac activity when the difference between signals on said first and second unipolar electrical leads exceeds a predetermined value and; if the difference between signals on said first and second unipolar electrical lines is below said predetermined value, alternatively evaluating the signal by a morphology method or algorithm using the decision logic ( 14 ).
The heart stimulator of claim 1, further comprising Means in the differential signal analysis device for a gradient pattern detection of the differential signal to identify the origin the heart activity.
The heart stimulator of claim 1, further comprising Means for deriving the respiratory rate from the differential Signal.
DE1998607986 1997-06-06 1998-06-03 Pacemaker Expired - Fee Related DE69807986T3 (en)
US870935 1997-06-06
DE69807986D1 DE69807986D1 (en) 2002-10-24
DE69807986T2 DE69807986T2 (en) 2003-05-22
DE69807986T3 true DE69807986T3 (en) 2009-03-19
DE1998607986 Expired - Fee Related DE69807986T3 (en) 1997-06-06 1998-06-03 Pacemaker
DE102004062399B4 (en) 2004-12-23 2009-02-05 Siemens Ag Implantable pacemaker
US5871507A (en) 1999-02-16
2008-11-13 8366 Restricted maintained after opposition proceedings