Pacing Output Coupling Capacitor for Automatic Capture Threshold Detection in Cardiac Pacing Systems

I. Field of the Invention

The present invention relates generally to the field of cardiac rhythm management devices, including atrial, ventricular, and dual chamber pacemakers. More specifically, the present invention relates to a method and apparatus for attenuating polarization voltages or "afterpotentials" which develop at the heart tissue/electrode interface following the delivery of a stimulus to the heart tissue. The present invention allows accurate detection of an evoked response of the heart, to thereby determine whether each stimulus resulted in heart capture or contraction. The present invention further facilitates improved tracking of the capture threshold for minimizing power consumption while assuring therapeutic efficacy.

II. Discussion of the Prior Art

Cardiac pacers have enjoyed widespread use and popularity through time as a means for supplanting some or all of an abnormal heart's natural pacing functions. Among the various heart abnormalities remedied by pacemakers include total or partial heart block, arrhythmias, myocardial infarctions, congestive heart failure, congenital heart disorders, and various other rhythm disturbances within the heart. The fundamental components of a cardiac pacemaker include an electronic pulse generator for delivering stimulus pulses to the heart and an electrode lead arrangement (unipolar or bipolar) for sensing evoked responses from the heart. Cardiac pacemakers may be categorized generally as either external or implantable. External cardiac pacemakers are characterized as having the electronic pulse generator which resides outside the body with one or more electrode leads passing through the skin and ultimately into the heart for delivering pacing stimulus pulses and sensing evoked responses. Such external pacemakers are typically employed for temporary pacing, such as following a heart attack or open heart surgery, and are removed when no longer needed. Implantable pacemakers are used for long-term pacing and are characterized as having both the electrical pulse generator and electrode lead arrangement surgically implanted within the body of the patient. Depending upon the heart abnormality, cardiac pacemakers may be designed to engage in ventricular pacing, atrial pacing, or dual chamber pacing in both the atrium and ventricle.

Regardless of which type of cardiac pacemaker is employed to restore the heart's natural rhythm, all operate to stimulate excitable heart tissue cells adjacent to the electrode of the pacing lead employed with the pacemaker. Myocardial stimulation or "capture" is a function of the positive and negative charges found in each myocardial cell within the heart. More specifically, the selective permeability of each myocardial cell works to retain potassium and exclude sodium such that, when the cell is at rest, the concentration of sodium ions outside of the cell membrane is approximately equal to the concentration of potassium ions inside the cell membrane. However, the selective permeability also retains other negative particles within the cell membrane such that the inside of the cell membrane is negatively charged with respect to the outside when the cell is at rest. When a stimulus is applied to the cell membrane, the selective permeability of the cell membrane is disturbed and it can no longer block the inflow of sodium ions from outside the cell membrane. The inflow of sodium ions at the stimulation site causes the adjacent portions of the cell membrane to lose its selective permeability, thereby causing a chain reaction across the cell membrane until the cell interior is flooded with sodium ions. This process, referred to as depolarization, causes the myocardial cell to have a net positive charge due to the inflow of sodium ions. The electrical depolarization of the cell interior causes a mechanical contraction or shortening of the myofibrils of the cell membrane. The syncytial structure of the myocardium will cause the depolarization originating in any one cell to radiate through the entire mass of the heart muscle so that all cells are stimulated for effective pumping. Following heart contraction or systole, the selective permeability of the cell membrane returns and sodium is pumped out until the cell is repolarized with a negative charge within the cell membrane. This causes the cell membrane to relax and return to the fully extended state, referred to as diastole.

In a normal heart, the sino-atrial (SA) node initiates the myocardial stimulation or "capture" sequence described above. The SA node comprises a bundle of unique cells disposed within the roof of the right atrium. Each cell membrane of the SA node has a characteristic tendency to leak sodium ions gradually over time such that the cell membrane periodically breaks down and allows an inflow of sodium ions, thereby causing the SA node cells to depolarize. The SA node cells are in communication with the surrounding atrial muscle cells such that the depolarization of the SA node cells causes the adjacent atrial muscle cells to depolarize. This results in atrial systole wherein the atria contract to empty blood into the ventricles. The atrial depolarization from the SA node is detected by the atrioventricular (AV) node which, in turn, communicates the depolarization impulse into the ventricles via the Bundle of His and Purkinje fibers following a brief conduction delay. In this fashion, ventricular systole lags behind atrial systole such that the blood from the ventricles is pumped through the body and lungs after being filled by the atria. Atrial and ventricular diastole follow wherein the myocardium is repolarized and the heart muscle relaxed in preparation for the next cardiac cycle. It is when this system fails or functions abnormally that a cardiac pacemaker may be needed to deliver an electronic pacing stimulus for selectively depolarizing the myocardium of the heart so as to maintain proper heart rate and synchronization of the filling and contraction of the atrial and ventricular chambers of the heart.

The success of a cardiac pacemaker in depolarizing or "capturing" the heart hinges on whether the energy of the pacing stimulus as delivered to the myocardium exceeds a threshold value. This threshold value, referred to as the capture threshold, represents the amount of electrical energy required to alter the permeability of the myocardial cells to thereby initiate cell depolarization. If the energy of the pacing stimulus does not exceed the capture threshold, then the permeability of the myocardial cells will not be altered and thus no depolarization will result. If, on the other hand, the energy of the pacing stimulus exceeds the capture threshold, then the permeability of the myocardial cells will be altered such that depolarization will result. Changes in the capture threshold may be detected by monitoring the efficacy of stimulating pulses at a given energy level. If capture does not occur at a particular stimulation energy level which previously was adequate to effect capture, then it can be surmised that the capture threshold has increased and that the stimulation energy should be increased. On the other hand, if capture occurs consistently at a particular stimulation energy level over a relatively large number of successive stimulation cycles, then it is possible that the capture threshold has decreased such that the stimulation energy is being delivered at level higher than necessary to effect capture. This can be verified by lowering the stimulation energy level and monitoring for loss of capture at the new energy level. The ability to detect capture in a pacemaker is extremely desirable in that delivering stimulation pulses having energy far in excess of the patient's capture threshold is wasteful of the pacemaker's limited power supply. In order to minimize current drain on the power supply, it is desirable to automatically adjust the pacemaker such that the amount of stimulation energy delivered to the myocardium is maintained at the lowest level that will reliably capture the heart. To accomplish this, a process known as "capture verification" must be performed wherein the pacemaker monitors to determine whether an evoked depolarization or R-wave occurs in the heart following the delivery of each pacing stimulus pulse.

The prior art is replete with patents which address the problem of polarization voltage or "afterpotentials" hindering capture verification in cardiac pacing systems. U.S. Pat. No. 4,373,531 to Wittkampf et al. teaches the use of pre and post stimulation recharge pulses to neutralize the polarization on the pacing lead. U.S. Pat. No. 4,399,818 to Money teaches the use of a direct-coupled output stage wherein polarization voltages at the heart tissue/electrode interface are dissipated by shorting the electrodes together. U.S. Pat. No. 4,498,478 to Bourgeois teaches the use of a resistor across the output terminals (electrodes) such that a current path is provided for discharging and recharging the effective capacitance at the electrode/tissue interface. U.S. Pat. No. 4,537,201 to Delle-Vedove et al. teaches a linearization of the exponentially decaying sensed signal by applying the sensed signal through an anti-logarithmic amplifier in order to detect a remaining nonlinear component caused by the evoked potential. U.S. Pat. No. 4,674,508 to DeCote, Jr. teaches the use of paired pacing pulses wherein the waveforms sensed through the pacing lead following the generation of each of the pair of pulses are electronically subtracted to yield a difference signal indicative of the evoked cardiac response. U.S. Pat. No. 4,686,988 to Sholder teaches the use of a separate sensing electrode connected to a detector for detecting P-waves in the presence of atrial stimulation pulses, wherein the P-wave detector has an input bandpass characteristic selected to pass frequencies that are associated with P-waves. U.S. Pat. No. 4,821,724 to Whigham et al. teaches the use of a triphasic stimulus having two positive pulses and one negative pulse for balancing the charge at the electrode/tissue interface. U.S. Pat. No. 4,858,610 to Callaghan et al. teaches the use of charge dumping following delivery of the stimulation pulse to decrease lead polarization and also the use of separate pacing and sensing electrodes to eliminate the polarization problem on the sensing electrode. U.S. Pat. No. 5,324,310 to Greeninger et al. teaches the use of the "ring-to-ring" sensing with corresponding atrial and ventricular EGM amplifiers whose outputs are multiplied and compared to a predetermined threshold to determine capture. U.S. Pat. No. 5,486,201 to Canfield discloses an active discharge circuit having a switching device which sequentially and repeatedly couples a charge transfer capacitor to the coupling capacitor to transfer charge therebetween and thereby actively discharge the coupling capacitor.

The foregoing prior art approaches, however, suffer from significant drawbacks. For example, the techniques of the '610 patent to Callaghan and '988 patent to Sholder, which involve using a separate electrode located at some distance from the stimulating electrode for the purpose of isolating the polarization voltages or "afterpotential," are disadvantageous in that they require the additional cost and complexity of the additional sensing electrode. The approaches of the '531 patent to Wittkampf et al. and '508 patent to DeCote, Jr. are unnecessarily wasteful of battery power and unduly complex due to the need to deliver opposite-polarity charges and pairs of closely spaced pacing pulses, respectively, to the electrode. The approach of the '201 patent to Delle-Vedove et al. is similarly disadvantageous in that it requires unnecessarily complex circuitry that it difficult to implement to produce the anti-logarithmic amplifier.

These and numerous other disadvantages of the prior art necessitates the need for the method and apparatus for automatic capture threshold detection provided by the present invention.

In accordance with a broad aspect of the present invention, the purpose of the present invention is to provide an improved pacing output circuit of a cardiac pacemaker, wherein the pacing circuit shortens pacing afterpotentials without significantly increasing the leading edge voltage pacing threshold. The present invention includes an improved coupling capacitor arrangement or afterpotential attenuating means that differs from the conventional coupling capacitor of the conventional pacing circuit. The improved coupling capacitor arrangement may be implemented during the automatic threshold mode and/or may be implemented during the normal pacing mode of the pacer so long as the pacing threshold does not exceed a predetermined amount. Use of the coupling capacitor arrangement during normal pacing for Brady therapy, for example, allows reliable evoked response detection and allows maximization of the power supply, thereby extending the device longevity. The coupling capacitor arrangement may further operate with a single unipolar lead, a bipolar lead or a plurality of unipolar or bipolar leads without the necessity of an indifferent electrode, thereby enhancing the adaptability of a pacemaker having the coupling capacitor arrangement of the present invention.

It is accordingly a principal object of the present invention to provide a new and improved low power consumption system that attenuates polarization voltages or "afterpotentials" at the heart tissue/electrode interface such that the evoked cardiac response may be readily detected.

It is a further object of the present invention to provide an improved cardiac pacemaker which minimizes the current drain to prolong the life of the battery.

Another object of the present invention is to provide an improved pacing circuit that reduces the required blanking period and attenuates afterpotentials developed at the pacing electrode, wherein the improved pacing circuit may be implemented in either the autothreshold or normal pacing modes.

In accordance with a broad aspect of the present invention, the foregoing objectives are attained by providing an improved pacing output circuit for use in a cardiac pacemaker comprising power supply means, first capacitor means, first switching means, second capacitor means, and afterpotential attenuation means. The first capacitor means is cooperatively operable with the power supply means for selectively storing a pacing charge to be delivered to myocardial tissue in a heart via an electrode. The first switching means is provided for selectively delivering the pacing charge from the first capacitor means to the myocardial tissue within the heart. The second capacitor means is coupled to the electrode and cooperatively operable with the first capacitor means for blocking DC components from the heart during pacing. The afterpotential attenuation means is provided for selectively attenuating afterpotentials which result due to the application of the pacing charge to the heart. The afterpotential attenuation means includes third capacitor means coupled to the second capacitor means and second switching means for selectively coupling the second capacitor means in series with the third capacitor means so as to reduce the effective capacitance of the second capacitor means. The afterpotential attenuation means may be implemented in either or both the threshold detection mode and the normal pacing mode, subject to limitations further discussed below in greater detail.

In accordance with yet another broad aspect of the present invention, the foregoing objectives are attained by providing an improved method for attenuating afterpotentials in cardiac pacing systems. The improved method comprises the steps of: (a) providing an improved pacing output circuit, the pacing output circuit having means for selectively delivering a stimulating pulse to an electrode disposed within a chamber of a patient's heart and a coupling capacitor coupled to the electrode for blocking DC components from entering the patient's heart; and (b) selectively reducing the capacitance of the coupling capacitor during the autothreshold and/or normal pacing modes.

In accordance with a still further broad aspect of the present invention, the foregoing objectives are attained by providing an improved cardiac pacemaker comprising pulse generation means for selectively generating stimulus pulses and lead means coupled to the pulse generation means for delivering the stimulus pulses to a preselected chamber within a patient's heart. The pulse generation means includes power supply means, first capacitor means cooperatively operable with the power supply means for selectively storing a pacing charge to be delivered to the chamber in the heart via the lead means, first switching means for selectively delivering the pacing charge from the first capacitor means to the chamber of the heart via the lead means, and afterpotential attenuation means for selectively attenuating afterpotentials which result due to the application of the pacing charge to the heart. The afterpotential attenuation means includes second capacitor means coupled to a third capacitor means and second switching means for selectively coupling the second capacitor means in series with the third capacitor means so as to reduce the effective capacitance of the second capacitor means.

These and other objects and advantages of the present invention will be readily apparent to those skilled in the art from a review of the following detailed description of the preferred embodiment in conjunction with the accompanying claims and drawings in which like numerals in the several views refer to corresponding parts.

FIG. 1 is a schematic diagram of a pacing output circuit 10;

FIG. 2 is a block diagram depicting a cardiac pacemaker 30 incorporating the improved pacing circuitry for automatic capture threshold detection in accordance with the present invention;

FIG. 3 is a schematic diagram of an improved pacing output circuit 80 provided in accordance with a preferred embodiment of the present invention;

FIG. 4 depicts a resulting pacing waveform observable between the ring and tip of a pacing lead positioned within the heart of a patient, when utilizing a conventional pacing circuit;

FIG. 5 depicts a resulting pacing waveform observable between the ring and tip of a pacing lead positioned within the heart of a patient, when utilizing the afterpotential attenuation means of the present invention;

FIG. 6 shows a strip chart tracing of the capture and noncapture sense signal when utilizing a pacing circuit having a 15 microfarad coupling capacitor with a recharge time of 30 milliseconds, together with a strip chart tracing of a surface ECG for reference; and

FIG. 7 shows a strip chart tracing of the capture and noncapture sense signal when utilizing a pacing circuit having a 1 microfarad coupling capacitor with a recharge time of 10 milliseconds, together with a strip chart tracing of a surface ECG for reference.

FIG. 1 is a circuit diagram illustrating a conventional pacing output circuit 10 having the specific components identified below and found in any of a variety of prior art pacemakers. The pacing output circuit 10 is designed to selectively generate and deliver stimulus pulses to the heart of a patient, indicated schematically as the resistive load 12, via a tip electrode 14 and ring electrode 16. The circuit 10 includes a power supply or battery 18, a first switch 20, a second switch 22, a third switch 24, a pacing charge storage capacitor 26 generally having a capacitance of between 10-30 microfarads, and a coupling capacitor 28 generally having a capacitance greater than 10 microfarads, all of which cooperatively operate under the direction of a microprocessor-based controller (not shown) to perform a charging cycle, a pacing cycle, and a recharging cycle. The charging cycle involves having the first switch 20 closed and the second and third switches 22, 24 open such that the pacing charge storage capacitor 26 is charged up to a predetermined voltage level. The pacing cycle involves having the first and third switches 20, 24 open and the second switch 22 closed such that the voltage within the pacing charge storage capacitor 26 may be discharged through the coupling capacitor 28 to the tip electrode 14 of the pacemaker. Immediately after pacing, the second and third switches 22, 24 are in the open state such that charges within the coupling capacitor 28 will decay slowly through leakage. The recharging cycle involves having the first and second switches 20 and 22 open and the third switch 24 closed for a predetermined period of time following the pacing pulse to allow the coupling capacitor 28 to be discharged through the load 12.

While the foregoing pacing circuit 10 is generally effective in delivering stimulus pulses to the heart 12, it has been found that the detection of evoked depolarization or "capture verification" is rendered very difficult due to polarization voltages or "afterpotentials" which develop at the heart tissue/electrode interface following the application of the stimulation pulses. The inventors in the present application have discovered that these polarization voltages are due, in large part, to the relatively large capacitance (e.g. 33 microfarads) of the coupling capacitor 28. The large capacitance of coupling capacitor 28 was believed necessary to deliver sufficient energy to the heart. However, the large capacitance of the coupling capacitor 28 also causes a charge dissipation or "afterpotential" which is relatively large (100 millivolts or greater) and which decays exponentially over a relatively long period of time (100 milliseconds). This is particularly troublesome due to the fact that the evoked potential or R-wave of the heart tissue is small in amplitude (5-20 millivolts) relative to the polarization voltage or "afterpotential" (100 millivolts). Moreover, the long decay period of the polarization voltage or "afterpotential" effectively masks the evoked response, which typically begins within approximately 10-20 milliseconds after the stimulation pulse. It will be appreciated that this creates difficulty in detecting the evoked response of the heart following the delivery of stimulus pulses. In that evoked response is indicative of capture, the undesirable masking of the evoked response by "afterpotentials" thus hampers the ability of the pacemaker to conduct automatic capture verification.

The present invention may find application in a variety of implantable or external cardiac rhythm management devices, including but not limited to bradycardia pacemakers, antitachycardia pacemakers, and defibrillators. For purposes of explanation and ease of discussion, the present invention will be described in connection with an implantable rate adaptive cardiac pacemaker 30 as illustrated in FIG. 2. By way of illustration and not limitation, the cardiac pacemaker 30 is a dual chamber (DDD) pacer having a microprocessor-based controller 32 operatively coupled to an atrial sense amplifier 34, an atrial pulse generator 36, a ventricular sense amplifier 38, a ventricular pulse generator 40, a transceiver 42, and an input/output module 44, all of which are disposed within a hermetically sealed housing designated schematically at 46. Those skilled in the art will appreciate that components of the atrial sense amplifier and pulse generator may be utilized by the ventricular sense amplifier and pulse generator.

The cardiac pacemaker 30 is operatively coupled to a patient's heart 48 via a main pacing lead 50 which branches off into an atrial lead 52 and a ventricular lead 54. Bipolar pacing is provided, by way of example, wherein the atrial lead 52 has a tip electrode 56 and a ring electrode 58, and the ventricular lead 54 has a tip electrode 60 and a ring electrode 62. The atrial pulse generator 36 is electrically coupled to the tip electrode 56 of the atrial lead 52 via a conductor 64 for delivering stimulating pulses to the atrium under the direction of the microprocessor controller 32. The atrial sense amplifier 34 is electrically coupled to the ring electrode 58 of the atrial lead 52 via a conductor 66 for sensing the occurrence of P-wave activity relating to atrial events and forwarding this atrial information to the microprocessor controller 32. The ventricular pulse generator 40 is similarly electrically coupled to the tip electrode 60 of the ventricular lead 54 via a conductor 68 for delivering stimulus pulses to the ventricle under the direction of the microprocessor controller 32. The ventricular sense amplifier 38 is electrically coupled to the ring electrode 62 of the ventricular lead 54 for sensing the R-wave activity relating to ventricular depolarization and forwarding this ventricular information to the microprocessor controller 32. The cardiac pacemaker 30 also includes read-only memory (ROM) 70 and random access memory (RAM) 72 communicatively coupled to the microprocessor controller 32. The transceiver 42 is cooperatively operable with a conventional input/output module 44 for transmitting and receiving information to and from an external programmer 74.

With reference to FIG. 3, the present invention includes an improved pacing output circuit 80 for use within the atrial and ventricular pulse generators 36, 40 of the pacemaker 30 shown in FIG. 2. As will be explained below, the improved pacing output circuit 80 is capable of quickly attenuating polarization voltages or "afterpotentials" which result due to the application of stimulus pulses to the heart 48. By attenuating the polarization voltages or "afterpotentials" in this fashion, the improved pacing circuit 80 of the present invention facilitates the task of capture verification in that the presence or absence of evoked responses may be readily determined without the masking caused by afterpotentials. Capture verification may advantageously allow the pacemaker 30 to automatically adjust the capture threshold so as to minimize power consumption while assuring therapeutic efficacy.

In a preferred embodiment, the improved pacing output circuit 80 of the present invention includes a power supply or battery 82, a first switch 84, a second switch 86, a third switch 88, a fourth switch 90, a pacing charge storage capacitor 92, a first coupling capacitor 94, and a second coupling capacitor 96, all of which are cooperatively operable under the direction of the microprocessor-based controller 32 shown in FIG. 2. By way of example, the improved pacing output circuit 80 is illustrated in a ventricular pacing arrangement for delivering stimulus pulses to the heart 48 via the tip electrode 60 and ring electrode 62 of the ventricular pacing lead 54 shown in FIG. 2.

It is to be readily understood, however, that the improved pacing output circuit 80 of the present invention may also find application in an atrial pacing arrangement. The power supply or battery 82 is preferably the battery provided to power the pacemaker 30 and may comprise any number of commercially available batteries suitable for pacing applications. The switches 84-90 are illustrated as discrete components but are preferably carried out via any number of commercially available microprocessor-directed semiconductor integrated circuit switching means. The pacing charge storage capacitor 92 may also comprise any number of commercially available storage capacitors, but is preferably provided with a capacitance in the range greater than 10 microfarads so as to develop a sufficient pacing charge for stimulating the heart 48.

One function of the second coupling capacitor 96 is to block DC signals from reaching the heart 48 during pacing. In order to minimize the pacing pulse droop the second coupling capacitor 96 should have a sufficiently large capacitance, for example, greater than 10 microfarads. In an important aspect of the present invention, the first coupling capacitor 94 is advantageously provided having a capacitance preferably less than 5 microfarads and substantially smaller than that of the second coupling capacitor 96. As will be described in greater detail below, the first coupling capacitor 94 may be selectively operable, via the fourth switch 90, so as to selectively reduce the effective capacitance of the second coupling capacitor 96, thereby quickly attenuating the polarization voltage or "afterpotentials" which result from pacing.

Referring next to FIGS. 4 and 5, the respective resulting pacing waveforms 150 and 152 observed between the tip and ring of a pacing lead, for the conventional pacing circuit (FIG. 4) and the pacing circuit of the present invention (FIG. 5), are shown for comparison. By electrical analysis theory, familiar to those skilled in the art, the pacing afterpotential signal decay characteristics are determined by the time constant formed by the product of the coupling capacitor (blocking) and the load (a combination of the impedance of the lead body, electrode/tissue interface, and myocardium). When the capacitance of the coupling capacitor is reduced, the afterpotential has a larger initial amplitude but dissipates faster (compare afterpotential amplitudes 154 and 156 for the respective pacing afterpotential waveforms 150 and 152). The blanking period 158 before sensing for the conventional capacitor is greater than the required blanking period 160 when utilizing a 1 microfarad coupling capacitor (see FIGS. 4 and 5 for comparison). Also, the recharge time 162 when utilizing the conventional coupling capacitor is significantly longer than the required recharge time 164 required for the 1 microfarad capacitor. Further, the recharge time 162 overlaps into sensing period 166 for the conventional capacitor, whereas the recharge time 164 terminates prior to the beginning of the sensing period 168 for the 1 microfarad capacitor. Hence, when the coupling capacitance is sufficiently small, for example, less than 5 microfarads, the pacing afterpotential will settle to baseline at a faster rate and before the onset of the evoked response, thereby making detection of the evoked response feasible.

Those skilled in the art will appreciate that as the coupling capacitance decreases, the pacing pulse seen by the heart will bear a larger droop and the threshold voltage that evokes a response increases. Thus, if a small coupling capacitance is utilized during a determination of the threshold, the determined threshold will be greater than the actual threshold required during normal pacing (assuming that a conventional coupling capacitance is utilized during normal pacing), thereby increasing the pacing safety margin. It is believed by the inventors that use of a coupling capacitor having a capacitance in the range of 2 microfarads will not significantly increase the pacing threshold, with the required increase being under ten percent. The increase in pacing threshold becomes a greater significance when the coupling capacitance is set below 1 microfarad.

Referring next to FIGS. 6 and 7, the sensed signals 176 and 178 observed from the electrodes of a pacing lead utilizing a conventional pacing circuit and the pacing circuit of the present invention respectively, are shown for comparison. FIG. 6 shows a recorded signal 176 received when implementing a 15 microfarad coupling capacitor having a recharge time of 30 milliseconds and a blanking of 15 milliseconds. Those skilled in the art will appreciate that the intracardiac signal 176 is overwhelmed with pacing afterpotential and, thus, the evoked response 180 and non-captured artifacts 182 during capture and non-capture respectively are not easily distinguishable within 100 milliseconds after pacing. FIG. 7 shows a recorded signal 178 received when implementing a 1 microfarad coupling capacitor having a 10 millisecond recharge time and a blanking time of 12 milliseconds. The evoked response 184 and non-captured artifacts 186 are readily distinguishable during capture and non-capture for the signal 178. Without limitation, a conventional peak detector utilized for intrinsic sensing may be adapted for detecting the peaks in the signal 178 received after pacing while using a 1 microfarad coupling capacitor having a 10 millisecond recharge time. The high-low-high pacing output scheme in both FIGS. 6 and 7 was implemented to ensure that capture would result from at least half of all the pacing stimulus.

Having described the constructional features of the present invention, the operation of the improved pacing output circuit 80 will now be described. During a normal pacing mode, the pacing output circuit 80 engages in a charging cycle, a pacing cycle, and a recharge cycle. The charging cycle is characterized as having the first switch 84 in a closed state with the second and third switches 86-90 in an open state. In this configuration, the pacing charge storage capacitor 92 may be charged up to a predetermined pacing voltage level, such as 3 volts. After the pacing charge storage capacitor 92 has been charged up to the predetermined pacing voltage level, the pacing cycle then operates to deliver the pacing charge from the pacing charge storage capacitor 92 to the heart 48. To accomplish this pacing cycle, the first switch 84 and third switch 88 are in the open state and the second switch 86 and fourth switch 90 may be in the closed state. This allows the voltage within the pacing charge storage capacitor 92 to be discharged through the second coupling capacitor 96 to the tip electrode 60 of the pacemaker 30. Maintaining the fourth switch 90 in a closed state effectively bypasses the first coupling capacitor 94 such that the second coupling capacitor 96 is at its full capacitance level of approximately greater than 10 microfarads. This, once again, effectively blocks any DC signals from reaching the heart 48. In another alternate preferred embodiment, during the normal pacing mode, the fourth switch 90 may be open so long as the pacing threshold does not exceed a predetermined limit. In this manner detection of an evoked response (autocapture) may be enhanced during the normal pacing mode. During the autothreshold pacing mode, the fourth switch 90 is always in the open state and is closed for normal pacing.

The recharge cycle during normal pacing involves having the first switch 84 and the second switch 86 in the open state, while having the third switch 88 in the closed state. This allows the circuit 80 to passively recharge, such that the charge within the heart 48 is allowed to flow back into the circuit 80 to balance out. As noted above, during this passive recharge period, the charge on the second coupling capacitor 96 may be such that the afterpotential signal exponentially decays over a relatively long period of time lasting up to 100 milliseconds. This large "afterpotential" signal unwontedly masks out any evoked response from the heart 48. This is because the evoked responses from the heart 48 typically occur within 20 milliseconds from the delivery of the stimulus pulse and are substantially smaller in magnitude than the large "afterpotential" which would develop within the second coupling capacitor 96, were it not for the present invention.

It is an important aspect of the present invention that the polarization voltages or "afterpotentials" which result from pacing quickly attenuate. This is achieved by having fourth switch 90 in the open state such that the first coupling capacitor 94 and second coupling capacitor 96 are connected in series. The series coupling of the first coupling capacitor 94 and second coupling capacitor 96 causes the overall capacitance to approximate the lower capacitance, or in other words, the capacitance of the first coupling capacitor 94. In a preferred embodiment, the first coupling capacitor 94 may be provided having a capacitance in the range of 1-2 microfarads such that, for a brief moment, the overall capacitance between the afterpotential reduction capacitor 94 and coupling capacitor 96 is approximately 1-2 microfarads. Advantageously, it has been found that reducing the effective capacitance of the second coupling capacitor 96 quickly attenuates the polarization voltages or "afterpotentials" which result immediately following the application of a stimulus pulse such that the evoked responses within the heart 48 will not be masked or buried within the "afterpotential." By eliminating the adverse affects of "afterpotentials" in this fashion, the pacemaker 30 can easily determine and track the capture threshold of the heart 48 over time. Those skilled in the art will appreciate that with the continuous knowledge of the capture and pacing threshold in hand, the pacemaker 30 may be automatically adjusted to maintain an optimal pacing stimulus level which ensures safe pacing while minimizing power consumption.

This invention has been described herein in considerable detail in order to comply with the Patent Statutes and to provide those skilled in the art with the information needed to apply the novel principles and to construct and use such specialized components as are required. However, it is to be understood that the invention can be carried out by specifically different equipment and devices, and that various modifications, both as to the equipment details and operating procedures, can be accomplished without departing from the scope of the invention itself.