this new pacemaker is intended to render a stimulation of a high septal penetration as already mentioned called herein “ eb ( electric bypass )” as previously mentioned , and which involves a real approach to the permanent physiological pacing . apart from the method for application to facilitate the implantation and to avoid the connection and disconnection of the catheter , a deflectable sheath can be used with an electrode on its edge which allows a stimulation to verify the proper place and then screw the catheter in said place . this sheath is removed after finding the proper place for stimulation and is eventually disposable . likewise , in the present invention apart from the new pacemaker and its method of application , a new right septal stimulation is described , which allows the generation of a wave front with simultaneous ventricular depolarization and qrs narrowing either in patients with normal qrs or in those with conduction disorders . the normal conduction throughout the his - purkinje system produces a fast synchronic sequential depolarization of the myocardial fibers causing a more efficient ventricular contraction . it is already known that the best place for pacing to prevent the ventricular dissynchrony keeping its normal activity while applying the catheter is the his bundle . several methods have been developed to reach the his bundle by septal stimulation . however there were several troubles in its implementation , requiring special treatment for finding the catheter , with variable results . together with the pacing system including the new pacemaker and its method of application , by septal implementation the wavefront penetration to the hisian mainstream is obtained . the result is a narrow qrs , similar to the one in the normal conduction and with an almost normal hemodynamic efficiency . with reference to fig1 and 12 , a heart h is shown in cross - section showing a right ventricle rv and a left ventricle lv divided by a septum s . a catheter is provided in the right ventricle rv with a distal electrode 12 secured to the septum and a proximal electrode 14 in the right ventricle . the right - hand side of the figures show the catheter 10 enlarged and energized by a pacemaker 1 to create two monopolar pulsewaves between the electrodes 12 , 14 and the pacemaker 1 . fig1 and 12 differ only in the figures show two different phases for the pulsewaves . the present pacemaker 1 is a pulse generator , single - chambered or dual - chambered , with conventional features : it has a ventricular output including at least two superimposed monopolar pulsewaves of reversed polarity between each other , with programmable configuration , in respect to a neutral which can be the pacemaker &# 39 ; s metallic box or a third electrode in the case of a tripolar catheter . the distal electrode 12 of this catheter 10 is fixed in the right ventricular rv septum s for the ventricular stimulation , thus producing an electrical alternative circuit or electrical bypass ( eb ) of the bundle block , being a non - conventional cardiac stimulation application place , so we are in the presence of a new use by the creation of a virtual electrode for the physiological electric synchrony of the heart . two charts showing two different options can be seen in fig9 and 10 . one of them is entitled “ septal stimulation eb1 ” and the other is entitled “ septal stimulation eb2 ”. in fig9 ( septal stimulation eb1 ), the distal electrode 14 is secured to the apex of the right ventricle rv . in fig1 , the distal electrode is secured to the septum s . in each of fig9 and 10 , the heart h is shown divided into regions 1 - 5 . in fig9 , region 1 is the left ventricle postero basal side . region 2 is the left ventricle lateral . region 3 is the right ventricle basal side . region 4 is the apex right ventricle septum apical and region 5 is the apex left ventricle . in fig1 , region 1 is the left ventricle postero basal side . region 2 is the left ventricle lateral . region 3 is the apex left ventricle . region 4 is the apex right ventricle septum apical and region 5 is the right ventricle lateral . in the method of application and the way to facilitate the implantation and to avoid the connection and disconnection of the catheter , a deflectable sheath with an electrode in its edge can be used , which allows stimulation , in order to check the proper place and then screw the catheter in said place . this sheath is removed after finding the proper stimulation place and is eventually disposable . according to one example , a new pacemaker and its method of application includes the following items : a pulse generator , single - chambered or dual - chambered , with conventional features : it has a ventricular output including at least two superimposed monopolar pulsewaves of reversed polarity between each other , with programmable configuration , in respect to a neutral which can be the pacemaker &# 39 ; s metallic box or a third electrode in the case of a tripolar catheter ; the right interventricular septum stimulation place , is the one which allows a greater interventricular synchrony making the left stimulation easier and the application of the electric alternative circuit principle or electrical bypass that reestablishes the physiological conduction of the heart when damaged . apart from the new pacemaker and its method of application with the deflectable sheath with an electrode on its edge , the present invention describes a new technique for the right septal stimulation which allows the generation of a wave front with simultaneous ventricular depolarization and qrs narrowing either in patients with normal qrs or in those with conduction disorders . this is obtained by the formation of a virtual electrode which generates a stimulation field significantly higher than the one in a traditional electrode for the physiological stimulation . said higher current field allows to compromise more distant areas than the pacemaker place even overcoming conduction disorders ,— electrical bypass ( eb )—. the use of said virtual electrode assures an energy saving with regards to the necessary high output and makes the placing in the septum easier avoiding difficult electrophysiological mapping procedures . for a better comprehension of the present invention , a septal ventricular stimulation system with high performance in the electric and probably contractile synchrony , is described . this system is intended to significantly modify the definitive pacemaker implantation , making it more physiological . patients with qrs narrowing were tested , as well as patients with av atrio - ventricular and interventricular conduction disturbances , showing in all of them the qrs narrowing phenomena and the orientation of the depolarization with vectors similar to those in the depolarization through the his - purkinje system . the embodiments of my invention are shown in the application of traditional pacemakers made in 50 consecutive patients who were stimulated in right septum with standard bipolar catheters . they were used for the record of the his bundle activity and with the pacing technique of my invention , pacemakers , method of application and a special high penetration technique of system eb . in order to use a conventional voltage a pulse generator driven by a traditional over - stimulation pacemaker was used , with programming outputs from 1 to 36 volts and two types of waves , a sequential biphasic and another superimposed biphasic wave , with pulse widths programmable from 0 . 1 to 2 milliseconds . the second wave uses each electrode individually with reference to an indifferent one with opposed polarities . this allows the use of a traditional output and generating a virtual electrode of great magnitude of current which is the objective of eb stimulation ( electrical bypass ), and reducing the use of high energy with the results previously tested . in order to know the behavior of the left ventricle in normal patients and with several branch conduction disturbances , a multipolar catheter through the coronary sinus was used . the distal dipole represents the side basal portions of the left ventricle , as it was recently shown by carto ® search . forty - nine patients were successively analyzed at the ep lab during the procedures to evaluate sinus function and a - v conduction . group a ( 31 patients ) was tested with pacing on edge of rv and in septum with high ouput ( 20 volt ). group b ( 18 patients ) was tested with the pacing stimulation of my invention , with the eb alternative electric pathway in septum . in both groups the duration of the qrs was measured , both the basal as well as during the different types of stimulation . in order to test the activation in basal and distal portions of the left ventricle , the gap between the beginning of the qrs and the depolarization in the coronary sinus of the most distant portion of the left ventricle was measured . table 1 describes the results in relation to features and magnitude of the width of the qrs obtained in each case . references : measures are expressed in milliseconds ; narrow ang = qrs lower than 100 msec ; ssep = width of qrs in septal stimulation ; sapex = width of qrs with stimulation from apex of rv ; r - lf = conduction time from r to a record of rv from the coronary cavity ; eb - rv = conduction time from septal stimulation eb to a record of rv from the coronary cavity ; srv - lv = conduction time from stimulation on apex of rv to a record of the lv from coronary cavity ; est = features of stimulation ; 20 ma = traditional stimulation with output of 20 mamperes . as described in the table above , there are no major differences between qrs eb and the spontaneous qrs . the average , qrs eb has 14 msec more than the spontaneous qrs . this delay is caused by a delta wave at the beginning of the qrs due to the septal penetration through a muscular pathway before the arrival of the stimulus to the specialized conduction system . then the remaining depolarization is exactly the same as the normal qrs configuration . differences regarding septal stimulation were not observed either when it was performed with higher energy ( 20 volts ). in the cases where rv apex was paced , a marked difference in spike - to - lv interval versus spike - to - lv ( eb ) interval was observed , lv activity being recorded as previously explained from the distal dipole of a multipolar catheter located in the coronary sinus . in average , the conduction time from the apex of rv to lv is increased by 54 msec in respect to the septal stimulation time eb to lv . this significant shortage of left - ventricle to right - ventricle time is also registered because of the presence of complete left branch block in the basal ecg , wherein the qrs significantly narrows ( 39 msec average ) after eb stimulation . it is also accompanied by significant narrowing of the qrs in both cases ( 61 msec average ), which supposes a more effective electric re - synchronization of the left ventricle . fig1 shows as an example of case 1 , a patient with narrow qrs . septal eb stimulation shows just a slight widening of the qrs ( first half of the figure ) with a conduction sequence similar to the one of the basal qrs . fig1 . fig2 corresponds to a patient with a complete left branch block and ventricular malfunction , the time of basal conduction from the beginning of the qrs to the deflection corresponding to the left ventricle through the distal electrode of a multipolar catheter placed in the coronary sinus ( 164 msec ). fig3 shows the reduction of such time of conduction when eb is stimulated in septum ( 90 msec ). fig3 . fig4 shows the same patient , the stimulation in apex of the right ventricle keeps a conduction time to the left ventricle ( 169 msec ( similar to the basal time ), when keeping the complete left branch block . fig5 shows a ecg of a patient with sinusal rhythm and complete block of the left branch , as the septal stimulation of high penetration ( eb ) “ normalizes ” the qrs , narrowing it . a proof of the “ physiological ” change in the sequence of intraventricular conduction is also the presence of the qrs narrowing , changes of the ventricular repolarization , with negative t waves in the precordial leads , certainly secondary to “ electrotonic memory ”. stimulation on apex of the right ventricle follows a behavior similar to the presence of the complete left branch block in the basal ecg . in this case septal eb stimulation narrows the qrs and generates the same changes of the ventricular repolarization ( fig6 ). in three cases , stimulation was conducted after the radiofrequency av node ablation , in order to avoid the high frequency response in cases of paroxystic atrial fibrilation . in these patients septal stimulation showed ventricular capture , from the same place wherein ablation was realized , with narrow qrs despite of the proper complete av block obtained . fig7 shows the bypass of the ablation site and the narrow capture of the qrs . on the right of the record the basal rhythm is vvi pacemaker mode with complete av block post ablation of the av node . note the presence of the atria dissociated from the ventricles in the “ ablat ” channel . at the left side , stimulation eb , from the ablation catheter in the same place of the ablation captures the ventricles with narrow qrs and normal depolarization - repolarization . septal eb stimulation shows a significant narrowing of the qrs similar to the normal conduction , through the his purkinje system . it is possible to interpret this fact as an entrance of the wavefront to the his bundle , due to the special features of the eb stimulation . in some cases , the qrs similarity so suggests . however , in some circumstances , particularly when the previous qrs has a delay by the presence of the branch block , a significant narrowing is observed , similar to the one observed in the simultaneous stimulation of both ventricles ( re - synchronization ). fig8 . in a patient with left bundle branch block , the fusion with extrasystoles coming from the right ventricle are expressed as a significantly narrow qrs . the various embodiments described above are provided by way of illustration only and should not be construed to limit the invention . based on the above discussion and illustrations , those skilled in the art will readily recognize that various modifications and changes may be made without strictly following the exemplary embodiments and applications illustrated and described herein . such modifications and changes do not depart from the true spirit and scope of the present invention .
a new pacemaker apparatus for treating the physiological electric conduction of the heart that includes a conduction abnormality in a ventricle . the pacemaker includes a pulse generator and a pacing electrode located in the heart , the pulse generator providing pacing signals to the pacing electrode . the pacemaker further includes a signal generation circuit that generates electrical signals from heart - related feedback signals that indicate that the pacing electrode is delivering the pacing signals in a region at or near the his bundle of the heart . the combination of the pulse generator and the signal generation circuit indicates that the pacing electrode is delivering the pacing signals in the region , at or near the his bundle of the heart , to electrically bypass the conduction abnormality of the heart in the ventricle .