Energy Saving in Permanent Cardiac Pacing: Pulse Waveform and Charge Balancing Deserve Consideration

The pacing pulse produced by implantable stimulators can be described as a truncated exponential decay from the starting peak amplitude, corresponding to the discharge of the output stage capacitance (reservoir and isolation capacitors, in series) along the application time. Pulse decay and charge balancing have relevant implications on the ideal setting of a pacing device, as demonstrated by mathematical predictions based on well-acknowledged theoretical statements. Successful stimulation is achieved with minimum energy expense at a pulse duration shorter than the chronaxie time, which represents the upper border of the advisable duration interval. With any start amplitude, the stimulation safety margin can be improved by a duration increase beyond the chronaxie only up to an absolute limit (longest useful duration), which depends on the chronaxie and the pulse time-constant. At the longest useful duration, the threshold start amplitude is at the minimum and cannot decrease any further, though it and the corresponding pulse mean amplitude largely exceed the rheobase. The overall pacing performance is affected, in addition, by the load resistance and the electrode capacitance. Pulse amplitude decay limits the effectiveness of extended duration in implantable stimulators, making short pulses preferable whenever possible. Proper pulse settings based on actual waveform properties can prevent energy waste and reduce pacing consumption, thus prolonging the service life of the stimulator.