Analysis device for assisting in the implantation of a device for stimulation of the human or animal heart

0001The invention relates to an analysis device for supporting the implantation of an arrangement for stimulating the human or animal heart according to the preamble of claim 1, a computer program product according to the preamble of claim 10 and a method for data evaluation according to the preamble of claim 11.

0002Implantable arrangements for stimulating a human or animal heart, such as pacemakers, have long been known. You can perform different functions. Various stimulation programs can be carried out by an appropriate pacemaker to bring the treated heart back to a normal state.

0003From the <patcit id="pcit0001" dnum="US8565880B2"><text>US 8,565,880 B2</text></patcit> a pacemaker is known which is suitable for stimulating the His bundle. The His bundle is a bundle of specific cardiac muscle cells that is part of the cardiac conduction system. The His bundle is distal to the atrioventricular node towards the apex. Since the His bundle is a relatively small unit within a human or animal heart, it can sometimes be difficult to correctly hit and excite the His bundle with an electrode. The aforementioned US patent is concerned with determining a correct detection of the His bundle or dividing the type of detection of the His bundle into different categories. Depending on the particular category of His bundle detection, different stimulation configurations of the pacemaker can then be specified.

0004Also the US patent <patcit id="pcit0002" dnum="US8761880B2"><text>US 8,761,880 B2</text></patcit> deals with the detection of a His bundle recording. For this purpose, a time is determined within which a first cardiac activity information is received in response to a His bundle stimulation. The quality of the His bundle detection is determined as a function of the determined time period.

0005The U.S. patent <patcit id="pcit0003" dnum="US9168382B2"><text>US 9,168,382 B2</text></patcit> also deals with methods for determining His bundle detection. To this end, cardiac activity signals are detected that are generated as a result of an assumed His bundle stimulation. The detected signals are analyzed to determine whether they come from conductive tissue or from myocardial tissue. Only the signals that come from conductive tissue are used for the selective verification of the His bundle detection.

0006In the methods known from the prior art for implanting cardiac pacemakers, which can stimulate the His bundle, an electrophysiological examination at an electrophysiology exhibition site is regularly required. In the course of such an electrophysiological examination, it is then determined whether sufficiently large His bundle-specific signals can be detected manually in an electrocardiogram, in order then to determine a suitable electrode position within the heart. However, there are only a few centers in Germany that are equipped with such an electrophysiology exhibition center. In addition, there is only a very limited group of medical professionals who are able to carry out an electrophysiological examination and to be able to reliably identify His bundle-specific signals. The implantation of a pacemaker that is suitable for His bundle stimulation is therefore extremely complex.

0007In addition, the physicians performing such an electrophysiological examination require extensive experience in order to be able to manually recognize the His bundle-specific signals in an electrocardiogram (EKG). Thus, the number of implantation centers at which the implantation of a pacemaker that is suitable for a His bundle simulation is severely limited.

0008The object of the present invention is to simplify the implantation of a pacemaker which is suitable for His bundle stimulation, and thus to permit such an implantation at a far larger number of implantation centers than was previously possible.

0009This object is achieved by an analysis device for supporting the implantation of an arrangement for stimulating the human or animal heart with the features of claim 1. Such an analysis device has a processor and a memory unit.

0010According to the invention, the memory unit has a computer-readable program which causes the processor to carry out the steps explained below when it is executed on the processor.

0011First, an electrocardiogram of a human or animal heart, into which an arrangement for stimulating this heart is implanted, is received. The electrocardiogram can be any type of electrocardiogram. Particularly suitable electrocardiograms are intracardiac electrograms.

0012This is followed by an automatic identification of signals from the electrocardiogram, which are caused by His bundle stimulation. These signals appear between an atrial signal and a ventricular signal.

0013According to advantageous embodiments of the present invention, signals of the electrocardiogram that are triggered by an HIS bundle stimulation can be identified by the following steps:<ol id="ol0001" compact="compact"><li>a) preprocessing of the EKG signal by amplification, damping, filtering, differentiation, smoothing, averaging, a phase shift and / or an offset correction,</li><li>b) Evaluation of the ECG signal morphology to identify typical HIS bundle signals. The HIS signal appears after an atrial signal and before a ventricular signal; therefore, according to embodiments of the invention, the HIS signal can be identified between them. According to further aspects of the invention, the atrial and ventricular signals can be differentiated by evaluating the signal amplitudes and relationships to one another. With a suitable HIS position, the amplitude of the atrial signal is smaller than the amplitude of the HIS signal, and the amplitude of the ventricular signal is significantly larger (eg 2-10 times) than the amplitude of the HIS signal.</li></ol>

0014The previously identified signals are then marked in the received electrocardiogram.

0015The electrocardiogram marked in this way is then output on an output device. The output device can be a component of the analysis device or a separate output device to which the analysis device is connected.

0016The marking made can be done optically or acoustically, for example. Optical marking can be implemented particularly easily, for example, by highlighting the identified His bundle-specific signals. This makes it significantly easier for a user of the analysis device to recognize His bundle-specific signals within the electrocardiogram and to use the quality or Characterization of these His bundle-specific signals to correctly position an electrode intended for His bundle stimulation within a human or animal heart.

0017By using such an analysis device, it is no longer necessary to carry out an electrophysiological examination using an electrophysiology measuring station during the implantation of a pacemaker or another arrangement for stimulating the human or animal heart. Rather, such a separate examination is not necessary. Instead, by using the analysis device claimed according to the invention, it can be checked directly during the implantation how well, that is to what extent, the His bundle of the heart in question is contacted by the corresponding electrode and whether there is sufficient stimulation of the His bundle in the selected one Positioning of the electrode is guaranteed.

0018The output device can be, for example, a monitor or a combination of a monitor and a loudspeaker. The output device can alternatively also be a printer which is suitable for printing out a marked electrocardiogram on paper or another medium.

0019The analysis device can also be referred to as a pace sense analyzer (PSA).

0020In one variant, the analysis device can be designed in the form of a separate device. In another variant, the analysis device is part of an arrangement for stimulating the human or animal heart. In such a case, it can also be referred to as an analysis module. It is provided in this variant that the analysis device does not have a separate processor and no separate memory unit, but instead uses a processor and a memory unit of the arrangement for stimulating the human or animal heart. In this way, the additional possibility of analyzing correct electrode positioning can be realized without additional equipment. This considerably simplifies the implantation of pacemakers that are suitable for His bundle stimulation.

0021In one variant, the analysis device has a stimulation unit for stimulating the His bundle of a human or animal heart and a detection unit for detecting an electrical signal of the same heart. In this variant, the program causes the processor to carry out the steps explained below when it is executed on the processor.

0022First, cardiac stimulation is carried out using the stimulation unit. This cardiac stimulation is suitable for determining the stimulus threshold of the His bundle. A cardiac electrical signal is subsequently detected, which was generated by the previous cardiac excitation as a result of the cardiac stimulation carried out. The detection unit is used for this.

0023An excited state of the heart stimulated by the cardiac stimulation is then determined on the basis of the detected electrical signal.

0024This state of excitation is then classified into one of at least three classes. These at least three classes include a first class, which indicates a first state of excitation of the heart. They also include a second class that indicates a second state of excitation of the heart that differs from the first state of excitation. Finally, they comprise a third class, which indicates unsuccessful stimulation without a detectable state of excitation.

0025Such a classification of a detected state of excitation makes it particularly easy to recognize whether adequate contacting of the His bundle has been achieved by means of an electrode of a pacemaker or another arrangement for stimulating a heart.

0026In one variant, suitable stimulation amplitudes of the pulses emitted by the stimulation unit to determine the stimulation threshold of the His bundle lie in a range from 12 V to 30 V, in particular 15 V to 25 V, in particular 20 V to 22 V.

0027Suitable pulse widths of the pulses emitted by the stimulation unit for determining the stimulation threshold of the His bundle lie in a range between 1 ms and 15 ms, in particular between 2 ms and 12 ms, in particular between 3 ms and 10 ms, in particular between 4 ms and 9 ms , in particular between 5 ms and 8 ms.

0028As already mentioned, one of the at least three classes is a class which is intended for unsuccessful stimulation without a detectable state of excitation. The other classes of the at least three classes (ie the first class, the second class and an optionally provided further class) are selected in a variant from the classes explained below. One class relates to an arousal state of the heart for which stimulation of the His bundle of the stimulated heart has taken place exclusively. This means that an excitation state in which selective stimulation of the His bundle has occurred falls into this class. Another class relates to an arousal state for which both the bundle of His heart has been stimulated and the ventricular myocardium has been stimulated. This class therefore relates to an arousal state based on non-selective stimulation. One class concerns an arousal state for which only the ventricular myocardium of the stimulated heart has been stimulated. This means that this state of excitement is based on a stimulation in which the His bundle has not been detected. It can be described as a purely ventricular state of excitement. One class relates to an arousal state in which His bundle stimulation and left ventricular conduction pathway stimulation have taken place. Another class relates to an arousal state in which His bundle stimulation has taken place without stimulation of left ventricular conduction pathways. Such stimulation is also referred to as a right bundle branch block or right bundle branch block image (RSB or RBBB).

0029The classification of the state of excitation into one of the predefined classes automatically means a classification of the stimulation on which the state of excitation is based into such a class.

0030In one variant, the program causes the processor to perform an automatic stimulus threshold test (ATM). In the context of such a stimulus threshold test, a stimulus threshold for successful His bundle stimulation is determined. A selective or non-selective His bundle stimulation is regarded as successful, while a stimulation in which the His bundle is not detected or which only results in ventricular pacing are considered unsuccessful.

0031In one variant, the program causes the processor to classify each cardiac stimulation performed by the stimulation unit. For example, an active acquisition control (ACC) can be used for this purpose, optionally using a beat-to-beat algorithm.

0032In a variant, the program prompts the processor to use a width of the QRS complex in the electrocardiogram or an analysis criterion correlated to this QRS complex width to classify the excitation state. This is because the breadth of the QRS complex shows whether selective His bundle stimulation or non-selective His bundle stimulation has taken place.

0033In a variant, the program causes the processor to use a time offset between the execution of the cardiac stimulation on the one hand and the detection of the cardiac electrical signal on the other hand for the classification of the excitation state. In other words, in this variant the time that elapses between the stimulation and the detected cardiac excitation is taken into account in order to be able to classify the excitation state accordingly. Because the different cardiac states of excitation prepare at different speeds. Therefore, the point in time at which cardiac excitation can be detected after a previous stimulation is sometimes an important criterion in order to be able to assign the detected excitation to a certain class.

0034In one variant, the program causes the processor to use at least one signal profile of the electrocardiogram to classify the state of excitation, the electrocardiogram in this variant being a unipolarly derived electrocardiogram from a pole of the electrode of the stimulation unit against a large-area body electrode of the patient in question.

0035In one variant, the analysis device is equipped with a detection unit. This detection unit can be particularly suitable for detecting His bundle-specific excitation impulses of the heart or can be specifically designed and prepared for it.

0036For this purpose, the detection unit in one variant has a low-pass filter which is particularly suitable for signals which are generated by excitation of the His bundle. Such a low-pass filter has a cut-off frequency of at least 100 kHz (ie 100 kHz or greater), in particular at least 10 kHz, in particular at least 1 kHz, in particular at least 500 Hz, in particular at least 200 Hz and very particularly at least 100 Hz. In one variant, such a low-pass filter has a cut-off frequency which lies in a range between 100 Hz and 100 kHz, in particular between 200 Hz and 10 kHz, in particular between 500 Hz and 1 kHz. Such a low-pass filter allows signal components with a frequency below the cut-off frequency to pass essentially unimpeded. In contrast, signal components with a frequency that is greater than the cutoff frequency are attenuated or attenuated.

0037The particular suitability of the detection unit for the detection of His bundle-specific pulses or the formation and preparation of the detection unit for this purpose can also be realized by a sampling rate which, in one variant, is at least 500 Hz, in particular at least 1 kHz, in particular at least 2 kHz , in particular at least 5 kHz, in particular at least 10 kHz, in particular at least 100 kHz, in particular at least 1 MHz. In one variant, the sampling rate of the detection unit is in a frequency range between 500 Hz and 1 MHz, in particular between 1 kHz and 100 kHz, in particular between 2 kHz and 10 kHz, in particular between 3 kHz and 5 kHz.

0038In one variant, the detection unit has a sensitivity which is in a range between 0.01 mV and 0.25 mV, in particular between 0.05 mV and 0.2 mV, in particular between 0.1 mV and 0.15 mV. Such a sensitivity of the detection unit is particularly well suited to being able to detect His bundle-specific electrical cardiac signals.

0039In a variant, the program prompts the processor to use a morphological analysis criterion from the electrocardiogram for the automatic identification of the signals which are caused by His bundle stimulation. In this way, for example, a pattern recognition can be carried out in the electrocardiogram obtained in order to identify certain patterns and thus enable the identification of His bundle-specific signals.

0040In a variant, the analysis device has a first stimulation unit for stimulating the His bundle of a human or animal heart, a second stimulation unit for stimulating a heart region of the same heart different from the His bundle, a first detection unit and a second detection unit, each for detecting one electrical signal of the same heart are suitable. In this case, an electrode of the second stimulation unit is particularly intended to be implanted at an atrial or ventricular implantation site in order to perform an atrial or ventricular stimulation (ie no stimulation of the His bundle) as a conventional heart electrode. The first detection unit is particularly intended to detect a stimulation of the His bundle of the heart. In contrast, the second detection unit is intended to detect a stimulation of a heart region by the second stimulation unit. If the second stimulation unit is provided for stimulating an atrium of the heart, the second detection unit is in particular an atrial detection unit. If the second stimulation unit is intended to stimulate a ventricular heart area, the second detection unit is in particular a ventricular detection unit. In this variant it is thus possible not only to stimulate the His bundle of a heart and to detect the corresponding stimulation, but also to perform an atrial and / or ventricular stimulation with subsequent detection of appropriate cardiac signals.

0041In one variant, the program causes the processor to trigger a stimulation of the His bundle by means of the first stimulation unit when an intrinsic excitation of one of the two atria of the stimulated heart is detected by the first detection unit or the second detection unit. By providing several stimulation units and several detection units, it is therefore possible to trigger stimulation of the His bundle as a function of other cardiac stimulations. A particularly effective stimulation of the His bundle can thereby be achieved, whereby a positive influence on the cardiac signals generated by a corresponding His bundle stimulation and their subsequent detection can be achieved.

0042In one variant, the analysis device is designed as a single-channel stimulator or is part of such a single-channel stimulator. Such a single-channel stimulator has only a single connection for a stimulation and detection electrode. The stimulation and detection electrode is part of the stimulation unit and the detection unit. Thus, it can also be referred to as a His bundle stimulation and detection electrode or as a His bundle stimulation and detection channel. The detection unit is not only provided and set up for the detection of His bundle-specific cardiac signals of the heart to be stimulated. Rather, it is also intended and set up to detect intrinsic excitation of one of the two atria of the heart to be stimulated. Signals that result from such intrinsic excitation of one of the two atria are also referred to as the P wave. If the detection unit is provided and set up for the detection of such atrial signals, the stimulation of the His bundle of the heart to be stimulated can be triggered or carried out particularly easily depending on these intrinsic atrial signals.

0043In one variant, the analysis device is designed as a two-channel stimulator or part of such a two-channel stimulator. It then has a first connection for a His bundle stimulation and detection electrode (or for a His bundle stimulation and detection channel) and a second connection, which can be configured as an atrial stimulation and detection channel or as a ventricular stimulation and detection channel for connecting a corresponding atrial stimulation and detection electrode or a ventricular stimulation and detection electrode . In such a variant, in addition to the stimulation unit and the detection unit, the arrangement typically has a second stimulation unit and a second detection unit, to which the atrial or ventricular stimulation and detection electrode is then assigned.

0044In one variant, the analysis device is designed as a three-channel stimulator or as part of such a three-channel stimulator. Such a three-channel stimulator has a first connection for a His bundle stimulation and detection channel (or for a His bundle stimulation and detection electrode), a second connection for an atrial stimulation and detection channel (or for an atrial stimulation and detection electrode) and a third connection for a ventricular stimulation and detection channel (or for a ventricular stimulation and detection electrode on). With such a three-channel stimulator, both His-bundle-specific stimulations can be carried out and His-Bundle-specific signals can be detected, atrial and ventricular stimulations can be carried out and atrial and ventricular signals can be detected particularly easily.

0045In one variant, the analysis device is designed as a four-channel stimulator or is part of such a four-channel stimulator. Such a four-channel stimulator has a first connection for a His bundle stimulation and detection channel (or for a His bundle stimulation and detection electrode), a second connection for an atrial stimulation and detection channel (or for an atrial stimulation and detection electrode), a third connection for a first ventricular stimulation and detection channel (or a first ventricular stimulation and detection electrode) and a fourth connection for a second ventricular stimulation and detection channel (or for a second ventricular Stimulation and detection electrode). With such a four-channel stimulator, for example, both ventricles of a human or animal heart can be stimulated simultaneously. In the same way, signals from both ventricles can be acquired simultaneously. In addition, the His bundle-specific stimulation and detection, as well as an atrial stimulation and detection, already explained in connection with the previous variants, are possible.

0046In a further variant, the analysis device is designed as a five-channel stimulator or part of such a five-channel stimulator. Such a five-channel stimulator has a total of five connections. A first connection is provided for a His bundle stimulation and detection channel (or for a His bundle stimulation and detection electrode). A second connection is for an atrial stimulation and detection channel (or for an atrial stimulation and detection electrode). A third connection is used to connect a first ventricular stimulation and detection channel (or a first ventricular stimulation and detection electrode). A fourth connection is provided for a second ventricular stimulation and detection channel (or for a second ventricular stimulation and detection electrode). Finally, a fifth connection is provided for a third ventricular stimulation and detection channel (or for a third ventricular stimulation and detection electrode). For example, the implantable arrangement can be used as a stimulator that is set up for cardiac resynchronization (CRT) (CRT stimulator) and that has a quadropolar left ventricular channel. Alternatively, the implantable arrangement can enable multipolar stimulation (a so-called multipole pacing) using a His bundle-specific stimulation channel.

0047In a variant, the analysis device has a device for automatic cardioversion and / or defibrillation of the heart or is part of such a device. It is then equipped with appropriate connections in order to connect this device to suitable heart regions.

0048In a variant, the program prompts the processor to carry out a signal quality check (also abbreviated as SQC according to the technical term "signal quality check") before determining the state of excitation. Such a signal quality check can be used to determine whether the signals provided for determining the state of excitation are suitable for evaluation. This suitability can result, for example, from the absolute signal intensity or from a signal / noise ratio.

0049If the signal quality check reveals that the signals provided for determining the state of excitation are not of sufficient quality, the classification provided can at least partially be switched off temporarily. Alternatively, it is also possible to label the result of the classification accordingly, ie to indicate there that this result was based on signals that did not pass the signal quality check. This marks the corresponding classification as less reliable compared to other classifications.

0050In one variant, the program causes the processor to automatically adapt a signal processing parameter to the arrangement depending on the signal quality check carried out. This can involve, for example, amplification, damping, filtering, differentiation, smoothing, averaging, a phase shift or an offset correction of the measured signals in order to be able to achieve a better evaluation of these signals. In this way it is possible to amplify signals that may not pass the signal quality check or only barely pass them, or to lift them off the ground in such a way that the quality is still sufficient, i.e. the signal quality check is passed, so that the corresponding signals can be reliably evaluated becomes.

0051One aspect of the present invention relates to a computer program product having computer readable code that causes a processor to perform the steps outlined below when executed on the processor.

0052First, an electrocardiogram of a human or animal heart, into which an arrangement for stimulating this heart is implanted, is received.

0053This is followed by an automatic identification of signals from the electrocardiogram, which are caused by His bundle stimulation. These signals appear between an atrial signal and a ventricular signal.

0054The previously identified signals are then marked in the received electrocardiogram.

0055The electrocardiogram marked in this way is then output on a suitable output device.

0056Such a computer program product is used for the software implementation of those method steps which are also carried out by the analysis device claimed according to the invention. Such an analysis of cardiac signals to support the implantation of an arrangement for stimulating the human or animal heart can thus be implemented either in terms of hardware (in the form of the analysis device claimed according to the invention) or in terms of software (in the form of the computer program product claimed according to the invention).

0057One aspect of the present invention relates to a method for evaluating data obtained when an arrangement for stimulating the human or animal heart is implanted. This method is a pure data evaluation method that can be carried out without closer interaction with a human or animal body.

0058An electrocardiogram of a human or animal heart, into which an arrangement for stimulating this heart is implanted, is received for this data evaluation method.

0059Subsequently, electrocardiogram signals caused by His bundle stimulation are automatically identified.

0060The signals identified in this way are marked in the received electrocardiogram.

0061The electrocardiogram marked in this way is then output on a suitable output device.

0062One aspect of the present invention relates to a method for implanting an arrangement for stimulating the human or animal heart. This implantation is performed on a patient who needs such an arrangement. The implantation process comprises the steps explained below.

0063First, an area of ​​the patient's heart, in which the His bundle of the heart is suspected, is contacted with an electrode. This electrode is part of a stimulation unit for stimulating the His bundle of a human or animal heart.

0064A stimulation of the His bundle is then carried out by means of the stimulation unit.

0065An electrocardiogram is then detected using a detection unit. If the previous His bundle stimulation by means of the stimulation unit was successful, His bundle-specific signals can be found in this electrocardiogram.

0066These His-bundle-specific signals are now automatically identified in the electrocardiogram.

0067The previously identified signals are marked in the received electrocardiogram. A marked electrocardiogram is obtained in this way.

0068The marked electrocardiogram is output on an output device.

0069Now the position of the electrode can be adjusted depending on the marked signals. Such an adjustment is not necessary if the His bundle-specific signals that are marked in the electrocardiogram already correspond to a predefined or predeterminable quality criterion. If the marked signals are sufficiently large, for example, this indicates good contacting of the His bundle by means of an electrode. There is then no need to adjust the position of the electrode.

0070If, on the other hand, the signals do not yet indicate sufficient contacting of the His bundle (because they are either too weak overall or appear too weak or too weak in comparison to other cardiac signals), the position of the electrode is adjusted. The steps of performing stimulation of the His bundle, detection of an electrocardiogram, automatic identification of His bundle-specific signals in the electrocardiogram, marking of these identified signals and outputting the electrocardiogram marked in this way are then repeated until the marked ones Signals correspond to a selectable criterion. This selectable criterion can be the predefined or act predeterminable quality criterion. For example, this criterion can be a qualitative or quantitative criterion of the detected and automatically identified His bundle-specific signals. An absolute value or a relative value of the corresponding signals can be used to check whether the criterion is met or not.

0071If the selectable criterion is met, that is to say if, for example, sufficiently large or sufficiently pronounced or, in comparison to other cardiac signals, sufficient His bundle-specific signals have been identified and marked in the electrocardiogram, the electrode is implanted at the last selected position. Because then this position is suitable to stimulate the His bundle of the heart in a sufficient manner.

0072One aspect of the present invention relates to an implantable arrangement for stimulating a human or animal heart with the features explained below. Such an arrangement has a first stimulation unit and a first detection unit. The first stimulation unit serves to stimulate at least one heart chamber of a human or animal heart. The first detection unit is used to detect an electrical signal of at least one heart chamber of the same human or animal heart. This can be, for example, an electrical signal that was generated as a result of a previous stimulation by the stimulation unit. However, it can also be an electrical signal from the heart chamber that was generated intrinsically by the heart chamber (without prior external stimulation).

0073According to the invention, it is provided that the implantable arrangement has a second stimulation unit that is specifically designed and prepared to stimulate the His bundle of the same human or animal heart. This means that the bundle of His of the heart is not stimulated via the conventionally used stimulation unit, but via a separate stimulation unit, which is also provided in the arrangement. This second stimulation unit is optimized with regard to the requirements that the His bundle places on stimulation. Specifically, the second stimulation unit is specifically designed and prepared for His bundle stimulation in that it has a maximum stimulation energy that is at least 10% higher than the maximum stimulation energy of the first stimulation unit. This higher maximum stimulation energy enables better stimulation of the His bundle. This is because the His bundle is relatively difficult to stimulate compared to other cardiac regions, so that a higher level of energy is regularly required for this. In contrast, such a higher stimulation energy is not required or provided in conventional cardiac pacemakers. Because these are usually only used to stimulate those heart regions that can already be stimulated well with a lower stimulation energy.

0074In one variant, the stimulation energy of the second stimulation unit is at least 15% higher, in particular at least 20% higher, in particular at least 25% higher, in particular at least 30% higher, in particular at least 35% higher, in particular at least 40% higher, in particular at least 45% higher, in particular at least 50% higher, in particular at least 60% higher, in particular at least 70% higher, in particular at least 80% higher, in particular at least 90% higher, in particular at least 100% higher than the maximum stimulation energy of the first stimulation unit.

0075In one variant, the maximum stimulation energy of the second stimulation unit is higher by a defined percentage than the maximum stimulation energy of the first stimulation unit, which is formed from an interval from the aforementioned percentages. This means that in this variant the maximum stimulation energy of the second stimulation unit is in particular higher by a percentage than the maximum stimulation energy of the first stimulation unit, which is between 10% and 100%, in particular between 15% and 90%, in particular between 20% and 80% etc . lies. To excite the His bundle or To be able to detect an activity of the His bundle in a particularly simple and reliable manner, the arrangement has in a variant a second detection unit which is specifically designed and prepared to detect an electrical signal of the His bundle of the same human or animal heart. The specific design and preparation of the second detection unit for detecting electrical signals of the His bundle can be achieved in different ways. The second detection unit can have a sensitivity that is at least 10% higher than the sensitivity of the first detection unit. Alternatively or additionally, the second detection unit can have a detection bandwidth that is at least 10% larger than the detection bandwidth of the first detection device. Alternatively or additionally, the second detection unit can have a sampling rate that is at least 10% higher than the sampling rate of the first detection device. Such an increased sensitivity and / or larger detection bandwidth and / or larger sampling rate compared to a conventional detection unit makes the detection of signals of the His bundle particularly easy or even possible at all.

0076In one variant, the sensitivity of the second detection unit is at least 15% higher, in particular at least 20% higher, in particular at least 25% higher, in particular at least 30% higher, in particular at least 35% higher, in particular at least 40% higher, in particular at least 45% higher, in particular at least 50% higher, in particular at least 60% higher, in particular at least 70% higher, in particular at least 80% higher, in particular at least 90% higher, in particular at least 100% higher than the sensitivity of the first detection unit.

0077In a variant, the sensitivity of the second detection unit is a defined percentage higher than the sensitivity of the first detection unit, which is formed from an interval from the aforementioned percentages. This means that in this variant the sensitivity of the second detection unit is in particular higher by a percentage than the sensitivity of the first detection unit, which is between 10% and 100%, in particular between 15% and 90%, in particular between 20% and 80% etc. .

0078In a variant, the detection bandwidth of the second detection unit is at least 15% higher, in particular at least 20% higher, in particular at least 25% higher, in particular at least 30% higher, in particular at least 35% higher, in particular at least 40% higher, in particular at least 45% higher, in particular at least 50% higher, in particular at least 60% higher, in particular at least 70% higher, in particular at least 80% higher, in particular at least 90% higher, in particular at least 100% higher than the detection bandwidth of the first detection unit.

0079In a variant, the detection bandwidth of the second detection unit is a defined percentage higher than the detection bandwidth of the first detection unit, which is formed from an interval from the aforementioned percentages. This means that in this variant the detection bandwidth of the second detection unit is in particular a percentage higher than the detection bandwidth of the first detection unit, which is between 10% and 100%, in particular between 15% and 90%, in particular between 20% and 80% etc. .

0080In one variant, the sampling rate of the second detection unit is at least 15% higher, in particular at least 20% higher, in particular at least 25% higher, in particular at least 30% higher, in particular at least 35% higher, in particular at least 40% higher, in particular at least 45% higher, in particular at least 50% higher, in particular at least 60% higher, in particular at least 70% higher, in particular at least 80% higher, in particular at least 90% higher, in particular at least 100% higher than the sampling rate of the first detection unit.

0081In one variant, the sampling rate of the second detection unit is higher by a defined percentage than the sampling rate of the first detection unit, which is formed from an interval from the aforementioned percentages. This means that in this variant the sampling rate of the second detection unit is in particular higher than the sampling rate of the first detection unit, which is between 10% and 100%, in particular between 15% and 90%, in particular between 20% and 80% etc. .

0082In one variant, the arrangement has a first timer, which serves to emit stimulation pulses in a defined time by the first stimulation unit. In addition, the arrangement in this variant has a second timer which is provided and set up to coordinate the time of delivery of at least one pulse to be delivered by the second stimulation unit with a time of delivery of at least one pulse to be delivered by my first stimulation unit. While the implantable arrangement known from the prior art for stimulating the human or animal heart often have a single timer with which stimulation therapy can be carried out in a time sequence which is meaningful for the heart to be stimulated, the provision of a second timer is for a Synchronization of the second stimulation unit with the first stimulation unit ensures, not known from the prior art. This second timer thus enables the stimulation of the His bundle to be synchronized with the stimulation of another heart region by the first stimulation unit. In this way, a synergy effect between the His bundle stimulation and a conventional stimulation of another heart region can be achieved particularly easily.

0083In a variant, the second timer serves not only to synchronize a His bundle stimulation with a conventional stimulation of another heart region, but also to such a conventional stimulation of a heart region with a His bundle stimulation to be carried out by the same implantable arrangement to synchronize. It is provided in this variant that the second timer also serves to coordinate the time of delivery of at least one pulse that is to be delivered by the first stimulation unit with a time when at least one pulse is to be delivered by the second stimulation unit .

0084In one variant, the arrangement has a first stimulus threshold test device. With such a stimulation threshold test device, a stimulation threshold of the His bundle of a human or animal heart that is to be stimulated by the device can be determined. Typically, such a stimulus threshold initially rises after the implantation of a corresponding arrangement, in order to drop again to a lower level in the following weeks. A stimulation threshold test device can be used to determine which stimulation threshold must currently be exceeded in order to achieve sufficient stimulation of the His bundle. A stimulation energy of the second stimulation unit can then be set as a function of the determined stimulation threshold. If this stimulus threshold is lower than shortly after implantation, only a lower stimulation energy is required. This significantly reduces the energy expenditure per stimulation process, even if the stimulation success is equally good. In this way, the life of the implantable arrangement can be extended.

0085The stimulation threshold test device can, for example, automatically monitor the stimulation threshold (ATM), actively carry the stimulation energy with every heartbeat (Automated Capture Control, ACC) or automatically carry the stimulation energy one or more times a day after a stimulation threshold measurement (Automated Threshold Test, ATT) to determine the stimulus threshold of the His bundle.

0086In a variant, the arrangement not only has a first threshold test device, but also a second threshold test device. With such a second stimulus threshold test device, a stimulus threshold of another heart region (ie not of the His bundle) can be detected, which is to be stimulated by the first stimulation unit. The current stimulation threshold can then also be determined for these heart regions in order to set the stimulation energy of the first stimulation unit as a function of this determined stimulation threshold. In this way, not only the energy required for the His bundle stimulation but also the energy required for conventional stimulation of a heart region can be adapted to the required level. On the one hand, this ensures a sufficiently high stimulation energy that is required for stimulation success. On the other hand, only as much energy as necessary is used for the stimulation, which - as explained above - extends the life of the implantable arrangement. The second stimulus threshold test device can also carry out different methods such as ATM, ACC and ATT to determine the stimulus threshold of the relevant heart regions.

0087In one variant, the arrangement has a storage unit. This storage unit comprises a storage area which is used exclusively for storing data which have been recorded by the second detection unit and / or which relate to an activity of the second stimulation unit. The activity of the second stimulation unit is expressed in particular by the type, frequency and number of stimulations that are emitted by the second stimulation unit to stimulate the His bundle. This memory area thus serves to record all processes which are detected or carried out by the implantable arrangement and which relate to stimulation of the His bundle. In this way, a His bundle stimulation by the implantable arrangement can be read out and evaluated separately from other activities of the implantable arrangement.

0088In order to open up a particularly simple possibility of accessing data that is stored within the implantable arrangement, the arrangement has a remote communication unit in a variant. By means of this remote communication unit, it is possible to transmit data that were recorded by the second detection unit and / or data that relate to an activity of the second stimulation unit. Alternatively or additionally, it is possible by means of this remote communication unit to monitor the second detection unit and / or the second stimulation unit. Alternatively or additionally, it is also possible by means of the remote communication unit to adapt a stimulation that is to be delivered by the second stimulation unit. This means that remote access to the second stimulation unit is possible via the remote communication unit. In this way, stimulation parameters of a His bundle stimulation to be carried out can be adapted remotely. Likewise, the remote communication unit can be used to remotely call up data from the implantable arrangement which reflect a previous His bundle stimulation. Finally, the remote communication unit enables a correct functioning of the second detection unit and / or the second stimulation unit to be checked remotely.

0089In one variant, the implantable arrangement has a processor and a memory unit. The storage unit can be the storage unit already explained above, which has a specific storage area which is reserved for events relating to the activity or stimulation of the His bundle. According to the variant explained above, this memory unit has a computer-readable program which, when it is executed on the processor, causes the processor to carry out the steps explained below. First, the arrangement is placed in a His bundle stimulation mode in which only a His bundle stimulation can be carried out by means of the second stimulation unit. This means that the first stimulation unit, which can enable conventional stimulation of another heart region, is deactivated in this His bundle stimulation mode. Then a His bundle stimulation in the form of electrical pulses is emitted by means of the second stimulation unit, which should lead to stimulation of the His bundle. This delivery takes place when an event justifying the delivery was detected by means of the first detection unit and / or by means of the second detection unit. If, for example, a suspension of the natural heartbeat or an unphysiological reduction in the heartbeat frequency has been detected, the His bundle can be stimulated by means of the second stimulation unit in order to restore an ordinary heart rhythm. If a normal heart rhythm can then be determined again by the first detection unit and / or the second detection unit, no further stimulation by the implantable arrangement is required, in particular no conventional stimulation of another region of the heart by means of the first stimulation unit.

0090In a further variant, the arrangement also has a processor and a memory unit. This can again be the same memory unit which has a memory area reserved for the His bundle stimulation and which optionally has a program with which the arrangement can be put into a His bundle stimulation mode. However, it is also possible for the storage unit discussed below to be a storage unit different from the previous storage unit. In this variant, the memory unit has a computer-readable program which causes the processor to carry out the steps explained below when it is executed on the processor. First, the arrangement is placed in a safety mode. In this safety mode, both a stimulation of at least one heart chamber by means of the first stimulation unit and a His bundle stimulation by means of the second stimulation unit are possible. This means that the safety mode serves to enable the first stimulation unit and the second stimulation unit to be activated in principle. A ventricular stimulation is then delivered by means of the first stimulation unit and / or a His bundle stimulation by means of the second stimulation unit. This delivery takes place when an event justifying the delivery was detected by means of the first detection unit and / or by means of the second detection unit. In the safety mode, therefore, not only is a bundle of His bundles stimulated, but also a conventional stimulation of any heart region on which the first stimulation unit can act is carried out simultaneously with or at a time offset from the His bundle stimulation.

0091In one variant, the arrangement has a marker channel. An electrocardiogram (EKG) or an intracardiac electrogram (IEGM) can be read out via such a marker channel. The electrocardiogram or the intracardiac electrogram has at least one marker that is specific for a His bundle stimulation by means of the second stimulation unit and / or specific for a detection of a signal of the His bundle by means of the second detection unit. The readable electrogram or the readable intracardiac electrogram is therefore specifically marked with a His bundle-specific marking. In other words, His bundle-specific markers are used to provide the EKG or IEGM with such His bundle-specific markings. The EKG or IEGM can be read using real-time telemetry. Alternatively, it is also possible for the EKG and / or the IEGM to be stored in the arrangement or in a storage unit of the arrangement and then to be read out at a later point in time. Remote transmission of EKGs or IEGMs is also possible. A remote transmission unit can in particular be used for this purpose. The remote transmission unit explained above is suitable for this, for example.

0092In order to make it particularly easy for a user to use an arrangement according to the invention and to avoid misuse, the variant has a first stimulation output and a second stimulation output. The first stimulation output is used to connect a stimulation electrode that is part of the first stimulation unit. The second stimulation output is used to connect a second stimulation electrode, which is part of the second stimulation unit. Any heart region in one of the two atria or ventricles (but not the His bundle) can be stimulated by means of the first stimulation electrode. The second stimulation electrode, on the other hand, is used for specific stimulation of the His bundle of the human or animal heart to be treated. In order to enable a connection of the first stimulation electrode to the first stimulation output and in particular a correct connection of the second stimulation electrode to a second stimulation output, at least the second stimulation output is provided with a specific marking which makes it clear to a user that the second stimulation output is a stimulation output. which is provided and set up for connecting a His bundle stimulation electrode. This special marking can be, for example, a text marking and / or a colored marking of the stimulation output. The marking can be provided directly on the stimulation output or on a region of the implantable arrangement which surrounds the stimulation output or is arranged adjacent to the stimulation output. For example, a label or a sticker can be provided on the implantable arrangement, which identifies the corresponding specific configuration of the second stimulation output as a His bundle stimulation output.

0093Alternatively or additionally, provision can also be made for a corresponding marking to be provided on the packaging of the implantable arrangement. Alternatively or additionally, it is provided that a corresponding marking is provided in an accompanying document of the implantable arrangement (such as, for example, an instruction manual or application instructions). As an alternative or in addition, such a marking is provided on an electrode line of the second stimulation electrode. For example, the electrode line of the second stimulation electrode can have a specific color coding that corresponds to a color coding of the second stimulation output. A user is then visualized particularly simply which stimulation electrode is to be inserted into which stimulation output of the implantable arrangement.

0094As an alternative or in addition, a marking that the second stimulation output is configured as a His bundle stimulation output can also be provided on a programming device that is used for programming the implantable arrangement. Alternatively or additionally, such a marking can also be provided in a remote monitoring system. For example, a corresponding marking can be present on a graphical user interface (GUI) of the remote monitoring system which visualizes to a user which of the available stimulation outputs is a conventional stimulation output and which output is a His bundle stimulation output. The marking of the His bundle stimulation output is typically sufficient, since unmarked stimulation outputs are typically recorded by a user as conventional stimulation outputs.

0095One aspect of the present invention relates to a computer program product having computer readable code that causes a processor to perform the steps outlined below when executed on the processor.

0096First, a first detection unit and / or a second detection unit is used to determine whether a cardiac arrhythmia to be treated is present in a human or animal heart. The first detection unit is provided for the detection of an electrical signal of at least one heart chamber of the human or animal heart. The second detection unit is specifically designed and prepared to detect an electrical signal of the His bundle of the same human or animal heart.

0097If a cardiac arrhythmia to be treated is present, an atrial or ventricular stimulation is then carried out by means of a first stimulation unit and / or His bundle stimulation by means of a second stimulation unit.

0098One aspect of the present invention relates to a method of treating a human or animal patient in need of such treatment. This method is carried out using an implantable arrangement as described above. Such an arrangement has a first stimulation unit and a first detection unit. The first stimulation unit is used to stimulate at least one heart chamber of the patient's heart. The first detection unit is used to detect an electrical signal of at least one ventricle of the patient's heart.

0099The method is characterized in that the arrangement has a second stimulation unit, which is specifically designed and prepared to stimulate a His bundle of the patient's heart. For the purpose of this specific design and preparation, the second stimulation unit has a maximum stimulation energy which is at least 10% higher than the maximum stimulation energy of the first stimulation unit. Optionally, a second detection unit can be present, which is specifically designed and prepared to detect an electrical signal of the His bundle of the patient's heart.

0100According to the method, it is provided that when an event requiring treatment in the heart of the patient is detected by means of the first detection unit and / or the second detection unit, a stimulation of a heart chamber of the patient by means of the first stimulation unit and / or a stimulation of the His bundle of the Patients is carried out by means of the second stimulation unit. Stimulation of the His bundle of the patient's heart leads to simultaneous stimulation of both cardiac chambers. In contrast, only a single ventricle of the patient can be directly stimulated with the first stimulation unit. A stimulation of the His bundle is therefore particularly suitable for biventricular stimulation and for ventricular resynchronization.

0101One aspect of the present invention relates to an implantable arrangement for stimulating a human or animal heart with the features explained below. Such an arrangement has a processor, a memory unit, a stimulation unit and a detection unit. The stimulation unit serves to stimulate the His bundle of a human or animal heart. The detection unit is used to detect an electrical signal from the same heart.

0102According to the invention, the arrangement is characterized in that the memory unit has a computer-readable program that causes the processor to carry out the steps explained below when it is executed on the processor.

0103First, cardiac stimulation is carried out using the stimulation unit.

0104A cardiac electrical signal is then detected by means of the detection unit. This cardiac electrical signal was generated by a cardiac excitation for which the previously performed cardiac stimulation is the cause.

0105The detected electrical signal is then used to determine the state of excitation of the heart stimulated by the cardiac stimulation.

0106Once this state of arousal has been determined, it is classified into one of at least three classes. These at least three classes include a first class, which is provided for a first state of excitation, and a second class, which is provided for a second state of excitation. The second state of excitation differs from the first state of excitation. A third class of the at least three classes is intended for unsuccessful stimulation without a detectable state of excitation. Thus, two different cardiac excitation states can be distinguished from each other and additionally from an unsuccessful stimulation using this classification. With such an unsuccessful stimulation, only an extremely weak cardiac electrical signal is detected or a cardiac electrical signal that does not or only slightly stands out from the background. Such a signal indicates that the stimulation previously carried out did not lead to cardiac excitation with a pronounced cardiac electrical response signal, and was therefore unsuccessful.

0107Subsequently, at least one control parameter of the arrangement is automatically adapted as a function of the classification carried out. This means that the assignment of the determined state of excitation to one of the at least three classes is the cause of how the at least one control parameter is adjusted. The implantable arrangement thus takes immediate account of the stimulation success achieved, so that subsequent stimulations are optimized with regard to the physiological requirements of the heart to be stimulated.

0108If the determined state of excitation shows that this corresponds exactly to the expected value, no separate adjustment of the control parameter is necessary. Rather, it would then be actively decided that no automatic adjustment would have to be made.

0109The automatically adaptable control parameter is selected from a His bundle stimulation energy, a His bundle stimulation vector, an operating mode of the arrangement, at least one parameter of a timer of the arrangement and a stimulation control parameter which is suitable for cardiac resynchronization therapy.

0110An operating mode of the arrangement can be, for example, a His bundle stimulation mode and a conventional stimulation mode in which the algorithms used are not adapted to stimulate the His bundle. Other suitable operating modes are right ventricular back-up stimulation and left ventricular back-up stimulation. The parameters of a timer of the arrangement are used to determine the chronological sequence of different stimulations or coordinate individual impulses within a stimulation. Such timers are typically responsible for defining a time interval between a first stimulation and a second stimulation.

0111The need-based automatic adaptation of the control parameter of the arrangement as a function of the previously performed classification of the excited state of the stimulated heart enables the implantable arrangement to be optimized in terms of operation with regard to the His bundle stimulation.

0112In one variant, the stimulation unit is not only suitable for stimulating the His bundle of a human or animal heart, but is specifically designed and prepared for this. This can be achieved in particular via the maximum stimulation energy that is emitted by the stimulation unit or via the pulse width of the pulses that are emitted by the stimulation unit.

0113In one variant, suitable stimulation amplitudes of the pulses emitted by the stimulation unit lie in a range from 12 V to 30 V, in particular 15 V to 25 V, in particular 20 V to 22 V.

0114Suitable pulse widths of the pulses emitted by the stimulation unit lie in a range between 1 ms and 15 ms, in particular between 2 ms and 12 ms, in particular between 3 ms and 10 ms, in particular between 4 ms and 9 ms, in particular between 5 ms and 8 ms .

0115The detection unit can likewise either be particularly suitable for detecting His-bundle-specific excitation impulses of the heart or it can be specifically designed and prepared for this. For example, the detection unit can have a low-pass filter that is particularly suitable for signals that are generated by excitation of the His bundle. In one variant, such a low-pass filter has a cutoff frequency of at least 1 kHz (ie 1 kHz or greater), in particular at least 500 Hz, in particular at least 200 Hz and very particularly at least 100 Hz. In one variant, such a low-pass filter has a cut-off frequency which lies in a range between 100 Hz and 1 kHz, in particular between 200 Hz and 500 Hz, in particular between 100 Hz and 200 Hz. Such a low-pass filter allows signal components with a frequency below the cut-off frequency to pass essentially unimpeded. In contrast, signal components with a frequency that is greater than the cutoff frequency are attenuated or attenuated.

0116The particular suitability of the detection unit for the detection of His bundle-specific pulses or the formation and preparation of the detection unit for this purpose can also be realized by a sampling rate which, in one variant, is at least 500 Hz, in particular at least 1 kHz, in particular at least 2 kHz , in particular at least 5 kHz and very particularly at least 10 kHz. In one variant, the sampling rate of the detection unit lies in a frequency range between 500 Hz and 10 kHz, in particular between 1 kHz and 5 kHz, in particular between 2 kHz and 4 kHz.

0117In one variant, the detection unit has a sensitivity which is in a range between 0.05 mV and 0.25 mV, in particular between 0.1 mV and 0.2 mV. Such a sensitivity of the detection unit is particularly well suited to being able to detect His bundle-specific electrical cardiac signals.

0118As already mentioned, one of the at least three classes is a class which is intended for unsuccessful stimulation without a detectable state of excitation. The other classes of the at least three classes (ie the first class, the second class and an optionally provided further class) are selected in a variant from the classes explained below. One class relates to an arousal state of the heart for which stimulation of the His bundle of the stimulated heart has taken place exclusively. This means that an excitation state in which selective stimulation of the His bundle has occurred falls into this class. Another class relates to an arousal state for which both the bundle of His heart has been stimulated and the ventricular myocardium has been stimulated. This class therefore relates to an arousal state based on non-selective stimulation. One class concerns an arousal state for which only the ventricular myocardium of the stimulated heart has been stimulated. This means that this state of excitement is based on a stimulation in which the His bundle has not been detected. It can be described as a purely ventricular state of excitement. One class relates to an arousal state in which His bundle stimulation and left ventricular conduction pathway stimulation have taken place. Another class relates to an arousal state in which His bundle stimulation has taken place without stimulation of left ventricular conduction pathways. Such stimulation is also referred to as a right bundle branch block or right bundle branch block image (RSB or RBBB).

0119The classification of the state of excitation into one of the predefined classes automatically means a classification of the stimulation on which the state of excitation is based into such a class.

0120In one variant, the program causes the processor to perform an automatic stimulus threshold test (ATM) once or more times a day. In the context of such a stimulus threshold test, a stimulus threshold for successful His bundle stimulation is determined. A selective or non-selective His bundle stimulation is regarded as successful, while a stimulation in which the His bundle is not detected or which only results in ventricular pacing are considered unsuccessful.

0121In one variant, the program causes the processor to classify each cardiac stimulation performed by the stimulation unit. For example, an active acquisition control (ACC) can be used for this purpose, optionally using a beat-to-beat algorithm.

0122In one variant, the arrangement is designed as a single-channel simulator that has only a single connection for a stimulation and detection electrode. The stimulation and detection electrode is part of the stimulation unit and the detection unit. Thus, it can also be referred to as a His bundle stimulation and detection electrode or as a His bundle stimulation and detection channel. The detection unit is not only provided and set up for the detection of His bundle-specific cardiac signals of the heart to be stimulated. Rather, it is also intended and set up to detect intrinsic excitation of one of the two atria of the heart to be stimulated. Signals that result from such intrinsic excitation of one of the two atria are also referred to as the P wave. If the detection unit is provided and set up for the detection of such atrial signals, the stimulation of the His bundle of the heart to be stimulated can be triggered or carried out particularly easily depending on these intrinsic atrial signals.

0123In one variant, the implantable arrangement is designed as a two-channel stimulator. It then has a first connection for a His bundle stimulation and detection electrode (or for a His bundle stimulation and detection channel) and a second connection, which can be configured as an atrial stimulation and detection channel or as a ventricular stimulation and detection channel for connecting a corresponding atrial stimulation and detection electrode or a ventricular stimulation and detection electrode . In such a variant, in addition to the stimulation unit and the detection unit, the arrangement typically has a second stimulation unit and a second detection unit, to which the atrial or ventricular stimulation and detection electrode is then assigned.

0124In one variant, the implantable arrangement is designed as a three-channel stimulator. Such a three-channel stimulator has a first connection for a His bundle stimulation and detection channel (or for a His bundle stimulation and detection electrode), a second connection for an atrial stimulation and detection channel (or for an atrial stimulation and detection electrode) and a third connection for a ventricular stimulation and detection channel (or for a ventricular stimulation and detection electrode on). With such a three-channel stimulator, both His-bundle-specific stimulations can be carried out and His-Bundle-specific signals can be detected, atrial and ventricular stimulations can be carried out and atrial and ventricular signals can be detected particularly easily.

0125In one variant, the implantable arrangement is designed as a four-channel stimulator. Such a four-channel stimulator has a first connection for a His bundle stimulation and detection channel (or for a His bundle stimulation and detection electrode), a second connection for an atrial stimulation and detection channel (or for an atrial stimulation and detection electrode), a third connection for a first ventricular stimulation and detection channel (or a first ventricular stimulation and detection electrode) and a fourth connection for a second ventricular stimulation and detection channel (or for a second ventricular Stimulation and detection electrode). With such a four-channel stimulator, for example, both ventricles of a human or animal heart can be stimulated simultaneously. In the same way, signals from both ventricles can be acquired simultaneously. In addition, the His bundle-specific stimulation and detection, as well as an atrial stimulation and detection, already explained in connection with the previous variants, are possible.

0126In a further variant, the implantable arrangement is designed as a five-channel stimulator which has a total of five connections. A first connection is provided for a His bundle stimulation and detection channel (or for a His bundle stimulation and detection electrode). A second connection is provided for an atrial stimulation and detection channel (or for an atrial stimulation and detection electrode). A third connection is used to connect a first ventricular stimulation and detection channel (or a first ventricular stimulation and detection electrode). A fourth connection is provided for a second ventricular stimulation and detection channel (or for a second ventricular stimulation and detection electrode). Finally, a fifth connection for a third ventricular stimulation and detection channel (or for a third ventricular stimulation and detection electrode). For example, the implantable arrangement can be used as a stimulator that is set up for cardiac resynchronization (CRT) (CRT stimulator) and that has a quadropolar left ventricular channel. Alternatively, the implantable arrangement can enable multipolar stimulation (a so-called multipole pacing) using a His bundle-specific stimulation channel.

0127In one variant, the implantable arrangement has a device for automatic cardioversion and / or defibrillation of the heart and is equipped with corresponding connections in order to connect this device to suitable heart regions. In one variant, the arrangement has a stimulation success control unit, which is designed as a module that is designed separately from the stimulation unit and the detection unit in terms of hardware. This stimulation success control unit takes over at least some steps with which the success of a previously performed cardiac stimulation is carried out, in particular the steps of determining the state of excitation of the stimulated heart and the classification of the state of excitation in one of at least three classes. Such a stimulation success control unit can then send suitable control signals to the stimulation unit or a control unit of the implantable arrangement in order to achieve automatic adaptation of at least one control parameter of the arrangement.

0128In principle, at least two stimulation stimulation thresholds are important in the stimulation unit for His bundle stimulation. The first of these thresholds is the threshold for stimulating the ventricular myocardium. This is comparable to the tissue stimulus threshold of conventional stimulation channels and depends in particular on the electrical connection of the corresponding electrode to the myocardium and on the basic stimulability properties of the corresponding myocardium. The second stimulus threshold is the stimulus threshold of the actual His bundle stimulation. Exceeding this stimulation threshold is necessary in order to excite the His bundle structures themselves sufficiently so that the effects of the His bundle stimulation carried out are achieved, in particular that a spread of excitation is achieved.

0129With conventional arrangements for stimulating a human or animal heart, such as conventional cardiac pacemakers, it is not possible to monitor the course of both stimulus thresholds. Rather, only a single stimulus threshold per stimulation channel is always recorded and stored here. However, if only one of the two relevant stimulus thresholds can be recorded and saved, there is a risk of incorrect operation and misinterpretation of the saved result. There is a significant risk of confusion, especially when different people are entrusted with identifying and storing the corresponding stimulus threshold. If a first person identifies and stores the first stimulation threshold (i.e. the stimulation threshold of the ventricular myocardium) as a relevant stimulation threshold, but another person identifies and stores the second stimulation threshold (i.e. the His bundle stimulation threshold) as a relevant stimulation threshold, this can be done during follow-up monitoring misinterpretation may result. For example, if the stimulation threshold of the His bundle stimulation is saved and evaluated at least temporarily instead of the stimulation threshold of the ventricular myocardium, the misdiagnosis could be made that a general increase in the stimulation threshold has occurred, which indicates poor stimulability, for which, for example, necrotic tissue could be responsible. In fact, in such a case, the proportion of necrotic tissue in the heart would not have changed at all; only the "wrong" stimulus threshold was considered.

0130In one variant, the program therefore causes the processor to determine at least two stimulus threshold measured values ​​at the same time and to store them in a measured value memory. A first stimulus threshold value indicates a stimulus threshold of a first state of excitation of the stimulated heart, while a second stimulus threshold value indicates a stimulus threshold of a second state of excitation of the stimulated heart.

0131The measured value memory can be a defined memory area of ​​the memory unit or can also be designed as a memory configured separately from the memory unit. The temporally synchronous recording of two different stimulus threshold measurement values ​​opens up the possibility of monitoring two different stimulus thresholds and thus drawing different medical conclusions from these monitored stimulus thresholds.

0132In a variant, the first excitation state and the second excitation state are selected from the excitation states explained below. This can be an arousal state for which only stimulation of the His bundle of the stimulated heart has taken place (selective stimulation). Furthermore, the state of excitation can be a state for which both stimulation of the His bundle of the stimulated heart and stimulation of the ventricular myocardium have taken place (non-selective stimulation). Finally, the state of arousal can be a state for which only the ventricular myocardium of the stimulated heart has been stimulated (without stimulation of the His bundle).

0133By such a subdivision of the different excitation states and the assignment of the at least two specific stimulus threshold measured values ​​to such an excitation state, it is possible to distinguish the stimulation threshold of a His bundle stimulation from the stimulation threshold of a ventricular myocardial stimulation. It is therefore possible to recognize, for example, a histological change in the stimulated heart by an increase in the stimulus threshold of a ventricular myocardial stimulation that occurs over time. Because if the stimulation threshold, which is relevant for ventricular myocardial stimulation, increases, this indicates an overall poorer stimulability of the human or animal heart to be stimulated, which can be caused by an increase in the proportion of necrotic tissue.

0134If, on the other hand, the stimulus threshold that is relevant for the His bundle stimulation increases over time, this does not indicate a poorer stimulation of the heart as a whole, but rather a (possibly only slight) dislocation of the corresponding stimulation electrode. This means that the separate monitoring of two different stimulus thresholds can be used to obtain medically relevant data that significantly reduce the risk of misdiagnosis and thus have a significant impact on patient safety.

0135One aspect of the present invention therefore relates to an implantable arrangement for stimulating a human or animal heart, in which such a detection is provided for at least two stimulus threshold measured values ​​- including the variants of this stimulus threshold measured value detection explained above and below, which, however, does not include a classification of a determined state of excitation into one of at least three predefined classes and no subsequent automatic adaptation of a control parameter of the arrangement depending on the classification carried out. Such an arrangement can also be described as follows: Implantable arrangement for stimulating a human or animal heart, comprising a processor, a memory unit, a stimulation unit for stimulating a His bundle of a human or animal heart and a detection unit for detecting an electrical signal of the same heart, characterized in that the memory unit is a computer-readable program which causes the processor to perform the following steps, if it is running on the processor:<ol id="ol0002"><li>a) performing cardiac stimulation by means of the stimulation unit,</li><li>b) using the detection unit to detect a cardiac electrical signal which was generated by cardiac excitation as a result of the cardiac stimulation previously carried out,</li><li>c) determining an excited state of a heart stimulated by cardiac stimulation using the electrical signal,</li><li>d) determining two stimulus threshold measured values ​​at the same time and storing the stimulus threshold measured values ​​in a measured value memory, a first stimulus threshold measured value indicating a stimulus threshold of a first excited state of the stimulated heart and a second stimulated threshold measured value indicating a stimulated threshold of a second excited state of the stimulated heart.</li></ol>

0136The variants and exemplary embodiments explained above and below relate both to the implantable arrangement for stimulating a human or animal heart, in which an excitation state is classified into one of at least three classes and subsequently an automatic adaptation of at least one control parameter, as well as to such Variants in which this classification and automatic adjustment is not carried out. In addition, the variants explained below can also be combined with further aspects of the invention described here.

0137In one variant, the program causes the processor to save a time profile of the at least two stimulus threshold measured values. By storing such a course, a temporal course control of the stimulus threshold measured values ​​is possible in a particularly simple manner. In this way, a trend of the stimulus threshold measured values ​​can be identified particularly easily, from which the corresponding conclusions can then be drawn with regard to a possible change in the cardiac stimulability or a possible dislocation of a stimulation electrode.

0138In one variant, the arrangement is provided and set up for defining a warning threshold value for each of the at least two stimulus threshold measured values. It is provided that the program prompts the processor to issue a warning if at least one of the warning threshold values ​​is exceeded. In this way it is possible to inform a user of the implantable arrangement in good time about deviations from the expected behavior of the arrangement. Measures can then be taken at an early stage to stop or regress a possible tissue change in the human or animal heart to be stimulated, or to relocate an electrode.

0139The warning threshold values ​​can be stored, for example, in the implantable arrangement itself, in a programming device which is used for programming the implantable arrangement or for programming its components, or in a remote monitoring system with which the implantable arrangement can be accessed by means of remote data transmission.

0140In one variant, the stimulus threshold measured values ​​stored in the measured value memory each have at least one pair of values ​​that relate to the stimulus threshold in the form of an amplitude (measured in volts or a comparable voltage unit) and a pulse width (measured in milliseconds or another time unit). A stimulus threshold can then typically be specified as voltage for a specific pulse width. In a further variant, a time of the measurement is also assigned to each stimulus threshold measured value.

0141In order to be able to identify the different stimulus thresholds particularly easily, in one variant these are given the designations “His bundle selective”, “His bundle non-selective” and “only ventricular” or with comparable contents. For example, representations on a graphical user interface or in printouts can be marked accordingly to make work easier for medical specialists who evaluate the relevant data.

0142In one variant, the arrangement has a remote data transmission unit, by means of which the stored stimulus threshold measured values ​​can be transmitted, for example, to a remote monitoring system. In such a remote monitoring system, for example, stimulus threshold measurements of numerous different implantable arrangements for stimulating the heart can be collected and evaluated. It is then possible to monitor stimulus threshold measured value curves in different implantable arrangements from such a central remote monitoring system and, if necessary, to inform the users of these arrangements or to access the arrangements for correction.

0143For a particularly simple evaluation, the stimulus threshold measured values ​​are shown in a variant together with a difference from a predeterminable stimulus threshold value. Then it is particularly easy to see whether the currently determined stimulus threshold measured value is higher or lower than the predefined or predefinable stimulus threshold value.

0144In order to easily differentiate the determined stimulus threshold values ​​from one another and to achieve a particularly simple assignment to a stimulus threshold type, one variant provides that a user can assign at least one of the following descriptions of the selected cardiac stimulation type to the stimulus thresholds: "low atrial pacing", "combined atrial pacing and His-bundle pacing", "His-bundle pacing", "combined atrial pacing, ventricular-septal pacing and His-bundle pacing", "combined ventricular-septal pacing and His bundle pacing "and" ventricular pacing ". By identifying such stimulation types with real names, different stimulus thresholds can be assigned to the respective stimulation types in a particularly simple manner. In this way, confusion between different stimulus thresholds can be avoided.

0145In a variant, the program prompts the processor to carry out a signal quality check (also abbreviated as SQC according to the technical term "signal quality check") before determining the state of excitation. Such a signal quality check can be used to determine whether the signals provided for determining the state of excitation are suitable for evaluation. This suitability can result, for example, from the absolute signal intensity, from a signal / noise ratio, a signal offset or a signal morphology criterion, such as a signal slew rate or the number of zero line crossings within a time window.

0146If the signal quality check reveals that the signals provided for determining the state of excitation are not of sufficient quality, the classification used for checking the stimulation success and the subsequent automatic adaptation of at least one control parameter of the arrangement can be switched off at least partially temporarily. Alternatively, it is also possible to label the result of the classification accordingly, ie to indicate there that this result was based on signals that did not pass the signal quality check. This marks the corresponding classification as less reliable compared to other classifications.

0147In one variant, the program causes the processor to automatically adapt a signal processing parameter to the arrangement depending on the signal quality check carried out. This can involve, for example, amplification, damping, filtering, differentiation, smoothing, averaging, a phase shift or an offset correction of the measured signals in order to be able to achieve a better evaluation of these signals. In this way it is possible to amplify signals that may not pass the signal quality check or only barely pass them, or to lift them off the ground in such a way that the quality is still sufficient, i.e. the signal quality check is passed, so that the corresponding signals can be reliably evaluated becomes.

0148In a variant, the program prompts the processor to use a morphological analysis criterion from a derived electrocardiogram or a morphological analysis criterion from an electrocardiogram, which was obtained by means of an electrode belonging to the stimulation unit, to classify the state of excitation. In this way, for example, a pattern recognition can be carried out in the electrocardiogram obtained in order to identify certain patterns and to be able to use them to make corresponding statements regarding a stimulation success.

0149In a variant, the program prompts the processor to use a width of the QRS complex in the electrocardiogram or an analysis criterion correlated to this QRS complex width to classify the excitation state. This is because the breadth of the QRS complex shows whether selective His bundle stimulation or non-selective His bundle stimulation has taken place.

0150In a variant, the program causes the processor to use a time offset between the execution of the cardiac stimulation on the one hand and the detection of the cardiac electrical signal on the other hand for the classification of the excitation state. In other words, in this variant the time that elapses between the stimulation and the detected cardiac excitation is taken into account in order to be able to classify the excitation state accordingly. Because the different cardiac states of excitation prepare at different speeds. Therefore, the point in time at which cardiac excitation can be detected after a previous stimulation is sometimes an important criterion in order to be able to assign the detected excitation to a certain class.

0151In one variant, the program causes the processor to use at least one signal profile of the electrocardiogram to classify the state of excitation, the electrocardiogram in this variant being a unipolarly derived electrocardiogram from a pole of the electrode of the stimulation unit against a large-area body electrode (for example a housing of the arrangement for stimulation of the heart) of the patient concerned.

0152One aspect of the present invention relates to a computer program product having computer readable code that causes a processor to perform the steps outlined below when executed on the processor.

0153Cardiac stimulation is first carried out by means of a stimulation unit.

0154A cardiac electrical signal is then detected by means of a detection unit. This signal was generated by cardiac excitation as a result of the previous cardiac stimulation.

0155The excited state of the heart stimulated by cardiac stimulation is then determined on the basis of the detected electrical signal.

0156Now the state of excitement is classified into one of at least three classes. The at least three classes include a first class that is representative of a first state of arousal, a second class that is representative of a second state of arousal that is different from the first state of arousal, and a third class that is representative of unsuccessful stimulation without detectable state of excitation is representative.

0157Subsequently, at least one control parameter of an implantable arrangement for stimulating a human or animal heart is automatically adjusted. This automatic adjustment takes place depending on the classification carried out previously. The control parameter is a His bundle stimulation energy, a His bundle stimulation vector, an operating mode of the arrangement used for stimulation, at least one parameter of a timer of the arrangement or a stimulation control parameter which is suitable for cardiac resynchronization therapy.

0158Another aspect of the present invention relates to a medical method for treating a human or animal patient in need of such treatment. This method is carried out using an implantable arrangement for stimulating the heart of the patient. The arrangement has a processor, a memory unit, a stimulation unit for stimulating the His bundle of the patient's heart and a detection unit for detecting an electrical signal of the patient's heart. The method comprises the steps explained below.

0159First, cardiac stimulation of the patient's heart is performed using the stimulation unit.

0160A cardiac electrical signal is subsequently detected by means of the detection unit. The cardiac electrical signal was triggered or generated by the previously performed cardiac stimulation.

0161An excitation state of the patient's heart, which has been studied by cardiac stimulation, is then determined. This determination is based on the previously detected electrical signal.

0162Now the determined state of arousal is classified into one of at least three classes. These at least three classes comprise a first class for a first state of excitation, a second class for a second state of excitation and a third class for unsuccessful stimulation without a detectable state of excitation. The second state of excitation differs from the first state of excitation.

0163After the classification, an automatic adjustment of at least one control parameter of the arrangement takes place depending on the classification carried out. The control parameter can be a His bundle stimulation energy, a His bundle stimulation vector, an operating mode of the implantable arrangement, at least one parameter of a timer of the arrangement or a stimulation control parameter that is suitable for cardiac resynchronization therapy.

0164One aspect of the present invention relates to an implantable arrangement for stimulating a human or animal heart with the features explained below. Such an arrangement has a processor, a memory unit, a stimulation unit and a detection unit. The stimulation unit serves to stimulate the His bundle of a human or animal heart. It can be suitable for such a stimulation or can be specifically provided and set up for it. The detection unit is used to detect an electrical signal from the same heart.

0165According to the invention, this arrangement is characterized in that the storage unit has a computer-readable program which causes the processor to carry out the steps explained below when it is executed on the processor.

0166First, the detection unit is used to determine whether a tachycardia is present in a human or animal heart in which the arrangement is implanted.

0167If such a tachycardia has been detected, His bundle stimulation is carried out by means of the stimulation unit. The His bundle stimulation is carried out by delivering at least one stimulation pulse. This stimulation pulse has an amplitude which is in a range from 7.5 V to 30 V, in particular from 12 V to 30 V, in particular from 15 V to 25 V, in particular from 20 V to 22 V, in particular from more than 20 V. to 30 V, in particular from more than 20 V to 25 V, in particular from more than 20 V to 22 V. Furthermore, the stimulation pulse has a pulse width which is in a range from 1 ms to 15 ms, in particular from 2 ms to 12 ms, in particular from 3 ms to 10 ms, in particular from 4 ms to 9 ms, in particular from 5 ms to 8 ms lies.

0168A particularly effective stimulation of the His bundle can be achieved by means of a stimulation pulse with such an amplitude and such a pulse width. It is not absolutely necessary for a stimulation electrode of the stimulation unit to be arranged directly in the His bundle. Rather, a stimulation of the His bundle can also be achieved with a stimulation pulse having such a stimulation amplitude and such a pulse width if the corresponding stimulation electrode is arranged on the His bundle or in the vicinity of the His bundle. This simplifies the implantation of such a stimulation electrode. Because the exact detection of the His bundle is not as crucial for a later effective stimulation of the His bundle with such a specification of the stimulation pulse as in other cases. However, with the selected stimulation amplitude and the selected pulse width of the stimulation pulse, an accurate detection of the His bundle facilitates later stimulation of the His bundle.

0169In one variant, the program causes the processor to classify a detected tachycardia into one of at least two classes. In this variant, the implantable arrangement is therefore able to discriminate between different tachycardiac arrhythmias of the heart. Then tachycardiac arrhythmias, in which stimulation of the His bundle promises particularly good treatment, can be distinguished from other tachycardic arrhythmias, in which treatment of the His bundle is less promising. In a variant, the triggering of stimulation of the His bundle can depend on the class into which the detected tachycardia is classified.

0170In a variant, a first of the at least two classes is provided for AV node reentry tachycardia (AVNRT). Because with AV node reentry tachycardia, stimulation of the His bundle is particularly suitable to end the AV node reentry tachycardia and return the treated heart to a normal state. It is not necessary to give additional medication or to carry out ablation therapy. Rather, stimulation of the His bundle alone is sufficient to end a detected AV node reentry tachycardia. The device claimed according to the invention is therefore particularly suitable for treating a detected AV node reentry tachycardia, this treatment not having the serious side effects and risks of the treatment methods known from the prior art for AV node reentry tachycardia.

0171In a variant, the program causes the processor to only perform His bundle stimulation if the tachycardia has been identified as AV node reentry tachycardia. In this variant, the implantable arrangement is only used for the treatment of AV node reentry tachycardia, but not for the treatment of other tachycardiac arrhythmias or not to treat other tachycardia arrhythmias of the heart with His bundle stimulation.

0172In a variant, the program causes the processor to evaluate the signals of an electrocardiogram in order to determine whether there is tachycardia. This evaluation can take place, for example, in the detection unit or in a separate evaluation unit. A morphological analysis of the electrocardiogram can be carried out, for example. A morphological analysis criterion of the corresponding electrocardiogram is suitable for this. To identify this morphological analysis criterion, for example, pattern recognition or image recognition can be carried out in the electrocardiogram in order to identify certain patterns that are typical of the presence of tachycardia.

0173In one variant, the electrocardiogram is an intracardiac electrogram or a far-field electrocardiogram (also known under the partial English term far-field electrocardiogram or far-field ECG). It is also possible to evaluate both an intracardiac electrogram and a far field ECG.

0174In one variant, the program causes the processor to evaluate a chronological sequence of atrial and ventricular signals in the electrocardiogram in order to determine whether tachycardia is present. For example, atrial and ventricular signals appearing almost simultaneously at an increased heart rate indicate AV node reentry tachycardia. In such a case, the detected tachycardia can then be classified as AV node reentry tachycardia.

0175In a variant, the His bundle stimulation is coupled by the stimulation unit with a defined or predefinable coupling interval to an intrinsic tachycardic excitation of the heart to be treated. The program has appropriate commands that cause the processor to control the stimulation unit accordingly.

0176In one variant, the program causes the processor to execute the His bundle stimulation as a pulse sequence with at least two pulses. In one variant, a time interval between two pulses of this pulse sequence is selected that is less than the cycle length of the tachycardia determined. This means that the His bundle stimulation takes place in this variant as so-called overdrive stimulation.

0177In another variant, a pulse train with at least two pulses is also used for His bundle stimulation. In this variant, however, a time interval between two pulses of the pulse sequence is selected such that it is greater than the cycle length of the tachycardia determined. This means that in this variant the His bundle stimulation takes place as so-called underdrive stimulation.

0178The decision as to whether an overdrive stimulation or an underdrive stimulation is carried out can be made, for example, on the basis of the specific form of the tachycardia determined, in particular the AV node reentry tachycardia.

0179In one variant, the program causes the processor to determine a time interval between two pulses of a pulse sequence used for His bundle stimulation from at least two pulses with a freely selectable adaptation factor to a previously determined cycle length of the detected tachycardia, in particular the detected AV node. Reentry tachycardia, adjust. Then the His bundle stimulation takes place with exactly the same time characteristic as the tachycardia determined; the His bundle stimulation is therefore synchronized with the detected tachycardia.

0180In a further variant, the program causes the processor to perform the His bundle stimulation using a single pulse. If such a single pulse is used, His bundle stimulation can be carried out particularly easily since a chronological sequence of two or more pulses need not be taken into account. In a variant, however, a single stimulation pulse is coupled to the intrinsic excitation of the heart to be treated, that is to say matched to the intrinsic excitation of the heart.

0181One aspect of the present invention relates to a computer program product having computer readable code that causes a processor to perform the steps outlined below when executed on the processor.

0182First, a detection unit is used to determine whether there is tachycardia in a human or animal heart.

0183If such a tachycardia has been detected, His bundle stimulation is carried out by means of a stimulation unit. At least one stimulation pulse is delivered by the stimulation unit. This stimulation pulse has an amplitude that is in a range from 7.5 V to 30 V. The stimulation pulse also has a pulse width that is in the range from 1 ms to 15 ms.

0184One aspect of the present invention relates to a method of treating a human or animal patient in need of such treatment. This treatment is carried out by means of an implantable arrangement for stimulating the patient's heart. This arrangement is implanted in the patient. The arrangement has a processor, a storage unit, a stimulation unit and a detection unit. The stimulation unit is used to stimulate the His bundle of the patient's heart. It can be suitable for such a stimulation or can be specifically provided and set up for it. The detection unit is used to detect an electrical signal of the patient's heart. The method has the steps explained below.

0185First, the detection unit detects whether there is tachycardia in the patient's heart.

0186If such a tachycardia has been detected, His bundle stimulation is carried out by means of the stimulation unit. At least one stimulation pulse is emitted by the stimulation unit for the His bundle stimulation. This stimulation pulse has an amplitude that is in a range from 7.5 V to 30 V. In addition, the stimulation pulse has a pulse width that is in a range from 1 ms to 15 ms.

0187All of the variants and alternative configurations which have been described in connection with the various implantable arrangements can be combined with one another as desired and can be transferred to the other arrangements. In an analogous manner, they can also be transferred in any combination to the described analysis device, the described methods and the described computer program products. Furthermore, the different variants of the analysis device can be combined with one another as desired and can be transferred to the different implantable arrangements and, analogously, also to the described methods and the described computer program products. Furthermore, the variants of the methods described can be combined with one another as desired and can be transferred to the other methods as well as to the computer program products and the arrangements and the analysis device. In the same way, the described variants of the computer program products can be combined with one another as desired and can be transferred to the other computer program products as well as to the described methods and the described arrangements and the analysis device.

0188Further details of aspects of the invention are explained in more detail below in connection with exemplary embodiments and drawings. Show it:<dl id="dl0001"><dt>Figure 1</dt><dd>a block diagram of an embodiment of an implantable arrangement for stimulating the human or animal heart;</dd><dt>Figure 2</dt><dd>a schematic representation of an embodiment of an implantable arrangement of the human or animal heart;</dd><dt>Figure 3</dt><dd>a block diagram of an embodiment of an implantable arrangement for stimulating the human or animal heart, which performs a stimulation success control during operation;</dd><dt>Figure 4</dt><dd>a simplified block diagram of an embodiment of an analysis device;</dd><dt>Figure 5</dt><dd>an embodiment of one of the analysis device of the <figref idref="f0003">Figure 4</figref> output representation; and</dd><dt>Figure 6</dt><dd>a block diagram of an embodiment of an implantable arrangement for stimulating the human or animal heart.</dd></dl>

0189The <figref idref="f0001">Figure 1</figref> shows a block diagram of an embodiment of a pacemaker 100, which serves as an implantable arrangement for stimulating the human or animal heart. The pacemaker 100 has an energy source 101 and a first electrode connection 102, which serves as a first stimulation output. Connected to the electrode connection 102 is a first stimulation unit 103, from which stimulation pulses can be conducted through the first electrode connection 102 to a first electrode. In addition, a first detection unit 104 is connected to the first electrode connection 102. The first stimulation unit 103 and the first detection unit 104 act as a conventional detection and stimulation stage of the pacemaker 100.

0190In order to ensure that stimulation pulses are delivered in a time-defined manner by the first stimulation unit 103 and to adapt the corresponding stimulation pulses to the signals of a heart detected by the first detection unit 104, the pacemaker 100 also has a first timer 105, which is also in a conventional manner works.

0191In addition, the pacemaker 100 has a second electrode connection 110, which serves as a second stimulation output. It is connected to a second stimulation unit 120 and a second detection unit 130. The second stimulation unit is specifically designed and prepared to stimulate the His bundle of the heart to be treated. The second detection unit 130 is specifically designed and prepared to detect an electrical signal of the His bundle of this heart.

0192Both the second stimulation unit 120 and the second detection unit 130 are connected to a second timer 140. This is also operatively connected to the first timer 105. By means of the second timer 140, it is possible to synchronize the stimulation pulses to be emitted by the second stimulation unit 120 with the stimulation pulses which are emitted by the first stimulation unit 103. In this way, a stimulation of the His bundle of the heart can take place at a point in time at which the His bundle is particularly susceptible to such a stimulation and which offers itself in a physiologically sensible manner for restoring a natural heart rhythm. The second timer 140 also opens up the possibility, via signals that are detected by the second detection unit 130, of synchronizing the temporal delivery of stimulation pulses that are output by the first stimulation unit 103 with stimulation pulses that are output by the second stimulation unit 120 , to reach.

0193Downstream of the second timer 140 are a His bundle marker channel 150, a His bundle stimulus threshold test unit, which serves as the first stimulus threshold test device, and a His bundle diagnostic memory 190.

0194Using the His bundle marker channel 150, it is possible to read out an electrocardiogram (EKG) or an intracardiac electrogram (IEGM) from the pacemaker 100, the EKG or the IEGM being provided with markings that are specific to a His bundle. Stimulation by means of the second stimulation unit 120 and / or specific for detection of a signal of the His bundle by means of the second detection unit 130. In this way, EKGs or IEGMs can be called up from the pacemaker 100 via the His bundle marker channel 150, which are provided with His bundle-specific information.

0195The His bundle stimulus threshold test unit 180 serves to determine a stimulation threshold of the His bundle before a corresponding stimulation of the His bundle is carried out by means of the second stimulation unit 120. In this way, a sufficiently strong stimulation pulse can always be provided by means of the second stimulation unit 120, but without having to use more energy than necessary for this. Thus, the His bundle stimulus threshold test unit 180 serves on the one hand to ensure that the stimulation pulses emitted by the second stimulation unit 120 are strong enough to achieve excitation of the His bundle, and on the other hand that the stimulation pulses emitted by the second stimulation unit 120 only one if possible have low energy, so that the energy source 101 of the pacemaker 100 is loaded as little as possible by the second stimulation unit 120.

0196Events relating to the His bundle stimulation or the His bundle activity are stored in the His bundle diagnostic memory 190, which can be configured, for example, as a memory area of ​​a larger storage unit. The His bundle diagnostic memory is used to record stimulation pulses emitted by the second stimulation unit 120 and, moreover, also to record data which is detected by the second detection unit 130 in relation to the His bundle of the heart to be treated.

0197A His-Bundle remote monitoring and programming unit 200 is assigned to the His-Bundle diagnostic memory 190, via which the His-Bundle diagnostic memory 190 can be read out. In addition, by means of the His bundle remote monitoring and programming unit 200, the second stimulation unit 120 and / or the second detection unit 130 can be monitored. It is also possible to use the His bundle remote monitoring and programming unit 200 to adapt the His bundle stimulation to be delivered by the second stimulation unit 120. This His-Bundle remote monitoring and programming unit 200 thus allows access to specific components of the pacemaker 100, whereby both reading out and writing data is made possible.

0198The <figref idref="f0002">Figure 2</figref> shows a schematic side view of the pacemaker 100, whose block diagram in the <figref idref="f0001">Figure 1</figref> is shown. The same elements are provided with the same reference symbols.

0199In the schematic representation of the <figref idref="f0002">Figure 2</figref> A header 160 can be seen in which the first electrode connection 102 and the second electrode connection 110 are formed. A first electrode 106 is inserted into the first electrode connection 102 and a second electrode 170 into the second electrode connection 110. The first electrode 106 and the second electrode 107 are shown in FIG<figref idref="f0002">Figure 2</figref> shown in sections.

0200The first electrode 106 is used for conventional stimulation of any heart area in one of the heart chambers. They also serve to detect electrical signals in one of these heart chambers.

0201The second electrode 170 is used specifically for a His bundle stimulation and a detection of His bundle specific electrical signals. In order to make it easier for a user to use the pacemaker 100, the second electrode 170 is identified by the inscription "HIS" as a His bundle electrode. So that this second electrode 170 is inserted into the correct electrode connection, namely the second electrode connection 110, the latter is provided with the additional identification "HIS" in the header 160 of the pacemaker 100.

0202It can also be provided that the second electrode connection 110 is structurally different from the first electrode connection 102, so that it is not even possible to insert the second electrode 170 (ie the His bundle electrode) into the first electrode connection 102.

0203In addition to an inscription such as "HIS", color coding of the second electrode 170 and / or the second electrode connection 110 or a corresponding area of ​​the header 160 can also be provided.

0204The pacemaker 100 also has a marking 210 on its side, which schematically represents the first electrode connection 100 and the second electrode connection 110 and provides a corresponding identification. The marking 210 indicates that the first (upper) electrode connection 102 is provided for connecting a first electrode 106 leading into the right atrium (RA) and the second (lower) electrode connection 110 for connecting a second electrode 170 leading to the His bundle is. This additional marking 210 also makes it easier for a user of the pacemaker 100 to connect the correct electrodes 106, 170 to the electrode connections 102, 110 provided therefor.

0205The <figref idref="f0002">Figure 3</figref> shows a block diagram of an embodiment of a pacemaker 300, which serves as an implantable arrangement for stimulating the human or animal heart. This pacemaker 300 carries out a stimulation success control and is able to automatically adapt an internal control parameter as a function of the stimulation success control carried out.

0206The pacemaker has an energy source 310 and a His bundle stimulation unit 320, which serves as a stimulation unit. Furthermore, a detection unit 330 is provided, which serves as a detection unit. The His bundle stimulation unit 320 and the detection unit 330 are operatively connected to a processor 340. This processor 340 can in turn access a storage unit 350 and receive or send data from this storage unit 350.

0207A program is stored in the memory unit 350, with which the processor 340 can carry out certain steps. Processor 340 thus prompts His bundle stimulation unit 320 to use one of the<figref idref="f0002">Figure 3</figref> not shown stimulation electrode to perform cardiac stimulation (in particular of the His bundle). The processor 340 then causes the detection unit 330 to detect a cardiac electrical signal from the previously stimulated heart. This signal is then used to determine an aroused state of the heart.

0208The state of excitation is classified into one of at least three different classes. Then, depending on the classification carried out, an automatic adjustment of a specific control parameter of the pacemaker 300 takes place.

0209The steps of determining the state of excitation, classifying the state of excitation and automatically adapting at least one control parameter can be carried out in a stimulation success control module which can be implemented either in terms of hardware or software. In the embodiment of the<figref idref="f0002">Figure 3</figref> this stimulation success control module is implemented in terms of software, so that it is not shown separately.

0210The automatic adaptation of at least one control parameter of the cardiac pacemaker 300 enables a therapy success check of a previously performed His bundle stimulation to be carried out in a particularly simple manner, with the automatic adaptation of a control parameter ensuring particularly safe and effective therapy even over a long period of time.

0211The <figref idref="f0003">Figure 4</figref> shows a simplified block diagram of a His bundle pace sense analyzer (His-PSA), which serves as an analysis device. This His-PSA has a His bundle stimulation unit 410 which comprises an electrode interface by means of which a His bundle electrode can be connected to the His bundle stimulation unit 410. The His bundle stimulation unit 410 is used to deliver a high-energy stimulation with which the His bundle of a human or animal heart can be stimulated well.

0212The His-PSA also has a first detection unit 420, which can also directly access an electrode with which a stimulation of the His bundle can be detected. The first detection unit 420 is provided and set up to record an electrocardiogram in the form of a broadband intracardiac electrogram (IEGM) and to undergo a morphological signal analysis. With the aid of a digital signal processor (DSP), which is part of the first detection device 420, His-bundle-typical signal morphologies can be identified and marked within the recorded electrocardiogram. The first detection unit 420 then passes the IEGM processed in this way to a control and display unit 430, which serves as an output device for outputting the marked IEGM.

0213The control and output unit 430 is also connected to a processor 440, which in turn can access a storage unit 450. In this way it is possible to retrieve program information from the memory unit 450 by the processor 440 and to transmit it via the control and display unit 430 to the His bundle stimulation unit 410 and the first detection unit 420.

0214In addition, the His-PSA has one or more further stimulation units 460, which are designed as conventional stimulation units and comprise conventional electrode interfaces for connecting atrial or ventricular electrodes. Conventional stimulation specifications of the corresponding electrodes can be provided. In addition to the further stimulation units 460, one or more further detection units 470 are also provided, which are used for the detection and evaluation of atrial and ventricular cardiac signals. For this purpose, these further detection units 470 use conventional detection specifications. Using these further detection units 470, it is possible to identify and mark ventricular and atrial signals in recorded electrocardiograms. The control and display unit 430 can therefore display His bundle-specific signals as well as atrial and / or ventricular signals in an electrocardiogram such as an IEGM. The control and display unit 430 is able to display different channels (in particular an atrial channel, a ventricular channel and a His bundle-specific channel) separately from one another.

0215This is in the <figref idref="f0003">Figure 5</figref> shown schematically as an example. So it shows<figref idref="f0003">Figure 5</figref> from top to bottom a first marker channel 510 for marking atrial signals As and ventricular signals Vs.

0216Below this, a second marker channel 520 is shown, which serves to mark His-bundle-specific signals HIS.

0217In an atrial IEGM channel 530, only atrial signals 531 are shown schematically.

0218In a His-bundle-specific channel 540, in addition to atrial signals 541 and ventricular signals 542, His-bundle-specific signals 543 are shown and marked separately. This can typically be done in color. In the representation of the<figref idref="f0003">Figure 5</figref> His bundle-specific signals 543 are shown circled.

0219Finally, only ventricular signals 552 are shown in a schematic representation in a ventricular IEGM channel 550.

0220A user can display several channels 510-550 simultaneously or individual channels 510-550 separately from other channels 510-550. This makes it particularly easy for the user to filter the information relevant to the specific question. The automatic identification and separate marking of His-bundle-specific signals 543 make it particularly easy to check the correct positioning of a His-Bundle-specific stimulation electrode and to optimize it with regard to the best possible contacting of the His bundle.

0221The <figref idref="f0004">Figure 6</figref> shows a pacemaker 600 which serves as an implantable arrangement for stimulating the human or animal heart. This pacemaker 600 is specifically designed and configured to treat AV node reentry tachycardia (AVNRT).

0222The pacemaker 600 comprises an energy source 610, a tachycardia detection and classification unit 620, which serves as a detection unit, and a His bundle stimulation unit 630, which serves as a stimulation unit. The tachycardia detection and classification unit 620 and the stimulation unit 630 are connected to a control unit 640. The control unit 640 in turn is operatively connected to a processor 650, which can access a storage unit 660.

0223The tachycardia detection and classification unit 620 has an electrode connection 621 to which a first electrode can be connected. By means of this first electrode, the tachycardia detection and classification unit 620 can detect whether there is a tachycardia in the heart of the patient who is wearing the pacemaker 600. The tachycardia detection and classification unit 620 is also able to recognize and classify the type of tachycardia. In particular, an AV node reentry tachycardia can be distinguished from other tachycardias by means of the tachycardia detection and classification unit 620.

0224If such an AV nodal reentry tachycardia is recognized by the tachycardia detection and classification unit 620, the control unit 640 ensures that the stimulation unit 630 delivers a stimulation which is specifically suitable for stimulation of the His bundle of the patient's heart. For this purpose, the stimulation unit 630 has an electrode connection 631, to which, in the operation of the pacemaker 600, a second electrode is connected, which is arranged in the His bundle or so close to the His bundle that a His bundle stimulation by means of this electrode is possible. The control unit 640 transmits the corresponding signal to the stimulation unit 630 after it has received a corresponding command from the processor 650. A program runs on the processor 650, which the processor 650 obtains from the memory unit 660.

0225The individual components of the pacemaker 600 are supplied with the energy required for operation by the energy source 610.

0226The tachycardia detection and classification unit 620 uses ECG signals, which are supplied to it via the electrode connection 621, for the detection and classification of a tachycardia, in particular for the detection of an AV node reentry tachycardia. The ECG signals can be derived from either the atrium and / or the ventricle of the patient's heart. In addition, corresponding ECG signals can be provided directly via a His bundle electrode, for example via the second electrode, which is also connected to the second electrode connection 631 of the stimulation unit 630.

0227To classify the detected tachycardia, i.e. to differentiate between different tachycardias, and in particular for identifying an AV nodal reentry tachycardia, the tachycardia detection and classification unit 620 can use morphological analysis criteria within the provided electrocardiogram or, instead of such a morphological analysis of the electrocardiogram, evaluate a chronological sequence of atrial and / or ventricular signals in the electrocardiogram. It is also possible to carry out both a morphological analysis of an electrocardiogram provided and an analysis of the chronological sequence of the signals contained in this electrocardiogram.

0228This pacemaker 600 provides a new, device-based therapy for tachycardias, in particular for AV node reentry tachycardia. This extends the therapeutic spectrum of active implants.