New aspects in electrostimulation of the heart.

The interaction of the autonomic nervous system (ANS) and the heart is characterized by a new interdisciplinary field known as neurocardiology which presents the newest strategy for electro-cardiostimulation. In this context, the reestablishment of chronotropy with physiological, closed-loop pacing, as well as the prevention and treatment of a malignant arrhythmia by ANS modulation, is of the highest priority. The main objective toward this goal consists of appropriate monitoring of the autonomic balance and stimulation, respectively, so that neuromodulation of the cardiac efferents can be established. The electrode, as a sensor and an actuator, with its interface on the cellular level becomes of essential importance. The electrode-myocardium interface is determined by the structure of the Helmholtz double layer with regard to its physical, electrochemical, and physiological behavior. The transportation of electrons across the boundary, as well as the electro-chemical reactions determining the biocompatibility of the interface, can be improved by the microstructure of the solid component by creating a fractal surface coating with titanium-nitride or iridium. Experimental and clinical results have demonstrated that the fractal structure ensures negligible polarization as well as improved detection performance, thus, detecting the evoked response of the myocardial cells makes it possible to monitor the neural response of the myocardium as a consequence of a superimposed chronotropic disturbance. The stimulation electrode also monitors the sympathetic activity extracted from intracardiac impedance measurements, thereby providing a new principle of rate adaptation in which the pacemaker is an integral part of the ANS, reestablishing normal chronotropy. Further advantages of the improved electrode interface performance open new aspects in the treatment and prevention of tachyarrhythmia, and in the follow-up of transplanted hearts for the prevention of the rejection processes.