Pacemakers in Uruguay
In 1959, Orestes Fiandra considered the the possibility of pacemaker implantation based on the increase of frequency of syncope. The first human experience with an implantable pacemaker had failed, and the small generator had not worked as expected. Fiandra had suggested to Rune Elmqvist the consideration of recent technological advances, such as the silicon transistor which seemed more suitable for an implantable pacemaker than the germanium transistor, and a new epoxy resin, Araldite, produced by Ciba AG, which had excellent biocompatability for pulse generator encapsulation.
Elmqvist was able to provide an implantable pulse generator powered by two rechargeable nickel-cadmium batteries, each delivering 50 microampere/hours. Recharging was accomplished by a 150 kHz current generated by an external 220 volt unit. The current was transmitted by induction from an external flexible coil 25 em in diameter (Fig. 1) placed on the skin over the pacemaker, to a coil 50 mm in diameter within the implanted generator. The pacemaker required charging once a week for 12 hours.
The cylindrical unipolar, asynchronous implantable generator consisted of the nickel-cadmium batteries, the electronic circuit and the recharging antenna, all encapsulated in epoxy. It was 52.5 mm in diameter, 17.5 mm thick and weighed 64.3 grams The lead had a braided nylon core surrounded by four flat stainless steel bands insulated by a polyethylene coating. The stimulating electrode was a platinum disc 9 mm in diameter, to be sutured to the epicardium through two small holes. The cathodal stimulating surface area was 63.6 square mm, the anode was a metal ring 10 mm wide on the pacemaker's edge. The ring was not completely circumferential to avoid interruption of the magnetic field created by the charging current.
Dr. Robert Rubio implanted this unit on 3 February 1960 at the CASMU Clinic of Montevideo, Uruguay in a woman who was experiencing Adams-Stokes seizures. The epicardial electrode was sutured to the left ventricular surface and the pulse generator was placed in the abdominal wall. She experienced increased exercise tolerance and the absence of Adams-Stokes seizures. Infection developed in the thoracic incision and she died of sepsis on October 20, 1960. Despite the outcome, this initial experience with an implantable pacemaker was the starting point of a prolonged effort to develop pacemaker technology in Uruguay and to make it available to the entire nation's population.
The National Fund was created to provide pacemakers for that purpose. After 14 years the health authorities were persuaded of the benefits of the project. This national fund now provides pacemakers and also covers other medical interventions such as cardiac catheterization, cardiac surgery, renal analysis and transplantation, and hip prostheses for the entire population. The fund is supported by a monthly contribution of US $0.48 per person from the middle income and wealthy population and a larger government contribution on behalf of the indigent population. As a result of this system, 311 pacemaker implants per million inhabitants were performed in Uruguay annually as of 1988.
The second project was the creation of a pacemaker industry to supply pacemakers at a reasonable price and to serve as a financial support for research projects in cardiology and pacing. Manufacture of pacemakers started in 1970. Initially Uruguay received technical assistance from the Instituto Dante Passanese of Sao Paulo, Brazil, where pacemakers were already being manufactured under the direction of Drs. Adibe Jatene and Décio Kormann. Mercury, nuclear, and lithium power sources were used in manufacture and the Uruguay manufacturing operation was the sixth plant to use lithium batteries. By 1988 Uruguay, with a population of 2.97 million people, was one of only 17 countries in the world with an indigenous pacemaker industry.
Interview with Adibe Jatene (in Portuguese)
Biography of Décio Kormann (in Portuguese)