the standard for pacemaker designs. a further impediment to the reliability of the early devices was the diffusion of water vapor from body fluids through the epoxy resin encapsulation, affecting the electronic circuitry. this phenomenon was overcome by encasing the pacemaker generator in a hermetically sealed metal case, initially by telectronics of australia in 1969, followed by cardiac pacemakers, inc. of st. paul, minnesota in 1972. this technology, using titanium as the encasing metal, became the standard by the mid-1970s. on july 9, 1974, manuel a. villafaña and anthony adducci, the founders of cardiac pacemakers, inc. (guidant), manufactured the world's first pacemaker with a lithium anode and a lithium-iodide electrolyte solid-state battery. lithium-iodide or lithium anode cells increased the life of pacemakers from one year to as long as eleven years, and has become the standard for pacemaker designs. they began designing and testing their implantable cardiac pacemaker powered by a new longer-life lithium battery in 1971. the first patient to receive a cpi pacemaker emerged from surgery in june 1973. intra-cardial in 2013, several firms announced devices that could be inserted via a leg catheter rather than invasive surgery. the devices are roughly the size and shape of a pill, much smaller than the size of a traditional pacemaker. once implanted, the device's prongs contact the muscle and stabilize heartbeats. development of this type of device was continuing. in november 2014, bill pike of fairbanks, alaska, received a medtronic micra pacemaker in providence st vincent hospital in portland, oregon. d. randolph jones was the ep doctor. also in 2014, st. jude medical inc. announced the first enrollments in the company's leadless pacemaker observational study evaluating the nanostim leadless pacing technology. the nanostim pacemaker received european ce marking in 2013. post-approval implant trials were carried out in europe. the european study was stopped after reports of six perforations that led to two patient deaths. after investigations, st jude medical restarted the study. in the united states, this therapy had not been approved by the fda as of 2014. while the st jude nanostim and the medtronic micra are single-chamber pacemakers, it was anticipated that leadless dual-chamber pacing for patients with atrioventricular block would become possible with further development. reusable pacemakers worldwide each year, in a simple procedure to avoid explosions, thousands of pacemakers are removed from bodies to be cremated. pacemakers with significant remaining battery life are potentially life-saving devices for people in low- and middle-income countries (lmics). the institute of medicine, a us non-governmental organization, has reported that inadequate access to advanced cardiovascular technologies is a major contributor to cardiovascular disease morbidity and mortality in lmics. ever since the 1970s, multiple studies worldwide have reported on the safety and efficacy of pacemaker reuse. as of 2016, widely acceptable standards for safe pacemaker and icd reuse had not been developed, and there continued to be legal and regulatory barriers to widespread adoption of medical device reuse. manufacturers current and prior manufacturers of implantable pacemakers biotronik (germany) boston scientific (usa) cardiac pacemaker inc. ; guidant (usa) (now owned by boston scientific) intermedics (usa) lepu medical (china) medico (italy) medtronic (usa) sorin group (italy) (merged with cyberonics to form livanova; in 2018, livanova sold its cardiac rhythm management business unit to microport for $190m ) st. jude medical (usa) (now owned by abbott laboratories)