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Dual-Chamber Timing Göran Mathson, 2005 Reaction to sensing III 0=None T=Triggered I=Inhibited D=Dual (T+I) Rate Modulation IV 0=None R=Rate Modulation.

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Presentation on theme: "Dual-Chamber Timing Göran Mathson, 2005 Reaction to sensing III 0=None T=Triggered I=Inhibited D=Dual (T+I) Rate Modulation IV 0=None R=Rate Modulation."— Presentation transcript:

1

2 Dual-Chamber Timing Göran Mathson, 2005

3 Reaction to sensing III 0=None T=Triggered I=Inhibited D=Dual (T+I) Rate Modulation IV 0=None R=Rate Modulation What is stimulated? I 0=None A=Atrium V=Ventricle D=Dual (A+V) S=Single (A or V) Multisite Pacing V 0=None A=Atrium V=Ventricle D=Dual (A+V) What is sensed? II 0=None A=Atrium V=Ventricle D=Dual (A+V) S=Single (A or V) The Revised NASPE/BPEG Generic Code for Antibradycardia, Adaptive-Rate, and Multisite Pacing, PACE, Volume 25, No. 2, February 2002 NASPE/BPEG Generic Pacemaker Code

4 Pacing systems AAI(R) VDD(R)DDD(R) VVI(R) = Sensing point = Stimulation point = Sensing and Stimulation point

5 A-A

6 AV Delay

7 A-A PV Delay

8 AV and PV Delay... 150 ms 170 ms

9 AV and PV interval... Late atrial activation 150 ms 250 ms The AV Delay can be programmed max. 100 ms longer than the PV Delay

10 Late Atrial Activation In this case: AV Delay should be 80 ms longer than PV Delay

11 A-A AV Delay

12 A-A terminated by intrinsic P-wave A-A AV Delay

13 A-A terminated by a PVCA-A – AV delay timer starts on detection of a PVC A-A AV Delay

14 A-A PVARP Post Ventricular Atrial Refractory Period AV Delay

15 A-A PVARP AV/PV Delay + PVARP = Total Atrial Refractory Period, TARP AV Delay

16 300 325 350 375 400 150 175 200 225 250 425 450 475 500 275 25, 30, 40, 50…170…350 Example of programmability...

17 Noise Mode, Atrial Channel PVARP Programmable PVARP Absolute Relative A-A Interval

18 Example Identity ADx: 100 ms175 ms Relative Absolute Sensed Event NSW 150 ms Sensed Event NSW 150 ms Noise sampling window (NSW) Sensed Event NSW 150 ms Sensed Event

19 Noise Mode, Atrial Channel A-A Interval

20 A-A PVARP VRP Ventricular Refractory Period AV Delay

21 A-A PVARP VRP Ventricular Blanking Period AV Delay

22 Far-field sensing Intrinsic activity is sensed in the wrong chamber Crosstalk Pacemaker activity is sensed in the wrong chamber = Sensing point = Stimulation point = Sensing and Stimulation point

23 125 300 325 350 375 400 150 175 200 225 250 425 450 475275 12…51ms Example of programmability...

24 A-A PVARP VRP MTRI Maximum Tracking Rate Interval AV Delay

25 Maximum Tracking Rate Interval A-A PVARP VRP MTRI AV Delay

26 MTR Interval Pseudo Wenckebach Upper Rate Behaviour

27 A-A PVARP VRP MTRI MSRI AV Delay

28 A = Atrial paced event P = Atrial sensed event V = Ventricular paced event R = Ventricular sensed event Markers…

29 AV -Pacing AR -Pacing PV -Pacing PR -Pacing DDD(R) Pacing States

30 AV-Pacing DDD(R) Pacing States

31 PV-Pacing DDD(R) Pacing States

32 PR-Pacing DDD(R) Pacing States

33 AR-Pacing DDD(R) Pacing States

34 AAVPRRVP Pacing States

35 Markers A V P R 142 546 694 170 617 759 P R Atrial Refractory period Ventricular Refractory period

36 DDI Timing

37 Reaction to sensing III 0=None T=Triggered I=Inhibited D=Dual (T+I) Rate Modulation IV 0=None R=Rate Modulation What is stimulated? I 0=None A=Atrium V=Ventricle D=Dual (A+V) S=Single (A or V) Multisite Pacing V 0=None A=Atrium V=Ventricle D=Dual (A+V) What is sensed? II 0=None A=Atrium V=Ventricle D=Dual (A+V) S=Single (A or V) The Revised NASPE/BPEG Generic Code for Antibradycardia, Adaptive-Rate, and Multisite Pacing, PACE, Volume 25, No. 2, February 2002 NASPE/BPEG Generic Pacemaker Code

38 PVARP VRP MSRI AEI AVI VEI

39 AVI AEI PVARP VRP VEI MSRI

40 AVI AEI PVARP VRP VEI MSRI P P P P PP V

41 AVI AEI PVARP VRP VEI MSRI

42 Lower Rate

43 Rest Rate, and its Sensor Driven! Rest Rate Basic Rate

44 Hysteresis Rate Rate Hysteresis Classic single-chamber version

45 Intervention- rate Hysteresis rate Basic rate Advanced Hysteresis Response Cycle Count Intervention Duration Sensor Recovery Rate Search Interval Cycle Count

46 A V P V A R A R Crosstalk…

47 Crosstalk Decrease atrial output? Decrease ventricular sensitivity? Prolong ventricular blanking? Enable Ventricular Safety Standby!

48 Ventricular Safety Standby Blanking Period Crosstalk Detection Window

49 Ventricular Safety Standby Crosstalk V. Safety Pacing after 120 ms

50 Is Ventricular Safety Pacing Present In This Panel?

51 Vetricular Safety Pacing

52 Ventricular Safety Standby Sensing in Crosstalk Detection Window V. Safety Pacing after 120 ms

53 Ventricular Safety Standby Blanking Period Undersensing V. Pacing after programmed AV Interval

54 Blanking period undersensing can be dangerous at long AV intervals

55 Special Features AutoIntrinsic Conduction Search Neg. AV/PV Hysteresis AF Suppression

56 AutoIntrinsic Conduction Search Programming Suggestions

57 AutoIntrinsic Conduction Search in Intermittent High Degree AV-Block P V 150 788 938 150 Progr. PV Interval Programme the optimal AV/PV Delay for time in high degree AV-block 1 Add an AutoIntrinsic Conduction Search of e.g. 100 - 120 ms to allow for intrinsic conduction within a hemodynamically acceptable conduction time 2 100 AICS

58 AutoIntrinsic Conduction Search in Intermittent High Degree AV-Block P R 232 634 812 The pacemaker will now allow for intrinsic conduction within the prolonged AV/PV Delay, in this case 250 ms. 100 AICS 150 Progr. PV Interval

59 AutoIntrinsic Conduction Search in Intermittent High Degree AV-Block 150 ms Search 150+100 ms 150 ms Programmed AV/PV Delay AutoIntrinsic Conduction Search

60 AutoIntrinsic Conduction Search in Intermittent High Degree AV-Block 150 ms Search 150+100 ms 150 ms Programmed AV/PV Delay AutoIntrinsic Conduction Search

61 AutoIntrinsic Conduction Search in Sinus Node Disease 120 AICS P R 171 767 938 200 Programmed PV Interval Let the pacemaker measure the PR- and AR-Interval at rest 1 Program PV- and AV Delay slightly longer than intrinsic conduction 2 Add an AutoIntrinsic Conduction Search of 120 ms 3

62 AutoIntrinsic Conduction Search in Sinus Node Disease P R 268 670 841 200 Programmed PV Interval The pacemaker will now allow for intrinsic conduction within the prolonged AV/PV Delay, in this case 320 ms. 120 AICS

63 AutoIntrinsic Conduction Search in Sinus Node Disease 200 + 120 ms 225 + 120 ms Preference of intrinsic conduction... Programmed AV/PV Delay AutoIntrinsic Conduction Search

64 AutoIntrinsic Conduction Search in Sinus Node Disease 200 + 120 ms200 ms Back-up pacing if, against all odds, intrinsic conduction is lost... 200 ms Programmed AV/PV Delay AutoIntrinsic Conduction Search

65 Neg. AV/PV Hysteresis Programming in HOCM

66 HOCM Hypertrophic Obstructive CardioMyopathy

67 Negative AV/PV-hysteresis Measure, with the puls generator, the PR interval Program, with the aid of Echo, the optimal PV- Delay. (Longest PV Delay with full capture) To make this dynamic, program how much faster pacing should be, compared to a sensed R-wave (PR Meas – PV Opt ). This is called Neg. AV/PV Delta.

68 Negative AV/PV-Hysteresis 124 ms Neg. AV/PV-Delta (Programmable, -10 to -110 ms) Resulting PV-interval Measured PR-interval 124 - 50 ms 124 - 50 ms (search) 74 ms 81 ms

69 AF Suppression

70 > 90% Atrial Pacing AFx ensures a high percentage of atrial stimulation at a rate following the patients natural circadian variations, thereby maintaining control of the atrium, reducing ectopy, and suppressing atrial tachyarrhythmias AF Suppression, AFx

71 MSR Basic Rate AFx Intrinsic Rate AF Suppression, AFx

72 AFx

73 Search for intrinsic activity 676665 Activity found (two P-waves) 6465 Increase stimulation rate 74 AF Suppression, AFx

74 … and to programme: ON / OFF ! AF Suppression, AFx

75


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