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CorePace _6 - Single and Dual Chamber Pacemaker Timing

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CorePace _6 - Single and Dual Chamber Pacemaker Timing Powered By Docstoc
					Single and Dual Chamber Pacemaker Timing
                Module 6




                                           1
Objectives

• Identify VVI, AAI, DDI, and DDD pacing on an ECG strip
• Identify basic dual chamber timing concepts
  – Rate intervals
  – Inhibition
  – Triggering

• Complete a simple VVI and DDD timing diagram
  – Demonstrating rate calculation
  – Demonstrating inhibition
  – Demonstrating magnet application



                                                           2
Pacemaker Mode

• Defines the chambers that are paced/sensed
• Defines how the pacemaker will respond to intrinsic events
• Defines if rate modulation is available (i.e., DDDR)




                                                               3
NBG Code

         I                   II                  III             IV              V
Chamber(s)          Chamber(s)            Response to        Rate         Multisite
Paced               Sensed                Sensing            Modulation   Pacing
O = None            O = None              O = None           O = None     O = None
A = Atrium          A = Atrium            T = Triggered      R = Rate     A = Atrium
                                                             modulation
V = Ventricle       V = Ventricle         I = Inhibited                   V = Ventricle
D = Dual (A + V)    D = Dual (A + V)      D = Dual (T + I)                D = Dual (A + V)
S = Single (A or V) S = Single (A or V)
NBG Code – The Usual Pacing Modes

        I                   II                  III             IV              V
Chamber(s)         Chamber(s)            Response to        Rate       Multisite
Paced              Sensed                Sensing            Modulation Pacing
O = None           O = None              O = None           O = None     O = None
A = Atrium         A = Atrium            T = Triggered      R = Rate     A = Atrium
                                                            modulation
V = Ventricle      V = Ventricle         I = Inhibited                   V = Ventricle
D = Dual (A + V)   D = Dual (A + V)      D = Dual (T + I)                D = Dual (A + V)
S = Single (A or   S = Single (A or V)
V)

             • Examples
                – DDD              – VVI
                – DDDR             – VVIR
                – DDIR             – AAI
Rate and Interval Review

• Calculated on the horizontal axis
  – At 25 mm/s speed
     • Each small box = 40 ms
     • Each bold box = 200 ms




   How do you convert intervals to rate?      Click for Answer
    60,000 / (Interval in ms) = Rate in bpm

                                                                 6
VVI Mode

• Chamber paced: Ventricle
• Chamber sensed: Ventricle
• Response to sensing: Inhibited
  – A ventricular sense:
     • Inhibits the next scheduled ventricular pace




                                                      7
VVI Example

• Chamber paced: Ventricle

• Chamber sensed: Ventricle

• Response to sensing: Inhibition
    – VVI 60 = Lower Rate timer of 1000 ms
       • Pacing every 1 second if not inhibited


     Lower Rate Timer 1000 ms    Lower Rate Timer 1000 ms   Lower Rate Timer ….




V                            V                          V
P                            P                          P

                                                                                  8
VVI Example
VVI 60


• Chamber paced: Ventricle
    – VVI 60 = Lower Rate timer of 1000 ms
       • Pacing every 1 second if not inhibited       A ventricular sense interrupts
                                                      the pacing interval, resets the
• Chamber sensed: Ventricle                           lower rate timer, and inhibits
                                                      the next scheduled paced (x)
• Response to sensing: Inhibition

     Lower rate timer 1000 ms                           Lower rate timer 1000 ms




                                                            x

V                               V                 V                                V
P                               P                 S                                P


                                                                                        9
 VOO Mode
 VOO 60
                        The intrinsic ventricular event
                        cannot be sensed, and thus, does
                        not interrupt the pacing interval.



          1000 ms               1000 ms                  1000 ms




 V                  V                           V                           V
 P                  P                           P                           P

Chamber paced: Ventricle             VOO results in fixed-rate pacing in
Chamber sensed: None                 the ventricle. Placing a magnet
Response to sensing: None            over the pacemaker usually results
                                     in this behavior at known rates, for
                                     example, 85 ppm.

                                                                                10
DDD Mode
• Chamber paced: Atrium & ventricle
• Chamber sensed: Atrium & ventricle
• Response to sensing: Triggered & inhibited
  – An atrial sense:
     • Inhibits the next scheduled atrial pace
     • Re-starts the lower rate timer
     • Triggers an AV interval (called a Sensed AV Interval or SAV)

  – An atrial pace:
     • Re-starts the lower rate timer
     • Triggers an AV delay timer (the Paced AV or PAV)

  – A ventricular sense:
     • Inhibits the next scheduled ventricular pace

                                                                      11
DDD Examples
The Four Faces of DDD


• Atrial and ventricular pacing




          A    V                      A     V
          P    P                      P     P


  – Atrial pace re-starts the lower rate timer and triggers an AV delay
    timer (PAV)
     • The PAV expires without being inhibited by a ventricular sense, resulting
       in a ventricular pace




                                                                                   12
DDD Examples
The Four Faces of DDD


• Atrial pacing and ventricular sensing




             A V                          A   V
             P S                          P   S

  – Atrial pace restarts the lower rate timer and triggers an AV delay
    timer (PAV)
     • Before the PAV can expire, it is inhibited by an intrinsic ventricular event
       (R-wave)




                                                                                      13
DDD Examples
The Four Faces of DDD


• Atrial sensing, ventricular pacing




        A     V                  A    V
        S     P                  S    P

  – The intrinsic atrial event (P-wave) inhibits the lower rate timer and
    triggers an AV delay timer (SAV)
     • The SAV expires without being inhibited by an intrinsic ventricular event,
       resulting in a ventricular pace




                                                                                    14
DDD Examples
The Four Faces of DDD


• Atrial and ventricular sensing




            A V                       A V
            S S                       S S


  – The intrinsic atrial event (P-wave) inhibits the lower rate timer and
    triggers an AV delay timer (SAV)
     • Before the SAV can expire, it is inhibited by an intrinsic ventricular event
       (R-wave)




                                                                                      15
Dual Response to Sensing
DDD


• The pacemaker can:
  – Inhibit and trigger
  – A P-wave inhibits atrial pacing and triggers an SAV interval
  – An atrial pace triggers a PAV interval
  – An R-wave inhibits ventricular pacing
      • We’ll see later how a PVC can affect atrial timing




                                                                   16
Nuggets

• Note that in both the single and dual chamber examples:
  – When the device paces – for the purposes of timing – capture is
    assumed
     • Some newer devices have algorithms to check for capture

  – Sensing is critical to timing
     • If the device fails to sense, undersensing, it will usually pace
     • If it “oversenses,” e.g., senses myopotentials, it will inhibit pacing




                                                                                17
Remember This Strip?

• Intermittent loss of capture (LOC)
   – Note how the underlying timing is unaffected by the failure to
     capture
   – For timing purposes, pace = capture
                                                     Review question:
                                                     Name some possible
                                                     causes for this
                                                     condition.
                                               DDD


 Click for Answer
Incomplete fracture, insulation failure, lead dislodgement, poor
connection in header, programming error, change in pacing
thresholds…


                                                                          18
Diagnose This Strip

• Undersensing, the device fails to reliably “see” P-waves


                                                          How do we know
                                                          this is
                                                          undersensing?


                                               DDD

Click for Answer
Because:
• The atrial lower rate timer is not inhibited – there are atrial pacing spikes
• The intrinsic P-waves do not start an SAV


                                                                                  19
DDI Mode
• Chamber paced: Atrium & ventricle
• Chamber sensed: Atrium & ventricle
• Response to sensing: Inhibited
  – An atrial sense:
     • Inhibits the next scheduled atrial pace
     • Re-starts the lower rate timer

  – An atrial pace:
     • Re-starts the lower rate timer
     • Starts an AV delay timer (the Paced AV or PAV)

  – A ventricular sense:
     • Inhibits the next scheduled ventricular pace



                                                        20
DDI Example

• Why would we want a dual chamber pacing mode that
  does not trigger an SAV?


                                                                  What rhythm
 P           P   P    P   P     P    P      P     P   P   P   P   is this?




     Click for Hint

The underlying rhythm is an atrial tachycardia.

                                                                            21
DDI Example
• Why would we want to use DDI?
  – To control pacemaker timing during atrial tachycardias
     • Avoids a fast paced ventricular response to AT/AF
     • May limit patient symptoms during AT/AF             Click to change
DDD – tracking the AF

                                    DDI – Not tracking the AF
                                  540ms = 110bpm




 This function has come to be called “Mode Switching”
                                                                             22
Status Check

• Calculate the atrial rate
• Measure the P-R interval
• Measure the QRS duration




Click for Answer   Atrial Rate: 70 bpm (860 ms)
                   P-R: 120 ms
                   QRS: About 100 ms


                                                  23
Status Check
Which pacemaker modes could be operating on this strip?
   •   Assume normal pacemaker operation                   Click for Answer




             A. DDD – Yes, the intrinsic rate could be faster than the lower rate, and
A. DDD          the PAV/SAV is longer than the P-R interval.

             B. VVI – Yes, the ventricular rate is faster than the lower rate, thus
B. VVI          inhibiting the IPG.

C. AAI       C. AAI – Yes, the atrial rate is faster than the lower rate, thus inhibiting
                the IPG.
D. DOO
             D. DOO – No, DOO results in fixed rate pacing.       No sensing is possible,
                no inhibition is possible.

                                                                                            24
Status Check
Which pacemaker modes could be operating on this strip?
   •     Assume normal pacemaker operation               Click for Answer




              A. DDD – Yes, this is very likely the DDD mode.
A. DDD        B. VVI – Yes, it could be, but the consistent A-V relationship should
                 make us suspicious.
B. VVI
              C. AAI – No, not possible. Cannot have ventricular pacing in the
C. AAI           AAI mode.
              D. DOO – No, DOO results in fixed rate pacing. No sensing is
D. DOO           possible, no inhibition is possible. We would see atrial and
                 ventricular pacing if this was DOO.
                                                                                  25
Status Check
 Which pacemaker modes could be operating on this strip?
    •    Assume normal pacemaker operation                       Click for Answer




           A. DDD – Yes, this is very likely the DDD mode.        This is sometimes called
              “tracking,” as the ventricle is tracking the atrium.

A. DDD     B. DDI – Not possible.  The consistent AV intervals suggest the P-wave is
              triggering an SAV. DDI inhibits only, triggering not possible.
B. DDI     C. VOO – Not likely because of the consistent AV intervals.   Unable to
              diagnose until we see the IPG response to an intrinsic ventricular event
C. VOO        (evidence of sensing).

D. DOO     D. DOO – No, DOO results in fixed rate pacing.      No sensing is possible,
              no inhibition is possible. We would see atrial and ventricular pacing if this
              was DOO.

                                                                                              26
Brief Statements
Indications
•   Implantable Pulse Generators (IPGs) are indicated for rate adaptive pacing in patients who ay benefit from increased
    pacing rates concurrent with increases in activity and increases in activity and/or minute ventilation. Pacemakers are
    also indicated for dual chamber and atrial tracking modes in patients who may benefit from maintenance of AV
    synchrony. Dual chamber modes are specifically indicated for treatment of conduction disorders that require restoration
    of both rate and AV synchrony, which include various degrees of AV block to maintain the atrial contribution to cardiac
    output and VVI intolerance (e.g. pacemaker syndrome) in the presence of persistent sinus rhythm.
•   Implantable cardioverter defibrillators (ICDs) are indicated for ventricular antitachycardia pacing and ventricular
    defibrillation for automated treatment of life-threatening ventricular arrhythmias.
•   Cardiac Resynchronization Therapy (CRT) ICDs are indicated for ventricular antitachycardia pacing and ventricular
    defibrillation for automated treatment of life-threatening ventricular arrhythmias and for the reduction of the symptoms of
    moderate to severe heart failure (NYHA Functional Class III or IV) in those patients who remain symptomatic despite
    stable, optimal medical therapy and have a left ventricular ejection fraction less than or equal to 35% and a QRS
    duration of ≥130 ms.
•   CRT IPGs are indicated for the reduction of the symptoms of moderate to severe heart failure (NYHA Functional Class
    III or IV) in those patients who remain symptomatic despite stable, optimal medical therapy, and have a left ventricular
    ejection fraction less than or equal to 35% and a QRS duration of ≥130 ms.
Contraindications
•   IPGs and CRT IPGs are contraindicated for dual chamber atrial pacing in patients with chronic refractory atrial
    tachyarrhythmias; asynchronous pacing in the presence (or likelihood) of competitive paced and intrinsic rhythms;
    unipolar pacing for patients with an implanted cardioverter defibrillator because it may cause unwanted delivery or
    inhibition of ICD therapy; and certain IPGs are contraindicated for use with epicardial leads and with abdominal
    implantation.
•   ICDs and CRT ICDs are contraindicated in patients whose ventricular tachyarrhythmias may have transient or
    reversible causes, patients with incessant VT or VF, and for patients who have a unipolar pacemaker. ICDs are also
    contraindicated for patients whose primary disorder is bradyarrhythmia.




                                                                                                                                  27
Brief Statements (continued)
Warnings/Precautions
• Changes in a patient’s disease and/or medications may alter the efficacy of the device’s programmed
  parameters. Patients should avoid sources of magnetic and electromagnetic radiation to avoid
  possible underdetection, inappropriate sensing and/or therapy delivery, tissue damage, induction of an
  arrhythmia, device electrical reset or device damage. Do not place transthoracic defibrillation paddles
  directly over the device. Additionally, for CRT ICDs and CRT IPGs, certain programming and device
  operations may not provide cardiac resynchronization. Also for CRT IPGs, Elective Replacement
  Indicator (ERI) results in the device switching to VVI pacing at 65 ppm. In this mode, patients may
  experience loss of cardiac resynchronization therapy and / or loss of AV synchrony. For this reason,
  the device should be replaced prior to ERI being set.
Potential complications
• Potential complications include, but are not limited to, rejection phenomena, erosion through the skin,
  muscle or nerve stimulation, oversensing, failure to detect and/or terminate arrhythmia episodes, and
  surgical complications such as hematoma, infection, inflammation, and thrombosis. An additional
  complication for ICDs and CRT ICDs is the acceleration of ventricular tachycardia.
• See the device manual for detailed information regarding the implant procedure, indications,
  contraindications, warnings, precautions, and potential complications/adverse events. For further
  information, please call Medtronic at 1-800-328-2518 and/or consult Medtronic’s website at
  www.medtronic.com.
Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.




                                                                                                            28
Brief Statement: Medtronic Leads
Indications
• Medtronic leads are used as part of a cardiac rhythm disease management system. Leads are
  intended for pacing and sensing and/or defibrillation. Defibrillation leads have application for patients
  for whom implantable cardioverter defibrillation is indicated
Contraindications
• Medtronic leads are contraindicated for the following:
• ventricular use in patients with tricuspid valvular disease or a tricuspid mechanical heart valve.
• patients for whom a single dose of 1.0 mg of dexamethasone sodium phosphate or dexamethasone
  acetate may be contraindicated. (includes all leads which contain these steroids)
• Epicardial leads should not be used on patients with a heavily infracted or fibrotic myocardium.
• The SelectSecure Model 3830 Lead is also contraindicated for the following:
• patients for whom a single dose of 40.µg of beclomethasone dipropionate may be contraindicated.
• patients with obstructed or inadequate vasculature for intravenous catheterization.




                                                                                                              29
Brief Statement: Medtronic Leads (continued)
Warnings/Precautions
• People with metal implants such as pacemakers, implantable cardioverter defibrillators (ICDs), and
  accompanying leads should not receive diathermy treatment. The interaction between the implant and
  diathermy can cause tissue damage, fibrillation, or damage to the device components, which could
  result in serious injury, loss of therapy, or the need to reprogram or replace the device.
• For the SelectSecure Model 3830 lead, total patient exposure to beclomethasone 17,21-dipropionate
  should be considered when implanting multiple leads. No drug interactions with inhaled
  beclomethasone 17,21-dipropionate have been described. Drug interactions of beclomethasone
  17,21-dipropionate with the Model 3830 lead have not been studied.
Potential Complications
• Potential complications include, but are not limited to, valve damage, fibrillation and other arrhythmias,
  thrombosis, thrombotic and air embolism, cardiac perforation, heart wall rupture, cardiac tamponade,
  muscle or nerve stimulation, pericardial rub, infection, myocardial irritability, and pneumothorax.
  Other potential complications related to the lead may include lead dislodgement, lead conductor
  fracture, insulation failure, threshold elevation or exit block.
• See specific device manual for detailed information regarding the implant procedure, indications,
  contraindications, warnings, precautions, and potential complications/adverse events. For further
  information, please call Medtronic at 1-800-328-2518 and/or consult Medtronic’s website at
  www.medtronic.com.
Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.




                                                                                                               30
Disclosure

                               NOTE:
   This presentation is provided for general educational purposes
    only and should not be considered the exclusive source for this
         type of information. At all times, it is the professional
       responsibility of the practitioner to exercise independent
               clinical judgment in a particular situation.




                                                                      31

				
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