Interrogation and programming workshop part I - … · • Check lead integrity ... “PBL STOP ”...
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Interrogation and programming workshop part I - Pacemaker follow-up LING Hon-Lun Associate Sales Manager Cardiac Rhythm Disease Management (CRDM)
Transcript of Interrogation and programming workshop part I - … · • Check lead integrity ... “PBL STOP ”...
Interrogation and programming
workshop part I
- Pacemaker follow-up
LING Hon-Lun
Associate Sales Manager
Cardiac Rhythm Disease Management (CRDM)
Interrogation and programming
workshop part II
Hands-on session
Medtronic helpers
Aims Of Pacemaker Follow Up
• Determine battery status
• Check lead integrity
• Check Sensing Threshold
• Check Pacing Threshold
• Analyse diagnostics
• Assess current parameters
• Obtain documentation
Device interrogation
Question?
What is the most important piece attached
to an pacemaker system?
The PatientThe PatientThe PatientThe PatientThe PatientThe PatientThe PatientThe Patient
Treat the patient, not the device
Interrogation
Presenting Rhythm
& Rate
Battery Status
Lead impedance
Threshold
Sensing
Observation
Program & Print
P Presenting Rhythm and Rate
B Battery Status
L Lead Status
S Sensing
T Threshold
O Observation, Data, and Events
P Program & Print
“PBL STOP”
‘PBL STOP’ – Your acronym for
a standardized follow-up
Programming step by step
• Determine battery status
• Check lead integrity
• Check Sensing Threshold
• Check Pacing Threshold
• Analyse diagnostics
• Assess current parameters
• Obtain documentation
Device battery status
Programming step by step
• Determine battery status
• Check lead integrity
• Check Sensing Threshold
• Check Pacing Threshold
• Analyse diagnostics
• Assess current parameters
• Obtain documentation
Check lead integrity
Lead integrity – in office test
Lead integrity – in office test
Programming step by step
• Determine battery status
• Check lead integrity
• Check Sensing Threshold
• Check Pacing Threshold
• Analyse diagnostics
• Assess current parameters
• Obtain documentation
Sensing
Sensing – in office test
Programming step by step
• Determine battery status
• Check lead integrity
• Check Sensing Threshold
• Check Pacing Threshold
• Analyse diagnostics
• Assess current parameters
• Obtain documentation
Threshold
Threshold – in office test
1. Pulse amplitude – the amount of voltage
delivered to the heart by the pacemaker to ensure capture
of the heart (strength of an output pulse)
2. Pulse width – time (duration) of the pacing pulse
2 Settings Used to Ensure Capture
GOAL Find the minimum amount of energy needed to
consistently capture the heart (stimulation threshold).
Amplitude Threshold Testing
Keeping pulse width stable, decrement voltage until loss of
capture
1.5V 1.0V .5V
@ 0.5ms
Pulse Width Threshold TestingKeeping voltage stable, decrement in pulse width
.30ms .20ms .1ms
@ 2 volts
.06ms
Programming step by step
• Determine battery status
• Check lead integrity
• Check Sensing Threshold
• Check Pacing Threshold
• Analyse diagnostics
• Assess current parameters
• Obtain documentation
Analyse diagnostics (Observation)
Analyse diagnostics (Observation)
Programming step by step
• Determine battery status
• Check lead integrity
• Check Sensing Threshold
• Check Pacing Threshold
• Analyse diagnostics
• Assess current parameters
• Obtain documentation
Assess current parameters (Program)
Assess current parameters (Program)
Assess current parameters (Program)
Programming step by step
• Determine battery status
• Check lead integrity
• Check Sensing Threshold
• Check Pacing Threshold
• Analyse diagnostics
• Assess current parameters
• Obtain documentation
“P”
Programming &
Printing Final Reports
(obtain documentation)
Print final report
Printed final report – post f/u parameter
Print Reports
• Print Final Reports
– Sensing test results
– Threshold test results
– Key observations
– Any changes this session noted on final report (initial and
final)
– Documented all tested result and parameters
P Presenting Rhythm and Rate
B Battery Status
L Lead Status
S Sensing
T Threshold
O Observation, Data, and Events
P Program & Print
“PBL STOP”
PBL STOP
P
B
L
OT
P
S
Interrogation and programming
workshop part II
Hands-on session by Ray Chan
Medtronic helpers:
Poly Fu, Ray Chan, Brandon Chen, Chapman Lee, Fayzi Lee, Tina Ling, Shirley Chau, Cristina Leung
Hands-on session
• Hands-on for a pacemaker follow-up
• Divided into 5 groups each of 8-10 persons
• 5 tables of Medtronic simulators
• Two virtual patient A & B
• Each one perform both patient with printed reports
45mins
Post hands-on f/u observation~ 10mins
Patient historyPatient B
• Post implant 1 day
• Implanted with Medtronic dual chamber pacemaker
• RA & RV active fixation leads
• First degree AVB
Patient A
• Replacement done with a Medtronic dual chamber pacemaker over 1 year
• RA & RV old passive leads implanted in 2002
• Syncope, AF, long pause ~ 5 sec
Parameters during replacement
P wave: 2.0mV
R wave: 18mV
Pacing threshold:
Imp:
RA: 688Ω
RV: 1200Ω
Parameters during implant
P wave: 1.8mV
R wave: 10mV
Pacing threshold:
Imp:
RA: 632Ω
RV: 887Ω
Post follow up observation
Patient A Old leads implanted 11yrs
old
RV lead parameters Impedance: 1200 > 4xxΩΩΩΩ
R wave: 18mV > 2.0mV
Threshold ↑↑↑↑ to 5.0V
Conclusion: RV parameters change showing a suspected RV lead insulation break and degradation
Clinical concern:
1. Pacing dependency?
2. Intact AV conduction?
3. RV lead replacement need?
Patient B Post implant one day with new RA &
RV active leads
RA lead parameters Impedance: normal
P wave: ~ 3.0mV (normal? EGM?)
RA threshold: n/a but capture RV@ 5.0V
Conclusion: RA parameters, ECG & EGM signals shown a suspected RA lead dislodgement to RV chamber
Clinical concern:1. RA reposition need
2. Active fixation on alternative RA position?
3. Passive lead?
