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![Page 1: New Findings in the Management of AF in Pacemaker Patients Results from the MINERVA Trial a Medtronic sponsored trial February 2014.](https://reader035.fdocuments.us/reader035/viewer/2022062315/5697bfeb1a28abf838cb80ed/html5/thumbnails/1.jpg)
New Findings in the Management of AF in Pacemaker Patients
Results from the MINERVA Triala Medtronic sponsored trial
February 2014
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Steven Zweibel, MD, FACC, FHRS, CCDS
Director of Electrophysiology
Hartford Hospital
Hartford, CT
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2013 Late-Breaking Clinical
Trial Abstracts
Circulation. 2013;128:2704-2722
World Wide Web at:
http://circ.ahajournals.org/content/128/24/2704
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Study Aim and DesignAim: to evaluate whether DDDRP + MVP or MVP reduces mortality, morbidity, or progression to permanent AF compared with standard dual chamber pacing.
Multicenter (63 centers), international, randomized, single blind study with 3 arms enrolling 1,166 patients with:
• Class I or class II indications for dual chamber pacing
• Previous atrial tachyarrhythmias
• No history of permanent AF or third degree AV block
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Primary Objective
Compare the Control DDDR to DDDRP + MVP arms at 2 years using thecomposite clinical endpoint of:
• All-cause death
• CV hospitalizations
• Permanent AF
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Patient Baseline Characteristics
* p < 0.05 DDDRP + MVP vs. the other two groups
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Primary Outcome(All-Cause Death, CV Hospitalizations, or Permanent AF)Intention-to-treat survival analysis using time to first event
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All-Cause DeathIntention-to-treat survival analysis using time to first event
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CV HospitalizationsIntention-to-treat survival analysis using time to first event
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Permanent AFIntention-to-treat survival analysis using time to first event
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Permanent AFIntention-to-treat survival analysis using time to first event
• Cardioversion for atrial arrhythmias occurred less frequently in the DDDRP + MVP vs. Control DDDR (49% relative reduction, p = 0.001)
• AF-related hospitalizations and ER visits occurred less
frequently in the DDDRP + MVP vs. Control DDDR (52% relative reduction, p < 0.0001)
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Incidence of AFIntention-to-treat survival analysis using time to first event
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Potential Contribution of Reactive ATPRisk of AF > 7 days and aATP efficacy
Note:since ATP treated only episodes longer than 2 minutes, to compare the different groups in a correct and balanced way, this analysis considered only patients with at least 2 minutes of AF
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Not conclusive results …Select Studies on Atrial Therapies
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Evolution of Atrial ATPFirst Generation
Treated atrial arrhythmias as if they were ventricular arrhythmias All therapies exhausted within 10 minutes
• AT/AF detected
8 hours
• Rhythm changed
• No ATP available to potentially terminate
100 ms 350 ms
220 ms 320 ms
• All therapies delivered in 10 minutes
• ATP unsuccessful
Atrial Therapy Zone
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Evolution of Atrial ATPSecond Generation
Reactive ATP
• AT/AF detected
8 hours
• Rhythm changed
• ATP Therapy available for possible termination
100 ms 350 ms
220 ms 320 ms
• All therapies delivered
• ATP Unsuccessful
150 ms 200 ms 250 ms 300 ms
Atrial Therapy Zone
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Example of Legacy ATP
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Successful Ramp Following the Rhythm Transition (11 hour episode)
Ramp ATP delivered
Successful termination
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Example of Reactive ATP in a MINERVA Patient
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Discussion Recap
• The MINERVA study demonstrates the potential ability of atrial pacing interventions and reactive ATP to slow the progression to permanent AF
• Reactive ATP was a key therapy component affecting the reduction in time to permanent AF
• Reactive ATP opportunistically treats episodes of AF when they spontaneously organize or slow down
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Potential Practice Implications
• No reduction in mortality at 2 years
• No change in CV hospitalizations at 2 years
• 52% relative reduction in atrial cardioversion, 49% relative reduction in AF hospitalization and ER visits
• AFIB begets AFIB and NSR begets NSR
– Providing an extended opportunity for AF ablation
• Reasonable to consider Reactive ATP in any patient receiving a PM with history of AF or at risk
• Reasonable to consider Reactive ATP in ICD and/or CRT patients; however, they have not been studied
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Thank You
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Brief Statement
www.medtronic.com
World HeadquartersMedtronic, Inc.710 Medtronic ParkwayMinneapolis, MN 55432-5604USATel: (763) 514-4000Fax: (763) 514-4879
Medtronic USA, Inc.Toll-free: 1 (800) 328-2518(24-hour technical support for physicians and medical professionals)
UC201405311 ENFebruary 2014
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Back Up
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Intervention algorithms
• Atrial rate stabilization (ARS)
• Atrial pacing preference (APP)
• Post mode switch overdrive pacing (PMOP)
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Atrial Rate Stabilization (ARS)• Intrinsic premature beats not followed by a long
pause (“short-long”)
• Each atrial interval is measured. The next pacing escape is this interval + a percentage (12.5, 25 or 50%)
• The fastest pace allowed is set by the Minimum Interval (shared by APP)
• Marker Channel paces are marked “PP” if generated by ARS
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ARS - Atrial Rate Stabilization
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Atrial Pacing Preference (APP)
• Designed to maintain a high percentage of atrial pacing
• On every non-refractory atrial sense, pacing escape interval is shortened. Amount of decrease is programmable, nominally 50ms
• After consecutive atrial paces (nominally 10), the escape interval is lengthened by 20 ms
• APP cannot go faster than the Minimum Interval.• Marker Channel paces are marked “PP” if
generated by APP
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APP - Atrial Pacing Preference
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Post Mode Switch Overdrive
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paced beats
Atrial tachyarrhythmia
pacing rate(DDDR)
time
Atrial rate
Sinus RhythmOverdrive Rate
(DDIR)pacing rate (not slower than 70)
(DDIR)
Overdrive Period
Confirm sinus (about 15 beats)