Special Timing Functions PMT PVC Crosstalk Auto Ventricular Blanking
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Transcript of Special Timing Functions PMT PVC Crosstalk Auto Ventricular Blanking
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Special Timing Functions
• PMT
• PVC
• Crosstalk
• Auto Ventricular Blanking
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Pacemaker - Mediated Tachycardia• Initiation• Prevention• Detection• Therapy
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PMT – Endless Loop Tachycardia
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PMT – Endless Loop Tachycardia
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PMT – Endless Loop Tachycardia
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PMT - Conditions to be fulfilled
• Initiator
•Retrograde (VA) conduction
•VDD or DDD Pacemaker
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PMT – Cycle Length
PMT cycle time=
VA conduction time +
programmed AV delay
(or Maximum Tracking Rate interval)
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PMT – Endless Loop Tachycardia
• Initiation• PVC• Atrial undersensing• Atrial oversensing• Atrial noncapture• Long AV delay
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PMT – Initiation by PVC
PVCSurface ECG
Esophageal ECG
Retrograde P-waves
ASAP
VSVP
AP
VP
AS AS AS AS AS AS
VP VP VP VP VP VP VP
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PMT – Initiation by PVC
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PMT – Initiation
Atrial noncapture
causes ventricular stimulation
without the AV node being blocked
by anterograde event
Atrial oversense
Inhibits atrial output: causes ventricular stimulation without the AV node being
blocked by anterograde event
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PMT – Initiation by loss of atrial capture
Surface ECG
Retrograde P-waves
Esophageal ECG
AP
VP
AP
VP
AS AS AS AS AS AS
VP VP VP VP VP VP
AP
VP
AP
VP
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PMT – Initiation
Atrial undersense
Results in a long AV interval, allowing the AV node time to recover and conduct
retrograde
Long AVI
Allows the AV node time to recover
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PMT – Initiation by loss of atrial sensing
Surface ECG
Esophageal ECG
Retrograde P-waves
AP AS AS AS AS AS AS
VP VP VP VP VP VP VP
AS
VP
AS
VP
AS
VP
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PMT – Endless Loop Tachycardia
•Prevention (not SJM specific)
• PVARP• PVARP extension after PVC• Differential atrial sensing; anterograde /
retrograde p-wave morphology comparison• Rate adaptive PVARP• High max tracking rate – retrograde fatigue
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PMT – Endless Loop Tachycardia
•Detection• P tracking at upper rate limit• P tracking at intermediate rate• AV interval modulation• Discrepancy between sensed atrial rate and
sensor indicated rate
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PMT Options SJM
•Off (nominal for Identity and Integrity)
•10 Beats > PMT
•Auto detect (nominal for Zephyr and Victory)
• No PMT options during AMS or Magnet Application
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PMT Options SJM - 10 Beats > PMT
Detection•10 consecutive AS-VP events at a rate > PMT Detection Rate
•PMT Detection Rate: 90 – 150 bpm, nominal 110
Response•Reset of PVARP to 480 ms for a single cycle
After PVARP extension•PMT detection is suspended for 256 cycles
•the atrial alert period is 330 ms
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10 Beats > PMT
PVARP: 480ms
Atrial Alert Period 330ms
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PMT Options SJM – Auto Detect
Detection• Rapid stable VP – AS interval
› Rapid: atrial rate > PMT Detection Rate› Stable: compares average of 8 VP – AS intervals to average
of all cycles. If all VP - AS intervals are with 16 ms of average stable
• On the 9th cycle the AS – VP delay is› Shortened 50 ms if AS – VP 100 ms› Lengthened 50 ms if AS – VP < 100 ms› If VP – AS cycle is within 16 ms of average VP – AS cycle
PMT. Else Sinus Tachycardia
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PMT Options SJM – Auto Detect
(VP-AS)1 (VP-AS)2
therefore:
sinus tachycardia
(VP-AS)2(VP-AS)1
(VP-AS)1 (VP-AS)2
(VP-AS)1 = (VP-AS)2
therefore:
PMT
AS - VP AS - VP(AS-VP) -
AS - VP AS - VP(AS-VP) -
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PMT Options SJM – Auto Detect
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PMT – Endless Loop Tachycardia
•Termination• PVARP extension• Withhold of ventricular output• Withhold of ventricular output with early atrial
pace
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PMT Options SJM – Auto Detect and Response
Response• After 9th interval no ventricular response
• Atrial pulse 330 ms after retrograde P-wave
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PMT Option Auto Detect
AVI: +50ms
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Special Timing Functions
• PMT
• PVC
• Crosstalk
• Auto Ventricular Blanking
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PVC Options
• To distinguish between a premature ventricular
contraction (PVC) and a conducted R-wave in
DDD(R) or VDD(R) mode
• A response to a PVC to prevent the evolution into a
PMT
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PVC Detection
A PVC is confirmed if
• An R-wave is not preceded by an atrial event
Or
• A P-wave is detected in the relative portion of the
PVARP but is not followed by an R-wave within 280ms
of the atrial event
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PVC Options: + PVARP on PVC
After PVC Detection• PVARP extension to 480 ms
• Followed by atrial alert period of 330 ms
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PVC Options: Atrial Pace on PVC
After PVC Detection• PVARP extension to 480 ms• If retrograde P-wave is detected PVARP is terminated• No ventricular output• Atrial Escape Interval 330 ms
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Atrial Pace on PVC
Extension of PVARP to 480
Atrial Alert Period of 330ms
330ms
DDD 60
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Special Timing Functions
• PMT
• PVC
• Crosstalk
• Auto Ventricular Blanking
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What’s up Doc?
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Crosstalk
• Sensing of an atrial output in the ventricular channel resulting in
inhibition of the ventricular pulse
• Clinical manifestation: atrial pacing with no ventricular output.
Can be overcome with Ventricular Safety Standby
• Crosstalk can occurs with
• High atrial pulse amplitude
• High ventricular sensitivity
• Short ventricular blanking
• Rapid pacing rates
• Unipolar pacing and sensing
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Crosstalk
Decrease atrial output?
Decrease ventricular sensitivity?
Prolong ventricular blanking?
Enable Ventricular Safety Standby!
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Ventricular Safety StandbyB
lan
kin
g
Per
iod
Cro
ssta
lk
Det
ecti
on
W
ind
ow
64ms
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Ventricular Safety Standby
Crosstalk
Ventricular Safety Pacing
after 120 ms
V EGM
sensitivity
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Ventricular Safety Standby
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Is Ventricular Safety Standby Pacing Present In This Panel?
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Ventricular Safety Standby
Sensing in
Crosstalk Detection Window
Ventricular Safety Pacing
after 120 ms
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Ventricular Safety Standby
Blanking Period - No sensing
Ventricular Pacing after
programmed AV Interval
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Blanking period undersensing can be dangerous at long AV intervals
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Crosstalk – Ventricular Safety Standby
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Special Timing Functions
• PMT
• PVC
• Crosstalk
• Auto Ventricular Blanking
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Auto Ventricular Blanking
Maximizes the ventricular alert window.
Minimizes inappropriate inhibition due to crosstalk.
• When crosstalk is present, ventricular blanking period automatically lengthens
• In the absence of crosstalk, ventricular blanking period remains short
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Auto Ventricular Blanking - Zephyr
Auto Ventricular Blanking - Programmability
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Auto Ventricular Blanking - Zephyr
Programmable values
Shipped setting is Auto
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Auto Ventricular Blanking - Zephyr
• AP - a 12 ms absolute blanking window begins.
• If ventricular activity (crosstalk) is sensed, a retriggerable 12 ms relative refractory window begins and can retrigger to a maximum of 52 ms.
• If no ventricular activity is sensed the ventricular channel enters an alert period.
time
AP
12 ms
Absolute v. Blanking
52 ms
Maximum ventricular blanking interval
64 ms
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Auto Ventricular Blanking - Zephyr
• Crosstalk ends before 52 ms.• No need for crosstalk detection window.• Ventricular channel enters an alert period.
R R
time
AP
Ventricular Crosstalk
No Crosstalk Detection Window
170 ms VP
40 ms
64 ms
Alert12 ms
52 ms
No Sensed Ventricular Event
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Auto Ventricular Blanking - Zephyr
• Crosstalk reaches the maximum of 52 ms
• Ventricular Safety Standby will initiate a crosstalk detection
window from 52 ms - 64 ms
• Normal Ventricular Safety Standby behavior will apply
Ventricular Crosstalk
time
AP
Crosstalk Detection Window
VP120 ms VSS
12 ms 40 ms Alert12 ms
64 ms
R R R R
52 ms
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Auto Ventricular Blanking - Zephyr
• If there is sensing of constant ventricular events and the maximum
of 52 ms is reached
• VSS will initiate a crosstalk detection window from 52 ms - 64 ms
• Normal Ventricular Safety Standby behavior will apply
Ventricular Crosstalk
time
APCrosstalk
Detection Window
VP120 ms VSS
12 ms 40 ms Alert12 ms
64 ms52 ms
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Ventricular Blanking
Programming EGM trigger
High Ventricular Rate V Blanking to 12ms
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Auto Ventricular Blanking
Auto Ventricular Blanking OFF
•Ventricular Blanking will auto program to 40 ms with the following:
• Atrial output 6 Volts and higher
• Atrial pulse width 1.0 ms or longer
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