Professional Documents
Culture Documents
Basics & Timing-Pm
Basics & Timing-Pm
DN
HISTORY
1958 Senning and Elmqvist
Asynchronous (VVI) pacemaker implanted by
thoracotomy and functioned for 3 hours
Arne Larsson
First pacemaker patient
Used 23 pulse generators and 5 electrode systems
Died 2001 at age 86 of cancer
1960 First atrial triggered pacemaker
1964 First on demand pacemaker (DVI)
1977 First atrial and ventricular demand pacing (DDD)
1981 Rate responsive pacing by QT interval, respiration,
and movement
1994 Cardiac resynchronization pacing
What is a Pacemaker?
Leads
Body tissue
Cathode
S
The Pulse Generator
Contains a battery that provides the
energy for sending electrical
impulses to the heart
Battery
Anatomy of a Pacemaker
Resistors
Atrial connector
Defibrillation protection
Output capacitors
Hybrid
Clock
Telemetry antenna
Battery
General Characteristics of Pacemaker
Batteries
Hermeticity, as defined by the pacing industry,
is an extremely low rate of helium gas leakage
from the sealed pacemaker container
9
Leads
Fixation mechanism
Active/Screw-in
Passive/Tined Insulator
Silicone
Shape Polyurethane
Straight
J-shaped used in the atrium
Lead components
Conductor
Connector Pin
Insulation
Electrode
Transvenous Leads - Fixation Mechanisms
Passive fixation
Negatively charged
Anode:-receives the
electrical impulse after
depolarization of cardiac
tissue
Returns through
body fluid and tissue -
to the PG (anode) Cathode
A Bipolar Pacing System
Stimulates the
heart
electrode above
the lead tip Cathode
Unipolar leads
One electrode on the tip & one conductor coil
Capture Non-Capture
The Strength-Duration Curve
The strength-duration
width Capture
.50
Values on or above
.25
the curve will result
0.5 1.0 1.5
in capture Duration
Pulse Width (ms)
Rheobase- (the lowest point on the curve) by definition is the
lowest voltage that results in myocardial depolarization at
infinitely long pulse duration
At high pulse durations, the voltage and current requirements may be low,
but the energy and charge values are unacceptable
-Safety margins
-When a threshold is determined by decrementing the pulse
width at a fixed voltage
At a given voltage where the pulse width value is < .30 ms:
Tripling the pulse width will provide a two-time voltage
safety margin.
V
V=IXR
I=V/R I x R
R=V/I
Impedance and Electrodes
It is this capacitance effect at the electrode tissue interface, that is the basis
of polarization
Lead Maturation Process
Fibrotic capsule develops around the electrode following lead
implantation
3 phases
1. A/c phase, where thresholds immediately following implant
are low
2. Peaking phase- thresholds rise and reach their highest
point(1wk) ,followed by a in the threshold over the next 6
to 8 wks as the tissue reaction subsides
3. C/c phase- thresholds at a level higher than that at
implantation but less than the peak threshold
3
Volts
1
Steroid-Eluting Electrode
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Implant Time (Weeks)
Pulse Width = 0.5 msec
Sensing
Sensing is the ability of the pacemaker to
detect an intrinsic depolarization
Intrinsic deflection on
an EGM occurs when
a depolarization wave
passes directly under
the electrodes
Two characteristics of
the EGM are:
Signal amplitude(mv)
Slew rate(v/sec)
Intrinsic R wave Amplitude
The Intrinsic R wave amplitude is usually much greater than the T wave amplitude
Slew Rate of the EGM Signal Measures the Change in
Voltage with Respect to the Change in Time
Voltage
greater sensing Slope
Scheduled pace
Intrinsic beat delivered
not sensed
VVI / 60
Oversensing
...though no
Marker channel activity is present
shows intrinsic
activity...
VVI / 60
VP VP
VVI / 60
Refractory Period
Interval initiated by a paced or sensed event
Designed to prevent inhibition by cardiac or non-cardiac
events
Events sensed in the refractory period do not affect the
Lower Rate Interval but start their own Refractory Periods
VP VP
VVI / 60
Refractory Period
Blanking Period
The first portion of the refractory period
Pacemaker is blind to any activity
Designed to prevent oversensing of pacing
stimulus/depolarisation
VP VP
VVI / 60
Blanking Period
Refractory Period
Physiologic Classification of Sensors- rate adaptive
Primary
Physiologic factors that modulate sinus function
Catecholamine level, Autonomic nervous system activity
Secondary
Physiologic parameters that are the consequence of
exercise
QT, respiratory rate
Minute ventilation,temperature
pH, stroke volume, Preejection interval, SVO2
Peak endocardial acceleration
Tertiary
External changes that result from exercise
Vibration
Acceleration
Upper Sensor Rate Interval
Defines the shortest interval (highest rate) the
pacemaker can pace as dictated by the sensor (AAIR,
VVIR modes)
Limit at which sensor-driven pacing can occur
VP VP
VVIR / 60 / 120
Blanking Period
Refractory Period
Hysteresis
Allows the rate to fall below the programmed
lower rate following an intrinsic beat
lower rate limit is initiated by a paced event, while
the hysteresis rate is initiated by a non-refractory
sensed event.
VP VP VS VP
Noise Reversion
Continuous refractory sensing will cause pacing at the
lower rate
Noise Sensed
SR SR SR SR
VP VP
VVI/60
Modes-SINGLE CHAMBER
AOO & VOO-asynchronous modes
By application of magnet
VP VP
Blanking Period
VOO / 60
VOO TIMING
VP VP VP VP VP
VVI Mode
Pacing inhibited with intrinsic activity
VP VS VP
Blanking/Refractory
VVI / 60
VVI TIMING
VS
VP VP VP VP
VVIR
Pacing at the sensor-indicated rate
Lower Rate
VP VP
Refractory/Blanking
VVIR / 60/120
Rate Responsive Pacing at the Upper Sensor Rate
AAI
Useful for SSS with N- AV conduction
Should be capable of 1:1 AV to rates 120-140 b/m
Atrial tachyarrhythmias should not be present
Atria should not be silent
If no A activity, atria paced at LOWER RATE limit (LR)
If A activity occurs before LR,- resetting
Caution- far-field sensing of V activity
AAIR
Atrial-based pacing allows the normal A-V activation
sequence to occur
AP AP
Refractory/Blanking
AAIR / 60 / 120
(No Activity)
Single-Chamber Triggered-Mode
AP AP
VP VP
DDD 60 / 120
AV Delay
PAV SAV
200 ms 170 ms
AP AS
VP VP
DDD 60 / 120
Paced AV Delay Sensed AV Delay
The time period between The time period between
the paced atrial event and the sensed atrial event and
the next paced ventricular the next paced ventricular
event event
The pacemaker has to sense
The pacemaker spike the atrial event before the
initiates the paced AV delay timing cycle is initiated
timing cycle there is usually a slight time
Programmable value lag
Program the sensed AV
delay to a value slightly
shorter than the paced AV
delay (~ 25 ms)
Atrial Escape Interval (V-A Interval)
The V-A interval is the longest period that may elapse after a ventricular event before the
atrium must be paced in the absence of atrial activity.
The V-A interval is also commonly referred to as the atrial escape interval
Atrial Escape Interval (V-A Interval)
AV Interval VA Interval
AP AP
VP VP
DDD 60 / 120
PAV 200 ms; V-A 800 ms
Upper Activity (Sensor) Rate
In rate responsive modes, the Upper Activity Rate
provides the limit for sensor-indicated pacing
DDDR 60 / 120
A-A = 500 ms
AP AP
VP VP
Upper Tracking Rate
The maximum rate the ventricle can be paced in
response to sensed atrial events
Prevents rapid ventricular pacing rates in response to
rapid atrial rates
Lower Rate Interval {
Upper Tracking Rate Limit
SAV VA SAV VA
AS AS
VP VP
AP
A-V Interval Post Ventricular Atrial
(Atrial Refractory) Refractory Period (PVARP)
Ventricular Refractory Period VP
(VRP)
Post-Ventricular Atrial Refractory
Period
PVARP is initiated by a ventricular
event(sensed/paced), but it makes the atrial
channel refractory
PVARP is programmable (typical settings
around 250-275 ms)
Benefits of PVARP
Prevents atrial channel from responding to
premature atrial contractions, retrograde P-waves,
and far-field ventricular signals
Can be programmed to help minimize risk of
pacemaker-mediated tachycardias
PVARP and PVAB
The PVAB is the post-ventricular atrial
blanking period during which time no signals
are seen by the pacemakers atrial channel
PVAB-independently programmable
Typical value around 100 ms
PVAB and PVARP
Blanking Periods
First portion of the refractory period-sensing is disabled
AP AP
VP
Atrial Blanking Post Ventricular Atrial
(Nonprogrammable) Blanking (PVAB)
DDD VP VP
LR = 60 ppm (1000 ms)
UTR = 100 bpm (600 ms) SAV PVARP SAV PVARP
TARP
{
No SAV started for events sensed in the TARP
Wenckebach
Occurs when the intrinsic atrial rate lies
between the UTR and the TARP rate
AS AS AR AP
VP VP VP
SAV PVARP SAV PVARP PAV PVARP
TARP TARP TARP
Wenckebach Operation
AS AS
AR AR
VP VP
AV PVARP AV PVARP
Sinus rate = 133 bpm (450 ms) TARP TARP
PVARP = 300 ms SAV = 200 ms
{
TARP=500 ms
P Wave Blocked
2:1 Block
PAV Interval
DDD 60 / 120
VDD Mode
Atrial Synchronous pacing or Atrial Tracking Mode
A sensed intrinsic atrial event starts an SAV
The Lower Rate Interval is measured between Vs to Vp or Vp to Vp
If no atrial event occurs at the end of the Lower Rate Interval a Ventricular
pace occurs
Paces in the VVI mode in the absence of atrial sensing
AV block with intact sinus node function (esp useful in congenital AV
block)
VDD
Provides atrial synchronous pacing
System utilizes a single lead
AS AS
VP VP VP
VDD
LR = 60 ppm
UTR = 120 ppm
Spontaneous A activity = 700 ms (85 ppm)
DDD Mode
Chamber paced: Atrium & ventricle
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
Four Faces of Dual Chamber Pacing
Atrial Sense, Ventricular Sense (AS/VS)
AV V-A AV V-A
AS AS
VS VS
Rate (sinus driven) = 70 bpm / 857 ms
Spontaneous conduction at 150 ms
A-A = 857 ms
Four Faces of Dual Chamber Pacing
Atrial Pace, Ventricular Pace (AP/VP)
AV V-A AV V-A
AP AP
VP VP
AV V-A AV V-A
AP AP
VS VS
Rate = 60 ppm / 1000 ms
A-A = 1000 ms
Four Faces of Dual Chamber Pacing
Atrial Sense, Ventricular Pace (AS/ VP)
AV V-A AV V-A
AS AS
VP VP
Y N
Are atrial
Is AV conduction
tachyarrhythmias
intact?
present?
N Y N
Is AV conduction Are they Y VVI
intact? chronic? VVIR
Y N Is SA node function
Is SA node function presently adequate?
presently adequate?
Y N
N (SSS) N
DDD, VDD
DDDR DDDR
AAIR DDDR, DDIR
DDDR
Optimal Pacing Mode (BPEG)
Y N
Are atrial
Is AV conduction
tachyarrhythmias
intact?
present?
N Y N
Is AV conduction Are they Y VVI
intact? chronic? VVIR
Y N Is SA node function
Is SA node function presently adequate?
presently adequate?
Y N
N (SSS) N (CSS,
VVS)
DDD, VDD
DDDR DDDR
AAIR DDD, DDI
DDDR with RDR
Pacing Modes
Stuart Allen 06
Ventricular Demand VVI
AMP
Output circuit
VVI
Ventricular Demand VVIR
Sensor
AMP
Output circuit
Sensor indicated
rate Stuart Allen 06
Atrial Demand AAI
AMP
Output circuit
AAI
Stuart Allen 06
Pacing Modes - Summary
Ventricular Demand VVI Atrial Demand AAI
AMP
Output circuit
AMP
Output circuit
AMP
AMP AMP
Output circuit Output circuit
Stuart Allen 06