ECG Analysis of AF Suppression™ Scenarios

I. Intermittent PACs

Initially, the ECG demonstrates dual-chamber pacing at a rate of 60 ppm. Since AF

Suppression™ is programmed “ON” we can assume that the patient’s intrinsic atrial rate
is less than the paced rate of 60 ppm. The device then senses a P-wave and begins a 16-
cycle window, looking for further P-waves. This window expires with no further P-wave
activity, so the device does not begin overdrive pacing. After the end of this 16-cycle
window, a second P-wave is seen. This starts a second 16-cycle window. Once more, the
window expires with no further P-waves seen, so the device simply continues to AV pace
at a rate of 60 ppm.
II. Two PACs

Initially, the ECG demonstrates dual-chamber pacing at a rate of 60 ppm. Since AF

Suppression™ is programmed “ON”, we can assume that the patient’s intrinsic atrial rate
is less than the paced rate of 60 ppm. The device then senses two P-waves in a 16-cycle
window. Upon sensing the second P-wave within this window, the device responds by
overdriving the rate from 60 ppm to 70 ppm. (AF Suppression™ will increase the rate on
a sliding scale, from 10 ppm for paced rates below 60, to 5 ppm for paced rates above
150.) During the 15 overdrive cycles there are no further intrinsic P-waves. The
algorithm then starts rate recovery (12 ms are added to each cycle for rates less than 100
ppm, 8 ms if the rate is greater than or equal to 100 ppm). The rate recovers slowly until
it reaches the base rate of 60 ppm where it continues to AV pace, successfully
overdriving the atrium.
III. Frequent PACs

Initially, the ECG demonstrates dual-chamber pacing at a rate of 60 ppm. Since AF

Suppression™ is programmed “On” we can assume that the patient’s intrinsic atrial rate
is less than the paced rate of 60 ppm. The device then senses two P-waves in 16 cycles,
so the device responds by overdriving the rate from 60 ppm to 70 ppm. (AF
Suppression™ will increase the rate on a sliding scale, from 10 ppm for paced rates
below 60, to 5 ppm for rates above 150.) While in overdrive, the device senses five
consecutive P-waves at a rate of 90 bpm. The device responds by overdriving the rate in
a stepwise manner. Here is how it works:

A. P-#1 and P-#2 are two P-waves sensed in a 16-cycle window. The device
immediately starts overdrive with the second P-wave, increasing the rate from 70
ppm to 80 ppm, resets the “P” counter to zero, ends the window and begins
looking for P-waves.

B. P-#3 starts another 16-cycle window, and P-#4 is the second P-wave sensed
in the window. This causes a further increase in the overdrive rate (from 80 ppm
to 87 ppm), again resetting the “P” counter to zero and ending the window.
 C. P-#5 is another intrinsic P, which starts another 16-cycle window. Later in
this window, the device senses an additional P-wave resulting in another increase
in the overdrive pacing rate (from 87 ppm to 95 ppm).

Next, the ECG demonstrates a run of four P-waves during overdrive. As before, the
device will have to increase the rate twice to achieve pacing. The details are:

A. P-#1 and P-#2 overdrive from 95 ppm to 103 ppm

B. P-#3 and P-#4 overdrive from 103 ppm to 110 ppm.

We are now continually overdriving the patient’s intrinsic atrial activity. The device
completes its overdrive cycles and enters the rate recovery phase, extending the interval
with each beat while continuing to search for the patient’s intrinsic activity. (During rate
recovery, 12 ms are added to each cycle for rates less than 100 ppm; 8 ms are added if the
rate is greater than or equal to 100 ppm.) Since no further intrinsic atrial activity is seen,
the device completes rate recovery and then continues to AV pace at 60 ppm.
IV. Episodes of AF with Mode Switch

Initially, the ECG demonstrates dual-chamber pacing at a rate of 60 ppm. Since AF

Suppression™ is programmed “On” we can assume that the patient’s intrinsic atrial rate
is less than the paced rate of 60 ppm. The patient spontaneously enters a very rapid atrial
arrhythmia (designated by “F” for atrial fibrillation). In response to this accelerated atrial
rate, the AF Suppression™ algorithm increases the rate after every two sensed P-waves.
(AF Suppression will increase the rate on a sliding scale, from 10 ppm for paced rates
below 60, to 5 ppm for paced rates above 150.) Since the intrinsic atrial rate increased
so quickly, the paced atrial rate (driven by the algorithm and increasing in a step-wise
fashion) doesn’t catch up until the eighth interval into the arrhythmia. When the filtered
atrial rate interval (FARI) exceeds the programmed atrial tachycardia detection rate
(ATDR) the device mode switches. During this mode switch the mode changes to DDI/R
and the ventricular rate (80 ppm) reflects the programmed Auto Mode Switch (AMS)
base rate. Once the device mode switches, the AF Suppression™ algorithm is

suspended and becomes inactive. When the patient’s atrial arrhythmia spontaneously
converts back to sinus rhythm, the device still remains mode switched (DDI/R mode)
until FARI has decreased to either the maximum tracking rate (MTR) or the sensor
indicated rate, whichever is higher. The device then exits mode switch (V-V interval
923 ms) and returns to DDD/R pacing. Upon return to DDD/R, the AF suppression™
algorithm re-engages, and senses two consecutive P-waves, causing the device to
overdrive. After 15 overdrive cycles, as there are no more P-waves sensed, the device
enters the rate recovery phase. (During rate recovery, 12 ms are added to each cycle for
rates less than 100 ppm; 8 ms if the rate is greater than or equal to100 ppm). Therefore,
each interval is extended (or increased) by 12 ms, searching for the patient’s intrinsic
activity. As there is no visible intrinsic P-wave activity, the rate decreases to the base rate
of 60 ppm while still successfully overdriving the atrium.