Cardiac Rhythm

Device
Management

‘PBL STOP’ – Your acronym for a standardized follow-up

 What’s in it for you?
• What do you need to feel comfortable
with a pacemaker/ICD follow-up?

UC200702005 EN
Medtronic, Inc. USA
2 September 2006
 CORE OBJECTIVE

• Provide a technique for you to complete a

successful device follow-up

UC200702005 EN
Medtronic, Inc. USA
3 September 2006
 “PBL STOP”
P Presenting Rhythm and Rate
B Battery Status
L Lead Status

S Sensing
T Threshold
O Observation, Data, and Events
P Program & Print UC200702005 EN
Medtronic, Inc. USA
4 September 2006
 “P”
Presenting Rhythm and Rate

UC200702005 EN
Medtronic, Inc. USA
5 September 2006
 Rhythm Recognition

Atrial Fibrillation: No Pacing VVI / 60

Atrial Flutter: No Pacing DDDR / 60

UC200702005 EN
Medtronic, Inc. USA
6 September 2006
 Paced Rhythm Recognition

Single Chamber Device: Ventricular Pacing

Single Chamber Device: Atrial Pacing (AAI)

UC200702005 EN
Medtronic, Inc. USA
7 September 2006
 Paced Rhythm Recognition

Sensing in the Atrium & Sensing in the Ventricle (AS-VS)

Pacing in the Atrium & Sensing in the Ventricle (AP-VS)

UC200702005 EN
Medtronic, Inc. USA
8 September 2006
 Paced Rhythm Recognition

Sensing in the Atrium & Pacing in the Ventricle (AS-VP)

Pacing in the Atrium & Ventricle (AP-VP)

UC200702005 EN
Medtronic, Inc. USA
9 September 2006
 Troubleshooting

VVI / 60

Loss of Capture

UC200702005 EN
Medtronic, Inc. USA
10 September 2006
 Troubleshooting

Loss of Atrial Sensing

UC200702005 EN
Medtronic, Inc. USA
11 September 2006
 “B”
Battery Status
(Volts and Longevity)

UC200702005 EN
Medtronic, Inc. USA
12 September 2006
 Assessing Battery Status

UC200702005 EN
Medtronic, Inc. USA
13 September 2006
 Assessing Battery Status

UC200702005 EN
Medtronic, Inc. USA
14 September 2006
 “L”

Lead Impedance (ohms)

UC200702005 EN
Medtronic, Inc. USA
15 September 2006
 Lead Impedance Trends

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Medtronic, Inc. USA
16 September 2006
 Assessing Lead Status

UC200702005 EN
Medtronic, Inc. USA
17 September 2006
 “S”

Sensing (millivolts mV)

The ability of the pacemaker to see

Intrinsic Heart Beats

UC200702005 EN
Medtronic, Inc. USA
18 September 2006
 Normal Sensing Values

• Acute Phase (within 3 months of

implant)
– P-waves = > 1.5mV
– R-waves = > 6mV
• Chronic Phase (>3 months post-implant)
– P-waves = > 1.0mV
– R-waves = > 5mV

UC200702005 EN
Medtronic, Inc. USA
19 September 2006
 Sensitivity: Not Sensitive Enough
As You Lower The Number,
You Make The Pacemaker More Sensitive

5 mV
Amplitude (mV)

5.0 2 mV

2.5

1mV
1.25

Time UC200702005 EN
Medtronic, Inc. USA
20 September 2006
 Sensitivity: Too Sensitive

5 mV

2 mV

1mV
Amplitude (mV)

5.0

2.5

1.25

UC200702005 EN
Time Medtronic, Inc. USA
21 September 2006
 Sensitivity: Just Right

5 mV

2 mV

1mV
Amplitude (mV)

5.0

2.5 Why is sensing so

1.25 important?

UC200702005 EN
Time Medtronic, Inc. USA
22 September 2006
 Oversensing vs. Undersensing

Scheduled pace
Intrinsic beat delivered
not sensed

Marker Channel™ ...though no

shows intrinsic activity is present
activity...

UC200702005 EN
Medtronic, Inc. USA
23 September 2006
 “T”

Threshold

The least amount of energy it takes

to “capture” the heart

UC200702005 EN
Medtronic, Inc. USA
24 September 2006
 During Pacing, the Impulse:

Travels via the myocardium,

not the native cardiac
conduction system,
therefore, the QRS is wide

Normal QRS Paced QRS

UC200702005 EN
Medtronic, Inc. USA
25 September 2006
 Capture

UC200702005 EN
Medtronic, Inc. USA
26 September 2006
 2 Settings Used to Ensure Capture

GOAL  Find the minimum amount of energy needed to

consistently capture the heart (stimulation threshold).

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

UC200702005 EN
Medtronic, Inc. USA
27 September 2006
 Amplitude Threshold Testing

Keeping pulse width stable, decrement voltage

until loss of capture

@ 0.5ms

1.5V 1.0V .5V

UC200702005 EN
Medtronic, Inc. USA
28 September 2006
 “O”
Observations, Data, and Events

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Medtronic, Inc. USA
29 September 2006
 Diagnostic Information

UC200702005 EN
Medtronic, Inc. USA
30 September 2006
 Cardiac Compass®
•Up to 14 months of data
•Annotations to mark Programming
(P), Interrogation (I) or
Remote Interrogations ( _ )
•Rhythm-control assessment with
Treated VT/VF episodes per day and
AT/AF total hours/day
•Rate-control assessment with V.
Rate during AT/AF and V. Rate
during VT/VF
•%Pacing/day to assess reduction of
unnecessary right ventricular pacing
•Three HF Status Indicator Trends
–Average V. Day/Night heart
rates
–Patient Activity
–HR variability

UC200702005 EN
Medtronic, Inc. USA
31 September 2006
 “P”
Programming &
Printing Final Reports

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Medtronic, Inc. USA
32 September 2006
 Programmed Parameters

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Medtronic, Inc. USA
33 September 2006
 Print Reports

• Print Final Reports

– Sensing test results
– Threshold test results
– Key observations
– Any changes this session noted on final
report

UC200702005 EN
Medtronic, Inc. USA
34 September 2006
 “PBL STOP”
P Presenting Rhythm and Rate
B Battery Status
L Lead Status

S Sensing
T Threshold
O Observation, Data, and Events

35
P Program & Print UC200702005 EN
Medtronic, Inc. USA
September 2006