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Noise, Reset, EGM, Magnet, Advanced Hysteresis
Noise
Göran Mathson, 2005
for internal use only
Noise
• Electromagnetic Interference (EMI) or Noise
• At least 400 cycles per minute
• Is very unlikely to be caused by myopotentials
for internal use only
Noise
• EMI in Relative Refractory Period of (RRP) initiates
a Noise Sampling Window (NSW)
• NSW is extension of the RRP
• Noise detected in the Ventricular Channel during
DDD / DDI mode operation extends A and V
refractory period
for internal use only
Noise
• If the Noise persists there will be asynchroneous
pacing at the Base Rate (or Sensor Indicated Rate if
the Sensor is On)
• Pacemaker resumes normal operation at the
programmed parameters as soon as the Noise stops
for internal use only
Noise Mode, Atrial Channel
PVARP
Programmable PVARP
Absolute RelativeA-A Interval
for internal use only
100 ms 175 ms
RelativeAbsolute
Sensed Event
NSW 150 ms
Sensed Event
NSW 150 ms
Noise sampling window (NSW)
Sensed Event
NSW 150 ms
Sensed Event Sensed
Event
for internal use only
Noise Mode, Atrial Channel
A-A Interval
Reset
Göran Mathson, 2005
for internal use only
Reset
When the device has reverted to backup VVI operation, the programmer will display a pop-up message indicating that the device is in back up VVI values.
Under most conditions the previously programmed settings can be restored, by following the on-screen instructions.
for internal use only
Reset parameters
Stored Electrograms
Göran Mathson, 2005
for internal use only
Stored Electrograms
Programmability
Triggers
for internal use only
Stored Electrograms
Stored electrograms are available in the following devices*:
• Zephyr®
• Victory®
• Identity®
• Integrity®
Stored Electrograms
Programmability
for internal use only
Programmability
The device can store a variety of intracardiac configurations for various time frames
The following screen shot demonstrates this programmability
for internal use only
Programmability
for internal use only
Programmability
Sampling Option• This parameter determines how the device treats
additional Stored EGMs after the allocated memory has been filled
• Freeze (nominal) • Once the device has stored the programmed number of
EGMs no more EGMs will be stored
• Continuous• Allows a new Stored EGM to overwrite the oldest
Stored EGM
• First in, First out
for internal use only
Programmability
Number of Stored EGMs
• Determines how many EGMs the device can store
• 1, 2, 4, 8, 12
Maximum Duration
• Calculated by the device based on programmed values
for internal use only
Programmability
Channel
• Determines what IEGMs will be recorded by the device
• Programmed Options• Atrial• Ventricular• Dual• Cross-Channel (nominal)
for internal use only
Programmability
Channel
• Atrial• When selected, this value will cause an Atrial
IEGM to be stored
• Ventricular• When selected, this value will cause a
Ventricular IEGM to be stored
for internal use only
Programmability
Channel
• Dual• Both an Atrial and Ventricular IEGM will be
stored
• Cross-Channel• Both the Atrial and Ventricular IEGM will be
stored on a single electrogram• In some patients, this may resemble a surface
ECG
for internal use only
Programmability
for internal use only
Programmability
for internal use only
Programmability
Atrial EGM Configuration
• Determines the IEGM to be recorded for the Atrial channel on the Stored EGMs
• The various configurations can be viewed on the real-time EGM
for internal use only
Programmability
Atrial Dynamic Range
• Sets the Stored EGM gain for the Atrial channel
• Programmable Options• 15.0, 7.5, 3.0, 1.5 mV (nominal 3.0 mV)
• These parameters can be previewed on the real-time electrogram
for internal use only
Programmability
Ventricular EGM Configuration
• Determines the IEGM to be recorded for the Ventricular channel on the Stored EGMs
• The various configurations can be viewed on the real-time EGM
for internal use only
Programmability
Ventricular Dynamic Range
• Programmable Options• 15.0, 7.5, 3.0, 1.5 mV (nominal 15.0 mV)
• These parameters can be previewed on the real-time electrogram
for internal use only
Programmability
If AutoCapture™ Pacing Systems is enabled then the Ventricular Configuration is fixed to Vtip-Vring
Stored EGMs
Stored Electrogram Triggers
for internal use only
Stored Electrogram Triggers
The device can be programmed to automatically store an EGM when triggered by*:
• Advanced Hysteresis• AT/AF Detection• High Atrial Rate• High Ventricular Rate• AMS Entry• AMS Exit• PVCs• PMT Termination• Patient Activated / Magnet application* Available triggers depend on the pacemaker model. See device manual.
for internal use only
Programmability
for internal use only
Stored Electrogram Triggers
Trigger Options
• Advanced Hysteresis• Triggered when Advanced Hysteresis is
activated
• AT/AF Detection• Triggered when AT/AF Detection meets
programmed criteria
• High Atrial Rate• Off, 175, 200, 225, 250, 275, 300
› No, of Consecutive Cycles- 2, 3, 4, 5, 10, 15, 20
for internal use only
Stored Electrogram TriggersTrigger Options
• High Ventricular Rate• Off, 175, 200, 225, 250, 275, 300
› No, of Consecutive Cycles- 2, 3, 4, 5, 10, 15, 20
• AMS Entry• Triggered when the device enters mode
switches
• AMS Exit• Triggered when the device exits mode
switches
for internal use only
Stored Electrogram Triggers
Trigger Options
• PVCs• No. of Consecutive PVCs
› 2, 3, 4, 5
• PMT Termination
• Patient Activated • Magnet Placement (magnet applied for at least 1 sec)
for internal use only
Stored Electrogram Triggers
Additional Considerations• Pre-trigger data is collected, approximately 50%
of the EGM• Some triggers require an associated feature to be
active• Advanced Hysteresis, AMS Entry, AMS Exit and
PMT Termination
• EGM Storage for High Atrial Rate and AMS Entry and Exit are mutually exclusive
• Can’t be programmed on together
for internal use only
Stored Electrogram Triggers
Stored EGMs are disabled:
• When Telemetry is active
• When Elective Replacement Indicator (ERI), has been achieved
for internal use only
Impact of SEGM on Victory
Victory DR - 5816
frozen rolling
No egm 25% egm 50% egm 100% egm
2.5 V atrium and ventricle, 100% inhibited 17.8 14.1 11.6 8.6
2.5 V atrium, 1.0 V ventricle, 100 % pacing 13 10.9 9.3 7.3
2.5 V atrium and ventricle, 100% pacing 11.7 10 8.6 6.8
SR - 5610
frozen rolling
No egm 25% egm 50% egm 100% egm
11.4 8.8 7.2 5.2
10.1 8 6.7 4.9
8.8 7.2 6.1 4.6
for internal use only
Conclusions & RecommendationField -> Customer Education
SEGM in latest SJM pacemakers always records pre-onset the trigger.This may have a significant effect on PG longevity
Use SEGM selectively (for example, if episodes are in the log, patient is symptomatic). Consider using Frozen, not continuous, since it is likely to collect SEGM, then turn off, minimizing current drain.
Magnet Response
Göran Mathson, 2005
for internal use only
•Settings: Off; Battery Test (Nominal: Battery Test)
• How will the PM respond to the magnet placement• Telemetry is disabled when magnet is held over device.• Temporarily suspended functions during magnet is held over
• or Cancelled
The Magnet Response
for internal use only
Terminologie:BOL = Beginning of life
EOL = End of life
ERT = Elective replacement time
ERI = Elective replacement indicator: indication ERT is reached
TMT = Threshold margin test: automatic action
PM Response: VOO DOO AOO Modus Freq. = indication of batt. Condition
Use: Freq. = indication of batt. Condition Troubleshooting – deactivation of algorithms Inhibition of sensing
The Magnet Response
for internal use only
Pacemaker reference guide
for internal use only
Pacemaker reference guide
WWW.SJM.COM
Devices
For Physicians & Health Care Professionals
Implantable Device Reference Guide
Neurocardiogenic Syncope
Göran Mathson, 2005
for internal use only
Neurocardiogenic Syncope
Common faint also called “Neurally mediated syncope” or “Vasovagal syncope”
Young adult, structurally normal heart
Malignant vasovagal syncope pacing
• First line therapy: medication
• Ineffective and bradycardic component
3 types: Cardioinhibitory, vasodepression and mixed
for internal use only
Neurocardiogenic Syncope
3 Major Objectives
• Provide high rate pacing only during the spells
• Otherwise inhibit the pacemaker
• Maintain AV Synchrony
for internal use only
Auto Rate Hysteresis With Search
Most patients with Neurocardiogenic Syncope are in sinus rhythm with intact conduction the majority of the time.
However, if they have an abrupt drop in rate, they may benefit from an elevated rate of pacing.
for internal use only
Programmable parameters
• Hysteresis Rate • Programmable Search Interval• Programmable Cycle Count• Intervention Rate• Intervention Duration• Recovery Time
Advanced Hysteresis Response
for internal use only
Advanced Hysteresis Response
Hysteresis Rate
Allows intrinsic activity to be tracked
below the base rate
Programmable Values: OFF, 30 - 130 in 5 min-1, 140, 150
for internal use only
Advanced Hysteresis Response
Search Interval
Allows the device to periodically extend the pacing interval to search for intrinsic activity
Programmable Values: OFF, 5, 10, 15, or 30 min.
for internal use only
Cycle Count
The number of intervals the device will extend the pacing interval to search for intrinsic activity.The Cycle Count also serves as the number of cycles thepatient’s intrinsic rate will be allowed to drop below thehysteresis rate before pacing at the Intervention Ratebegins.
Programmable Values: 1-16 cycles
Advanced Hysteresis Response
for internal use only
Advanced Hysteresis Response
The rate the pacemaker will operate at if the patients intrinsic rate falls below the Hysteresis Rate for the programmed Cycle Count. It is programmable as a fixed value or as a function of the Intrinsic rate.**
Programmable Values: OFF,
Base Rate, 80 - 120 (steps of 10 min-1), Intrinsic + 0, + 10, +20, +30 min-1
** The Intrinsic rate is calculated as the average Ventricular Rate over the previous 64 cycles
Intervention Rate
for internal use only
Advanced Hysteresis Response
The time in minutes that the pacemaker will operate at the
Intervention Rate.
Following the Intervention Duration the rate will be
decreased, according to the programmed Recovery Time,
until either the Base Rate or Sensor Indicated Rate is
reached.
Programmable Parameters: 1-10 min (steps of 1 min)
Intervention Duration
for internal use only
Advanced Hysteresis Response
Programmable Values• Fast • Medium • Slow • Very Slow
The length of time (in min) that it will take for the pacemaker to reduce the pacing rate from the Intervention Rate to the Base Rate
NOTE: This parameter also servesas the setting for thesensor Recovery Time
Recovery Time
for internal use only
Parameter settings forNeurocardiogenic syncope
Parameter Value Rationale
Pacing mode DDD
DDI
Excer. AV block
Rate modulation DISABLE Even no mild levels
Base Rate 60 -100 bpm Sympt. dependent
Intervention rate
10 – 20 bpm
Above av. rate
Av.= intrins.rate before drop
Hysteresis rate ≤ 45 bpm Asist. >3 sec = 20bpm
for internal use only
Parameter settings forNeurocardiogenic syncope
Parameters Value Rationale
Rest Rate 45 – 50 bpm Lower rate at rest
Escape Cycles 2 Persistent slow
Cycle Number 3 Sinus warm up
Intervention Duration
2 to 5 minutes The spells are very brief
Recovery Time Medium Same as sensor
AV delay Sufficient / VIP VP not needed
Autocapture Enable Threshold rise
for internal use only
Parameter settings forNeurocardiogenic syncope
OFF
for internal use only
Parameter settings forNeurocardiogenic syncope
for internal use only
Parameter settings forNeurocardiogenic syncope
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