Medtronic 9526 Reference Guide

REVEAL® PLUS 9526

Insertable Loop Recorder System:

Product Information Manual

Caution: Federal Law (USA) restricts this device to sale by or on the order of a physician.

The following are trademarks of Medtronic: Medtronic, Reveal Plus

Contents

1 Prescribing the Reveal® Plus ILR 5

1.1 System Description 5

1.2 Indications and Contraindications 5

1.3 Precautions 6

1.4 Potential Adverse Events 8

1.5 Storage, Handling, and Resterilization 8

1.6 ILR Longevity 9

2 Implant, Initial Programming, and Operation 11

2.1 Implant Procedure 11

2.2 Starting the ILR Application 12

2.3 ILR Main Screen 12

2.4 Telemetry 15

2.5 Real-Time ECG 15

2.6 Setup Procedure for Programming the ILR 16

2.7 Storing an Event 30

2.8 Clearing Memory Without Changing Gain and Sensitivity Settings 31

3 Conducting a Patient Session 33

3.1 Starting a Patient Session 33

3.2 Viewing Events 35

3.3 Printing Events, Settings, and Screens 40

3.4 Connecting an External Printer 41

3.5 Disk Operations 43

3.6 Ending A Patient Session 44

3.7 Follow-up Visits 44

4 Activator 45

4.1 Description 45

4.2 Cleaning and Care 46

4.3 Service 46

4.4 Longevity 46

4.5 Operation 46

4.6 Activator Pouch 47

5 Appendix A 49

5.1 ILR Specifications 49

5.2 Activator Specifications 51

5.3 External Printers 51

5.4 Setting the Programmer Clock 52

5.5 Special Notice 52

5.6 Technical Support 52

1 Prescribing the Reveal® Plus ILR

1.1 System Description

The Reveal® Plus Insertable Loop Recorder (ILR) is designed to improve the capture of subcutaneous electrocardiograms (ECG) during a symptomatic episode. The ILR provides storage of both patient-activated and automatically detected (auto-activated) events. Auto activation may help to detect abnormal heart rhythms in patients who fail to activate the ILR.

Note: The subcutaneous ECG of the ILR may differ from a surface ECG due to differences in electrode separation, ILR placement position in the body, and the difference between subcutaneous and surface contact impedance.

The ILR system has three primary components:

Insertable Loop Recorder – An implantable, single-use, programmable device containing two electrodes on the body of the device for continuous (i.e., looping) recording of the patient’s subcutaneous ECG.

Activator – A hand-held, battery-operated telemetry device used by the patient during or after a symptomatic event to store an event into the ILR memory.

Programmer – A Medtronic Model 9790 and 2090 programmers, programming head (excluding Model 9766), and Model 9809 Software are used to enable ILR operations, and view, save, or print stored data.

Insertable Loop Recorder Activator

Figure 1. Model 9526 Reveal Plus Insertable Loop Recorder and Model 6191 Activator

1.2 Indications and Contraindications

1.2.1 Indications

The Reveal Plus ILR is an implantable patient-and automatically- activated monitoring system that records subcutaneous ECG and is indicated for

■

Patients with clinical syndromes or situations at increased risk of cardiac arrhythmias.

■

Patients who experience transient symptoms that may suggest a cardiac arrhythmia.

1.2.2 Contraindications

There are no known contraindications for the implantation of the Reveal Plus ILR. However, the patient’s particular medical condition may dictate whether or not a subcutaneous, chronically implanted device can be tolerated.

1.3 Precautions

1.3.1 Activator Environmental Precautions

The Model 6191 Activator has been carefully designed and tested to ensure reliability during normal use. However, electronic devices are susceptible to many environmental stresses. Precaution should be taken to avoid damage to the Activator, including (but not limited to) those listed herein.

Do not drop or mishandle the Activator in a way that might physically damage it. Avoid spilling fluid on the Activator. Do not submerge in liquid. Do not open the Activator. Do not sterilize the Activator by gamma radiation or by steam (e.g., autoclave) (see “Cleaning and Care” on page 46 for more information). Do not use the Activator in the presence of flammable anesthetics. Other environmental factors may impact proper performance of the Activator. Use of good electronic device practices will help to prevent environmental damage to the Activator.

Avoid exposing the Activator to temperatures below 48 °F (9 °C) for extended periods of time. Although the Activator will operate at temperatures as low as 5 °F (−15 °C), exposure to cold temperatures will shorten Activator battery life, and may have an adverse effect on Activator reliability (see also “Activator Specifications” on page 51).

If the Activator is dropped from a height of less than 1 meter, verify proper function by pressing the white button (while holding Activator away from implant site) and observing the flashing amber light above the symbol.

If the Activator is dropped from a height of greater than 1 meter, do not continue to use it (see “Service” on page 46).

1.3.2 Cellular Phones

There may be a potential interaction between cellular phones and Reveal Plus ILR operation. Potential effects may include corruption of the data stored in memory or inappropriate device operation. The following information provides a general guideline to patients having an ILR who desire to operate a cellular phone.

■

Maintain a minimum separation of 15 centimeters between a hand-held personal cellular phone and the implanted device. Portable and mobile cellular phones generally transmit at higher power compared to hand-held models. For phones transmitting above three watts, a minimum separation of 30 centimeters between the antenna and the implanted device is advised.

■

Patients should hold the phone to the ear opposite the side of the implanted device. Patients should not carry the phone in a breast pocket or on a belt over, or within 15 centimeters of, the implanted device, because some phones emit signals when they are turned on but not in use (i.e., in the Listen or Standby mode). Storing the phone in a location opposite the side of the implant is recommended.

1.3.3 Diathermy

Therapeutic diathermy should not be used at the implant site on patients who have a Reveal Plus ILR because of possible damage to the circuitry due to heating effects.

1.3.4 Electrocautery and Radio Frequency (RF) Ablation

Electrocautery or RF ablation may cause corruption of the data stored in memory, and/or cause electrical reset of the Reveal Plus ILR. Verify device function after electrocautery or radio frequency energy has been used.

1.3.5 Electromagnetic Interference (EMI)

Since the Reveal Plus ILR communicates with the programmer and Activator by means of radio frequency telemetry, electromagnetic interference (EMI) may cause short telemetry interruptions, or temporarily affect the recorded electrocardiogram. The ILR will function properly after exposure to such EMI signals.

1.3.6 External Defibrillation

The Reveal Plus ILR may be damaged if defibrillation paddles are placed directly over the device. In addition, defibrillation discharges may result in the corruption of the stored ECG data. Defibrillation paddles placed at least 13 cm from the implanted ILR should not damage the device. Verify ILR function after defibrillation.

1.3.7 Electronic Article Surveillance (EAS)

Many retail stores are equipped with EAS gates as a security measure against theft. Magnetic and radio frequency (RF) fields produced by EAS gates may trip the low battery indicator flag on the Reveal Plus ILR. The device will continue to operate normally if this occurs. To minimize the possibility of tripping the low battery indicator flag, avoid prolonged exposure while passing through these gates.

1.3.8 Home or Job Environment

The Reveal Plus ILR should not be affected by the normal operation of electrical equipment such as household appliances, electrical machine shop tools, microwave ovens, spark-ignited internal combustion engines, radio frequency transmitting systems, or microwave frequency transmitting systems. (See also “Cellular Phones” on page 6.)

1.3.9 Implanted Pacemakers and Defibrillators

To minimize the possibility of the programming head and telemetry interfering with implanted pacemakers and defibrillators, the Reveal Plus ILR should be implanted at least 7.5 cm away from any other implanted device.

Do not hold the Model 6191 Activator or programming head directly above another implanted device while the Reveal Plus application is active.

1.3.10 Irradiation

The Reveal Plus ILR should not be directly irradiated by therapeutic levels of ionizing radiation (such as that produced by cobalt machines or linear accelerators used for cancer treatment) because of the risk of permanent damage to the ILR circuitry. If such therapy is required in the vicinity of the implanted ILR, shield the device and confirm its function after treatment.

1.3.11 Lithotripsy

Permanent damage to the Reveal Plus ILR may occur if the device is at the focal point of the lithotripsy beam. Since this situation is easily avoided, lithotripsy may be used safely if the ILR is kept at least 2.5 to 5 cm away from the focal point of the lithotripsy beam.

1.3.12 Magnetic Resonance Imaging (MRI)

Magnetic and radio frequency (RF) fields produced by MRI may adversely affect the data being stored by the Reveal Plus ILR.

Also, since the ILR contains ferromagnetic components, the strong magnetic field of the MRI system may apply a mechanical force on the ILR. The patient may be able to feel this magnetic force on the ILR. While this does not represent a safety hazard, the patient must be made aware of this possibility to avoid undue patient concern.

1.3.13 Power-On Reset (POR)

Certain conditions (including but not limited to EMI, electrocautery, or transthoracic defibrillation) may cause an electrical reset, (also defined as a POR) of the Reveal Plus ILR, which may cause loss of stored data. Always interrogate the ILR at the beginning and end of each patient session to verify and document the desired programmed status of the ILR.

If a POR has occurred, interrogate the ILR, reprogram the ILR to desired parameters after the source of interference is removed, and notify your Medtronic representative.

1.3.14 Random Failure

All battery-operated devices will ultimately cease to function due to normal depletion of the battery and may also fail at any time due to random component or battery failure which cannot be predicted prior to their occurrence.

1.3.15 Sterile Package

The sterile package should be inspected prior to opening. If the seal or package is damaged, contact your local Medtronic representative.

1.3.16 X-Ray and Fluoroscopy

Exposure to normal diagnostic levels of X-ray and fluoroscopic radiation should not affect the Reveal Plus ILR.

1.4 Potential Adverse Events

Potential adverse events include, but are not limited to, the following:

■

Body tissue rejection phenomena, including local tissue reaction,

■

Infection,

■

Device migration,

■

Erosion of the device through the skin.

1.5 Storage, Handling, and Resterilization

1.5.1 Storage and Handling

The temperature range for transportation and storage of the Reveal Plus ILR is from 0 to 131 °F (−18 to 55 °C).

The temperature range for transportation and storage of the Activator is from −40 to 158 °F (−40 to 70 °C).

Do not implant the ILR if the package is damaged.

Dropping the ILR onto a hard surface (e.g., from a height of 30 cm or more onto a concrete floor) could damage the ILR. Should this occur, do not implant the ILR.

1.5.2 Resterilization

Medtronic has sterilized the device package contents with ethylene oxide prior to shipment. Resterilization is necessary only if the seal on the sterile package is broken. (Resterilization does not affect the “Use By” date.) If necessary, resterilize with ethylene oxide using a validated sterilization process, observing the following precautions:

■

Do not resterilize using an autoclave, gamma radiation, organic cleaning agents (such as alcohol, acetone, etc.), or ultrasonic cleaners.

■

Do not exceed 55 °C (131°F) or 103 kPa when sterilizing.

1.6 ILR Longevity

Projected longevity for the ILR from implant to a low battery condition is 14 months.1 When a low battery condition is reached, the ILR will continue to operate normally for a projected one month until an end of life condition is reached.

1.6.1 Battery Status

The battery status is displayed in the Device Status window after an interrogation and in pop-up messages.

Table 1. ILR Battery Status

Battery Status Message Suggested Action

Ok None

Low Interrogate the ILR (All Events and Settings).

If clinically appropriate, consider replacing the ILR.

End of life

Not Available

Remove ILR. If clinically appropriate, replace ILR.

Start recording, and interrogate device to obtain current status.

Being Updated Wait one minute and re-interrogate.

It is not possible to store events or retrieve data from the ILR when the battery has reached end of life.

The battery status may be unavailable when the device is in shipping mode. To obtain the battery status in this case, start recording, wait one minute, and then interrogate the ILR. IMPORTANT! Starting a recording session erases all stored events from the ILR memory.

Projected longevity based on a six-month shelf life.

2 Implant, Initial Programming, and Operation

2.1 Implant Procedure

The Reveal Plus ILR can be inserted in a single-incision procedure using aseptic technique. A subcutaneous pocket should be created, which is slightly smaller than the width of the ILR. The ILR should be inserted into the pocket with the electrodes facing outward (toward the skin). When inserted into the pocket, the ILR should enlarge the pocket to make a tight fit. It is important to keep movement of the ILR within the pocket to a minimum for good auto-activation performance. Suture the device in place using the suture holes to help minimize movement of the device.

For patients with an ILR programmed to patient activation only mode, an implantation anywhere in the subcutaneous area of the left anterior thorax should provide adequate signal amplitude.

For patients with an ILR programmed to manual mode plus the auto-activation mode, choose implant locations and orientations that provide the following requirements to help ensure a successful setup of the autoactivation feature, and to help minimize inappropriate auto-activation:

■

R-wave to T-wave and R-wave to P-wave peak-to-peak amplitude ratios (R/T and R/P ratios), which are as large as possible (preferably greater than 2:1 for R/T and 5:1 for R/P).

■

Minimal device movement due to body and arm movement, and changes in posture. Implantation closer to the sternum and away from the lower half of the pectoral region and breast area may help minimize device movement.

■

The largest possible R-wave signal amplitudes considering the two preceding requirements.

■

Implantation in an orientation more parallel to midline may help to minimize device movement and may help to provide a larger R-wave.

Suitable implant locations and orientations can be determined before implant with surface ECG measurements in the locations and orientations of interest. This can be done using standard surface ECG electrodes and placing them approximately four centimeters apart to roughly match the subcutaneous electrode spacing of the ILR. These measurements can be done using standard ECG measurement systems such as the Medtronic programmer (using accompanying ECG cables and Lead II on the Select Model Screen).

Before closing, verify that the ECG signal quality and amplitude are adequate.

Note: The ILR should be explanted when it is no longer clinically necessary, or when the battery is depleted.

2.1.1 Identification Card and Registration Form

An Implanted Device Identification Card is included in the shipping package. The information on this card should be filled out by the clinician, and the card given to the patient.

A Device Registration Form is also included in the shipping package. Upon completion by the clinician, this form serves as a permanent record of the facts related to the implanted ILR. A copy of this form should be returned to Medtronic.

Establishing a Patient Record – At the time of implant, the clinician should establish a record of the patient’s ILR. The registration form should not serve this purpose, as this form is intended for registering the patient and device with Medtronic.

2.2 Starting the ILR Application

How to Start the ILR Application

Use the following steps to prepare the ILR for programming.

1. From the Select Model screen select [OTHER] and then Reveal Plus Model 9526. At the bottom of the screen, press [Start]. The programmer displays the Main screen.

2. The ILR is shipped with factory settings as shown in the table on page 49. Press [Interrogate...] on the Main screen and select [Settings Only].

A Device Status Warning notifies you that the ILR is in its

shipping mode. To begin operation, a message on the Warning screen instructs you to select [Setup...] from the Main screen.

3. Press [Continue] at the bottom of the warning message. The Device Status window displays a message indicating that the ILR is in its shipping mode. Press [OK] at the bottom of the status window. A Setup Reminder message is displayed. The ILR is ready for programming and ECG recording.

4. Select [Setup...]

from the Main Screen to program the device.

2.3 ILR Main Screen

The Main screen has the following attributes (see Figure 2):

■

Displays real-time ECG waveform with sense markers when the programming head is positioned over the implanted ILR.

■

Provides function and menu buttons (see “Main Screen Button Descriptions” on page 14).

■

Displays heart rate summary graphs1, representing both patient-activated and auto-activated stored events.

– Heart rate summary graphs appear as a series of vertical bars. Each bar represents the minimum and

maximum heart rate in an ECG event segment.

– Arrow buttons scroll the heart rate summary graph to display other stored events.

– ECG waveform details are displayed by tapping the touch pen on the heart rate summary graph

display.

Heart rate summary graphs are not of diagnostic quality. Refer to event waveforms for diagnostic information.

Current time/date

Real-time

heart

rate

Message

line

Rate

scale

Summary

graph scroll

arrow

Sense Markers

Real-time ECGFile Name

Stored Event 1 start

date and time

Heart rate summary graph of stored event 1

Figure 2. Main Screen

Activation point

See Table 2 for button descriptions

Table 2. Main Screen Button Descriptions

Button Description

Displays ECG gain and sensitivity settings.

Adjusts real-time ECG sweep speed. Speed is programmable to 25 or 50 mm/sec using the up/down buttons.

Toggle button with which you select the telemetry range (Near (see page 15).

Toggle button that pauses the real-time ECG display. (Continue restarts it.)

Opens Interrogate window from which you select events or settings to retrieve from device memory (see page 33).

Opens Print window from which you select printing options (see page 40).

Opens Disk window from which you save data to disk, or read data from disk (see page 43).

Opens the Setup window from which you program patient and auto-activated stored event modes, ECG storage capacity, automatic activation parameters, and gain/sensitivity setup (see page 16).

Ends the current patient session (see page 44).

or Far)

2.4 Telemetry

The programmer and the ILR communicate via telemetry. Telemetry is possible only when the programming head is correctly positioned over the implanted ILR such that the yellow light on the programming head turns to green.

2.4.1 Telemetry Range

You can set the Telemetry range to Near or Far using the toggle switch on the ILR Main screen. The Near setting should be appropriate for most patients.

2.4.2 Verifying Proper Telemetry

A successful interrogation or programming operation verifies proper communication between the ILR and the programmer.

Under conditions that adversely affect telemetry, it may be difficult to program the ILR even when the green light indicates that telemetry should be possible. If this occurs, reposition the programming head slightly in one direction or the other over the ILR, and/or change the Telemetry range setting. If you encounter further difficulties establishing telemetry, contact your Medtronic representative.

2.5 Real-Time ECG

A real-time ECG waveform appears at the top of the main menu after establishing telemetry with the device. Vertical bars above the real-time ECG indicate device sense markers.

You can select 25 or 50 mm/sec real-time ECG sweep speed using the up/down buttons on the Main screen.

The real-time ECG display is paused temporarily during ILR interrogation.

2.5.1 Printing the Real-Time ECG Waveform

You can print the patient’s real-time ECG any time during a patient session using the programmer’s strip chart printer.

1. To start printing a real-time ECG, press the desired paper speed button on the programmer.

2. To stop printing, press the paper speed button again.

3. Press the paper advance button to advance the paper to a perforation before tearing off a printout.

2.5.2 Real-Time ECG Waveform Interruption

The real-time ECG waveform is momentarily interrupted while interrogating or programming the ILR. Interruptions may result in short periods of missing real-time ECG waveform data.

2.5.3 Markers on Real-Time ECG Printouts

▼

A “down” arrow (

) above the ECG trace on the printout indicates the transmission of a telemetry command from the programmer to the ILR. An “up” arrow (▲) indicates the reception of the telemetry response from the ILR.

Real-Time ECG is subcutaneous ECG in this device.

2.6 Setup Procedure for Programming the ILR

To program the ILR, press [Setup...] from the Main screen and follow the steps indicated on the Setup screen (see Figure 3).

Figure 3. Setup Screen

Note: With the Reveal Plus ILR, the P (Program) button on the programming head is functional only during

patient posture tests.

2.6.1 Step 1: Select number and type of events to store

Select the number of patient-activated and auto-activated events.

2.6.2 Step 2: Select ECG storage capacity

Select the ECG storage capacity.

2.6.3 Step 3: Select auto-activation parameters Note: Skip this step if you did not select an auto-activated event mode in step 1.

a. Press [Auto-Activation Parameters...]. The Auto-Activation Parameters screen is displayed (see

Figure 4).

b. From the Auto-Activation Parameters screen, select from the following options, and then press

[Accept].

■

Brady option (<30 or <40 bpm). An auto-activated event will be recorded after 4 consecutive bradycardia beats.

■

Asystole option (> 3 secs or >4.5 secs).

■

Tachy options: (Off, >115,... >230 bpm), and the number of consecutive beats (16 or 32).

■

Event storage option (to store either the last 5 or 13, or the first 6 or 14, auto-activated events).

Store the last auto-activated events from the Auto-Activation Parameters screen to assist in documenting the most recent events.

Figure 4. Auto-Activation Parameters Screen

Note: Once an auto-activation has occurred, a subsequent auto-activation cannot occur until four consecutive

normal intervals have been sensed and either 1.5 minutes (for a 21-minute storage capacity), or 3 minutes (for a 42-minute storage capacity) has elapsed. The ILR may not store an entire continuous event or a subsequent event until the post auto-activation criteria have been met. However, patient activation is still possible during this period.

2.6.4 Step 4: Start Gain Setup

This step defines the procedure for establishing the gain and sensitivity settings. From the Setup screen (Figure 3) press the [Gain Setup...] button to display the Gain and Sensitivity Setup screen (see Figure 5).

You can manually program the gain and sensitivity settings; however, the Auto-Setup procedure is recommended. Refer to page 29 for the Manual Gain and Sensitivity setup procedure.

+ 37 hidden pages