Medtronic E1DR06 Reference Guide

ENPULSE

E1DR00/20 Series E2VDD00 Series

E2SR00 Series

™

Pacemaker Reference Guide

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

EnPulse Pacemaker Reference Guide

A guide to the EnPulse pacemakers: E1DR00 Series E1DR20 Series E2VDD00 Series E2SR00 Series

Refer to the EnPulse Pacemaker Programming Guide for information on software and programming.

The following are trademarks of Medtronic:

Capture Management, Checklist, EnPulse, Fast Path, Implant Detection, Key Parameter History, Marker Channel, Medtronic, Medtronic Carelink, Rate Profile Optimization, Remote Assistant, Auto-PVARP, Quick Look II, Search AV+, Sensing Assurance, Observations, Sinus Preference, and Vision.

How to use this guide

Information is contained in two guides

Product information about EnPulse pacemakers and the associated software for the 9790/C series programmer and the 2090 programmer is presented in two separate guides.

This guide, the Pacemaker Reference Guide (PRG), provides detailed information on EnPulse pacemakers.

The Pacemaker Programming Guide (PPG) accompanies the programmer software for the EnPulse pacemakers and contains instructions on how to use the programmers with these pacemakers.

About the Pacemaker Reference Guide

This guide describes in detail, how the pacemaker operates and specifies the capabilities of each model.

■

Describes the pacing modes, rate response options, special therapy features, telemetry types, and data collection options. In some cases, guidelines are given on how to configure the pacemaker operation.

■

Contains troubleshooting information for electrical and hemodynamic problems.

■

Specifies parameter and data collection capabilities, longevity projections, and mechanical and electrical specifications.

■

Provides general warnings and cautions, potential interference sources, and general indications for pacing.

■

Contains a glossary of terms.

How to use this guide

EnPulse Pacemaker Reference Guide iii

How to use this guide

About the Pacemaker Programming Guide

This guide presents the following information to use the 9790/C programmer and 2090 programmer.

■

How to set up and configure the programmer and access online help.

■

How to start a patient session, use the various follow-up features during the session, and properly end the session.

■

How to use checklist to streamline a follow-up session.

■

How to view and print the patient’s ECG and EGM waveform traces.

■

How to configure the pacemaker to collect diagnostic data and how to retrieve and view this information.

■

How to measure stimulation thresholds and sensing levels.

■

How to program parameter values and verify rate response parameters settings.

■

How to run EP Studies.

iv EnPulse Pacemaker Reference Guide

Table of contents

How to use this guide iii

Information is contained in two guides iii About the Pacemaker Reference Guide iii About the Pacemaker Programming Guide iv

1. Pacing modes

Introduction 1-2

Pacing mode selection 1-2 NBG pacing codes 1-2

Further information 1-3 Mode selection decision tree 1-4 Mode pertinency tables 1-5 Indications 1-7 Contraindications 1-8 DDDR mode 1-9 DDD mode 1-10 DDIR mode 1-11 DDI mode 1-12 DVIR mode 1-13 DVI mode 1-14 VDD mode 1-15 AAIR / ADIR modes 1-16 AAI / ADI modes 1-17 VVIR / VDIR modes 1-18 VVI / VDI modes 1-19 AAT / VVT modes 1-20 DOOR / AOOR / VOOR modes 1-21 DOO / AOO / VOO modes 1-22 ODO / OAO / OVO modes 1-23

2. Rate response

Introduction to rate responsive pacing 2-2

Rate response 2-2

Automatic features 2-2

For further information 2-3 Preset rate response at implant 2-3

Overview 2-3

Three pacing rate controls 2-3

Independent control of submaximal and maximal rates 2-4

Starting rate response immediately 2-4

EnPulse Pacemaker Reference Guide v

Table of contents

For further information 2-4

Rate Profile Optimization operation 2-5

Overview 2-5 Submaximal and maximal rate control 2-5 Optimization using rate profiles 2-6 Daily optimization of rate response 2-7 Adaptations in Optimization operation 2-8

Individualizing Rate Profile Optimization 2-9

Overview 2-9 Submaximal rate profiles 2-9 Maximal rate profiles 2-9 Programming guidelines 2-9

Activity sensor operation 2-11

Overview 2-11 How Activity Threshold influences rate 2-11 Evaluating the Activity Threshold setting 2-12 How Activity Acceleration and Deceleration influence rate 2-13 Exercise Deceleration operation 2-15

Manual control of Rate Profile Optimization 2-16

Overview 2-16 Evaluate and program rate response 2-16

3. Pacemaker timing

Rates 3-2

Overview 3-2 A-A and V-V timing 3-3 Lower Rate 3-3 Operating lower rate 3-4 Selecting a Lower Rate 3-4 Sensor-indicated rate 3-5 Sensor indicated rate effect on other intervals 3-6 ADL Rate 3-6 Upper Tracking Rate 3-6 Upper Sensor Rate 3-7 Programming considerations and restrictions 3-7 Rate limit 3-7 Possible atrial competition at high rates 3-8 Mean atrial rate 3-8

AV i ntervals 3-9

Overview 3-9 Selecting PAV and SAV 3-11

Rate Adaptive AV 3-11

Overview 3-11

vi EnPulse Pacemaker Reference Guide

Programming for Rate Adaptive AV 3-12

RAAV operations 3-14

Programming considerations and restrictions 3-14

RAAV and sick sinus syndrome 3-14 Search AV+ and diagnostic 3-15

Overview 3-15

Programming to Search AV+ 3-15

Search AV+ operation 3-16

Suspension of Search AV+ operation 3-17

Programming considerations and restrictions 3-17

Recording AV interval adaptations 3-18 Blanking periods 3-19

Nonprogrammable blanking periods 3-19

Post-Ventricular Atrial Blanking 3-19

Ventricular blanking 3-20

Single chamber atrial blanking 3-20 Refractory periods 3-20

Overview 3-20

Post-Ventricular Atrial Refractory Period 3-21

Sensor-varied PVARP 3-22

Determining sensor-varied PVARP 3-23

Automatic PVARP 3-23

Determining automatic PVARP 3-24

Programming restrictions for automatic PVARP 3-24

Spontaneous PVARP extension 3-24

Total Atrial Refractory Period (TARP) 3-25

Ventricular Refractory Period 3-26

Atrial Refractory Period (single chamber) 3-27

Noise reversion 3-27

Preventing noise sensing 3-29 High rate atrial tracking 3-30

Overview 3-30

2:1 block 3-30

Pacemaker Wenckebach 3-31

High rate operation in the DDDR mode 3-32

Table of contents

4. Lead / cardiac tissue interface

Implant Detection 4-2

Overview 4-2

Verifying lead connection during Implant Detection 4-3 Automatic polarity configuration 4-3

Overview 4-3

Measuring lead impedance during configuration 4-3

EnPulse Pacemaker Reference Guide vii

Table of contents

How polarities are automatically configured 4-4 When automatic configuration is complete 4-6 Manually setting polarities 4-7 Programming interactions 4-7

Lead Monitor 4-8

Overview 4-8 How lead monitoring works 4-8

Lead impedance data 4-10

Automatic Lead Impedance (Chronic Lead Trend) 4-10 For further information 4-11

Capture Management and diagnostic 4-12

Overview 4-12 Ventricular Capture Management (VCM) 4-12 Atrial Capture Management (ACM) 4-12 Ventricular Capture Management (VCM) 4-14 The ventricular pacing threshold search 4-15 Atrial Capture Management (ACM) 4-24 Recording Capture Management data 4-29

Sensing Assurance and diagnostic 4-31

Overview 4-31 Monitoring sensitivity thresholds 4-31 Qualifying sensed events 4-32 Adjusting sensing thresholds 4-32 Programming considerations 4-33 Recording Sensing Assurance data 4-34

Manually selecting pacing parameters 4-36

Overview 4-36 Manually selecting pacing polarity 4-36 Muscle stimulation with unipolar pacing 4-36 Bipolar pacing polarity confirmation 4-37 Determining stimulation threshold at implant 4-37 Verifying stimulation threshold at follow-up 4-37 Selecting output parameters 4-38 For further information 4-38

Manually selecting sensing parameters 4-39

Overview 4-39 Manually selecting sensing polarity 4-39 Bipolar sensing polarity confirmation 4-40 Determining sensing threshold(s) at implant 4-40 Verifying sensing threshold(s) at follow-up 4-40 Selecting sensitivity settings 4-41 Effects of myopotentials during unipolar pacing 4-41 For further information 4-42

viii EnPulse Pacemaker Reference Guide

Transtelephonic follow-up features 4-43

Overview 4-43

The Threshold Margin Test (TMT) 4-43

Threshold Margin Test operation 4-43

Enhanced Transtelephonic Monitoring 4-45

For further information 4-45

5. Special therapy options

Mode Switch and diagnostic 5-2

Overview 5-2

How atrial tachyarrhythmia is defined 5-3

How atrial tachyarrhythmia is detected 5-3

Switching to non-atrial tracking mode 5-4

Switching back to atrial tracking mode 5-5

Mode switching interruption 5-6

Programming restrictions 5-6

Recording Mode Switch episode data 5-7 Ventricular Response Pacing 5-9 Non-competitive atrial pacing 5-10

Overview 5-10

How NCAP affects atrial timing 5-10

How NCAP affects ventricular timing 5-11

NCAP availability 5-11

For further information 5-12 PMT intervention 5-12

Overview 5-12

How the pacemaker defines PMT 5-12

Sensor corroboration before intervening 5-13

PMT therapy intervention 5-13

Automatic therapy suspension 5-14

Interactions with other features 5-14

Patient intervention for PMT 5-14

For further information 5-14 PVC Response 5-15

Overview 5-15

How the pacemaker defines a PVC 5-15

Extending PVARP 5-15

Interaction with other features 5-16

PVCs automatically counted 5-16

For further information 5-16 Ventricular Safety Pacing 5-17

Overview 5-17

How VSP operates 5-17

Table of contents

EnPulse Pacemaker Reference Guide ix

Table of contents

Sinus Preference 5-18

Overview 5-18 How Sinus Preference is defined 5-18 How Sinus Preference operates 5-19 Interaction with other features 5-20 For further information 5-20

Rate Drop Response and diagnostic 5-21

Overview 5-21 How the pacemaker intervenes 5-21 How the drop detection option defines a specified rate

drop 5-22 How the low rate detection operates 5-23 Programming guidelines 5-23 Programming restrictions 5-25 Recording of Rate Drop Episodes 5-25

Sleep Function 5-27

Overview 5-27 How the Sleep Function works 5-27 Interrupting the Sleep Function 5-28 Programming considerations 5-28 Evaluating Sleep Function operation 5-28

Single Chamber Hysteresis 5-29

Overview 5-29 How hysteresis works 5-29 Programming considerations 5-30 Interactions with Sleep Function 5-30

6. Telemetry data

Establishing telemetry 6-2

For further information 6-2

Parameter summary 6-3

Overview 6-3 Parameters reported 6-3 Possible variation from programmed values 6-4 For further information 6-4

Patient information 6-5

Overview 6-5 Parameters reported 6-5

Battery and lead information 6-6

Overview 6-6 Telemetered data 6-6 Conditions and variance in measurements 6-7 Chronic Lead Impedance Trend 6-7

x EnPulse Pacemaker Reference Guide

For further information 6-7 Marker Channel telemetry 6-8

Overview 6-8

Standard Marker Channel telemetry 6-8

Therapy Trace telemetry 6-9 Intracardiac electrograms 6-10

Overview 6-10

Intracardiac electrogram recording 6-10

Uses for the Intracardiac Electrogram 6-11

For further information 6-12 Extended Telemetry 6-12

Overview 6-12

Extended Telemetry options 6-12

Additional battery drain 6-12

7. Miscellaneous operations

Magnet Mode operation 7-2

Overview 7-2

Magnet Mode operation 7-2

Threshold Margin Test 7-3

Transtelephonic Monitor feature 7-3

Special operation with Extended Telemetry 7-3

For further information 7-3 Temporary programming 7-4

Overview 7-4

Temporarily programmable parameters 7-4

Temporary refractory period settings 7-4

For further information 7-5 Electrical reset 7-6

Overview 7-6

Partial electrical reset 7-6

Full electrical reset 7-7 Elective Replacement Indicator (ERI) 7-7

Overview 7-7

Basis for setting ERI 7-7

ERI verification 7-8 Emergency pacing 7-8

Table of contents

8. Diagnostics

Introduction to diagnostics 8-2

Automatic diagnostics 8-2

Clinician-selected diagnostics 8-4

Battery and lead data 8-5

EnPulse Pacemaker Reference Guide xi

Table of contents

Suspending and clearing of data 8-5

Heart Rate Histograms 8-6

Automatic data collection 8-6 Retrieving the atrial and ventricular rate histograms 8-7

AV Conduction Histograms 8-8

Automatic data collection 8-8 Retrieving the AV Conduction Histogram 8-9 For further information 8-9

Search AV+ Histogram 8-10

Automatic data collection 8-10 For further information 8-11

Sensor Indicated Rate Profile 8-11

Automatic data collection 8-11 Retrieving the Sensor Rate Profile 8-12 For further information 8-12

High Rate Episodes 8-12

Automatic data collection 8-12 Programmable data collection 8-14 How high rate episodes are defined 8-17 Limitation to detect high rate atrial events 8-18 Retrieving atrial and ventricular high rate diagnostics 8-18 For further information 8-18

Ventricular Rate Histogram During Atrial Arrhythmias 8-18

Automatic data collection 8-19 Refractory Sense Setup option 8-19 Retrieving Ventricular Rate Histogram During

Arrhythmias 8-19

Atrial Arrhythmia Trend 8-20

Automatic data collection 8-20 Retrieving Atrial Arrhythmia Trend diagnostics 8-20

Atrial Arrhythmia Durations 8-21 Remote Assistant 8-21

Programmable data collection 8-22 Retrieving Remote Assistant data 8-23 For further information 8-23

Custom Rate Trend 8-24

Data collection 8-24 Programmable data collection options 8-25 Retrieving Custom Rate Trend 8-25 For further information 8-25

Key Parameter Histor y 8-26

Automatic parameter value recording 8-26 Retrieving Key Parameter History information 8-26

xii EnPulse Pacemaker Reference Guide

For further information 8-26

9. Troubleshooting the pacing system

Troubleshooting strategy 9-2

Overview 9-2 Troubleshooting electrical problems 9-3

Defining electrical problems 9-3

Identifying the cause of an electrical problem 9-3

Correcting an electrical problem 9-5 Troubleshooting hemodynamic problems 9-6

Defining a hemodynamic problem 9-6

Identifying the cause of a hemodynamic problem 9-6

Correcting a hemodynamic problem 9-7

A. Appendix: Pacemaker description

Model number designator A-2 Radiopaque codes A-3 Physical dimensions A-3 Connector dimensions A-4

B. Appendix: Preset parameter settings

Shipping settings B-2 Nominal settings B-8 Electrical Reset settings B-14 Emergency settings B-21

Table of contents

C. Appendix: Longevity projections

Longevity projections (normal operating life) C-2 Longevity projections (after ERI) C-8

ERI longevity projections for Models E1DR01/03/06 C-8

ERI longevity projections for Model E1DR21 C-9

ERI longevity projections for Model E2VDD01 C-9

ERI longevity projections for Models E2SR01/03/06 C-10 Elective Replacement Indicator (ERI) C-11

Distinguishing ERI from full electrical reset C-11 Battery specifications C-12

D. Appendix: Telemetry and diagnostic values

Magnet Mode operations D-2 Telemetry functions D-3

Marker Channel and extended telemetry D-3

Electrograms (EGM) D-3

Battery and Lead Information D-4

Patient data D-5

EnPulse Pacemaker Reference Guide xiii

Table of contents

Automatic diagnostics D-6 Clinician-selectable diagnostics D-9 Cardiac event counters D-11

E. Appendix: Parameter values and restrictions

Programmable modes and parameters E-2 Rate Response programming guidelines E-13 Timing reference E-14

Dual chamber timing summary E-17

F. Appendix: Implant information

Warnings F-2

Device operation F-2 Pacemaker dependent patients F-2 Medical therapy hazards F-3 Hospital and medical environments F-4

Precautions F-5

Storage and handling F-5 Device operation F-6 Pacemaker-dependent patients F-8 Medical therapy hazards F-8 Home and occupational environments F-10

Potential complications F-12 Replace a device F-13

For further information F-13

Patient counseling information F-14

Patient counseling information F-14 Device registration form F-14 Establish a patient record F-14

G. Glossary

I. Index

xiv EnPulse Pacemaker Reference Guide

Pacing modes

This chapter provides information about the modes available with the pacemaker.

Introduction 1-2

Mode selection decision tree 1-4

Mode pertinency tables 1-5

Indications 1-7

Contraindications 1-8

DDDR mode 1-9

DDD mode 1-10

DDIR mode 1-11

DDI mode 1-12

DVIR mode 1-13

DVI mode 1-14

VDD mode 1-15

AAIR / ADIR modes 1-16

AAI / ADI modes 1-17

VVIR / VDIR modes 1-18

VVI / VDI modes 1-19

AAT / VVT modes 1-20

DOOR / AOOR / VOOR modes 1-21

DOO / AOO / VOO modes 1-22

ODO / OAO / OVO modes 1-23

EnPulse Pacemaker Reference Guide 1-1

Pacing modes

Introduction

Pacing mode selection

This chapter provides an introduction to pacemaker modes as an aid to pacing mode selection. The chapter is organized as follows:

Mode selection decision tree – This decision tree, based on the 1991 ACC/AHA guidelines for pacemaker implantation,

provides a simple

means of identifying pacing modes appropriate for given indications.

Mode pertinency tables – These tables show which features and parameters apply to each commonly used pacing mode.

Mode descriptions – These descriptions provide indications and contraindications for modes available with the pacemaker and brief descriptions of how these modes operate.

NBG pacing codes

The pacemaker modes are defined in NBG Code.2 Each five-letter NBG code describes a specific type of operation for implantable pacemakers. For simplicity, this manual uses only the first three or four letters, such as DDD, DDIR, DVIR, and so forth. Figure 1-1 describes the first four letters of the NBG code.

Dreifus LS, Fisch C, Griffin JC, et al. Guidelines for implantation of cardiac pacemakers and antiarrhythmia devices. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Pacemaker Implantation). Journal of the American College of Cardiology. 1991; 18: 1-13.

Bernstein A., et al., “The NASPE/BPEG Pacemaker Code,” PACE, 10(4), Jul-Aug 1987. (“NBG” stands for The North American Society of Pacing and Electrophysiology [NASPE] and the British Pacing and Electrophysiology Group [BPEG] Generic. NBG’s five-letter code supersedes the ICHD Code.

1-2 EnPulse Pacemaker Reference Guide

Pacing modes

Introduction

CHAMBER PACED

V = Ventricle

A = Atrium

D = Dual Chamber

S = Single Chamber

O = None

DDDR

CHAMBER SENSED

V = Ventricle

A = Atrium

D = Dual Chamber

S = Single Chamber

O = None

MODE OF RESPONSE

T = Triggered

I = Inhibited

D = Double (Both)

O = None

PROGRAMMABLE/ RATE RESPONSE

P = Programmable

M = Multiprogrammable

C = Communicating

R = Rate Responsive

O = None

Figure 1-1. NBG pacing codes

Further information

The mode descriptions in this chapter provide only a basic overview of each mode. For further details on the rate response, timing, and therapy capabilities, refer to “Rate response” on page 2-2, “Pacemaker timing” on page 3-1, and “Special therapy options” on page 5-1.

EnPulse Pacemaker Reference Guide 1-3

Pacing modes

Mode selection decision tree

Use the decision tree (Figure 1-2) as an aid to select the best pacing mode for the patient.

Figure 1-2. Mode selection decision tree

1-4 EnPulse Pacemaker Reference Guide

✓

✓✓✓ ✓✓

✓✓✓✓ ✓

Mode pertinency tables

Pacing modes

✓ ✓

✓✓✓✓

Mode pertinency tables

Tabl e 1-1. Pacing parameters available for each mode

DDDR DDD DDIR DDI DVIR DVI VDD VVIR VDIR VVI VDI VVT AAIR ADIR AAI ADI AAT

Lower Rate ✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓

Upper Tracking Rate ✓✓ ✓

Table 1-1 and Table 1-2 show which pacing parameters and features apply to each pacing mode as indicated by black check marks.

Dashes indicate parameters that are programmable when mode switch, RAAV, or sensor-varied PVARP are active or when rate

response is operative but not pertinent to basic mode operation. Note that asynchronous modes are not shown in these tables.

Pacing Parameter

Upper Sensor Rate ✓ – ✓ – ✓ ––✓✓ –––✓✓ –––

Paced AV Interval ✓✓✓✓✓✓

✓✓✓✓ ✓

Sensed AV Interval ✓✓ ✓

PVAB ✓✓✓✓ ✓ ✓ ✓

Rate Adaptive AV ✓✓✓✓✓

PVARP

✓✓✓✓✓✓✓✓✓✓✓✓

Atrial Refractory Period

✓✓✓✓✓✓

Atrial Blanking

Ventricular Refractory

Period

Ventricular Blanking (after

✓✓✓✓✓✓✓✓✓✓✓

AP)

Sensing Assurance ✓✓✓✓✓✓✓✓✓✓✓

Ventricular Capture

Management

See Chapter 3 for descriptions of these timing parameters. Sensing Assurance and Capture Management are described in Chapter 4.bSensor-varied PVARP is available in the DDDR, DDD, DDIR, and VDD modes. Automatic PVARP is available in the DDDR, DDD, and VDD modes.

Atrial Capture Management ✓✓

EnPulse Pacemaker Reference Guide 1-5

Mode pertinency tables

Pacing modes

✓✓

✓✓✓ ✓✓ ✓

Tab le 1-2 . Features available for each mode

✓✓

✓ _ ✓✓✓

DDDR DDD DDIR DDI DVIR DVI VDD VVIR VDIR VVI VDI VVT AAIR ADIR AAI ADI AAT

Managing Atrial Rhythm

Mode Switch ✓✓ ✓

Post Mode Switch

Overdrive Pacing (PMOP)

Non-Competitive Atrial

Pacing

Managing Ventricular

RhythmaPMT Intervention ✓✓ ✓

PVC Response ✓ ✓✓✓ ✓

Ventricular Safety Pacing ✓ ✓✓✓✓✓

Ventricular Response

Pacing (Regularize V-V

during AT/AT)

Rate Drop Response ✓✓

Search AV+ ✓ ✓✓✓✓✓✓

Special Pacing

Operations

Single Chamber Hysteresis

Sinus Preference ✓

Sleep Function ✓ ✓✓✓✓✓✓✓✓✓✓✓✓✓✓

Rate ResponsecADL Rate ✓ – ✓ – ✓ ––✓✓–––✓✓–––

Rate Profile Optimization ✓ – ✓ – ✓ ––✓✓–––✓✓–––

Activity Threshold ✓ – ✓ – ✓ ––✓✓–––✓✓–––

Activity Acceleration ✓ – ✓ – ✓ ––✓✓–––✓✓–––

See Chapter 5 for operational descriptions of special therapy options. Search AV+ is described in Chapter 3.bOnly available during Mode Switch. Ventricular Response Pacing is also continuously active in DDIR, VDIR, or VVIR modes.cSee Chapter 2 for operational descriptions of rate response features.

Activity Deceleration ✓ – ✓ – ✓ ––✓✓–––✓✓–––

EnPulse Pacemaker Reference Guide 1-6

Indications

Pacing modes

Indications

EnPulse pacemakers are indicated for use in patients who are experiencing accepted conditions warranting chronic cardiac pacing which include:

■

Symptomatic paroxysmal or permanent second or third-degree

AV block

■

Symptomatic bilateral bundle branch block

■

Symptomatic paroxysmal or transient sinus node dysfunctions

with or without associated AV conduction disorders.

■

Bradycardia-tachycardia syndrome

■

Vasovagal syndromes or hypersensitive carotid sinus

syndromes.

EnPulse pacemakers are also indicated for use in patients who may benefit from rate responsive pacing to support cardiac output during varying levels of activity. Using rate response modes may restore heart rate variability by improving cardiac output.

These devices are also indicated for use in patients who may benefit from maintenance of AV synchrony through the use of dual chamber modes and atrial tracking modes. Dual chamber modes are specifically indicated for treatment of conduction disorders that require restoration of both rate and AV synchrony. Dual chamber modes are indicated for use in patients who have experienced one or both of the following conditions.

■

Various degrees of AV block

■

VVI intolerance (for example, pacemaker syndrome) in the

presence of persistent sinus rhythm.

This device is also indicated for VDD pacing in patients who have adequate rates and one or both of the following conditions.

■

A requirement for ventricular pacing when adequate atrial rates

and adequate intracavitary atrial complexes are present. This

includes the presence of complete AV block when atrial

contribution is needed for hemodynamic benefit or when

pacemaker syndrome had existed or is anticipated.

■

A requirement for intermittent ventricular pacing despite a

normal sinus rhythm and normal AV conduction.

EnPulse Pacemaker Reference Guide 1-7

Pacing modes

Contraindications

EnPulse pacemakers are contraindicated for the following applications:

■

Dual chamber atrial pacing in patients with chronic refractory atrial tachyarrhythmias.

Asynchronous pacing in the presence (or likelihood) of competitive paced and intrinsic rhythms.

Unipolar pacing for patients with an implanted cardioverterdefibrillator (ICD) because it may cause unwanted delivery or inhibition of ICD therapy.

1-8 EnPulse Pacemaker Reference Guide

DDDR mode

Pacing modes

DDDR mode

In the DDDR mode, the pacemaker tracks the faster of the intrinsic atrial rate or the sensor-indicated rate. If the intrinsic rate is faster, the DDDR mode provides atrial synchronous pacing; otherwise, AV sequential pacing occurs at the sensor-indicated rate.

■

Rate limits for atrial tracking (Upper Tracking Rate)1 and sensor tracking (Upper Sensor Rate) are separately programmable.

■

The AV intervals that follow sensed atrial events (SAV) and paced atrial events (PAV) are separately programmable, and they can be programmed to shorten with increasing rates (Rate Adaptive AV) or to change with intrinsic conduction times (Search AV+).

■

A nonrefractory sensed event in either chamber inhibits pacing in that chamber. A ventricular nonrefractory sensed event in the VA interval that is not preceded by an atrial sense (AS or AR) is a pacemakerdefined PVC and starts a new VA interval.

Sensor-indicated

Interval

A P

V P

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms PVARP = 280 ms

Sensor-indicated Rate = 90 ppm (667 ms)

A P

V S

SAV Interval = 170 ms

Sensor-indicated

Interval

A S

V S

A P

V P

Figure 1-3. Example of DDDR mode operation

The Total Atrial Refractory Period (TARP) may limit the tracking rate to a lesser value. Refer to Chapter 3 for more information on TARP.

A S

V P

200 ms

EnPulse Pacemaker Reference Guide 1-9

Pacing modes

DDD mode

The DDD mode provides atrial synchronous pacing in the presence of intrinsic atrial activity; otherwise, AV sequential pacing occurs at the Lower Rate.

■

Each atrial paced or nonrefractory atrial sensed event starts an AV interval and a lower rate interval. The AV intervals that follow sensed atrial events (SAV) and paced atrial events (PAV) are separately programmable, and the SAV may be optionally programmed to shorten with increasing rate (Rate Adaptive AV) or to change with intrinsic conduction times (Search AV+).

■

A ventricular paced event may track an atrial sensed event up to the programmed Upper Tracking Rate.

■

A ventricular nonrefractory sensed event in the VA interval that is not

preceded by an atrial sense (AS or AR) is a pacemaker-defined PVC and starts a new VA interval.

Lower Rate Interval

A P

V P

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms

A P

V S

SAV Interval = 170 ms

Figure 1-4. Example of DDD mode operation

The Total Atrial Refractory Period (TARP) may limit the tracking rate to a lesser value.

Lower Rate Interval

A S

V S

A P

200 ms

1-10 EnPulse Pacemaker Reference Guide

DDIR mode

Pacing modes

DDIR mode

The DDIR mode provides dual chamber, sensor-driven, atrioventricular (AV) sequential pacing for heart rate variation without atrial tracking.

■

Atrial pacing occurs at the sensor-indicated rate. If it is not inhibited, ventricular pacing occurs at the end of the PAV interval.

■

The AV intervals that follow paced atrial events (PAV) are separately programmable, and they can be programmed to shorten with increasing rates (Rate Adaptive AV) or to change with intrinsic conduction times (Search AV+).

■

An atrial event sensed outside the PVARP will inhibit a scheduled atrial stimulus but will not start an AV interval. That is, ventricular paced events after such sensed atrial events occur at the sensorindicated rate. The following ventriculoatrial (VA) interval may be extended slightly to avoid an increasing atrial paced rate.

■

A ventricular nonrefractory sensed event in the VA interval starts a new VA interval.

Sensor-indicated

Interval

A P

V P

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms

Sensor-indicated Rate = 90 ppm (667 ms)

A P

Sensor-indicated

Interval

V P

A S

Sensor-indicated

V P

Figure 1-5. Example of DDIR mode operation

EnPulse Pacemaker Reference Guide 1-11

VA I n t erv a l

Sensor-indicated

Interval

A P

V P

200 ms

A P

Pacing modes

DDI mode

The DDI mode provides dual chamber atrioventricular (AV) sequential pacing with atrial sensing but without atrial tracking.

■

Atrial pacing occurs at the Lower Rate. If it is not inhibited, ventricular pacing occurs at the end of the PAV interval.

■

The AV intervals that follow paced atrial events (PAV) are separately programmable, and they can be programmed to change with intrinsic conduction times (Search AV+).

■

An atrial event sensed outside the PVARP will inhibit a scheduled atrial stimulus but will not start an AV interval. Ventricular paced events after such sensed atrial events occur at the Lower Rate.

■

A ventricular nonrefractory sensed event in the ventriculoatrial (VA) interval starts a new VA interval.

Lower Rate Interval

A P

V P

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms

A P

Lower Rate Interval Lower Rate VA Interval

V P

Figure 1-6. Example of DDI mode operation

A S

V P

200 ms

A P

1-12 EnPulse Pacemaker Reference Guide

DVIR mode

Pacing modes

DVIR mode

The DVIR mode provides AV sequential pacing at the sensor-indicated rate unless inhibited by ventricular sensed events.

■

Atrial pacing occurs at the sensor-indicated rate. If it is not inhibited, ventricular pacing occurs at the end of the PAV interval.

■

The DVIR mode ignores intrinsic atrial events. Sensing occurs only in the ventricle. A ventricular nonrefractory sensed event during the ventriculoatrial (VA) interval starts a new VA interval.

Sensor-indicated

Interval

A P

V P

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms

Sensor-indicated Rate = 90 ppm (667 ms)

A P

V S

Sensor-indicated

VA Interval

V S

Figure 1-7. Example of DVIR mode operation

Sensor-indicated

Interval

A P

V P

A P

200 ms

EnPulse Pacemaker Reference Guide 1-13

Pacing modes

DVI mode

The DVI mode provides dual chamber AV sequential pacing without atrial sensing/tracking.

■

Atrial pacing occurs at the Lower Rate. If it is not inhibited, ventricular pacing occurs at the end of the PAV interval.

■

The AV intervals that follow paced atrial events (PAV) are separately programmable, and they can be programmed to change with intrinsic conduction times (Search AV+).

■

Sensing occurs only in the ventricle, and intrinsic atrial events are ignored. A ventricular nonrefractory sensed event during the VA interval starts a new ventriculoatrial (VA) interval.

Lower Rate Interval

A P

V P

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms

A P

V S

Figure 1-8. Example of DVI mode operation

Lower Rate VA Interval

V S

A P

V P

200 ms

1-14 EnPulse Pacemaker Reference Guide

+ 294 hidden pages

Medtronic E1DR06 Reference Guide

Specifications and Main Features

Frequently Asked Questions

User Manual

How to use this guide

Information is contained in two guides

About the Pacemaker Reference Guide

About the Pacemaker Programming Guide

Table of contents

Pacing modes

Introduction

Pacing mode selection

NBG pacing codes

Further information

Mode pertinency tables

Indications

Contraindications

DDDR mode

DDD mode

DDIR mode

DDI mode

DVIR mode

DVI mode