Medtronic KD901 Reference Guide

Pacemaker Reference Guide

KAPPA®900/800

KDR900/920/930 Series
KD900 Series
KVDD900 Series
KSR900 Series
KDR800 Series

Kappa® 900/800 Series Pacemaker
Reference Guide

A guide to the Kappa
900/800 Series pacemakers:
KDR900/920/930 Series

D900 Series

K
KVDD900 Series
KSR900 Series
KDR800 Series

Refer to the Kappa® 900/800
Pacemaker Programming Guide for
information on software and
programming.

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

®

The following are trademarks of Medtronic.

Capture Management, Checklist, FAST, Fast Path, Implant Detection, Kappa, Key Parameter History,
Marker Channel, Medtronic, Rate Profile Optimization, Remote Assistant, Auto-PVARP, Quick Look,
Search AV, Sensing Assurance, Significant Events, Sinus Preference, and Vision.

How to Use This Guide

Information is Contained in Two Guides

Product information about Kappa 900/800 Series pacemakers and the
associated software for the 9790 series programmer is presented in two
separate guides.

This guide, the Pacemaker Reference Guide (PRG), is a supplementary
guide that provides detailed information on Kappa 900/800 Series
pacemakers.

The Pacemaker Programming Guide (PPG) accompanies the
programmer software for the Kappa 900/800 Series pacemakers and
contains instructions on how to use the programmer with these
pacemakers.

About this Guide

This supplementary 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

Kappa 900/800 Series Pacemaker Reference Guide iii

How to Use This Guide

About the Pacemaker Programming Guide

This guide presents the following information to use the 9790 programmer.

■

How to setup and configure the programmer and access on-line 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 Kappa 900/800 Series Pacemaker Reference Guide

Table of contents

Table of contents

How to Use This Guide iii

Information is Contained in Two Guides iii
About this 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 and usage 1-7
Contraindications 1-7
DDDR mode 1-8
DDD mode 1-9
DDIR mode 1-10
DDI mode 1-11
DVIR mode 1-12
DVI mode 1-13
VDD mode 1-14
AAIR / ADIR modes 1-15
AAI / ADI modes 1-16
VVIR / VDIR modes 1-17
VVI / VDI modes 1-18
AAT / VVT modes 1-19
DOOR / AOOR / VOOR modes 1-20
DOO / AOO / VOO modes 1-21
ODO / OAO / OVO modes 1-22

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

Kappa 900/800 Series 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 intervals 3-9

Overview 3-9
Selecting PAV and SAV 3-11

Rate Adaptive AV 3-12

Overview 3-12

vi Kappa 900/800 Series 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 Adaptive AV 3-15

Adaptive AV operation 3-16

Suspension of Adaptive AV operation 3-17

Programming to fixed AV hysteresis 3-17

Fixed AV hysteresis operation 3-18

Programming considerations and restrictions 3-18

Recording AV interval adaptations 3-19
Blanking periods 3-20

Nonprogrammable blanking periods 3-20

Post-Ventricular Atrial Blanking 3-20

Ventricular Blanking 3-21

Single chamber atrial blanking 3-21
Refractory periods 3-21

Overview 3-21

Post-Ventricular Atrial Refractory Period 3-22

Sensor-varied PVARP 3-23

Determining sensor-varied PVARP 3-24

Automatic PVARP 3-24

Determining automatic PVARP 3-24

Programming restrictions for automatic PVARP 3-25

Spontaneous PVARP extension 3-25

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

Kappa 900/800 Series Pacemaker Reference Guide vii

Table of contents

Overview 4-3
Measuring lead impedance during configuration 4-3
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
Clinician-selected Lead Impedance Detail 4-11
For further information 4-11

Capture Management and diagnostic 4-12

Overview 4-12
Initiating the pacing threshold search 4-12
The pacing threshold search 4-14
Automatic threshold adaptation 4-19
Programming interactions 4-23
Recording Capture Management data 4-23

Sensing Assurance and diagnostic 4-26

Overview 4-26
Monitoring sensitivity thresholds 4-26
Qualifying sensed events 4-27
Adjusting sensing thresholds 4-27
Programming considerations 4-28
Recording Sensing Assurance data 4-29

Manually selecting pacing parameters 4-31

Overview 4-31
Manually selecting pacing polarity 4-31
Muscle stimulation with unipolar pacing 4-31
Bipolar pacing polarity confirmation 4-32
Determining stimulation threshold at implant 4-32
Verifying stimulation threshold at follow-up 4-32
Selecting output parameters 4-33
For further information 4-33

Manually selecting sensing parameters 4-34

Overview 4-34
Manually selecting sensing polarity 4-34
Bipolar sensing polarity confirmation 4-35
Determining sensing threshold(s) at implant 4-35
Verifying sensing threshold(s) at follow-up 4-35
Selecting sensitivity settings 4-36

viii Kappa 900/800 Series Pacemaker Reference Guide

Effects of myopotentials during unipolar pacing 4-36

For further information 4-37
Transtelephonic follow-up features 4-38

Overview 4-38

The Threshold Margin Test (TMT) 4-38

Threshold Margin Test operation 4-38

The Fully Automated Self Test (FAST) 4-39

FAST operation 4-39

Enhanced Transtelephonic Monitoring 4-41

For further information 4-41

5. Special therapy options

Mode Switch and diagnostic 5-2

Overview 5-2

How atrial tachyarrhythmia is defined 5-2

How atrial tachyarrhythmia is detected 5-3

Switching to non-atrial tracking mode 5-4

Switching back to atrial tracking mode 5-4

Mode switching interruption 5-5

Programming restrictions 5-5

Recording Mode Switch episode data 5-6
Non-competitive atrial pacing 5-8

Overview 5-8

How NCAP affects atrial timing 5-8

How NCAP affects ventricular timing 5-9

NCAP availability 5-9

For further information 5-10
PMT intervention 5-10

Overview 5-10

How the pacemaker defines PMT 5-10

Sensor corroboration before intervening 5-11

PMT therapy intervention 5-11

Automatic therapy suspension 5-12

Interactions with other features 5-12

Patient intervention for PMT 5-12

PMT intervention counter 5-12

For further information 5-12
PVC Response 5-13

Overview 5-13

How the pacemaker defines a PVC 5-13

Extending PVARP 5-13

Interaction with other features 5-14

PVCs automatically counted 5-14

Table of contents

Kappa 900/800 Series Pacemaker Reference Guide ix

Table of contents

For further information 5-14

Ventricular Safety Pacing 5-15

Overview 5-15
How VSP operates 5-15

Sinus Preference and diagnostic 5-16

Overview 5-16
How Sinus Preference is defined 5-16
How Sinus Preference operates 5-17
Interaction with other features 5-18
Summary recording of Sinus Preference episodes 5-18
For further information 5-19

Rate Drop Response and diagnostic 5-20

Overview 5-20
How the pacemaker intervenes 5-20
How the drop detection option defines a specified rate

drop 5-21
How the low rate detection operates 5-22
Programming guidelines 5-22
Programming restrictions 5-24
Recording of Rate Drop Episodes 5-24

Sleep Function 5-26

Overview 5-26
How the Sleep Function works 5-26
Interrupting the Sleep Function 5-27
Programming considerations 5-27
Evaluating Sleep Function operation 5-27

Single Chamber Hysteresis 5-28

Overview 5-28
How hysteresis works 5-28
Programming considerations 5-29
Interactions with Sleep Function 5-29

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

x Kappa 900/800 Series Pacemaker Reference Guide

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

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

The Fully Automated Self Test (FAST) 7-3

Special operation with Extended Telemetry 7-3

For further information 7-4
Temporary programming 7-4

Overview 7-4

Temporarily programmable parameters 7-4

Temporary refractory period settings 7-5

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

Kappa 900/800 Series Pacemaker Reference Guide xi

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
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
For further information 8-8

AV Conduction Histograms 8-8

Automatic data collection 8-9
Retrieving the AV Conduction Histogram 8-10
For further information 8-10

Sensor Indicated Rate Profile 8-10

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

High Rate Episodes 8-12

Automatic data collection 8-12
Programmable data collection 8-14
How high rate episodes are defined 8-16
Limitation to detect high rate atrial events 8-17
Retrieving atrial and ventricular high rate diagnostics 8-17
For further information 8-17

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

xii Kappa 900/800 Series Pacemaker Reference Guide

Key Parameter History 8-26

Automatic parameter value recording 8-26

Retrieving Key Parameter History information 8-26

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
Handling, storage, and resterilization 9-8

Handling and storage 9-8

Resterilization 9-8
Pacemaker longevity 9-9

Background 9-9

Elective Replacement Indicator 9-9

Time from ERI to cessation of pacing 9-9

Distinguishing ERI from full electrical reset 9-9

For further information 9-10
Replacing the pacemaker 9-10

For further information 9-11
Patient information and service 9-11

Patient registration information 9-11

Establishing a patient record 9-11

Assistance information 9-12

For further information 9-12

Table of contents

A. Pacemaker description

Model number designator A-2
Radiopaque codes A-3
Physical dimensions A-4
Connector dimensions A-5

B. Preset parameter settings

Shipping settings B-2
Nominal settings B-7
Electrical Reset settings B-12
Emergency settings B-19

Kappa 900/800 Series Pacemaker Reference Guide xiii

Table of contents

C. Longevity projections

Longevity projections (normal operating life) C-2

Models K

DR

901/903/906, KDR801/803/806, and KD901/903/906

longevity projections C-2
Models K
Models K
Models K
Models K

DR

921 longevity projections C-3

DR

931/933 longevity projections C-3

VDD

901 longevity projections C-4

SR

901/903/906 longevity projections C-4

Longevity projections (after ERI) C-5

ERI longevity projections for Models K
KDR801/803/806, and KD901/903/906 C-5

ERI longevity projections for Model K
ERI longevity projections for Models K
ERI longevity projections for Model K
ERI longevity projections for Models K

Elective Replacement Indicator (ERI) C-8
Battery specifications C-9

D. 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

Automatic diagnostics D-6
Clinician-selectable diagnostics D-9
Cardiac event counters D-12

DR

901/903/906,

DR

921 C-6

DR

931/933 C-6

VDD

901 C-7

SR

901/903/906 C-7

E. Parameter values and restrictions

Programmable modes and parameters E-2
Rate Response programming guidelines E-12
Timing reference E-13

Dual chamber timing summary E-16

F. Warnings and precautions

Special notice F-2
Warnings F-3

Programming and pacemaker operation F-3
Pacemaker dependent patients F-3

Precautions F-4

Programming and pacemaker operation F-4
Rate increases F-5
Unipolar sensing F-6

xiv Kappa 900/800 Series Pacemaker Reference Guide

Implantable defibrillator F-6
Potential complications F-8

G. Environmental interference

Hospital or medical environment interference G-2

Therapeutic diathermy G-2

Magnetic resonance imaging G-2

Electrosurgical cautery G-3

External defibrillation G-4

High radiation sources G-4

Lithotripsy G-4

Radiofrequency ablation G-5

X-Ray and fluoroscopy G-5
Home and job environment interference G-6

High voltage power transmission lines G-6

Communication equipment G-6

Commercial electrical equipment G-6

Home appliances G-6

Electronic article surveillance (EAS) G-7

Cellular phones G-7

H. Glossary

I. Index

Table of contents

Kappa 900/800 Series Pacemaker Reference Guide xv

Table of contents

xvi Kappa 900/800 Series Pacemaker Reference Guide

Understanding
Pacemaker Operation

Chapters 1 - 9 provide detailed information
about the operation of the Kappa 900/800
Series pacemakers.

Pacing modes

Rate response

Pacemaker timing

Lead/cardiac tissue interface

Special therapy options

Telemetry data

Miscellaneous operations

Diagnostics

Troubleshooting the
pacing system

Pacing modes

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

1

Introduction 1-2

Mode selection decision tree 1-4

Mode pertinency tables 1-5

Indications and usage 1-7

Contraindications 1-7

DDDR mode 1-8

DDD mode 1-9

DDIR mode 1-10

DDI mode 1-11

DVIR mode 1-12

DVI mode 1-13

VDD mode 1-14

AAIR / ADIR modes 1-15

AAI / ADI modes 1-16

VVIR / VDIR modes 1-17

Kappa 900/800 Series Pacemaker Reference Guide 1-1

VVI / VDI modes 1-18

AAT / VVT modes 1-19

DOOR / AOOR / VOOR modes 1-20

DOO / AOO / VOO modes 1-21

ODO / OAO / OVO modes 1-22

Pacing modes

Introduction

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,

1

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.

1

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.

2

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 Kappa 900/800 Series 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 2-1, “Pacemaker timing” on
page 3-1, and “Special therapy options” on page 5-1.

Kappa 900/800 Series Pacemaker Reference Guide 1-3

Pacing modes

Mode selection decision tree

Mode selection decision tree

Figure 1-2 shows a basic decision tree used to select the pacing mode. In
the shaded boxes the preferred mode or modes are listed and the
alternate mode or modes appear below the dashed line.

Symptomatic

Bradycardia

(e.g., persistent

atrial fibrillation,

inexcitable atrium)

Is SA node conduction

presently adequate?

Ye s NoNo

AAI

DDD
AAIR

DDDR

No

VVIR

VVI

Ye s

Can the atrium be sensed

and/or paced reliably?

Is AV conduction

presently adequate?

AAIR

DDDR

Figure 1-2. Mode selection tree

Ye s

No

Is SA node conduction

presently adequate?

Ye s

DDD

DDDR

VDD

(e.g., complete or
transient AV block)

DDDR

DDIR

1-4 Kappa 900/800 Series Pacemaker Reference Guide

✓

Mode pertinency tables

Pacing modes

✓✓

✓✓✓ ✓✓

✓✓✓✓ ✓

✓✓✓✓

ibed in Chapter 4.

Mode pertinency tables

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

rate response is operative but not pertinent to basic mode operation. Note that certain features are not available in Kappa 800

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

asynchronous modes are not shown in these tables.

Series pacemakers for certain pacing modes; see “Parameter values and restrictions” on page E-1 for specific details. Also,

Table 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

a

Lower Rate ✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓

Upper Tracking Rate ✓✓ ✓

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

Pacing Parameter

Paced AV Interval ✓✓✓✓✓✓

✓✓✓✓ ✓

b

Rate Adaptive AV ✓✓✓✓✓

PVARP

Atrial Refractory Period

Sensed AV Interval ✓✓ ✓

PVAB ✓✓✓✓ ✓ ✓ ✓

Atrial Blanking

✓✓✓✓✓✓

See Chapter 3 for descriptions of these timing parameters. Sensing Assurance and Capture Management are descr

Ventricular Blanking (after

AP)

Period

Ventricular Refractory

Sensing Assurance ✓✓✓✓✓✓✓✓✓✓✓

Sensor-varied PVARP is available in the DDDR, DDD, DDIR, and VDD modes. Automatic PVARP is available in the DDDR, DDD, and VDD modes.

Capture Management ✓✓✓✓✓✓✓✓✓✓✓

a

b

Kappa 900/800 Series Pacemaker Reference Guide 1-5

Pacing modes

Mode pertinency tables

Table 1-2. Features available for each mode

✓ ✓

✓✓✓ ✓✓ ✓

eatures.

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

✓✓

a

a

a

Managing Ventricular

Managing Atrial Rhythm

Mode Switch ✓✓ ✓

Non-Competitive Atrial

Rhythm

Pacing

PMT Intervention ✓✓ ✓

Special Pacing

PVC Response ✓ ✓✓✓ ✓

Operations

Ventricular Safety Pacing ✓ ✓✓✓✓✓

Rate Drop Response ✓✓

Search AV ✓ ✓✓✓✓✓✓

Sleep Function ✓ ✓✓✓✓✓✓✓✓✓✓✓✓✓✓

Sinus Preference ✓

Single Chamber Hysteresis

1-6 Kappa 900/800 Series Pacemaker Reference Guide

b

Rate Response

ADL Rate ✓ – ✓ – ✓ ––✓✓ –––✓✓–––

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

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

See Chapter 5 for operational descriptions of special therapy options. Search AV is described in Chapter 3.

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

See Chapter 2 for operational descriptions of rate response f

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

a

b

Indications and usage

Kappa 900/800 Series pacemakers are indicated for the following uses:

■

Rate adaptive pacing in patients who may benefit from increased
pacing rates concurrent with increases in activity.

■

Accepted patient conditions warranting chronic cardiac pacing which
include:

– Symptomatic paroxysmal or permanent second or third-degree

– Symptomatic bilateral bundle branch block.

– Symptomatic paroxysmal or transient sinus node dysfunctions

– Bradycardia-tachycardia syndrome to prevent symptomatic

– Vasovagal syndromes or hypersensitive carotid sinus syndromes.

Kappa 900/800 Series pacemakers are also indicated for dual chamber
and atrial tracking modes in patients who may benefit from maintenance
of AV synchrony. Dual chamber modes are specifically indicated for
treatment of conduction disorders that require restoration of both rate and
AV synchrony, which include:

■

Various degrees of AV block to maintain the atrial contribution to
cardiac output.

■

VVI intolerance (e.g., pacemaker syndrome) in the presence of
persistent sinus rhythm.

Pacing modes

Indications and usage

AV b lock.

with or without associated AV conduction disorders.

bradycardia or some forms of symptomatic tachyarrhythmias.

Contraindications

Kappa 900/800 Series 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.

Kappa 900/800 Series Pacemaker Reference Guide 1-7

Pacing modes

DDDR mode

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

1

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

A
S

V
P

200 ms

1-8 Kappa 900/800 Series Pacemaker Reference Guide

DDD mode

m

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

1

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

1

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

A
S

V
S

Lower Rate Interval

200 ms

A
P

Kappa 900/800 Series Pacemaker Reference Guide 1-9

Pacing modes

DDIR mode

DDIR mode

o

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.

■

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

Sensor-indicated

A
S

V
P

Figure 1-5. Example of DDIR mode operation

VA Interval

Sensor-indicated

Interval

A

A
P

P

V
P

200 ms

A
P

1-10 Kappa 900/800 Series Pacemaker Reference Guide

DDI mode

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.

■

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

Kappa 900/800 Series Pacemaker Reference Guide 1-11

Pacing modes

DVIR mode

DVIR mode

m

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

1-12 Kappa 900/800 Series Pacemaker Reference Guide

DVI mode

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.

■

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

Paramete rs:

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

Kappa 900/800 Series Pacemaker Reference Guide 1-13

Pacing modes

VDD mode

VDD mode

The VDD mode provides atrial synchronous pacing (or VVI pacing at the
Lower Rate). The ventricle is paced synchronously up to the programmed
Upper Tracking Rate.

1

Sensing occurs in both the atrium and ventricle, but

pacing occurs only in the ventricle.

■

To promote atrial synchronous pacing at slow rates, a sensed atrial
event occurring near the end of the Lower Rate interval will be
followed by the programmed maximum SAV interval. The result is an
extension of the ventricular lower rate.

■

A ventricular nonrefractory sensed event in the V-V interval that is not
preceded by an atrial sense (AS or AR) is a pacemaker-defined PVC,
and it starts a new V-V interval.

Lower Rate Interval

SAV

Interval

A
S

V
P

Paramete rs:

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

Upper Tracking Rate = 120 ppm (500 ms) PVARP = 250 ms

A
S

V
P

Figure 1-9. Example of VDD mode operation

1

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

1-14 Kappa 900/800 Series Pacemaker Reference Guide

A
S

V
P

A
S

200 ms

AAIR / ADIR modes

The AAIR mode provides atrial-based rate responsive pacing in patients
with intact AV conduction. Sensing and pacing occur only in the atrium. In
the absence of sensed events, the chamber is paced at the sensor­indicated rate.

The ADIR mode operates the same as the AAIR mode except that events
sensed in the ventricle are recorded by the diagnostics. When used in
conjunction with Marker Channel recordings and concurrent ECG, this
mode may be used to observe the conducted ventricular rhythm without
affecting atrial pacing.

Note: In the AAIR and ADIR modes, atrial refractory sensed events do
not restart the Upper Sensor Rate interval.

Sensor-indicated Interval Sensor-indicated Interval

Pacing modes

AAIR / ADIR modes

A
P

Paramete rs

Sensor-indicated Rate = 75 ppm (800 ms)

Upper Sensor Rate = 100 ppm (600 ms)

A
R

:

Figure 1-10. Example of AAIR mode operation

A
P

A
S

A
P

200 ms

Kappa 900/800 Series Pacemaker Reference Guide 1-15

Pacing modes

AAI / ADI modes

AAI / ADI modes

The AAI mode provides single chamber inhibited atrial pacing. Sensing
and pacing occur only in the atrium. Pacing occurs at the programmed
Pacing Rate unless inhibited by sensed events.

The ADI mode operates the same as the AAI mode except that events
sensed in the ventricle are recorded by the diagnostics. When used in
conjunction with Marker Channel recordings and concurrent ECG, this
mode may be used to observe the conducted ventricular rhythm without
affecting atrial pacing.

Pacing Rate Interval

A
P

Parameters:

Pacing Rate = 75ppm (800 ms)

A
R

Pacing Rate Interval

A
P

A
S

Figure 1-11. Example of AAI mode operation

A
P

200 ms

1-16 Kappa 900/800 Series Pacemaker Reference Guide

VVIR / VDIR modes

The VVIR mode provides ventricular rate responsive pacing in patients for
whom atrial-based pacing is deemed unnecessary or inappropriate. In the
absence of sensed events, the ventricle is paced at the sensor-indicated
rate.

The VDIR mode operates the same as the VVIR mode except that events
sensed in the atrium are recorded by the diagnostics. When used in
conjunction with Marker Channel recordings and concurrent ECG, this
mode may be used to observe the underlying atrial rhythm without
affecting ventricular pacing.

Note: In the VVIR and VDIR modes, ventricular refractory sensed events
restart the Upper Sensor Rate interval.

Pacing modes

VVIR / VDIR modes

Sensor-indicated

Interval

V
P

Paramete rs:

Lower Rate = 60 ppm (1000 ms) Upper Sensor Rate = 120 ppm (500 ms)

Sensor-indicated Rate = 90 ppm (667 ms) Ventricular Refractory Period = 300 ms

Sensor-indicated

Interval

V
P

Upper Sensor

Rate Interval

V
R

Sensor-indicated

Interval

V
P

Figure 1-12. Example of VVIR mode operation

V
P

200 ms

Kappa 900/800 Series Pacemaker Reference Guide 1-17

Pacing modes

VVI / VDI modes

VVI / VDI modes

The VVI mode provides single chamber inhibited pacing at the
programmed Pacing Rate unless inhibited by sensed events. Sensing
occurs only in the ventricle.

The VDI mode operates the same as the VVI mode except that events
sensed in the atrium are recorded by the diagnostics. When used in
conjunction with Marker Channel recordings and concurrent ECG, this
mode may be used to observe the underlying atrial rhythm without
affecting ventricular pacing.

Pacing Rate Interval

V
P

Paramete rs:

Pacing Rate = 60 ppm (1000 ms)

Ventricular Refractory Period = 300 ms

Figure 1-13. Example of VVI mode operation

Pacing Rate Interval

V
P

V
S

200 ms

V
P

1-18 Kappa 900/800 Series Pacemaker Reference Guide

AAT / VVT modes

Pacing modes

AAT / VVT modes

In the AAT and VVT modes, pacing occurs at the programmed Pacing
Rate, but a nonrefractory sensed event triggers an immediate pacing
output (rather than inhibiting such output). With the exception that pacing
outputs occur when events are sensed, the triggered modes operate
identically to the corresponding inhibited modes.

Note: Programmed triggered pacing will not occur faster than 300 ms
(200 ppm) from the previous paced event. Temporary programmed
triggered pacing is not limited to 300 ms (200 ppm).

Pacing Rate Interval

V
P

Paramete rs:

Pacing Rate = 60 ppm (1000 ms)

Ventricular Refractory Period = 300 ms

V
R

Figure 1-14. Example of VVT mode operation

Pacing Rate Interval

V
P

T
P

V
P

200 ms

Kappa 900/800 Series Pacemaker Reference Guide 1-19

Pacing modes

DOOR / AOOR / VOOR modes

DOOR / AOOR / VOOR modes

The DOOR, AOOR, and VOOR modes operate as follows:

■

The DOOR mode provides asynchronous AV sequential pacing at
the sensor-indicated rate. Intrinsic events are ignored.

■

The AOOR and VOOR modes provide single chamber pacing at the
sensor-indicated rate. Intrinsic events are ignored.

Sensor-indicated

Interval

A
P

V
P

Paramete rs:

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

Sensor-indicated Rate = 90 ppm (667 ms)

Sensor-indicated

Interval

A
P

V
P

Sensor-indicated

Interval

A
P

V
P

Figure 1-15. Example of DOOR mode operation

Sensor-indicated

Interval

A
P

V
P

A
P

200 ms

1-20 Kappa 900/800 Series Pacemaker Reference Guide

DOO / AOO / VOO modes

The DOO, AOO, and VOO modes operate as follows:

■

The DOO mode provides AV sequential pacing at the programmed
Lower Rate with no inhibition by intrinsic events.

■

The AOO and VOO modes provide pacing at the programmed Pacing
Rate with no inhibition by intrinsic events in the applicable chamber.

In addition to being directly programmable, the DOO mode is the Magnet
mode of the corresponding dual chamber modes, except for the VDD
mode, which is the VOO mode. AOO and VOO modes are the Magnet
modes of the corresponding atrial and ventricular single chamber modes,
respectively.

DOO / AOO / VOO modes

Pacing modes

Lower Rate Interval

A
P

V
P

Paramete rs:

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

Lower Rate Interval

A
P

V
P

Figure 1-16. Example of DOO mode operation

Lower Rate Interval

A
P

V
P

200 ms

A
P

Kappa 900/800 Series Pacemaker Reference Guide 1-21

Pacing modes

ODO / OAO / OVO modes

ODO / OAO / OVO modes

w

Warning: Never program these modes for pacemaker-dependent
patients. For such patients, use the programmer’s inhibit function for brief
interruption of outputs.

In the ODO, OAO, and OVO modes, sensing occurs in the designated
chamber or chambers. When used in conjunction with Marker Channel
telemetry and concurrent ECG, these modes may be used to observe
underlying rhythms.

■

Blanking periods in these modes are automatically minimized to
maximize the sensing window or windows. Thus, Marker Channel
telemetry may display sense markers for cardiac events (for example,
far-field R waves) that otherwise would not appear due to longer
blanking.

■

No timing intervals or refractory periods are used.

1-22 Kappa 900/800 Series Pacemaker Reference Guide

Rate response

This chapter describes how the pacemaker’s automatic rate
response features operate and how to individualize rate
response.

2

Introduction to rate
responsive pacing 2-2

Preset rate response at implant 2-3

Rate Profile Optimization
operation 2-5

Individualizing Rate Profile
Optimization 2-9

Activity sensor operation 2-11

Manual control of Rate Profile
Optimization 2-16

Kappa 900/800 Series Pacemaker Reference Guide 2-1

Rate response

Introduction to rate responsive pacing

Introduction to rate responsive pacing

Rate response

The pacemaker may provide appropriate rate response for patients who
require cardiac pacing support at both submaximal and maximal rates. To
achieve appropriate rate response, the pacemaker provides activity
sensor-driven pacing with rate response control at the submaximal and
maximal rate ranges. Submaximal rates are moderate pacing rates
obtained during typical daily activities, such as walking or daily chores.
Maximal rates are rates at or near the upper rate obtained during vigorous
activities.

The pacemaker provides appropriate rate response by employing the
following operations:

■

Three programmable rates control the submaximal and maximal rate
ranges: Lower Rate, ADL Rate (Activities of Daily Living Rate), and
Upper Sensor Rate. The ADL Rate is equivalent to the average target
rate that the patient achieves for moderate activities.

■

Independent control of rate response is provided in both the
submaximal and maximal rate ranges.

Automatic features

For models implanted in a rate responsive mode, the pacemaker
automatically enables rate response after implant and automatically
adjusts rate response, if necessary, once each day.

■

During the first 30 minutes after implant, pacing occurs at the
implanted mode but without rate response. 30 minutes after implant,
nominal rate response operation is enabled.

■

Once each day, rate response is assessed and adjusted, if
necessary, in the submaximal or maximal rate ranges. The
assessment is based on comparing the pacemaker’s historical
sensor-indicated rate profiles against a clinician prescribed target
rate profile of the patient. If the rate profiles differ, rate response is
adjusted slightly in the appropriate rate range, and the assessment is
repeated again the next day.

2-2 Kappa 900/800 Series Pacemaker Reference Guide

For further information

Refer to “Rate Profile Optimization operation” on page 2-5 for information
on how the pacemaker optimizes rate response.

Preset rate response at implant

Overview

The pacemaker is shipped in the DDDR mode for dual chamber rate
responsive models and the VVIR mode for single chamber rate
responsive models. It effectively operates in a nonrate responsive mode—
DDD for dual chamber models and VVI for single chamber models—until
implant detection is completed, which is typically 30 minutes after implant.
Thereafter, the pacemaker automatically enables rate responsive pacing.
Consequently, no programming is required for nominal rate response
operation.

Note: Rate response is enabled for other operations in nonrate
responsive modes (e.g., DDD mode switching to DDIR).

Preset rate response at implant

Rate response

Three pacing rate controls

If customization of rate response is desired, three pacing rates are
provided to control the submaximal and maximal rate ranges:

■

Lower Rate defines the slowest rate at which pacing occurs in the
absence of a sinus rate or physical activity.

■

ADL Rate (Activities of Daily Living Rate) is the approximate rate that
the patient’s heart is expected to reach during moderate exercise.

■

Upper Sensor Rate provides the upper limit for the sensor-driven rate
during vigorous exercise.

Refer to “Rates” on page 3-2 for additional considerations when selecting
pacemaker rates.

Kappa 900/800 Series Pacemaker Reference Guide 2-3

Rate response

Preset rate response at implant

Independent control of submaximal and maximal rates

The pacemaker automatically assesses and independently adjusts, if
necessary, rate response levels for both submaximal and maximal rate
ranges on a daily basis using rate profile data. This operation allows the
pacemaker to respond to changes in submaximal or maximal exercise
levels without affecting rate response in the other rate range. This
independent control is accomplished by comparing rate profiles of the
patient’s sensor-indicated rates against a nominal or clinician prescribed
target rate profile.

■

If the rate profile data indicates that sensor-indicated rates are higher
than rates targeted for in the submaximal and/or maximal ranges, the
pacemaker decreases rate response slightly in the respective range.

■

If rates are lower than targeted for, rate response is increased slightly.

Starting rate response immediately

In situations where the clinician wishes to start rate responsive pacing
before the 30-minute implant detection period is completed, perform the
following steps:

1. Program Implant Detection to “Off/Complete.”

2. Configure pace and sense lead polarities and Lead Monitor.

3. Verify that Rate Profile Optimization is On.

4. Verify the appropriate ADL Response, Exertion Response, Activity

Threshold, Activity Acceleration, and Activity Deceleration settings.

For further information

Refer to “Rate Profile Optimization operation” on page 2-5 and
“Individualizing Rate Profile Optimization” on page 2-9.

2-4 Kappa 900/800 Series Pacemaker Reference Guide

Rate Profile Optimization operation

Overview

When Rate Profile Optimization is programmed On, the pacemaker can
adapt submaximal and maximal rate response levels once each day by
comparing the patient’s current sensor rate profiles against a nominal or
clinician prescribed target rate profile. This feature is intended to provide
automatic and independent monitoring of rate response at both
submaximal rates for daily patient activities, such as walking and daily
chores, and at maximal rates for vigorous patient activities.

Optimization can be individualized to the patient’s activity levels. Refer to
“Individualizing Rate Profile Optimization” on page 2-9.

Optimization can also operate in the background when a non-rate
responsive mode is programmed. This can provide appropriate rate
response to patient activity if rate response is needed later or for certain
therapy features, such as mode switching to a non-atrial tracking rate
responsive mode.

Rate Profile Optimization operation

Rate response

Submaximal and maximal rate control

The pacemaker maintains a linear relationship between the sensor input
and the sensor-indicated rate in both the submaximal and maximal rate
ranges. Optimization controls how rapidly and to what level the sensor­indicated rate increases and decreases in these two rate ranges. The
three programmable rate controls [Lower Rate, ADL Rate (Activities of
Daily Living Rate), and Upper Sensor Rate] define the rate ranges (see
Figure 2-1).

■

Submaximal rates are moderate pacing rates achieved during typical
daily patient activities. These rates are at or near the ADL Rate.

■

Maximal rates are rates at or near the Upper Sensor Rate achieved
during vigorous activities.

Optimization also controls rate responsiveness for rates below the
submaximal rate range (i.e., at or near the Lower Rate).

Kappa 900/800 Series Pacemaker Reference Guide 2-5

Rate response

Rate Profile Optimization operation

30%

Submaximal

Rate

Range

Maximal

Rate

Range

20%

10%

Indicated % of Time

Lower

Rate

ADL
Rate

Upper

Sensor Rate

Figure 2-1. Submaximal and maximal rate ranges

Optimization using rate profiles

Optimization of rate response occurs independently in both the
submaximal and maximal rate ranges. Rate response to activity sensor
changes is assessed daily based on the following rate profile data:

Sensor-indicated rate profile – An actual rate versus time distribution of
the patient’s averaged sensor-indicated rates. Once each day, the
pacemaker collects a daily sensor rate profile and cumulates the data into
a monthly average. Both the daily and monthly rate profiles are assessed
each day to determine if adjustments to rate response are required. The
monthly sensor rate profile is automatically stored in the Sensor Indicated
Rate Profile diagnostic.

Target rate profile – A programmable rate versus time distribution of the
patient’s desired rates. The ADL Response and Exertion Response
parameters define the percent of time the sensor-indicated rate is in the
submaximal and maximal ranges, respectively.

2-6 Kappa 900/800 Series Pacemaker Reference Guide

30%

20%

10%

Indicated % of Time

30%

20%

10%

Indicated % of Time

Daily Sensor

Rate Profile

Rate

Monthly Sensor

Rate Profile

Rate

Figure 2-2. Comparing rate profiles

Rate Profile Optimization operation

Rate response

C

o

m

p

a

r

e

e

r

a

p

m

o

C

30%

Tar ge t Rat e

Profile

20%

10%

Indicated % of Time

Rate

Daily optimization of rate response

Once each day, the pacemaker evaluates the percentage of time the
sensor rate is in the submaximal and maximal rate ranges by comparing
the daily and monthly sensor-indicated rate profiles against the target rate
profile (see Figure 2-2). From this comparison, the pacemaker
automatically adjusts rate response in the submaximal and maximal
ranges, if necessary, based on the following criteria:

■

If the sensor rate profiles show a higher percentage of time spent
pacing than the target rate profile, rate response for the pertinent rate
range is set to be less responsive. Conversely, if a lower percentage
of time spent pacing is profiled than targeted for, rate response is set
to be more responsive (see Figure 2-3).

■

If the sensor rate profiles match the target rate profile or the daily and
monthly sensor rate profiles contradict each other, no rate response
adjustments occur.

The goal of this operation is to keep the patient’s sensor rate profiles
equivalent to the target rate profile.

Kappa 900/800 Series Pacemaker Reference Guide 2-7

Rate response

Rate Profile Optimization operation

30%

25%

20%

15%

10%

5%

Indicated % of Time

60-70

Lower

Rate

=

Target Rate Profile

=

Sensor Rate Profile

Less paced rates
than targeted for:

rate response in the

maximal range will be

adjusted to be

more aggressive

Maximal

Rate Range

120-130

130-140

70-80

More paced rates than

targeted for: rate response

in the submaximal range

will be adjusted to be

less aggressive

Submaximal

Rate Range

80-90 90-100 100-110 110-120

ADL
Rate

Figure 2-3. Optimizing rate response

Adaptations in Optimization operation

Upper

Sensor Rate

The pacemaker adapts rate response more rapidly for the first ten days
after Optimization is first activated post-implant or after certain rate
response parameters are manually reprogrammed (e.g., Lower Rate,
ADL Rate, Upper Sensor Rate, ADL Response, or Exertion Response).
The intent is to quickly match rate response to the target rate profile under
these circumstances.

Optimization also adapts rate response more rapidly when the difference
between the sensor rate profile and target rate profile is significant or
when a need for less rate response is indicated.

Optimization is skipped on any day that a device interrogation or
parameter programming occurs.

2-8 Kappa 900/800 Series Pacemaker Reference Guide

Individualizing Rate Profile Optimization

Individualizing Rate Profile Optimization

Overview

For Kappa 900/800 Series pacemakers, the clinician can prescribe a
target rate profile using the ADL Response and Exertion Response
parameters to match the patient’s life-style or activity levels. The
programmable ADL Response parameter alters the targeted rate
distribution in the submaximal rate range, while the Exertion Response
parameter alters the rate distribution in the maximal rate range.
Optimization takes approximately one month to incrementally adjust rate
response to match the individualized target rate profile.

Submaximal rate profiles

The nominal setting for the ADL Response parameter is “3-Moderately
Active.” Programming a more active setting redefines the target rate
profile to spend more time pacing at or above the ADL Rate, thereby
increasing rate responsiveness in the submaximal rate range.
Programming a less active setting redefines the rate profile to spend less
time pacing at or above the ADL Rate, thereby decreasing rate
responsiveness.

Rate response

Maximal rate profiles

The nominal setting for the Exertion Response parameter is
“3-Moderately Frequent.” Programming a more frequent setting redefines
the target rate profile to spend more time pacing near the Upper Sensor
Rate, thereby increasing rate responsiveness in the maximal rate range.
Programming a less frequent setting redefines the rate profile to spend
less time pacing near the Upper Sensor Rate, thereby decreasing rate
responsiveness.

Programming guidelines

If it is necessary to adjust rate response from the nominal setting, first
verify that the three rate controls are appropriate for the patient. The
Lower Rate should provide sufficient cardiac support at rest; the ADL
Rate should be set for submaximal rate support during typical daily
activities; and the Upper Sensor Rate should limit the rate during maximal

Kappa 900/800 Series Pacemaker Reference Guide 2-9

Rate response

Individualizing Rate Profile Optimization

exertion. If these rate control settings are appropriate, the ADL Response
and/or Exertion Response settings can then be adjusted based on the
guidelines in Table 2-1.

Rate range Select settings

Submaximal or Moderate
Rates

Maximal or High Rates Rate Response

a

If a higher Exertion Response setting has not produced the desired rate response, increase
the ADL Response setting.

For more detailed programming guidelines, refer to Table E-12 and
Table E-13, which list the targeted time spent pacing for the five ADL
Response and Exertion Response settings.

Table 2-1. ADL Response and Exertion Response guidelines

ADL Response

Rate Response
To o A g gr e s si v e

Rate Response
To o L o w

To o A g gr e s si v e

Rate Response
To o L o w

Lower Number
(Less Active)

Higher Number
(More Active)

Exertion Response

Lower Number
(Less Frequent Exertion)

Higher Number
(More Frequent Exertion)

a

2-10 Kappa 900/800 Series Pacemaker Reference Guide

Activity sensor operation

Overview

Activity sensor based pacing is controlled by the following programmable
parameters:

■

Activity Threshold determines the minimum intensity of detected
physical activity to which the pacemaker responds.

■

Activity Acceleration and Activity Deceleration times control how
rapidly the pacing rate changes in response to increased or
decreased activity. One programmable Activity Deceleration setting,
”Exercise,” provides an extended deceleration period following
prolonged exercise.

Note that Activity Threshold, Activity Acceleration, and Activity
Deceleration are automatically set to shipping settings 30 minutes after
implant or can be manually programmed.

How Activity Threshold influences rate

Activity sensor operation

Rate response

A piezoelectric crystal, bonded to the pacemaker circuitry, is deflected by
physical motion. The activity sensor converts detected motion into
electrical signals. The programmed Activity Threshold screens out activity
signals below the selected setting. Detected sensor signals vary from
patient to patient due to body structure, placement of pacemaker, and so
forth. Only sensor signals whose amplitude exceeds the programmed
Activity Threshold (as shown in Figure 2-4) are used in computing the
sensor-indicated rate. The lower the Activity Threshold, the smaller the
signal required to influence the sensor-indicated rate.

Kappa 900/800 Series Pacemaker Reference Guide 2-11

Rate response

Activity sensor operation

Activity

Sensor

Output

Time

Activity Threshold = Medium/Low

Figure 2-4. Activity sensor signal (threshold set to medium/low)

Settings

High

Med/High

Med/Low

Low

Low

Med/Low

Med/High

High

Evaluating the Activity Threshold setting

Walking increases the pacing rate; sitting results in pacing at or near the
programmed Lower Rate. Use Table 2-2 as a guide for selecting an
appropriate setting.

Table 2-2. Activity Threshold guidelines

Programmable
settings

Low Responds to most body activity, including minimal

Medium/Low Limited response to minimal exertion; responds to

Medium/High Limited response to moderate body movements and

High Responds to only vigorous body movements and

2-12 Kappa 900/800 Series Pacemaker Reference Guide

Typical rate performance

exertion.

moderate or greater exertion.

exertion.

exertion.

Activity sensor operation

Rate response

How Activity Acceleration and Deceleration influence rate

Activity Acceleration and Activity Deceleration times control how rapidly
the pacing rate changes in response to increased or decreased physical
activity. One programmable Activity Deceleration setting, ”Exercise,”
provides an extended deceleration period following prolonged exercise.

■

Activity Acceleration time is the time required to achieve
approximately 90% of the difference between the current rate and a
higher steady-state rate consistent with the current level of activity.
Figure 2-5 shows a graphic representation of the acceleration curves
at the onset of strenuous exercise.

■

Activity Deceleration time is the time required to achieve
approximately 90% of the difference between the current rate and a
lower steady-state rate consistent with the current level of activity.
Figure 2-6 shows a graphic representation of the deceleration curves
at an abrupt cessation of strenuous exercise.

Upper

Sensor

Rate

Activity Acceleration

Programmable Settings

15 Seconds

30 Seconds

Rate Range

Lower

Rate

210453

Time (Minutes)

60 Seconds

Figure 2-5. Activity Acceleration curves

Kappa 900/800 Series Pacemaker Reference Guide 2-13

Rate response

Activity sensor operation

Upper

Sensor

Rate

Rate Range

Lower

Rate

Activity Deceleration

Programmable Settings

2.5 Minutes

5 Minutes

10 Minutes

6543210 78910

Time (Minutes)

Figure 2-6. Activity Deceleration curves

2-14 Kappa 900/800 Series Pacemaker Reference Guide

Activity sensor operation

Rate response

Exercise Deceleration operation

Activity Deceleration programmed to “Exercise” extends the rate slowing
period following an exercise episode, providing up to 20 minutes of rate
deceleration. When it is programmed on, the pacemaker uses activity
sensor data to detect periods of vigorous, prolonged exercise. At the end
of such an exercise period, the pacemaker uses a longer deceleration
curve for the central portion of the programmed rate range. The actual
deceleration rate is determined dynamically based on the intensity and
duration of exercise and the new level of activity. Figure 2-7 shows the
composite deceleration curve that applies after the abrupt cessation of
sustained exercise.

Upper

Sensor

Rate

Rate Range

Lower

Rate

5 Minute Deceleration Curve

Begins Exercise Deceleration

Ends Exercise

Deceleration

121086420 14161820

Time (Minutes)

Figure 2-7. Exercise Deceleration

5 Minute

Deceleration

Curve

22

Kappa 900/800 Series Pacemaker Reference Guide 2-15

Rate response

Manual control of Rate Profile Optimization

Manual control of Rate Profile Optimization

Overview

As an alternative to automatic Rate Profile Optimization, a programmer
assisted Exercise test can be used to manually set rate response for the
submaximal and maximal rates. The Exercise test is used to immediately
set rate response to certain levels. Rate response parameters remain set
to their programmed values if Optimization is Off. When Optimization is
On, it can adjust these parameters once each day.

Evaluate and program rate response

The Exercise test is used to evaluate the patient’s rate response and allow
manual programming of two rate response control parameters:

■

ADL Setpoint (Activities of Daily Living Setpoint) determines the
minimum sensor response to pace at the ADL Rate, which falls within
the submaximal rate range.

■

UR Setpoint (Upper Rate Setpoint) determines the minimum sensor
response to pace at the Upper Sensor Rate, which is at the upper
limit of the maximal rate range.

Note: The programmed ADL Setpoint setting must be less than the UR
Setpoint setting.

Refer to the Kappa 900/800 Series Pacemaker Programming Guide for
programming instructions.

2-16 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

This chapter describes the programmable and
nonprogrammable timing intervals that govern the operation
of the pacemaker.

3

Rates 3-2

AV interva ls 3-9

Rate Adaptive AV 3-12

Search AV and diagnostic 3-15

Blanking periods 3-20

Refractory periods 3-21

High rate atrial tracking 3-30

Kappa 900/800 Series Pacemaker Reference Guide 3-1

Pacemaker timing

Rates

Rates

Overview

The following programmable rates control timing in the pacemaker:

■

Normal operating rates:

– Lower Rate

– ADL Rate

– Upper Tracking Rate

– Upper Sensor Rate

■

Other operating rates:

– Sleep Rate (for Sleep function)

– Hysteresis Rate (for single chamber demand modes)

– Sinus Preference Zone (for Sinus Preference)

– Intervention Rate (for Rate Drop Response)

Additionally, rates calculated by the pacemaker are used for some
operations. These are:

■

Sensor-indicated rate

■

Mean atrial rate

The other operating rates are described in “Special therapy options” on
page 5-1 along with the functions that use them. The normal rates are
described in this chapter.

3-2 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

Rates

A-A and V-V timing

A-A timing – In all modes that pace the atrium, the pacemaker times

from atrial event to atrial event (A-A timing). This timing method mimics a
natural sinus rhythm, producing A-A intervals that are nearly equal, except
when timing is interrupted by one of the following:

■

PACs in DDIR and DDI modes

■

PVCs in DDDR, DDD, DDIR, DDI modes (PVC Response operation)

■

A ventricular sensed event during the VA interval in the DVIR and DVI
modes

■

An atrial refractory sensed event that triggers an NCAP extension

VA intervals vary due to adjustments by A-A timing operations in order to
achieve sensor-indicated or lower rate operation in the presence of
varying AV conduction.

V-V timing – In modes that do not pace the atrium (e.g., VDD or VDIR) or
single chamber ventricular modes, the pacemaker times from ventricular
event to ventricular event (V-V timing).

P

DDD

A

V

Paramete rs:

Lower Rate

The programmed Lower Rate defines the slowest rate at which pacing
occurs during a mode’s basic operation. In rate responsive modes, in the
absence of sensor-detected activity, the sensor-indicated rate is equal to
the programmed Lower Rate.

Lower Rate Interval Lower Rate Interval

P

P

Lower Rate = 60 ppm (1000 ms) PVARP = 300 ms

PAV Interval = 200 ms Ventricular Refractory Period = 240 ms

SAV Interval = 180 ms

S

Figure 3-1. Example of Lower Rate operation

Kappa 900/800 Series Pacemaker Reference Guide 3-3

S

S

P

P

200 ms

Pacemaker timing

Rates

Operating lower rate

Under certain circumstances, the programmed Lower Rate may be
overridden by an operating lower rate that is higher or lower than the
programmed value. The following rates may become the operating lower
rate:

■

Switching from and back to atrial tracking mode (for Mode Switch)

■

Sinus Preference Zone (for Sinus Preference)

■

Sleep Rate (for Sleep function)

■

Intervention Rate (for Rate Drop Response)

■

Hysteresis Rate (for single chamber modes)

■

Threshold Margin Test Rate of 100 ppm

■

Magnet Mode Rate of 85 ppm

■

Elective Replacement Indicator Rate of 65 ppm

Selecting a Lower Rate

Program the Lower Rate to maintain adequate heart rates during periods
of inactivity or during pauses in atrial rhythms in the DDDR, DDD, VDD,
AAIR, ADIR, AAI, and ADI modes.

Note: In the VDD mode, atrial tracking near the Lower Rate may result in
V-V intervals that exceed the Lower Rate interval. This is normal
operation.

Lower Rates from 120 to 130 ppm are intended for pediatric patients.
Lower Rates below 50 ppm and above 100 ppm are primarily intended for
diagnostic purposes.

3-4 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

Rates

Sensor-indicated rate

The sensor-indicated rate is the basic pacing rate in all rate responsive
modes (DDDR, DDIR, DVIR, DOOR, VVIR, VDIR, VOOR, AAIR, ADIR,
and AOOR). It is determined by the pacemaker based on the sensor­detected level of patient activity and the programmed rate response
parameters. The sensor-indicated rate will never be greater than the
Upper Sensor Rate or less than the Lower Rate.

Sensor-Indicated

Interval

Sensor Sensor Sensor

P

DDDR

A

V

Parameters:

P

Sensor-Indicated Rate = 90 ppm (667 ms) PVARP = 300 ms

PAV Interval = 200 ms Ventricular Refractory Period = 220 ms

SAV Interval = 190 ms

P

S

Sensor-Indicated

Interval

S

S

Figure 3-2. Example of Sensor-indicated rate operation

In rate responsive modes, the sensor-indicated rate tracks the activity
sensor, which is detected by the piezoelectric crystal sensor’s frequency
and amplitude.

■

In dual chamber rate responsive modes, the sensor-indicated interval
is the AS-AP or AP-AP interval.

■

In single chamber rate responsive modes, the sensor-indicated
interval is the A-A or V-V interval. In these modes, sensor-indicated
rate intervals start with a sensed or paced event in the chamber being
paced.

P

P

200 ms

Kappa 900/800 Series Pacemaker Reference Guide 3-5

Pacemaker timing

Rates

Sensor indicated rate effect on other intervals

The sensor-indicated rate is used to determine the values of certain other
timing intervals. These intervals are:

■

Rate adaptive paced AV (PAV) interval

■

Sensor-varied PVARP (even in non-rate responsive DDD and VDD
modes)

■

PVARP extension (sensor-corroboration before PMT intervention)

ADL Rate

The ADL Rate (Activities of Daily Living Rate) is the target rate which the
patient’s heart rate is expected to reach during moderate exercise.

Upper Tracking Rate

The programmable Upper Tracking Rate is the maximum rate at which the
ventricle may be paced in response to sensed atrial events in the DDDR,
DDD, and VDD modes. Sensed atrial events below the Upper Tracking
Rate will be tracked at a 1:1 ratio, but sensed events above the Upper
Tracking Rate will result in pacemaker Wenckebach (for example, 6:5, 4:3,
3:2, or 2:1 block). The Upper Tracking Rate usually should be
programmed to a value less than the 2:1 block rate. Refer to “High rate
atrial tracking” on page 3-30 for details.

Upper Tracking Rate

DDD

S

A

V

P

S

Figure 3-3. Example of Upper Tracking Rate (Wenckebach) operation

3-6 Kappa 900/800 Series Pacemaker Reference Guide

Paramete rs:

Sensor-indicated Rate =

75 ppm (800 ms)

Upper Tracking Rate =

100 ppm (600 ms)

SAV Interval = 200 ms

P

200 ms

Pacemaker timing

Rates

Upper Sensor Rate

In rate responsive modes, the programmable Upper Sensor Rate
provides the upper limit for the sensor-indicated rate during physical
activity, particularly during vigorous exercise. In the DDDR mode, the
Upper Sensor Rate may be higher than, lower than, or the same as the
Upper Tracking Rate.

Programming considerations and restrictions

ADL Rate – It is recommended that the ADL Rate be at least 10 ppm less

than the Upper Sensor Rate or 20 ppm greater than the Lower Rate.
However, programming the ADL Rate above or below these limits is
permitted.

Upper rates – Programming a combination of high Upper Sensor Rate
and Upper Tracking Rate and a long refractory period may result in a
shorter “sensing window.” Loss of sensing in such cases could result in
competitive pacing (unless Non-Competitive Atrial Pacing is programmed
On). See “Non-competitive atrial pacing” on page 5-8 for more
information.

■

Programming the Upper Tracking Rate to a value greater than the
Upper Sensor Rate permits the atrial rhythm to be tracked to a rate
higher than the sensor-driven rate.

■

The Upper Sensor Rate and/or Upper Tracking Rate must be greater
than the Lower Rate. The Upper Sensor Rate must be greater than
the ADL Rate.

Rate limit

An internal circuit, independent of the pacing timers, limits single chamber
atrial or ventricular pacing rates to 200 ppm (± 20 ppm) for most single
component failures. For dual chamber modes, atrial and ventricular rates
are limited independently to 200 ppm (± 20 ppm). The rate limit is
automatically disabled during temporary pacing in the AAI, ADI, AAT,
AOO, VVI, VDI, VVT, and VOO modes to allow high rate pacing for
diagnostic or therapeutic purposes.

Kappa 900/800 Series Pacemaker Reference Guide 3-7

Pacemaker timing

Rates

Possible atrial competition at high rates

At high sensor-driven rates in the DDDR and DDIR modes, sensor-driven
pacing may approximate the intrinsic atrial rate, with some intrinsic atrial
events falling into the PVARP. This could result in asynchronous pacing
with the potential for competitive atrial pacing. Consider the potential for
asynchronous pacing at high rates before selecting an Upper Sensor
Rate, especially for patients known to be susceptible to induction of atrial
tachyarrhythmias. Weigh the benefits of high rate sensor-driven pacing
against the potential for competitive pacing.

Note: Use of the Rate Adaptive AV feature and sensor-varied or
automatic PVARP can reduce the likelihood of the type of asynchronous
pacing described above. In the DDDR mode, Sinus Preference and NCAP
can also be considered.

Mean atrial rate

The mean atrial rate (MAR) is a running average of the atrial rate for use
by the Rate Adaptive AV and automatic PVARP features. The average
uses all A-A intervals (except AS-AP or AR-AP intervals). In order to
respond quickly to rapidly increasing atrial rates, the average gives
preference to shorter A-A intervals over longer intervals when calculating
the MAR. Figure 3-4 shows how the MAR tracks an increasing intrinsic
atrial rate.

Atrial Rate Increasing by 2 bpm/beat

200

180

160

140

120

Rate (bpm)

100

80

60

0 5 10 15 20 25 30 35

Figure 3-4. Increasing mean atrial rate

3-8 Kappa 900/800 Series Pacemaker Reference Guide

MAR

Intrinsic Rate

Time (Seconds)

AV intervals

Pacemaker timing

AV interval s

Overview

In dual chamber modes, the AV intervals determine the time between the
occurrence of an atrial event and the scheduled delivery of a ventricular
stimulus. Separate AV intervals for paced and sensed atrial events are
available. The lengths of these intervals may be programmed to fixed
values or (optionally) rate adaptive or therapeutically determined.

Paced AV Interval (PAV) – PAV follows an atrial pace in the DDDR, DDD,
DDIR, DDI, DVIR, DVI, DOOR, and DOO modes. The PAV interval
duration may differ from the programmed value due to one of the following
operations:

■

Rate Adaptive AV

■

Search AV

■

Ventricular Safety Pacing

■

Non-Competitive Atrial Pacing

PAV

Interval

PAV PAV

P

PAV

Interval

P

DDD

A

V

P

P

Figure 3-5. Example of PAV interval operation

Kappa 900/800 Series Pacemaker Reference Guide 3-9

Pacemaker timing

AV intervals

Sensed AV Interval (SAV) – SAV follows an atrial sensed event in atrial
synchronous pacing modes (DDDR, DDD, and VDD). The SAV interval
duration may differ from the programmed value due to one of the following
operations:

■

Rate Adaptive AV

■

Automatic PVARP

■

Search AV

■

Wenckebach

For Wenckebach operation, the SAV is extended to avoid violation of the
Upper Tracking Rate or the total atrial refractory period while tracking a
fast intrinsic atrial rate.

SAV

Interval

S

SAV SAV

DDD

A

V

PP

Figure 3-6. Example of SAV Interval operation

SAV

Interval

S

3-10 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

AV interval s

Selecting PAV and SAV

When programming AV intervals, the general hemodynamic goal is to
assure that, to the extent possible, left-atrial systole is completed before
left-ventricular systole begins. To achieve this, the AV interval durations
may be adjusted independently of each other.

■

To accommodate the difference in interatrial conduction times, the
SAV usually should be programmed to a shorter duration than the
PAV, typically 30 to 50 ms shorter. If an SAV greater than the PAV is
selected, the programmer notes that this is not usual, but the
selected values may be programmed if clinically warranted.

■

When the SAV is longer than the PAV, a V pace following an atrial
sense will always occur after the full SAV, even when the sensor­indicated rate or Lower Rate interval expires first.

■

In certain patients, short AV intervals may be used as a prophylaxis
for AV nodal or accessory pathway reentrant tachycardias in dual
chamber modes.

■

AV intervals should be programmed to allow for normal AV
conduction and ventricular depolarization in sick sinus patients.

■

Long PAV intervals (greater than or equal to 250 ms) should be used
with caution. If intrinsic ventricular events occur and are not sensed,
a long PAV may result in pacing into the ventricle’s relative refractory
period, including the T wave, or loss of AV synchrony, which may
precipitate retrograde activation of the atria with corresponding
hemodynamic consequences and symptoms. Long PAV intervals
may also result from some Search AV settings (see “Search AV and
diagnostic” on page 3-15).

Kappa 900/800 Series Pacemaker Reference Guide 3-11

Pacemaker timing

Rate Adaptive AV

Rate Adaptive AV

Overview

In the normal heart, AV conduction times tend to shorten as the heart rate
increases and to lengthen as the heart rate decreases. The Rate Adaptive
AV (RAAV) feature, available in the DDDR, DDD, DDIR, DVIR, DOOR,
and VDD modes, mimics this physiologic response. When RAAV is
programmed On, the pacemaker shortens AV intervals for atrial rates
within a programmed rate range. This feature provides increased
opportunity for atrial sensing, as follows:

■

Shortened SAV intervals increase the tracking range at fast atrial
rates by shortening the total atrial refractory period (TARP) and
increasing the 2:1 block rate. Refer to “Total Atrial Refractory Period
(TARP)” on page 3-25 and “High rate atrial tracking” on page 3-30 for
more information.

■

Shortened PAV intervals lengthen the atrial sensing window of the VA
interval at higher sensor-driven rates.

Note: RAAV will not shorten PAV intervals to less than 30 ms or shorten
SAV intervals to less than 10 ms.

Programming for Rate Adaptive AV

For RAAV operation, the SAV and PAV are programmed (as applicable) to
the values desired for low rates. Three additional programmable
parameters control how AV intervals are adjusted at higher rates:

Start Rate – RAAV operation of shortening SAV and PAV intervals begins
at this rate.

Stop Rate – The shortest SAV and PAV occur at this rate and at all higher
rates, up to the upper rate limits.

Maximum Offset – The maximum amount of time (in ms) by which the
SAV and PAV intervals can be shortened.

The PAV minus the Maximum Offset gives the shortest PAV interval at the
Stop Rate (e.g., 200 ms - 100 ms = 100 ms). Subtracting the Maximum
Offset from the SAV gives the shortest SAV interval (e.g., 170 ms ­100 ms = 70 ms).

3-12 Kappa 900/800 Series Pacemaker Reference Guide

240

220

200

180

160

140

120

100

AV Interval (ms)

80

60

40

20

Pacemaker timing

Rate Adaptive AV

Figure 3-7 shows how the SAV and PAV intervals are linearly shortened
as the rate increases from below the Start Rate to above the Stop Rate.

Programmed PAV

Programmed SAV

R

a

t

e

R

a

t

e

A

d

a

p

t

A

d

a

i

v

e

P

p

t

i

v

e

A

S

V

A

V

Shortest PAV

(PAV - Max. Offset)

Shortest SAV

(SAV - Max. Offset)

0

50

80

Start Rate Stop Rate

100

Rate (ppm)

Parameters:

Programmed SAV = 170 ms Start Rate = 80 ppm Maximum Offset = 100 ms

Programmed PAV = 200 ms Stop Rate = 150 ppm

Figure 3-7. Rate Adaptive AV operation (DDDR Mode)

Kappa 900/800 Series Pacemaker Reference Guide 3-13

150 180

Pacemaker timing

Rate Adaptive AV

RAAV operations

Shortening of the AV interval(s) occurs when the appropriate rate
exceeds the programmed Start Rate, as follows:

SAV – The mean atrial rate determines SAV adjustments. Because of
how the mean atrial rate is calculated:

■

SAV adjustments will lag during rapid increases or decreases in
intrinsic atrial rates.

■

The SAV is not adjusted for isolated events (PACs).

■

AS-AP or AR-AP intervals may affect the SAV value since these
intervals are not used in the mean atrial rate calculation.

PAV – The sensor-indicated rate determines PAV adjustments.

The approximate difference between programmed SAV and PAV is
maintained as the SAV and PAV intervals are adjusted.

Programming considerations and restrictions

Search AV – RAAV will adjust AV intervals in conjunction with Search AV.

Search AV will first determine the appropriate AV intervals and RAAV will
further modify the AV intervals. Note that with RAAV On, the adaptive
Search AV operation is limited to the RAAV minimum of 30 ms.

RAAV and sick sinus syndrome

If RAAV is activated for a sick sinus syndrome patient whose PAV and SAV
have been programmed to promote AV conduction, consider the following:

■

The rate at which AV conduction is lost should not be too low (i.e.,
below 90 bpm).

■

Review of the AV Conduction Histogram diagnostic data may aid in
appropriate programming of Start Rate and Stop Rate to maintain AV
conduction as long as possible.

3-14 Kappa 900/800 Series Pacemaker Reference Guide

Search AV and diagnostic

Overview

The Search AV feature is intended for patients with intact or intermittent
AV conduction and is available in the DDDR, DDD, DDIR, DDI, DVIR, DVI,
and VDD modes for dual chamber Kappa 900 Series pacemakers. The
pacemaker searches for the patient’s intrinsic AV conduction time and
adjusts the SAV and PAV intervals either longer or shorter to promote
intrinsic activation of the ventricles and to track fast atrial rates. When
Rate Adaptive AV is active, the pacemaker will also adjust the SAV and
PAV intervals relative to the rate adaptive values.

Two methods for adapting AV intervals are available:

■

Adjusting the AV intervals adaptively as intrinsic AV conduction times
vary.

■

Adjusting AV intervals at a fixed hysteresis value to sensed
ventricular events.

Pacemaker timing

Search AV and diagnostic

Programming to Adaptive AV

Programming Search AV to “Adaptive” operation requires setting the
Maximum Offset parameter. This parameter defines the maximum
amount of time (in ms) that the operating SAV and PAV intervals can be
lengthened.

Kappa 900/800 Series Pacemaker Reference Guide 3-15

Pacemaker timing

Search AV and diagnostic

Adaptive AV operation

The pacemaker attempts to keep intrinsic conducted events in an “AV
delay window” that precedes scheduled paced events. The AV delay
window is set to promote intrinsic conduction of the ventricles, but end
early enough to avoid fusion or pseudo-fusion beats if pacing is necessary
(see Figure 3-8).

Previous 16 AV events, 8 or more VS events are within 15 ms of the
scheduled VP, thus PAV and SAV are extended by 31 ms to
promote intrinsic conduction.

PAV i s n o w
181 ms

Previous 16 AV events, 8 or more VS events occur 55 ms
before the scheduled VP, thus PAV and SAV are shortened by
8 ms to limit long AV delays if ventricular pacing is needed.

Paramete rs:

DDDR SAV = 120 ms

Lower Rate = 60 ppm PAV = 150 ms

Sensor-Indicated Rate = 90 ppm Maximum Offset = 110 ms

Figure 3-8. Adaptive Search AV operation

To determine when intrinsic conducted events occur, the pacemaker
assesses the 16 most recent AV conduction sequences that start with a
nonrefractory atrial sense (DDDR, DDD, and VDD modes) or an atrial
pace (DDDR, DDD, DDIR, DDI, DVIR, and DVI modes) and end with a
ventricular pace or a nonrefractory ventricular sense.

3-16 Kappa 900/800 Series Pacemaker Reference Guide

PAV i s n o w
173 ms

200 ms

Pacemaker timing

Search AV and diagnostic

Search criteria of AV conduction times – The measured AV
conduction times are classified as either “too short” or “too long.”

■

Where too short means 8 or more of the last 16 ventricular sensed
events occurred within 15 ms of the scheduled ventricular pace, or 8
or more of the last 16 ventricular sensed events failed to occur before
the pace.

■

Where too long means 8 or more of the last 16 ventricular sensed
events occurred more than 55 ms before the scheduled ventricular
pace.

Resultant adjustment of SAV and PAV intervals – If AV conduction
times are classified as too short, the pacemaker will lengthen the
operating SAV and PAV intervals by 31 ms for the next 16 pacing cycles
to promote intrinsic conduction. The maximum that the SAV and PAV can
be lengthened is limited by the Search AV Maximum Offset parameter.

If the previous 16 AV intervals were lengthened and are now classified as
too long, the operating SAV and PAV intervals will be shortened by 8 ms
for the next 16 pacing cycles. Shortening of the SAV and PAV is limited by
the programmed SAV and PAV values or the RAAV Maximum Offset
parameter, if RAAV is On.

Suspension of Adaptive AV operation

If maximum extension of the SAV and PAV intervals is reached and the
search criteria indicate that the AV intervals are still too short, the
pacemaker will suspend all AV interval adjustments for 1 hour and reset
the SAV and PAV intervals to the programmed or current RAAV values.
Subsequent AV interval adjustments will be successively suspended at 2,
4, 8, and a maximum of 16 hours, provided the maximum AV interval
length is indicated as too short.

When the search criteria indicate that the AV intervals are too long, the
current suspension period is terminated and adjustments of AV intervals
resume.

Programming to fixed AV hysteresis

Programming Search AV to a specific AV hysteresis delay (in ms) defines
the amount of time the operating SAV and PAV intervals can be
lengthened.

Kappa 900/800 Series Pacemaker Reference Guide 3-17

Pacemaker timing

Search AV and diagnostic

Fixed AV hysteresis operation

The pacemaker modulates the AV intervals according to whether or not
the previous AV sequence started with an atrial event and ended with a
ventricular pace or sense.

■

If the AV sequence ended with a ventricular sense, the programmed
SAV and PAV intervals for the next pacing cycle will be lengthened by
the programmed fixed AV hysteresis delay value to promote intrinsic
conduction.

■

If the AV sequence ended with a ventricular pace, the programmed
SAV and PAV intervals are restored to the programmed or RAAV
values for the next pacing cycle.

After any A to VS event, SAV and PAV are
extended by 60 ms to promote intrinsic
conduction.

SAV is now
180 ms

Parameters:

DDDR SAV = 120 ms

Lower Rate = 60 ppm PAV = 150 ms

Sensor-Indicated Rate = 90 ppm AV Hysteresis set to 60 ms

Figure 3-9. Hysteresis Search AV operation

Programming considerations and restrictions

Automatic PVARP – When automatic PVARP is active and Search AV is

set to Adaptive, the pacemaker will ignore conduction times that are the
result of automatic PVARP shortening of the SAV interval.

Rate Adaptive AV – Rate Adaptive AV (RAAV) will adjust AV intervals in
conjunction with Search AV. Search AV will first determine the appropriate
AV intervals and RAAV will further modify the AV intervals. Note that with
RAAV On, the adaptive Search AV operation is limited to the RAAV
minimum of 30 ms.

PAV is n ow
210 ms

After any A to VP event, SAV and PAV return
to programmed values to limit long AV
delays if ventricular pacing is needed.

200 ms

3-18 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

Search AV and diagnostic

When RAAV is active between the RAAV Start Rate and Stop Rate,
Search AV will use the operating rate adaptive SAV and PAV intervals
when assessing and adjusting the AV intervals. At rates below the RAAV
Start Rate or when RAAV is Off, Search AV will use the programmed SAV
and PAV values.

Recording AV interval adaptations

AV interval diagnostics record data about AV operations for the Search AV
feature. Also, you have the option to record detailed data about AV
operations.

Automatic Search AV Histogram

Programming AV Search parameters automatically initiates recording of
data by the Search AV Histogram diagnostic. This histogram shows the
number of A-VS, VS from Search, and A-VP intervals versus rate. A
histogram can be displayed or printed from the Data icon.

Detail AV Interval Histogram

You have the option to record detailed histogram data on AV intervals for
the Search AV feature. The clinician-selected AV Interval Histogram
shows the number of AS-VS and AP-VS intervals versus rate. (Refractory
sensed events are not included.)

AV Interval Histograms record data about AV operations for the Search AV
feature.

Clearing AV interval data

AV interval data is normally cleared by the pacemaker one hour after a
programming session.

However, you can select the option to clear data immediately. Be sure to
save the session data or print the episode report before ending the patient
session.

Kappa 900/800 Series Pacemaker Reference Guide 3-19

Pacemaker timing

Blanking periods

Blanking periods

Blanking periods disable sensing for a programmable or
nonprogrammable interval. Signals that are blanked may originate in
either chamber or from outside sources such as noise from muscle
movement.

Note: Black bars indicate blanking
periods.

12

P

DDD

A

V

34

P

1. Nonprogrammable Atrial Blanking

2. Programmable Post-Ventricular Atrial

P

Blanking

3. Programmable Ventricular Blanking

4. Nonprogrammable Ventricular Blanking

Figure 3-10. Example of dual chamber blanking operation

Nonprogrammable blanking periods

Immediately following a sensed or paced event in either chamber, sensing
for that chamber is blanked for a nonprogrammable period that may vary
from 50 to 100 ms. The actual duration of the blanking period is
determined dynamically by the pacemaker, based on the strength and
duration of the signal. Dynamic blanking prevents sensing the same
signal twice, while minimizing total blanking time.

Post-Ventricular Atrial Blanking

The programmable Post-Ventricular Atrial Blanking (PVAB) period, used
in the DDDR, DDD, DDIR, DDI, VDD, VDIR, and VDI modes, prevents
sensing of ventricular paced events or far-field R waves on the atrial lead.
Any ventricular event (paced or sensed) starts the PVAB, which is also the
first portion of the Post-Ventricular Atrial Refractory period (PVARP). The
PVAB is limited to values equal to or less than the programmed PVARP,
except in VDIR and VDI modes where PVARP does not apply.

Note: PVAB is programmed to a value less than or equal to PVARP.

3-20 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

Refractory periods

Ventricular Blanking

The programmable Ventricular Blanking period, which follows an atrial
pacing stimulus in the DDDR, DDD, DDIR, DDI, DVIR, and DVI modes,
prevents ventricular inhibition or ventricular safety pacing due to sensing
of the atrial stimulus on the ventricular lead (crosstalk). The Ventricular
Blanking period also applies to the ADIR and ADI modes to prevent
sensing of the atrial stimulation.

■

Long blanking periods (36 ms or greater) increase the possibility of
unsensed ventricular events.

■

Long blanking periods used in conjunction with long PAV intervals
(250 ms or greater) may result in pacing into the Twave when
intrinsic ventricular events are blanked and not sensed. PAV values
(200 ms or less) should reduce the possibility of Twave pacing. Long
PAV intervals may also result from some Search AV settings (see
“Search AV and diagnostic” on page 3-15).

Single chamber atrial blanking

The programmable single chamber atrial blanking period, used in the
AAIR, ADIR, AAI, ADI, and AAT mode, prevents sensing of far-field
R waves. It is started by a paced, sensed, or refractory sensed atrial
event.

Note: Atrial Blanking must be programmed at least 50 ms less than the
Atrial Refractory Period.

Refractory periods

Overview

A refractory period is an interval during which an intrinsic event sensed on
a particular lead channel cannot start certain timing intervals. Each
refractory period begins with a blanking period, during which no sensing
occurs. During the unblanked portion of a refractory period, sensing
occurs, but sensed events may not directly affect timing operations.
Refractory periods are intended to prevent certain timing intervals from
being started by inappropriate signals such as retrograde P waves, far­field R waves, or electrical noise.

Kappa 900/800 Series Pacemaker Reference Guide 3-21

Pacemaker timing

Refractory periods

Though they may not start timing intervals, refractory sensed events are
monitored by the pacemaker, and they affect the operation of PVC
Response, Mode Switch, Rate Adaptive AV operation, automatic PVARP,
Non-Competitive Atrial Pacing, and other features for which the periodicity
or number of sensed events are pertinent. Refractory sensed events are
included on Marker Channel recordings.

Post-Ventricular Atrial Refractory Period

The Post-Ventricular Atrial Refractory Period (PVARP) follows a paced,
sensed, or refractory sensed ventricular event in the DDDR, DDD, DDIR,
DDI, and VDD modes. It is intended primarily to prevent the sensing of
retrograde P waves that might promote Pacemaker-Mediated
Tachycardias (PMTs) in atrial tracking modes. In the DDIR and DDI
modes, PVARP prevents atrial inhibition from retrograde P waves.

The first portion of the PVARP is the programmable Post-Ventricular Atrial
Blanking period (PVAB). During the remainder of the PVARP, intrinsic
atrial events may be sensed as refractory sensed events (AR) and
identified on Marker Channel recordings, but they do not affect stimulus
timing.

■

In the DDDR, DDD, and VDD modes, an SAV is not started.

■

In the DDDR, DDD, DDIR, and DDI modes, the scheduled atrial pace
is not inhibited.

P

DDD

A

V

Figure 3-11. Example of PVARP operation

The duration of the PVARP may be selected as follows:

■

The PVARP should be programmed to a value greater than the
patient’s ventriculoatrial (VA) retrograde time when retrograde
conduction is present.

3-22 Kappa 900/800 Series Pacemaker Reference Guide

PVARP

P

P

Pacemaker timing

Refractory periods

■

Excessively long PVARPs may induce 2:1 block at high intrinsic rates
in atrial tracking modes (DDDR, DDD, and VDD).

■

To reduce the 2:1 block point, PVARP can be set to vary based on the
sensor-indicated rate (sensor-varied PVARP) or the mean atrial rate
(automatic PVARP).

Sensor-varied PVARP

When sensor-varied PVARP is programmed, the pacemaker determines
a value for the PVARP based on the sensor-indicated rate. The intended
purpose of the sensor-varied PVARP depends upon the mode:

■

In the DDDR, DDD, and VDD modes, sensor-varied PVARP is
intended to do the following:

– Enhance protection against PMT at lower rates by providing

longer PVARPs at low sensor-indicated rates

– Allow tracking of higher atrial rates (that is, provide a higher

2:1 block rate) by shortening the PVARP at high sensor-

indicated rates

■

In the DDIR mode, the sensor-varied PVARP is intended to promote
AV synchrony by preventing inhibition of atrial pacing by an atrial
sense early in the VA interval. It also reduces the likelihood of
competitive atrial pacing at high sensor-indicated rates.

Upper

Sensor

Rate

Lower

Rate

400 ms 300 ms 400 ms

PAV PVARP PAV PVARP

200 ms

Figure 3-12. Sensor-varied PVARP operation (DDDR Mode)

Kappa 900/800 Series Pacemaker Reference Guide 3-23

Pacemaker timing

Refractory periods

Determining sensor-varied PVARP

The pacemaker determines the duration of the sensor-varied PVARP as
follows:

■

In the DDDR, DDD, and VDD modes, the sensor-varied PVARP is
limited to 400 ms at low rates and the programmed PVAB at high
rates (as shown in Figure 3-12).

■

In the DDIR mode, the sensor-varied PVARP is approximately
400 ms at low rates and the programmed PVAB at high rates.

■

In the DDDR, DDD, DDIR, and VDD modes, the sensor-varied
PVARP is automatically adjusted to maintain a 300 ms sensing
window (as shown in Figure 3-12).

Automatic PVARP

When automatic PVARP is programmed, the pacemaker determines a
value for the PVARP based on the mean atrial rate (which is an average
of all A-A intervals except those starting with an atrial sense or atrial
refractory sense and ending with an atrial pace). In the DDDR, DDD, and
VDD modes, automatic PVARP is intended to provide a higher 2:1 block
rate by shortening the PVARP and SAV (if necessary) at higher tracking
rates and protect against PMTs at lower rates by providing a longer
PVARP.

Determining automatic PVARP

The pacemaker determines the duration of the automatic PVARP as
follows:

■

After every four pacing cycles, a 2:1 block rate is calculated that is
30 bpm above the current mean atrial rate.

■

PVARP is then adjusted so the total atrial refractory period equals the
calculated 2:1 block rate. The programmable Minimum PVARP
parameter controls the minimum value that PVARP can be shortened
to.

■

If the minimum PVARP value is reached and the 2:1 block rate is still
too low, the SAV interval can be shortened to increase the 2:1 block
rate. The minimum SAV that can be set is the rate adaptive SAV value
(i.e., the programmed SAV value minus the RAAV Maximum Offset
value).

3-24 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

Refractory periods

The minimum adjustable 2:1 block rate is 100 ppm. The maximum
adjustable 2:1 block rate is the Upper Tracking Rate plus 35 ppm. If Mode
Switch is On, the maximum 2:1 block rate can be the Detect Rate if this
rate is less than the Upper Tracking Rate calculation.

Programming restrictions for automatic PVARP

Rate Drop Response – When programmed On in the DDD mode,

automatic PVARP is not available.

Spontaneous PVARP extension

The programmed PVARP duration, the sensor-varied PVARP, and the
automatic PVARP may be overridden by the PVC Response and PMT
Intervention features, as follows:

■

When the PVC Response feature is programmed On and a
pacemaker-defined PVC occurs, the PVARP is forced to 400 ms for
one cycle if a lesser value is in effect.

■

When PMT Intervention is programmed On and a pacemaker­defined PMT is detected, the PVARP is forced to 400 ms for one
cycle after the ninth paced ventricular event of the PMT.

Refer to “PMT intervention” on page 5-10 and “PVC Response” on
page 5-13 for further details on the PMT Intervention and PVC Response
features and their interactions with PVARP.

Total Atrial Refractory Period (TARP)

In dual chamber modes that sense in the atrium, the Total Atrial
Refractory Period (TARP) is the sum of two intervals, as follows:

AV Inter va l – The AV interval begins with an atrial event and ends with a
ventricular event. The first portion is a nonprogrammable blanking period.
Its complete duration is determined as follows:

■

In the DDDR, DDD, and VDD modes, the PAV or SAV interval is the
AV interval.

Kappa 900/800 Series Pacemaker Reference Guide 3-25

Pacemaker timing

Refractory periods

■

In the DDIR and DDI modes, the AV interval starts with the first atrial
sensed event in the VA interval or with an atrial pacing stimulus; it
ends when the PAV expires, even when ventricular pacing is
inhibited.

Post-Ventricular Atrial Refractory Period (PVARP) – The PVARP is
described on page 3-22.

TARP TA RP

SAV + PVARP

SAV

PVARP

SAV

PVARP

Figure 3-13. Total Atrial Refractory Period

During atrial tracking, TARP = SAV + PVARP, and its duration determines
the rate at which 2:1 block occurs. Refer to “High rate atrial tracking” on
page 3-30 for more information.

Ventricular Refractory Period

The programmable Ventricular Refractory Period (VRP) follows paced,
sensed, and refractory sensed ventricular events (including PVCs) in all
dual chamber and ventricular modes that sense in the ventricle. The VRP
is intended to prevent sensing of the T wave or a PVC. The first portion of
the VRP is a nonprogrammable blanking period. A ventricular refractory
sensed event affects pacemaker timing as follows:

■

Ventricular blanking and refractory periods restart in all modes.

■

In the DDDR, DDD, and VDD modes, the upper tracking rate interval,
PVARP, and PVAB also restart.

■

In the VVIR and VDIR modes, the upper sensor rate interval restarts.

Note: In dual chamber modes, the VRP should be programmed shorter
than the PVARP.

3-26 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

Refractory periods

P

DDD

A

V

P

Figure 3-14. Example of Ventricular Refractory Period operation

In dual chamber modes, a ventricular refractory sensed event does not
affect a scheduled sensor-driven or lower rate atrial output. Thus, a
sensor-driven atrial output pulse will initiate a PAV with a ventricular
output pulse following, unless inhibited.

P

VRP

Atrial Refractory Period (single chamber)

The programmable Atrial Refractory Period (ARP) follows paced, sensed,
and refractory sensed atrial events. The ARP is used in the AAIR, ADIR,
AAI, ADI, and AAT modes. It is intended to prevent inhibition due to far­field R wave sensing. The first portion of the ARP is a programmable
blanking period. The ARP should be programmed to a value long enough
(150 ms or greater) to prevent far-field R wave sensing but short enough
to ensure atrial sensing up to the programmed Upper Sensor Rate.

Noise reversion

When sensing occurs during the Atrial Refractory Period (ARP) or
Ventricular Refractory Period (VRP), the refractory period (and its
blanking period) are restarted. The operation associated with continuous
refractory sensing in the ARP or VRP is called noise reversion. Multiple
restarts of the ARP or VRP (continuous noise reversion) do not inhibit
scheduled pacing. Pacemaker behavior during continuous noise
reversion is as follows:

■

Pacing occurs at the sensor-indicated rate for all rate responsive
modes (except VVIR and VDIR).

Kappa 900/800 Series Pacemaker Reference Guide 3-27

Pacemaker timing

Refractory periods

Sensor Sensor Sensor

P

DDDR

A

V

Paramete rs:

■

Pacing occurs at the programmed Lower Rate for all non-rate
responsive modes (including VVIR and VDIR).

On the ECG, noise reversion may be difficult to distinguish from loss of
sensing, but Marker Channel recordings will show refractory sense
markers when noise reversion occurs.

Sensor-Indicated Interval

P

R

R

P

Lower Rate = 60 ppm (1000 ms) Upper Sensor Rate = 120 ppm (500 ms)

PAV Interval = 200 ms Ventricular Refractory Period = 240 ms

PVARP = 300 ms PVAB = 200 ms

R

P

P

P

200 ms

Figure 3-15. Example of noise reversion in DDDR at sensor-indicated rate.

Note: Atrial sensing during the PVARP, or refractory period following an
atrial paced or sensed event in the DDDR, DDD, DDIR, DDI, or VDD
modes does not restart the refractory period. An atrial refractory sensed
event, however, will start a short blanking period of 50 to 100 ms
depending on the signal strength and duration of the atrial event.

3-28 Kappa 900/800 Series Pacemaker Reference Guide

VVIR

V

Paramete rs:

Lower Rate

R R R R P

Sensor

P

Lower Rate = 60 ppm (1000 ms) Ventricular Refractory Period = 240 ms

Upper Sensor Rate = 120 ppm (500 ms)

Figure 3-16. Example of noise reversion in VVIR at lower rate.

Preventing noise sensing

Pacemaker timing

Refractory periods

Sensor

P

200 ms

Noise reversion may be caused by electromagnetic interference (EMI),
myopotentials, excessively high output settings, or low sensitivity settings.
When it has been identified, noise reversion usually can be reduced or
eliminated by one of the following actions:

■

Reprogram sensitivity to a less sensitive setting (higher numerical
value) or program Sensing Assurance to On, to monitor and if
necessary, adjust the sensitivity value. Refer to “Sensing Assurance
and diagnostic” on page 4-26.

■

Reprogram sensing polarity to bipolar polarity (if available).

■

Reduce the amplitude and/or pulse width in the same or opposite
chamber.

■

Program Capture Management to Adaptive to monitor ventricular
capture thresholds, and, if necessary, adjust amplitude and pulse
width values. Refer to “Capture Management and diagnostic” on
page 4-12.

■

Remove patient from EMI environment.

Kappa 900/800 Series Pacemaker Reference Guide 3-29

Pacemaker timing

High rate atrial tracking

High rate atrial tracking

Overview

In the DDDR, DDD, and VDD modes, the fastest atrial rate the pacemaker
can track is determined by the total atrial refractory period (TARP), which
is the sum of the SAV and the PVARP. Pacemaker behavior at high atrial
rates in these modes is determined by the relationship between the TARP
and the interval corresponding to the Upper Tracking Rate. In the DDDR
mode, the interval corresponding to the Upper Sensor Rate also must be
considered.

2:1 block

When the intrinsic atrial interval is shorter than the TARP, some atrial
events will fall in the PVARP and not be tracked. At the rate where this first
occurs, ventricular tracking occurs only on alternate beats, and 2:1 block
ensues. In the DDD and VDD modes, the ventricular pacing rate drops
precipitously.

■

When sensor-varied PVARP or automatic PVARP is selected, the
2:1 block rate may occur at a higher rate during activity due to
shortening of the PVARP and the SAV (automatic PVARP only), thus
increasing atrial tracking.

■

When Rate Adaptive AV operation is selected, the SAV shortens at
high atrial rates, shortening the TARP and raising the 2:1 block rate.

■

When the 2:1 block rate is less than the Upper Tracking Rate, the
Upper Tracking Rate cannot be achieved.

■

In the DDDR mode, pacing at the sensor-indicated rate may prevent
a precipitous rate drop at the 2:1 block point when activity is present.

■

For patients with a documented propensity for prolonged or
sustained atrial fibrillation or flutter, the clinician can select Upper
Tracking Rate, SAV, and PVARP values that induce 2:1 block at a
desired rate (2:1 block rate = 60,000/TARP). Alternatives for
controlling rates in these patients include use of the Mode Switch
feature and DDIR mode pacing.

■

In the DDDR mode, atrial competition may occur if the Upper Sensor
Rate exceeds the 2:1 block rate.

3-30 Kappa 900/800 Series Pacemaker Reference Guide

Pacemaker timing

High rate atrial tracking

Pacemaker Wenckebach

When the 2:1 block rate exceeds the programmed Upper Tracking Rate,
pacemaker Wenckebach may occur. When the intrinsic rate exceeds the
Upper Tracking Rate, a pacing stimulus at the expiration of the SAV would
violate the upper tracking rate. The pacemaker therefore extends the SAV
until the upper tracking rate interval expires. Subsequent SAVs require
greater extension, until an atrial event falls in the PVARP and is not
tracked.

■

In the DDDR, DDD, and VDD modes, the result is normally a fixed
ratio between atrial and ventricular rates (3:2, 4:3, and so forth).

■

In the DDDR mode, the pacemaker Wenckebach rate may be
smoothed by sensor-driven ventricular pacing, thereby overriding the
fixed ratio.

Figure 3-17 shows how pacemaker Wenckebach operation occurs in the
DDDR, DDD, or VDD modes.

S

DDDR

A

V

Paramete rs:

Upper Tracking

Rate Interval

S

P

Sensor-Indicated Rate = 90 ppm (667 ms) PVARP = 300 ms

PAV Interval = 230 ms Upper Tracking Rate = 100 ppm(600 ms)

SAV Interval = 200 ms

Upper Tracking

Rate Interval

P

Upper Tracking

Rate Interval

SAV

Interval

S

P

S

P

Figure 3-17. Example of pacemaker Wenckebach operation

Sensor

P

R

P

200 ms

Kappa 900/800 Series Pacemaker Reference Guide 3-31

Pacemaker timing

High rate atrial tracking

High rate operation in the DDDR mode

Table 3-1 summarizes how the total atrial refractory period (TARP), the
Upper Tracking Rate (UTR) interval, and the Upper Sensor Rate (USR)
interval may interact at high atrial rates in the DDDR mode.

Table 3-1. Upper rates interaction with TARP

Relationship Between
TARP and Upper Rate
Intervals

TARP > both USR and
UTR intervals

USR interval > TARP >
UTR interval

USR interval > UTR
interval > TARP

UTR interval > both
USR interval and TARP

a

Unless the Non-Competitive Atrial Pacing is On, see “Non-competitive atrial pacing” on
page 5-8.

Wenckebach

Before 2:1

Block

no no yes

no no no

yes yes no

yes yes yes

Achieve Upper

Tracking Rate

Pote ntial

Atrial

Competition

a

a

3-32 Kappa 900/800 Series Pacemaker Reference Guide

Lead / cardiac tissue interface

This chapter discusses programming and follow-up topics
relating to the lead/cardiac tissue interface.

4

Implant Detection 4-2

Automatic polarity
configuration 4-3

Lead Monitor 4-8

Lead impedance data 4-10

Capture Management and
diagnostic 4-12

Sensing Assurance and
diagnostic 4-26

Manually selecting pacing
parameters 4-31

Manually selecting sensing
parameters 4-34

Transtelephonic follow-up
features 4-38

Kappa 900/800 Series Pacemaker Reference Guide 4-1

Lead / cardiac tissue interface

Implant Detection

Implant Detection

Overview

Implant Detection is a 30-minute period, beginning at lead insertion,
during which the pacemaker verifies that each lead has been connected
by measuring lead impedance. After 30 minutes of continuous lead
connection, the pacemaker completes Implant Detection and activates
the following features (see Figure 4-1):

■

■

■

■

■

■

Operating polarity (automatic configuration occurs during Implant
Detection)

Adaptive sensitivity settings (Sensing Assurance)

Rate responsive pacing, including adaptive rate profile optimization
(Rate Profile Optimization)

Adaptive ventricular output settings for threshold management
(Capture Management)

Adaptive AV interval selection (Search AV)

Diagnostic data collection

Lead Connection Verified

Implant

Leads connected

Figure 4-1. Implant Detection period

Implant Detection is available in all pacing modes and is turned on at
shipment.

Note: Automatic polarity configuration does not occur during Implant
Detection if the Lead Monitor parameter is programmed to Monitor Only
before implant. Automatic configuration will take place if Lead Monitor is
programmed to Adaptive before implant or remains set to its shipping
setting of Configure.

4-2 Kappa 900/800 Series Pacemaker Reference Guide

30 Minutes

Lead polarities confirmed

Rate Response enabled

Adaptive features activated

Data collection activated

Verifying lead connection during Implant Detection

At the time of lead insertion, the pacemaker begins verifying that each
lead is present by measuring the impedance of each pacing pulse. When
a pace is delivered, the pacemaker determines if the impedance is within
the acceptable range, which is programmable between 200 to 4000
ohms for both bipolar and unipolar configurations.

■

High impedance paces cause Implant Detection to reset.

■

Low impedance paces (and continuous sensing) are considered
acceptable for the purpose of determining lead connection and
configuring polarity.

Automatic polarity configuration

Overview

During Implant Detection, bipolar pacemakers automatically configure
pacing and sensing polarities through the Lead Monitor feature. Bipolar
pacemakers are shipped with the Atrial and Ventricular Lead Monitor set
to Configure, enabling automatic polarity determination shortly after lead
connection.

Lead / cardiac tissue interface

Automatic polarity configuration

1

Unipolar-only pacemakers are configured to unipolar pacing and sensing
polarity at the time of manufacture and remain unipolar during the
operational life of the pacemaker.

Measuring lead impedance during configuration

Bipolar pacemakers, using either bipolar or unipolar leads, automatically
configure pacing and sensing polarities by measuring the impedance of
each pace during the configuration period. (Lead Monitor must be set to
Configure or Adaptive. See “Lead Monitor” on page 4-8.) Impedance
measurement during configuration is as follows:

1

The acceptable maximum impedance limit for a valid lead (bipolar or unipolar) can be
changed by programming the Notify If > (Greater Than) parameter, which is part of the Lead
Monitor and is found under the programmed lead polarities. The minimum impedance limit
of 200 ohms is nonprogrammable.

Kappa 900/800 Series Pacemaker Reference Guide 4-3

Lead / cardiac tissue interface

Automatic polarity configuration

■

The pacemaker issues a bipolar pace and immediately checks the
pace for high impedance.

– If the pace is within range, it is considered an acceptable bipolar

pace.

– If high impedance is found, the pacemaker immediately follows

the bipolar pace with a backup unipolar pace.

■

If a unipolar backup pace is issued, the pacemaker checks it for high
impedance.

– If the pace is within range, it is considered an acceptable

unipolar pace.

– If high impedance is found, the pacemaker assumes a lead is not

attached and restarts Implant Detection.

Notes:

■

During polarity configuration, the pacemaker also detects low
impedance paces but does not follow them with unipolar backup
paces. To avoid possible loss of capture due to continuous low
impedance pacing, the pacemaker sets unipolar polarity when 3 of 16
paces are detected as low impedance during the first phase of
configuration (see “Initial Configuration Phase” on page 4-5).

■

If the pacemaker assumes a lead is not present (a high impedance
unipolar pace is detected) in one chamber of a dual chamber
pacemaker, Implant Detection will restart.

How polarities are automatically configured

Atrial and ventricular lead polarities are configured independently in dual
chamber bipolar models, with the exception of Models K
have fixed bipolar atrial sensing only.

Operating pacing and sensing polarities for bipolar pacemakers are
configured automatically in two phases during Implant Detection. (See
Figure 4-2.) During these phases the pacemaker continues to measure
impedance as described above.

4-4 Kappa 900/800 Series Pacemaker Reference Guide

VDD

901, which

Implant Detection

Lead / cardiac tissue interface

Automatic polarity configuration

Implant

Leads Connected

Phase

5 Minutes

Lead polarities

configured

Confirmation PhaseInitial Configuration

30 Minutes

Lead polarities

Figure 4-2. Automatic configuration of bipolar models

Initial Configuration Phase – The pacemaker sets lead polarities five
minutes after lead connection unless a high impedance unipolar pace has
reset Implant Detection, a prevalence of low impedance bipolar paces has
set unipolar pacing, or if continuous sensing has occurred.

The pacemaker sets initial polarities as follows:

■

The pacemaker delivers three asynchronous paces at magnet rate.

■

If at least two of the three paces are determined to be bipolar, the
pacemaker remains set to bipolar polarity (with backup unipolar
paces) for the Confirmation Phase.

■

If at least two of the three paces are determined to be unipolar, the
pacemaker sets polarity to unipolar. Unipolar polarity becomes the
operating polarity for pacing and sensing, and no Confirmation
Phase is required.

confirmed

Note: If one of the asynchronous paces in a given chamber is a high
impedance unipolar pace, the pacemaker restarts Implant Detection
in both chambers. Polarity configuration restarts only in the affected
chamber, however.

Confirmation Phase – Twenty-five minutes after initial configuration, the
pacemaker confirms final operating polarity for leads configured bipolar in
the Initial Configuration Phase. During this 25-minute Confirmation
Phase, the pacemaker measure the leads for high and low impedance
paces. If 8 of 16 paces (or the programmed number of paces out of
sixteen) are out of range, the lead will automatically be reconfigured to
unipolar polarity.

At the end of twenty-five minutes, operating polarity for leads detected as
bipolar during the Initial Configuration Phase is determined as follows:

■

The pacemaker delivers three asynchronous paces at magnet rate.

Kappa 900/800 Series Pacemaker Reference Guide 4-5

Lead / cardiac tissue interface

Automatic polarity configuration

■

If at least two of the three paces are determined to be bipolar, the
pacemaker sets operating polarity to bipolar (or Adaptive operation if
Lead Monitor was programmed to Adaptive prior to implant). See
“Lead Monitor” on page 4-8.

■

If at least two of the three paces are determined to be unipolar, the
pacemaker sets operating pace and sense polarities to unipolar.

Note: If a high impedance unipolar pace occurs in a given chamber
at any time during the 25-minute Confirmation Phase, the pacemaker
restarts Implant Detection in both chambers. Polarity configuration
restarts only in the affected chamber, however.

Leads configured unipolar during the Initial Configuration Phase continue
to operate in the unipolar configuration. If bipolar polarity switches to
unipolar during the Confirmation Phase, the operating polarity remains
unipolar with no additional confirmation through asynchronous pacing.

w

Warning: If, at implant, the setscrews, both tip and ring, for a 3.2 mm
connector pacemaker are not properly engaged and all electrical contacts
are not sealed, leakage between the tip and ring contacts may occur.
Such leakage may cause the pacemaker to falsely identify a unipolar lead
as bipolar, resulting in a loss of output. The same result could occur for all
bipolar models if the electrical contacts were not properly sealed when
using lead extenders or adaptors.

When automatic configuration is complete

Thirty minutes after lead connection, Implant Detection and automatic
configuration are complete. If, after this time period, the leads are
detached and lead polarity type is changed, automatic configuration and
Implant Detection do not restart automatically at reinsertion. The clinician
must reprogram Implant Detection to On/Restart, which automatically
resets Lead Monitor to Configure.

The Lead Monitor feature (see “Lead Monitor” on page 4-8) monitors and
reports on lead stability when Implant Detection and automatic
configuration are complete. It is automatically set by the pacemaker as
follows:

■

Bipolar models are shipped with Lead Monitor set to Configure.
However, after Implant Detection ends, Lead Monitor is automatically
set to Monitor Only for bipolar and unipolar configurations.

4-6 Kappa 900/800 Series Pacemaker Reference Guide

Lead / cardiac tissue interface

Automatic polarity configuration

■

Bipolar models with Lead Monitor programmed to Adaptive before
implant are set to Adaptive if polarity was determined to be bipolar. If
polarity for these models was determined to be unipolar, they are set
to Monitor Only.

■

Unipolar models are shipped with Lead Monitor set to Monitor Only
and continue to operate at that setting both during and after Implant
Detection.

Manually setting polarities

To manually program atrial or ventricular lead polarities at implant, the
clinician first must “turn off” the Configure setting under Lead Monitor by
choosing the Monitor Only setting instead. Implant Detection still provides
the 30-minute detection period, followed by automatic feature and
diagnostics activation, when the pacemaker is programmed manually.

Programming interactions

■

Programming Implant Detection to Off /Complete before completion
of the 30-minute automatic polarity configuration period requires the
clinician to manually program Lead Monitor and polarities. The
pacemaker’s automatic features are activated when Implant
Detection is turned off.

■

Manually programming Implant Detection to On/Restart restarts lead
detection, polarity configuration (Lead Monitor is set to Configure),
and automatic feature activation.

■

Initiating a programming session at any time during Implant Detection
causes Implant Detection to be restarted.

■

While Implant Detection is in progress, the programmer is unable to
run temporary tests and battery and lead measurements.

■

If a dual chamber pacemaker is programmed to a single chamber
mode, only one lead is configured. If the mode is reprogrammed to a
dual chamber mode, the clinician will need to change the Lead
Monitor from Configure to Monitor Only or Adaptive for the
unconfigured lead, and then program pace and sense polarity for it
manually.

Kappa 900/800 Series Pacemaker Reference Guide 4-7

Lead / cardiac tissue interface

Lead Monitor

Lead Monitor

Overview

The Lead Monitor feature measures lead impedances during the life of the
pacemaker. When programmed to do so, Lead Monitor also enables the
pacemaker to switch bipolar pacing and sensing to unipolar when bipolar
lead integrity is in doubt. It also controls automatic configuration of lead
polarities at implant. Lead Monitor is available in all pacing modes.

#

Caution: If the Lead Monitor detects out-of-range lead impedance,
investigate lead integrity more thoroughly.

How lead monitoring works

The Lead Monitor feature monitors lead impedance of paced chambers,
as defined by the mode, by measuring the impedance of each pacing
pulse to see if it falls within the programmed impedance range for a stable
lead.

The three programmable values under Atrial or Ventricular Lead Monitor
are as follows:

■

Configure - provides automatic configuration of polarity (see “How
polarities are automatically configured” on page 4-4).

■

Adaptive

– monitors bipolar paces for high impedance and provides

unipolar backup paces when high impedance is detected.

– switches pacing and sensing polarity from bipolar to unipolar

when the pacemaker detects a prevalence of high or low
impedance paces (see Monitor Sensitivity parameter in
Table 4-1). The Lead Monitor setting changes to Monitor Only
when polarity switches.

– provides automatic polarity configuration when selected prior to

implant.

■

Monitor Only - monitors either unipolar or bipolar paces to
determine if they are out of range but does not switch polarity when
an out-of-range lead is indicated.

4-8 Kappa 900/800 Series Pacemaker Reference Guide

Lead / cardiac tissue interface

Lead Monitor

Lead Monitor is activated at lead connection, and it is automatically set to
its operating value of Monitor Only or Adaptive at the end of Implant
Detection. See “When automatic configuration is complete” on page 4-6.

When Lead Monitor is set to Adaptive or Monitor Only and a lead is
determined to be out of range, the pacemaker issues a lead warning that
appears on the programmer screen at the next interrogation.

Lead Monitor programmable parameters – The programmable
parameters for the Lead Monitor feature are shown below.

Table 4-1. Programmable parameters for Lead Monitor

General Parameters Meaning

Atrial Lead Monitor Monitors lead impedance in the atrium; option to

Ventricular Lead Monitor Monitors lead impedance in the ventricle; option to

Notify If < (Less Than) Nonprogrammable minimum boundary for

Notify If > (Greater
Than)

Monitor
Sensitivity

provide unipolar backup paces and to switch from
bipolar to unipolar polarity for an out-of-range lead;
provides automatic configuration of polarity at
implant.

provide unipolar backup paces and switch from
bipolar to unipolar polarity for an out-of-range lead;
provides automatic configuration of polarity at
implant.

acceptable atrial and ventricular bipolar lead
impedance. Fixed at 200 ohms.

Maximum boundary for acceptable atrial and
ventricular bipolar lead impedance.

Number of high or low impedance paces out of 16
that define an out-of-range lead on each channel.

Lead Monitor should not be programmed to Adaptive for patients with
implantable defibrillators. When a prevalence of out-of-range lead
impedance paces is detected, the monitor automatically reprograms the
selected lead(s) to unipolar polarity. Pacing in the unipolar configuration
may cause the defibrillator either to provoke inappropriate therapy or to
withhold appropriate therapy.

Kappa 900/800 Series Pacemaker Reference Guide 4-9

Lead / cardiac tissue interface

Lead impedance data

Lead impedance data

Lead impedance data is recorded automatically. In addition, you may
collect detailed daily information about lead impedance.

Automatic Lead Impedance
(Chronic Lead Trend)

The automatic Lead Impedance diagnostic data is based on
measurements taken every three hours for each chamber that is being
paced. The maximum and minimum lead impedance are compared to
initial values. If the difference between either value is approximately 30%,
data will be added to the Chronic Lead Trend for the life of the pacemaker.

The following data is continuously updated:

■

Lifetime minimum impedance

■

Lifetime maximum impedance

■

High impedance paces

■

Low impedance paces

If the maximum number of high impedance paces or low impedance
paces is reached, that value will remain until the data is cleared. All other
diagnostic data collection will continue.

Note: If pulse width is programmed to a value greater than 1.0 ms, the
reported lead impedance will be lower than the actual lead impedance. In
this case, the correct lead impedance can be measured during a patient
session by selecting the Battery and Lead Measurements option.
Accuracy of lead measurements for the Lead Monitor Adaptive or Lead
Monitor Only parameter is not affected by pulse width settings greater
than 1.0 ms.

Note: Chronic Lead Trend data collection can be programmed Off. To
display or print the data, select the Data icon.

4-10 Kappa 900/800 Series Pacemaker Reference Guide