Medtronic KDR603 Reference Guide

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KAPPA®700/600

Pacemaker Series

Pacemaker Reference Guide

Medtronic.Kappa™ 700/600 Series Pacemaker Reference Guide

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

A guide to the Medtronic.Kappa

™

700/600 Series pacemakers:

700/720/730 Series

700 Series

VDD

700 Series

KSR700 Series

600 Series

Refer to the Medtronic.Kappa™ 700/600 Pacemaker Programming Guide for information on software and programming.

The following terms are trademarks of Medtronic, Inc.

Capture Management, Checklist, FAST, Fast Path, Implant Detection, Kappa, Key Parameter History, Marker Channel, Medtronic, Medtronic.Kappa, Medtronic.Vision, 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 Medtronic.Kappa 700/600 Series software and pacemakers is presented in two separate guides.

The Pacemaker Reference Guide (PRG) is a supplementary guide that provides detailed information on Medtronic.Kappa 700/600 Series pacemakers.

The Pacemaker Programming Guide (PPG) accompanies Medtronic.Kappa 700/600 Series software and contains instructions on how to use the programmer and the programming software.

About this Guide

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

How to Use This Guide

■

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.

Medtronic.Kappa 700/600 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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Table of Contents

1. Pacing Modes

Table of Contents

How to Use This Guide iii

Introduction 1-2 Mode Selection Decision Tree: 1-4 Mode Pertinency Tables 1-5 Indications and Usage 1-7 Contraindications 1-8 DDDR Mode 1-9 DDD Mode 1-10 DDIR Mode 1-11 DDI Mode 1-12 DVIR Mode 1-13 DVI Mode 1-14 VDD Mode 1-15 AAIR / ADIR Modes 1-16 AAI / ADI Modes 1-17 VVIR / VDIR Modes 1-18 VVI / VDI Modes 1-19 AAT / VVT Modes 1-20 DOOR / AOOR / VOOR Modes 1-21 DOO / AOO / VOO Modes 1-22 ODO / OAO / OVO Modes 1-23

2. Rate Response

Introduction to Rate Responsive Pacing 2-2 Preset Rate Response at Implant 2-4 Rate Profile Optimization Operation 2-6 Individualizing Rate Profile Optimization 2-11 Activity Sensor Operation 2-13 Manual Control of Rate Profile Optimization 2-19

3. Pacemaker Timing

Rates 3-2 AV Intervals 3-12

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Table of Contents

Rate Adaptive AV 3-16 Search AV and Diagnostic 3-20 Blanking Periods 3-26 Refractory Periods 3-29 High Rate Atrial Tracking 3-40

4. Lead / Cardiac Tissue Interface

Implant Detection 4-2 Automatic Polarity Configuration 4-4 Lead Monitor 4-10 Lead Impedance Data 4-13 Capture Management and Diagnostic 4-15 Sensing Assurance and Diagnostic 4-31 Manually Selecting Pacing Parameters 4-37 Manually Selecting Sensing Parameters 4-41 Transtelephonic Follow-up Features 4-46

5. Special Therapy Options

Mode Switch and Diagnostic 5-2 Non-Competitive Atrial Pacing 5-9 PMT Intervention 5-12 PVC Response 5-16 Ventricular Safety Pacing 5-19 Sinus Preference and Diagnostic 5-21 Rate Drop Response and Diagnostic 5-25 Sleep Function 5-32 Single Chamber Hysteresis 5-34

6. Telemetry Data

Establishing Telemetry 6-2 Parameter Summary 6-3 Patient Information 6-6 Battery and Lead Information 6-8 Marker Channel Telemetry 6-10 Intracardiac Electrograms 6-12 Extended Telemetry 6-15

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

7. Miscellaneous Operations

Magnet Mode Operation 7-2 Temporary Programming 7-5 Electrical Reset 7-7 Elective Replacement Indicator (ERI) 7-9 Emergency Pacing 7-10

8. Diagnostics

Introduction to Diagnostics 8-2 Atrial and Ventricular Rate Histograms 8-9 AV Conduction Histograms 8-12 Sensor Indicated Rate Profile 8-15 Atrial and Ventricular High Rate Diagnostics 8-17 Remote Assistant Diagnostics 8-22 Custom Rate Trend 8-25 Key Parameter History 8-27

9. Troubleshooting the Pacing System

Troubleshooting Strategy 9-2 Troubleshooting Electrical Problems 9-3 Troubleshooting Hemodynamic Problems 9-6 Handling, Storage, and Resterilization 9-9 Pacemaker Longevity 9-10 Replacing the Pacemaker 9-12 Patient Information and Service 9-13

Table of Contents

A. Pacemaker Description

Model Number Designator A-2 Radiopaque Codes A-3 Physical Dimensions A-5 Connector Dimensions A-6

B. Preset Parameter Settings

Shipping Settings B-2 Nominal Settings B-8 Electrical Reset Settings B-14 Emergency Settings B-22

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

vii

Table of Contents

C. Longevity Projections

Longevity Projections (Normal Operating Life) C-2 Longevity Projections (After ERI) C-8 Elective Replacement Indicator (ERI) C-11 Battery Specifications C-12

D. Telemetry and Diagnostic Values

Magnet Mode Operations D-2 Telemetry Functions D-3 Automatic Diagnostics D-7 Clinician-Selectable Diagnostics D-9 Cardiac Event Counters D-12

E. Parameter Values and Restrictions

Programmable Modes and Parameters E-2 Rate Response Programming Guidelines E-13 Timing Reference E-14

F. Warnings and Precautions

Special Notice F-2 Warnings F-4 Precautions F-6 Potential Complications F-11

G. Environmental Interference

Hospital or Medical Environment Interference G-2 Home and Job Environment Interference G-6

H. Glossary

I. Index

viii

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Understanding Pacemaker Operation

Chapters 1 - 9 provide detailed information about the operation of the Kappa 700/600 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.

Introduction

Mode Selection Decision Tree:

Mode Pertinency Tables

Indications and Usage

Contraindications

DDDR Mode

DDD Mode

DDIR Mode

DDI Mode

DVIR Mode

DVI Mode

1-2

1-4

1-8

1-9

1-10

1-11

1-12

1-13

1-14

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

1-7

1-5

VDD Mode

AAIR / ADIR Modes

AAI / ADI Modes

VVIR / VDIR Modes

VVI / VDI Modes

AAT / VVT Modes

DOOR / AOOR / VOOR Modes

DOO / AOO / VOO Modes

ODO / OAO / OVO Modes

1-15

1-16

1-17

1-18

1-19

1-20

1-21

1-22

1-23

1-1

Pacing Modes

Introduction

Pacing Mode Selection

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

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

provides a simple means of identifying pacing modes appropriate for given indications.

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

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

NBG Pacing Codes

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

1-2

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). 18: 1-13.

Bernstein A., et al., “The NASPE/BPEG Pacemaker Code,” PACE, 10(4), Jul-Aug

1987. (“NBG” stands for The North American Society of Pacing and Electrophysiology [NASPE] and the British Pacing and Electrophysiology Group [BPEG] Generic. NBG’s five-letter code supersedes the ICHD Code.

Journal of the American College of Cardiology.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

1991;

Pacing Modes

Introduction

CHAMBER PACED

V = Ventricle A = Atrium D = Dual Chamber S = Single Chamber O = None

CHAMBER SENSED

V = Ventricle A = Atrium D = Dual Chamber S = Single Chamber O = None

Figure 1-1.

DDDR

NBG Pacing Codes

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

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, respectively.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

1-3

Pacing Modes

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(s) is listed and the alternate mode(s) appears 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

VVIR

VVI

Ye s

Can the atrium be sensed

and/or paced reliably?

Is AV conduction

presently adequate?

AAIR

DDDR

Figure 1-2.

Ye s

DDD

DDDR

VDD

Mode Selection Tree

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

Is SA node conduction

presently adequate?

Ye s

DDDR

DDIR

1-4

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacing Modes

Mode Pertinency Tables

black

✓

es.

✓ ✓

✓✓✓ ✓✓

✓✓✓✓ ✓

✓✓✓✓

. Automatic PVARP is available in the DDDR, DDD, and VDD mod

Mode Pertinency Tables

Pacing Parameters Available for Each Mode

Table 1-1.

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

Pacing Parameter

Lower Rate ✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓

Upper Tracking Rate ✓✓ ✓

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

Paced AV Interval ✓✓✓✓✓✓

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

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

are active or when rate response is operative but not pertinent to basic mode operation. These parameters ar

programmable. Note that certain features are not available in Kappa 600 Series pacemakers for certain pacing modes;

see Section E for specific details. Also, asynchronous modes are not shown in these tables.

Sensed AV Interval ✓✓ ✓

✓✓✓✓ ✓

Rate Adaptive AV ✓✓✓✓✓

PVARP

PVAB ✓✓✓✓ ✓ ✓ ✓

Atrial Refractory Period

Atrial Blanking

✓✓✓✓✓✓✓✓✓✓✓✓

✓✓✓✓✓✓

Ventricular Refractory

Period

Ventricular Blanking

(after AP)

Sensing Assurance ✓✓✓✓✓✓✓✓✓✓✓

See Chapter 3 for descriptions of these timing parameters. Sensing Assurance and Capture Management are described in Chapter 4.

Capture Management ✓✓✓✓✓✓✓✓✓✓✓

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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

1-5

Pacing Modes

Mode Pertinency Tables

Features Available for Each Mode

✓✓

✓✓✓ ✓✓ ✓

Tabl e 1- 2.

1-6

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

Managing Atrial

RhythmaMode Switch ✓✓ ✓

✓✓

Non-Competitive Atrial

Pacing

Managing Ventricular

RhythmaPMT Intervention ✓✓ ✓

PVC Response ✓✓✓✓ ✓

Ventricular Safety Pacing ✓✓✓✓✓✓

Special Pacing

Operations

Rate Drop Response ✓✓

Search AV ✓✓✓✓✓✓✓

Single Chamber

Hysteresis

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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

Sinus Preference ✓

Sleep Function ✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓

Rate Response

ADL Rate ✓ – ✓ – ✓ ––✓✓–––✓✓–––

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

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

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

See Chapter 2 for operational descriptions of rate response features.

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

Indications and Usage

Medtronic.Kappa 700/600 Series pacemakers are indicated for the following:

■

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 AV block.

– Symptomatic bilateral bundle branch block.

– Symptomatic paroxysmal or transient sinus node

dysfunctions with or without associated AV conduction disorders.

– Bradycardia-tachycardia syndrome to prevent

symptomatic bradycardia or some forms of symptomatic tachyarrhythmias.

Pacing Modes

Indications and Usage

– Vasovagal syndromes or hypersensitive carotid sinus

syndromes.

Medtronic.Kappa 700/600 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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

1-7

Pacing Modes

Contraindications

Medtronic.Kappa 700/600 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.

1-8

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

DDDR Mode

Pacing Modes

DDDR Mode

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

■

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

■

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

■

A nonrefractory sensed event in either chamber inhibits pacing in that chamber. A ventricular nonrefractory sensed event in the VA interval that is not preceded by an atrial sense (AS or AR) is a pacemaker-defined 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) SAV Interval = 170 ms

A P

V S

Figure 1-3.

Example of DDDR Mode Operation

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

Sensor-indicated

Interval

A S

V S

A P

V P

value.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

A S

V P

200 ms

1-9

Pacing Modes

DDD Mode

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

■

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

■

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

■

A ventricular nonrefractory sensed event in the VA interval

that is not preceded by an atrial sense (AS or AR) is a pacemaker-defined PVC, and starts a new VA interval.

1-10

Lower Rate Interval

A P

V P

Parameters:

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

Figure 1-4.

A P

V S

SAV Interval = 170 ms

Example of DDD Mode Operation

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

A S

V S

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Lower Rate Interval

200 ms

A P

DDIR Mode

Pacing Modes

DDIR Mode

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

■

Atrial pacing occurs at the sensor-indicated rate, with ventricular pacing at the end of the PAV interval unless inhibited.

■

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 sensor-indicated 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

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms Sensor-indicated Rate = 90 ppm (667 ms)

A P

Figure 1-5.

Sensor-indicated

Interval

A S

V P

Example of DDIR Mode Operation

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Sensor-indicated

VA Interval

V P

Sensor-indicated

A P

V P

Interval

200 ms

A P

1-11

Pacing Modes

DDI Mode

Lower Rate Interval

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

■

Atrial pacing occurs at the Lower Rate, with ventricular pacing at the end of the PAV interval unless inhibited.

■

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

Lower Rate Interval

VA Interval

A P

V P

Parameters:

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

A P

Figure 1-6.

1-12

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

A S

V P

Example of DDI Mode Operation

200 ms

A P

DVIR Mode

Pacing Modes

DVIR Mode

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

■

Atrial pacing occurs at the sensor-indicated rate, with ventricular pacing at the end of the PAV interval unless inhibited.

■

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

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms Sensor-indicated Rate = 90 ppm (667 ms)

A P

V S

Figure 1-7.

Example of DVIR Mode Operation

Sensor-indicated

V S

VA Interval

Sensor-indicated

A P

V P

Interval

A P

200 ms

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

1-13

Pacing Modes

DVI Mode

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

■

Atrial pacing occurs at the Lower Rate, with ventricular pacing at the end of the PAV interval unless inhibited.

■

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

Lower Rate Interval

A P

V P

Parameters:

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

Figure 1-8.

A P

V S

Example of DVI Mode Operation

V S

Lower Rate

VA Interval

A P

V P

200 ms

1-14

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

VDD Mode

Pacing Modes

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.

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

Parameters:

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.

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

Example of VDD Operation

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

A S

V P

A S

200 ms

1-15

Pacing Modes

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 sensor-indicated 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.

In the AAIR and ADIR modes, atrial refractory sensed

Note:

events do not restart the Upper Sensor Rate interval.

Sensor-indicated Interval Sensor-indicated Interval

1-16

A P

Parameters

Sensor-indicated Rate = 75 ppm (800 ms) Upper Sensor Rate = 100 ppm (600 ms)

A P

Figure 1-10.

Example of AAIR Mode Operation

A S

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

A P

200 ms

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 Modes

AAI / ADI Modes

Pacing Rate Interval

A P

Parameters:

Pacing Rate = 75ppm (800 ms)

A R

Figure 1-11.

Pacing Rate Interval

A P

A S

Example of AAI Mode Operation

800600400200 1000

A P

200 ms

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

1-17

Pacing Modes

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:

events restart the Upper Sensor Rate interval.

In the VVIR and VDIR modes, ventricular refractory sensed

Sensor-indicated

Interval

V P

Parameters:

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

Figure 1-12.

Sensor-indicated

Interval

Upper Sensor

Rate Interval

V P

V R

V P

Example of VVIR Mode Operation

Sensor-indicated

Interval

V P

200 ms

1-18

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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 Modes

VVI / VDI Modes

Pacing Rate Interval

V P

Parameters:

Pacing Rate = 60 ppm (1000 ms) Ventricular Refractory Period = 300 ms

Figure 1-13.

Pacing Rate Interval

V P

V S

Example of VVI Mode Operation

200 ms

V P

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

1-19

Pacing Modes

AAT / VVT Modes

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

Note:

ms (200 ppm) from the previous paced event. Temporary programmed triggered pacing is not limited to 300 ms (200 ppm).

Programmed triggered pacing will not occur faster than 300

Pacing Rate Interval

V P

Parameters:

Pacing Rate = 60 ppm (1000 ms) Ventricular Refractory Period = 300 ms

V R

Figure 1-14.

Pacing Rate Interval

V P

T P

Example of VVT Mode Operation

V P

200 ms

1-20

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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.

Pacing Modes

DOOR / AOOR / VOOR Modes

Sensor-indicated

Interval

A P

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms Sensor-indicated Rate = 90 ppm (667 ms)

Sensor-indicated

Interval

A P

V P

Figure 1-15.

Sensor-indicated

A P

Example of DOOR Mode Operation

Interval

V P

Sensor-indicated

Interval

A P

V P

A P

200 ms

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

1-21

Pacing Modes

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.

Besides 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.

Lower Rate Interval

A P

V P

Parameters:

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

Figure 1-16.

Lower Rate Interval

A P

V P

Example of DOO Mode Operation

Lower Rate Interval

A P

V P

200 ms

A P

1-22

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

ODO / OAO / OVO Modes

Pacing Modes

ODO / OAO / OVO Modes

Warning:

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(s). When used in conjunction with Marker Channel telemetry and concurrent ECG, these modes may be used to observe underlying rhythms.

■

Never program these modes for pacemaker-dependent

Blanking periods in these modes are automatically minimized to maximize the sensing window(s). 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.

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1-23

Pacing Modes

ODO / OAO / OVO Modes

1-24

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Rate Response

This chapter describes how the pacemaker’s automatic rate response features operate and how to individualize rate response. The sections are as follows:

Introduction to Rate Responsive Pacing

Preset Rate Response at Implant

Rate Profile Optimization Operation

Individualizing Rate Profile Optimization

2-4

2-6

2-11

2-2

Activity Sensor Operation

Manual Control of Rate Profile Optimization

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

2-19

2-13

2-1

Rate Response

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.

2-2

■

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

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Rate Response

Introduction to Rate Responsive Pacing

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.

For Further Information

Refer to “Rate Profile Optimization Operation” on page 2-6 for information on how the pacemaker optimizes rate response.

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2-3

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.

Rate response is enabled for other operations in nonrate

Note:

responsive modes (e.g., DDD mode switching to DDIR).

Three Pacing Rate Controls

2-4

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 sensordriven rate during vigorous exercise.

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

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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 sensorindicated 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 will decrease 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:

Program Implant Detection to “Off/Complete”.

Configure pace and sense lead polarities and Lead Monitor.

Verify that Rate Profile Optimization is On.

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 2-6 and “Individualizing Rate Profile Optimization” on page 2-11.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

2-5

Rate Response

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” later in this chapter.

Optimization can also operate in the background when a nonrate 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 nonatrial tracking rate responsive mode.

2-6

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Rate Response

Rate Profile Optimization Operation

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 sensor-indicated 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).

30%

20%

10%

Indicated % of Time

Lower

Rate

Figure 2-1.

Submaximal

Rate

Range

ADL Rate

Submaximal and Maximal Rate Ranges

Maximal

Rate

Range

Sensor Rate

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Upper

2-7

Rate Response

Rate Profile Optimization Operation

Optimization Using Rate Profiles

Optimization of rate response occurs independently in both the submaximal and maximal rate ranges. Rate response to activity sensor changes are 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.

2-8

30%

Daily Sensor

20%

10%

Indicated % of Time

30%

20%

10%

Indicated % of Time

Rate Profile

Rate

Monthly Sensor

Rate Profile

Rate

Figure 2-2.

Indicated % of Time

Comparing Rate Profiles

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

30%

Target Rate

Profile

20%

10%

Rate

Rate Response

Rate Profile Optimization Operation

Daily Optimization of Rate Response

Once each day, the pacemaker evaluates the percent 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 percent 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 percent 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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

2-9

Rate Response

Rate Profile Optimization Operation

30%

25%

20%

15%

10%

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

Upper

Sensor Rate

70-80

Figure 2-3.

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

Optimizing Rate Response

Adaptations in Optimization Operation

2-10

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Individualizing Rate Profile Optimization

Overview

For Kappa 700 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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

2-11

Rate Response

Individualizing Rate Profile Optimization

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

Tabl e 2- 1.

Rate Range Select Settings

Submaximal or Moderate Rates

Maximal or High Rates Rate Response

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

ADL Response and Exertion Response Guidelines

ADL Response

Rate Response Too Aggressive

Rate Response Too Low

Too Aggressive

Rate Response Too Low

Lower Number (Less Active)

Higher Number (More Active)

Exertion Response

Lower Number (Less Frequent Exertion)

Higher Number (More Frequent Exertion)

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.

2-12

Medtronic.Kappa 700/600 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 nominal settings 30 minutes after implant or can be manually programmed.

Rate Response

Activity Sensor Operation

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2-13

Rate Response

Activity Sensor Operation

How Activity Threshold Influences Rate

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.

Settings

High

Med/High

Med/Low

Low

2-14

Activity

Sensor

Output

Time

Activity Threshold = Medium/Low

Figure 2-4.

Activity Sensor Signal (Threshold Set to Medium/Low)

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Low

Med/Low

Med/High

High

Rate Response

Activity Sensor Operation

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 below as a guide for selecting an appropriate setting.

Table 2-2.

Programmable Settings

Low Responds to most body activity, including

Medium/Low Limited response to minimal exertion;

Medium/High Limited response to moderate body

High Responds to only vigorous body movements

Activity Threshold Guidelines

Typical Rate Performance

minimal exertion.

responds to moderate or greater exertion.

movements and exertion.

and exertion.

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

2-15

Rate Response

Activity Sensor Operation

■

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.

Upper

Sensor

Rate

Activity Acceleration

Programmable Settings

15 Seconds 30 Seconds 60 Seconds

Rate Range

Lower

Rate

2-16

Time (Minutes)

Figure 2-5.

Activity Acceleration Curves

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

210453

Rate Response

Activity Sensor Operation

■

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

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

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2-17

Rate Response

Activity Sensor Operation

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

Time (Minutes)

Figure 2-7.

Exercise Deceleration

5 Minute

Deceleration

Curve

121086420 1416182022

2-18

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Rate Response

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.

The programmed ADL Setpoint setting must less than the

Note:

UR Setpoint setting.

Refer to Medtronic.Kappa 700/600 Series Pacemaker Programming

Guide for programming instructions.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

2-19

Rate Response

Manual Control of Rate Profile Optimization

2-20

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

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

Rates

AV Intervals

Rate Adaptive AV

Search AV and Diagnostic

Blanking Periods

Refractory Periods

High Rate Atrial Tracking

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-2

3-12

3-16

3-26

3-29

3-20

3-40

3-1

Pacemaker Timing

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)

3-2

– 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.

Medtronic.Kappa 700/600 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:

■

PACs in the DDIR and DDI modes,

■

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

■

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

■

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).

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-3

Pacemaker Timing

Rates

Lower Rate Interval Lower Rate Interval

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 sensorindicated rate is equal to the programmed Lower Rate.

DDD

Parameters:

Lower Rate = 60 ppm (1000 ms) PAV Interval = 200 ms PVARP = 300 ms

Figure 3-1.

SAV Interval = 180 ms Ventricular Refractory Period = 240 ms

Example of Lower Rate Operation

200 ms

3-4

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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.

In the VDD mode, atrial tracking near the Lower Rate may

Note:

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-5

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 sensor-detected level of patient activity and the programmed rate response parameters. The sensorindicated rate will never be greater than the Upper Sensor Rate or less than the Lower Rate.

Sensor-Indicated

Interval

Sensor Sensor Sensor

DDDR

Parameters:

Sensor-Indicated Rate = 90 ppm (667 ms) PAV Interval = 200 ms PVARP = 300 ms SAV Interval = 190 ms Ventricular Refractory Period = 220 ms

Figure 3-2.

Example of Sensor-Indicated Rate Operation

Sensor-Indicated

Interval

200 ms

3-6

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

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 sensorindicated 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.

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 nonrate responsive DDD and VDD modes)

Rates

■

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.

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3-7

Pacemaker Timing

Rates

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 3-40 for details.

Upper Tracking Rate

Parameters:

Sensor-indicated Rate =

75 ppm (800 ms)

Upper Tracking Rate =

100 ppm (600 ms)

SAV Interval = 200 ms

3-8

DDD

Figure 3-3.

Example of Upper Tracking Rate (Wenckebach) Operation

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

200 ms

Pacemaker Timing

Rates

Programming Considerations and Restrictions

ADL Rate – It is recommended that the ADL Rate be 10 ppm less than the Upper Sensor Rate or 20 ppm greater than the Lower Rate. Although, 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 5-9 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 or equal to the ADL Rate.

Rate Limit

An internal circuit, independent of the pacing timers, limits single chamber atrial or ventricular pacing rates to 200 ppm for most single component failures. For dual chamber modes, atrial and ventricular rates are limited independently to 200 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.

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3-9

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.

Use of the Rate Adaptive AV feature and sensor-varied or

Note:

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.

3-10

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

200

180

160

140

120

Rate (bpm)

100

0 5 10 15 20 25 30 35

Pacemaker Timing

Rates

Atrial Rate Increasing by 2 bpm/beat

MAR Intrinsic Rate

Time (Seconds)

Figure 3-4.

Increasing Mean Atrial Rate

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-11

Pacemaker Timing

AV Intervals

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

3-12

■

Non-Competitive Atrial Pacing

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

AV Intervals

PAV

Interval

DDD

Interval

Figure 3-5.

PAV

PAV PAV

Example of PAV Interval Operation

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-13

Pacemaker Timing

AV Intervals

SAV

Interval

DDD

Interval

Figure 3-6.

SAV

SAV SAV

Example of SAV Interval Operation

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.

3-14

■

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 sensor-indicated 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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

AV Intervals

■

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 Twave, or loss of AV synchrony, which may precipitate retrograde activation of the atria with corresponding hemodynamic consequences and symptoms.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-15

Pacemaker Timing

Rate Adaptive AV

Overview

In the normal heart, AV conduction times tend to shorten as the heart rate increases and 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 3-34 and “High Rate Atrial Tracking” on page 3-40 for more information.

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

3-16

RAAV will not shorten AV intervals to less than 30 ms.

Note:

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

240

220

200

Pacemaker Timing

Rate Adaptive AV

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).

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

180

160

140

120

100

Programmed SAV

SAV

PAV

AV Interval (ms)

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

Shortest PAV

(PAV - Max. Offset)

Shortest SAV

(SAV - Max. Offset)

150 180

Figure 3-7.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Rate Adaptive AV Operation (DDDR Mode)

3-17

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.

3-18

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

Rate Adaptive AV

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-19

Pacemaker Timing

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 700 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.

3-20

Programming to Adaptive AV

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

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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 below.

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 is now 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.

Parameters:

DDDR SAV = 120 ms Lower Rate = 60 ppm PAV = 150 ms Sensor-Indicated Rate = 90 ppm

Figure 3-8.

Adaptive Search AV Operation

Maximum Offset = 110 ms

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

PAV is now 173 ms

200 ms

3-21

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.

■

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 previously 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.

3-22

Suspension of Adaptive AV Operation

If maximum extension of the SAV and PAV intervals is reached and the search criteria indicates 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 indicates that the AV intervals are too long, the current suspension period is terminated and adjustments of AV intervals resumes.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

Search AV and Diagnostic

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.

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 in 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 Lower Rate = 60 ppm Sensor-Indicated Rate = 90 ppm

Figure 3-9.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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

PAV is now 210 ms

SAV = 120 ms PAV = 150 ms AV Hysteresis set to 60 ms

Hysteresis Search AV Operation

200 ms

3-23

Pacemaker Timing

Search AV and Diagnostic

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.

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.

3-24

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

Search AV and Diagnostic

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

Programing 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 episode data is normally cleared by the pacemaker one hour after a programming session.

Also, 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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-25

Pacemaker Timing

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.

DDD

Note: Black bars indicate blanking periods.

1. Nonprogrammable Atrial Blanking

2. Programmable Post-Ventricular

Atrial Blanking

3. Programmable Ventricular

Blanking

4. Nonprogrammable Ventricular

Blanking

3-26

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

Blanking Periods

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 farfield R waves on the atrial lead. Any ventricular event (paced or sensed) starts the PVAB, which is also the first portion of the PostVentricular Atrial Refractory period (PVARP). PVAB is limited to values equal to or less than the programmed PVARP, except in the VDIR and VDI modes since PVARP does not apply to these modes.

PVAB is programmed to a value less than or equal to

Note:

PVARP.

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 T wave when intrinsic ventricular events are blanked and not sensed. PAV values (200 ms or less) should reduce the possibility of T wave pacing.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-27

Pacemaker Timing

Blanking Periods

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.

Atrial Blanking must be programmed at least 50 ms less

Note:

than the Atrial Refractory Period.

3-28

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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, far-field R waves, or electrical noise.

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.

Pacemaker Timing

Refractory Periods

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-29

Pacemaker Timing

Refractory Periods

The first portion of the PVARP is the programmable PostVentricular 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.

PVARP

DDD

3-30

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.

■

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).

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

Refractory Periods

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

Figure 3-12.

400 ms 300 ms 400 ms

PAV PVARP PAV PVARP

200 ms

Sensor-Varied PVARP Operation (DDDR Mode)

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-31

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 sensorvaried 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.

3-32

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

Refractory Periods

■

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).

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 Detect Rate if this rate is less than the Upper Tracking Rate calculation.

Programming Restrictions for Automatic PVARP

Automatic PVARP – For Kappa 600 Series pacemakers, automatic PVARP is not available.

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 pacemaker-defined 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 5-12 and “PVC Response” on page 5-16 for further details on the PMT Intervention and PVC Response features and their interactions with PVARP.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-33

Pacemaker Timing

Refractory Periods

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 Interval – 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.

■

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 earlier in this chapter.

3-34

TA RP TAR P

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 3-40 for more information.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

SAV

PVARP

Pacemaker Timing

Refractory Periods

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 Twave 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.

In dual chamber modes, the VRP should be programmed

Note:

shorter than the PVARP.

Figure 3-14.

DDD

Example of Ventricular Refractory Period Operation

VRP

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-35

Pacemaker Timing

Refractory Periods

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 far-field 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:

3-36

■

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

■

Pacing occurs at the programmed Lower Rate for all nonrateresponsive 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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Sensor-Indicated Interval

Sensor Sensor Sensor

DDDR

P R R R

Parameters:

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

Pacemaker Timing

Refractory Periods

200 ms

Figure 3-15.

Example of Noise Reversion in DDDR at Sensor-Indicated Rate.

Atrial sensing during the PVARP, or refractory period

Note:

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-37

Pacemaker Timing

Refractory Periods

VVIR

Sensor Sensor

Parameters:

Lower Rate = 60 ppm (1000 ms) Upper Sensor Rate = 120 ppm (500 ms) Ventricular Refractory Period = 240 ms

Lower Rate

R R R R P

200 ms

3-38

Figure 3-16.

Example of Noise Reversion in VVIR at Lower Rate.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

Refractory Periods

Preventing Noise Sensing

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 on to monitor and if necessary, adjust the sensitivity value. Refer to “Sensing Assurance and Diagnostic” on page 4-31.

■

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 4-15.

■

Remove patient from EMI environment.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-39

Pacemaker Timing

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.

3-40

■

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.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Pacemaker Timing

High Rate Atrial Tracking

■

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 Upper Sensor Rate exceeds the 2:1 block rate.

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.

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

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

The following example shows how pacemaker Wenckebach operation occurs in the DDDR, DDD, or VDD modes.

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

3-41

Pacemaker Timing

High Rate Atrial Tracking

Upper Tracking

Rate Interval

DDDR

Parameters:

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

Figure 3-17.

Upper Tracking

Rate Interval

Upper Tracking

Rate Interval

SAV

Interval

Example of Pacemaker Wenckebach Operation

Sensor

200 ms

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Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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.

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 TA R P

Unless the Non-Competitive Atrial Pacing is On, see “Non-Competitive Atrial Pacing” on page 5-9.

Upper Rates Interaction With TARP

Wenckebach

Before 2:1

Block

no no yes

no no no

yes yes no

yes yes yes

Achieve

Upper

Tracking

Rate

Potential

Atrial

Competition

Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

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Pacemaker Timing

High Rate Atrial Tracking

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Medtronic.Kappa 700/600 Series Pacemaker Reference Guide

Medtronic KDR603 Reference Guide

Specifications and Main Features

Frequently Asked Questions

User Manual

How to Use This Guide

Information is Contained in Two Guides

About this Guide

About the Pacemaker Programming Guide

Introduction

Pacing Mode Selection

NBG Pacing Codes

Further Information

Mode Pertinency Tables

Indications and Usage

Contraindications

DDDR Mode

DDD Mode

DDIR Mode

DDI Mode

DVIR Mode

DVI Mode

VDD Mode

AAIR / ADIR Modes

AAI / ADI Modes

VVIR / VDIR Modes

VVI / VDI Modes

AAT / VVT Modes

DOOR / AOOR / VOOR Modes

DOO / AOO / VOO Modes

ODO / OAO / OVO Modes

Rate Response

Automatic Features

For Further Information

Overview

Three Pacing Rate Controls

Starting Rate Response Immediately

For Further Information

Rate Profile Optimization Operation

Overview

Submaximal and Maximal Rate Control

Optimization Using Rate Profiles

Daily Optimization of Rate Response

Adaptations in Optimization Operation

Individualizing Rate Profile Optimization

Overview

Submaximal Rate Profiles

Maximal Rate Profiles

Programming Guidelines

Activity Sensor Operation

Overview

How Activity Threshold Influences Rate

Evaluating the Activity Threshold Setting

Exercise Deceleration Operation

Manual Control of Rate Profile Optimization

Overview

Evaluate and Program Rate Response

Rates

Overview

A–A and V–V Timing

Lower Rate

Operating Lower Rate

Selecting a Lower Rate

Sensor-Indicated Rate

Sensor Indicated Rate Effect on Other Intervals

ADL Rate

Upper Tracking Rate

Upper Sensor Rate

Programming Considerations and Restrictions

Rate Limit

Possible Atrial Competition at High Rates

Mean Atrial Rate

AV Intervals

Overview

Selecting PAV and SAV

Rate Adaptive AV

Overview

Programming for Rate Adaptive AV

RAAV Operations

Programming Considerations and Restrictions

RAAV and Sick Sinus Syndrome