Medtronic T60A1B Reference Guide

T-series
T60 DR T20 SR
T-series VSF08 1.6 (Vitatron CareLink)
T60A1 T20A1
Reference Manual
Caution: Federal Law (USA) restricts this device to sale by or on the order of a physician.
T-series Reference Manual
Part I General information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.1 About this manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.2 Programming instructions . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2 The pacemaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2 Vitatron T60 DR (Model T60A1) . . . . . . . . . . . . . . . . . . . . . 9
2.3 Vitatron T20 SR (Model T20A1) . . . . . . . . . . . . . . . . . . . . 10
2.4 Connector configuration . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.5 Patient Assistant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3 The patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.3 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.4 Potential adverse events . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.5 Pacing code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.6 Mode selection decision tree . . . . . . . . . . . . . . . . . . . . . . . 15
3.7 Mode descriptions, indications and contraindications by
mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4 The programmer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.2 How to start a programmer session . . . . . . . . . . . . . . . . . 26
4.3 How to use the cardiac dashboard . . . . . . . . . . . . . . . . . . 28
4.4 How to view pacemaker diagnostics . . . . . . . . . . . . . . . . . 33
4.5 How to program parameters . . . . . . . . . . . . . . . . . . . . . . . 34
4.6 How to start tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.7 How to enter patient information . . . . . . . . . . . . . . . . . . . . 40
4.8 How to save and reload data . . . . . . . . . . . . . . . . . . . . . . . 42
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4.9 How to print . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.10 How to adjust the programmer . . . . . . . . . . . . . . . . . . . . . 50
4.11 How to adjust the ECG window . . . . . . . . . . . . . . . . . . . . . 52
4.12 Emergency programming . . . . . . . . . . . . . . . . . . . . . . . . . 61
Part II Follow-up and diagnostics . . . . . . . . . . . . . . . . . . . . . . 63
5 Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.2 Post-implant configuration . . . . . . . . . . . . . . . . . . . . . . . . . 64
5.3 Record an ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
5.4 Program patient information . . . . . . . . . . . . . . . . . . . . . . . 65
5.5 Checks and programming . . . . . . . . . . . . . . . . . . . . . . . . . 65
5.6 Optimizing the pacemaker . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.7 The ECG/EGM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
5.8 Follow-up frequency and longevity . . . . . . . . . . . . . . . . . . 68
6 Optimizing pacing and sensing . . . . . . . . . . . . . . . . . . . . . . . 75
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.2 Optimizing pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.3 Optimizing sensing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
6.4 Lead measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
6.5 VA interval measurement . . . . . . . . . . . . . . . . . . . . . . . . . 90
6.6 Temporary test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
6.7 Atrial burst pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
6.8 Tests history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
7 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
7.2 Therapy Advisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
7.3 Data collection and storage periods . . . . . . . . . . . . . . . . 103
7.4 Displaying diagnostic data . . . . . . . . . . . . . . . . . . . . . . . . 104
7.5 Assessing atrial rhythm and AF . . . . . . . . . . . . . . . . . . . . 112
7.6 Assessing ventricular rhythm . . . . . . . . . . . . . . . . . . . . . . 116
7.7 Assessing AV synchrony . . . . . . . . . . . . . . . . . . . . . . . . . 122
7.8 Assessing rate response . . . . . . . . . . . . . . . . . . . . . . . . . 122
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7.9 Assessing sensing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8 Selected Episodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
8.2 Data collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
8.3 Setting up episode selection . . . . . . . . . . . . . . . . . . . . . . 133
8.4 Selected Episodes overview . . . . . . . . . . . . . . . . . . . . . . 138
8.5 Time line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
8.6 Selected Episodes histograms . . . . . . . . . . . . . . . . . . . . 140
8.7 Selected Episodes diary . . . . . . . . . . . . . . . . . . . . . . . . . 143
8.8 Selected Episodes stored EGM . . . . . . . . . . . . . . . . . . . 146
Part III Pacing therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
9 An introduction to Vitatron pacing therapies . . . . . . . . . . . 149
9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
9.2 Basic pacing therapies . . . . . . . . . . . . . . . . . . . . . . . . . . 150
9.3 Pacemaker timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
9.4 Lower rate pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
9.5 Maximum rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
9.6 Refractory period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
9.7 Blanking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
9.8 Ventricular safety pacing (VSP) . . . . . . . . . . . . . . . . . . . . 160
9.9 Atrial hysteresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
9.10 Interference management . . . . . . . . . . . . . . . . . . . . . . . . 166
10 Rate stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
10.2 Atrial rhythm classification . . . . . . . . . . . . . . . . . . . . . . . . 167
10.3 Atrial tracking behavior . . . . . . . . . . . . . . . . . . . . . . . . . . 169
10.4 Bradyarrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
10.5 Atrial tachyarrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
10.6 Rate stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
11 AV synchrony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
11.2 Paced and sensed AV delay . . . . . . . . . . . . . . . . . . . . . . 182
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11.3 Adaptive AV delay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
11.4 Refined Ventricular Pacing (RVP) . . . . . . . . . . . . . . . . . . 185
11.5 Atrial synchronization pace (ASP) interval . . . . . . . . . . . 187
11.6 Retrograde conduction and PVC management . . . . . . . . 188
12 Rate response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
12.2 Activity sensor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
12.3 Slope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
12.4 Daily learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
12.5 Fast learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
12.6 Activity acceleration and deceleration . . . . . . . . . . . . . . . 201
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
A Safety features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
A.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
A.2 Pacemaker restore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
B Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
B.1 Effects of extreme conditions . . . . . . . . . . . . . . . . . . . . . 207
B.2 Area restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
B.3 Environmental and medical therapy hazards . . . . . . . . . 207
C Product specifications Vitatron T60 DR . . . . . . . . . . . . . . . 213
C.1 Programming parameters . . . . . . . . . . . . . . . . . . . . . . . . 213
C.2 Technical parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
D Product specifications Vitatron T20 SR . . . . . . . . . . . . . . . 221
D.1 Programming parameters . . . . . . . . . . . . . . . . . . . . . . . . 221
D.2 Technical parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
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T-series Reference Manual

Part I

General information

1 Introduction

1.1 About this manual

This Reference Manual contains an extensive description of the Vitatron T-series of pacemakers (Vitatron T60 DR and Vitatron T20 SR).
For ease of use, the manual is divided into three parts.
In Part I, general information is given about the Vitatron pacing system. It begins with an introduction to the manual (see Chapter 1), and a description of each pacemaker (see Chapter 2). This is followed by a description of each available pacing mode, together with the relevant indications and contraindications (see Chapter 3). How to carry out common programming procedures and program the programmer preferences are described in Chapter 4.
In Part II, follow-up and diagnostic features are discussed. Basic follow-up procedures are described in Chapter 5. This is followed by a more detailed description of how to optimize pacing and sensing characteristics (see Chapter 6). Advice on how to make optimal use of the diagnostic features included in the pacemakers is given in Chapter 7. The Selected Episodes diagnostic feature is explained in Chapter 8.
In Part III, there is an extensive description of the pacing therapies. The basic pacing therapies, including timing characteristics are described in Chapter 9. This is followed by advice on maintaining rate stability (see Chapter 10), the importance of maintaining and restoring AV synchrony (see Chapter 11) and rate response (see Chapter 12).
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T-series Reference Manual Section 1.1
The appendices provide technical information. Safety features are described in Appendix A and precautions are listed in Appendix B. In Appendix C and Appendix D the programmable parameters of each individual pacemaker and their most important specifications are listed.

1.2 Programming instructions

The gray block at the beginning of some sections contains instructions for programming the parameter. For example:
Parameters
Therapies
Lower Rate…
Night Lower Rate
Range: 40 - (5) - 130 min Availability: All modes, except OOO
The first line contains the name of the icon in the control panel (see Section 4.3). You can press the tab or value boxes named on the following lines to program the parameter.
–1
The “Range” usually shows the lowest and highest values that you can program. The number in brackets shows the programming steps within this range. In some cases you can choose an option, for example “On” or “Off”.
The “Availability” line lists any restrictions on the use of the parameter, for example, in which modes it is available.
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2 The pacemaker

2.1 Introduction

The Vitatron T-series consists of a dual chamber pacemaker model (Vitatron T60 DR) and a single chamber pacemaker model (Vitatron T20 SR).
These pacemakers provide an extensive range of therapies for the treatment of bradycardia. Ventricular Rate Stabilization is specially designed to reduce ventricular irregularity.
Diagnostic tools quickly provide information about the effectiveness of pacemaker therapy and simplify follow-up sessions. Detailed information and intracardiac electrograms (EGMs), recorded during selected episodes of fast or irregular rhythm, are stored for interrogation at the next follow-up session. Storage of EGMs has a negligible effect on the pacemaker longevity.
Therapy Advisor automatically scans pacemaker data at the start of a follow-up session (battery status, diagnostic data and programmed parameters). It immediately reports any important events, including AF, and gives suggestions for programming the pacemaker.

2.2 Vitatron T60 DR (Model T60A1)

The Vitatron T60 DR is a dual chamber rate responsive pacemaker (activity sensing using an accelerometer) for permanent atrial and ventricular pacing. It has the following features:
Ventricular Rate Stabilization (VRS), to regulate the ventricular rate during episodes
of conducted atrial tachyarrhythmia
Refined Ventricular Pacing (RVP), to give further preference to intrinsic conduction
Refined Atrial Pacing (RAP), to give further preference to intrinsic atrial
depolarization
Therapy Advisor, which provides clear and concise advice on pacemaker settings
and therapies
Selected Episodes with stored EGMs, which provides detailed information about
episodes of fast or irregular rhythm
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T-series Reference Manual Section 2.3

2.3 Vitatron T20 SR (Model T20A1)

The Vitatron T20 SR is a single chamber rate responsive pacemaker (activity sensing using an accelerometer) for permanent atrial or ventricular pacing. It has the following features:
Ventricular Rate Stabilization (VRS), to stabilize the ventricular rate during episodes
of irregularity which are probably due to conducted atrial tachyarrhythmia (VVI(R) mode only)
Therapy Advisor, which provides clear and concise advice on pacemaker settings
and therapies
Selected Episodes with stored EGMs, which provides detailed information about
episodes of fast or irregular rhythm
2.4 Connector configuration
Vitatron digital pacemakers all have IS-1 connectors. Access to the connector screws is from above for single chamber pacemakers and from the engraved side for dual chamber pacemakers (see Figure 1).
Figure 1. Connector configuration
1 Dual chamber connection 2 Single chamber connection

2.5 Patient Assistant

The Patient Assistant is a pocket-size remote communications device that can be used by a patient to communicate with a Vitatron T-series pacemaker away from the hospital or clinic. Its main use is to record cardiac rhythm when the patient experiences symptoms, providing information for the physician to investigate at the next follow-up session.
The Patient Assistant allows the patient to perform the following actions:
Store information about cardiac rhythm in the pacemaker, by pressing the “Record
Symptoms” button. At the next follow-up session the physician can study this
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T-series Reference Manual Section 2.5
information and stored EGM using the Selected Episodes feature on the programmer (refer to Chapter 8).
Check heart rhythm by pressing the “Query” button. If the pacemaker detects an
atrial tachyarrhythmia at that moment, the AF indicator lights up on the Patient Assistant. (Refer to Chapter 10 for an explanation of how the pacemaker detects tachyarrhythmias.)
A third button, “Therapy”, is not operational with Vitatron pacemakers.
For more information on the Patient Assistant device, please refer to the relevant Patient Assistant manual.
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3 The patient

3.1 Introduction

Cardiac pacing is an accepted method of controlling heart rate in patients with symptomatic bradyarrhythmias. Vitatron pacemakers are therefore intended for use in patients for whom permanent cardiac pacing is indicated for the treatment of disorders in impulse formation or conduction.
This chapter describes specific indications and contraindications, together with a description of each of the available pacing modes.

3.2 Indications

Dual chamber pacing is indicated if AV synchrony needs to be restored to optimize cardiac output (for example, in patients with symptomatic second or third degree AV block).
Dual chamber rate responsive pacing modes are of specific benefit to patients with chronotropic incompetence of the sinus node.
Rate responsive modes can help patients who have a requirement for an increase in pacing rate, in response to physical activity.
Single chamber ventricular pacing can help patients with permanent atrial tachyarrhythmias, including atrial fibrillation and flutter.
Single chamber atrial pacing can help patients with symptomatic bradyarrhythmias and normal AV conduction.

3.3 Contraindications

There are no known contraindications to the use of pacemakers as a means to control the heart rate. The patient’s individual medical condition dictates which particular pacing system and mode of operation is chosen by the physician.
Pacemakers are contraindicated in the following situations:
dual chamber
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T-series Reference Manual Section 3.3
– permanent supraventricular tachyarrhythmias, including atrial fibrillation and
flutter
– expected aggravation of clinical symptoms (for example, angina pectoris) or
congestive heart failure caused by fast heart rates
– inadequate intracavitary atrial complexes
single chamber AAI(R)
– AV conduction disturbances
– inadequate intracavitary atrial complexes
single chamber VVI(R)
– known pacemaker syndrome
– a need for AV synchrony
– expected aggravation of clinical symptoms (for example angina pectoris) or
congestive heart failure caused by fast heart rates

3.4 Potential adverse events

Adverse events associated with pacemaker systems include: cardiac perforation, cardiac tamponade, death, erosion through the skin, hematoma/seroma, infection, improper operation caused by theft-prevention systems, myopotential sensing, nerve stimulation, muscle stimulation, pacemaker syndrome, rejection phenomena (local tissue reaction, fibrotic tissue formation, pacemaker migration), threshold elevation, and transvenous lead-related thrombosis.

3.5 Pacing code

Pacemaker modes are described using the NBG code. The five-letter NBG1code, named after The North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG), describes the operation of implantable pulse generators. The NBG code, which supersedes the ICHD Code, is described in Table 1.
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T-series Reference Manual Section 3.5
Permanent Atrial
Fibrillation/Flutter?
Sinus Node Dysfunction
VVIR
AV Block AV Block
Paroxysmal Atrial
Fibrillation/Flutter?
DDDR + MS DDD(R) AAI(R)
Y N
Paroxysmal Atrial
Fibrillation/Flutter?
DDDR + MS DDD/VDD
Y N
Y N
Y
AV Block
Y N
Y
Y

Table 1. The Revised NASPE/BPEG Generic Code for Antibradycardia Pacing

Position: I II III IV V
Category: Chamber(s)
Paced O = None
A = Atrium V = Ventricle D = Dual (A + V)
Manufacturers’
designation
S = Single (A or V)
Chamber(s) Sensed
O = None A = Atrium V = Ventricle D = Dual (A + V)
S = Single (A or V)
Response to Sensing
O = None T = Triggered I = Inhibited D = Dual (T + I)
Rate Modulation
O = None R = Rate modulation
Multisite Pacing
O = None A = Atrium V = Ventricle D = Dual (A + V)
only:
Note: The programmer displays A or V (not S) for chambers paced and sensed.

3.6 Mode selection decision tree

The following basic decision tree is an aid in selecting the best pacing mode for a particular patient.
Figure 2. Basic decision tree (from den Dulk, K et al. Selection of the optimal pacing mode. The Netherlands Journal of Cardiology 1992; 5:214-225)
1
Bernstein A.D, et al., The Revised NASPE/BPEG Pulse Generator Code, Pace, 25, No 2, Feb 2002.
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T-series Reference Manual Section 3.7

3.7 Mode descriptions, indications and contraindications by mode

3.7.1 DDDR mode

The pacemaker senses and paces in both the atrium and the ventricle. Sensed atrial events inhibit the atrial channel and start an AV delay. Sensed atrial events conducted to the ventricles before the end of the AV delay inhibit the ventricular channel. Sensed atrial events not conducted before the end of the AV delay trigger the release of a ventricular stimulus (tracking of the atrial rate).
Paced atrial events also start an AV delay. Paced atrial events conducted to the ventricles before the end of the AV delay inhibit the ventricular channel. Paced atrial events not conducted before the end of the AV delay trigger the release of a ventricular stimulus.
In the absence of sinus rhythm and spontaneous AV conduction, both chambers are paced at the sensor rate, the Flywheel rate, or the lower rate (whichever is highest).
In the presence of atrial tachyarrhythmias, Beat-to-Beat mode switching is initiated (the ventricular rate is stabilized by rate responsive ventricular pacing). The atrial rate is monitored on a beat to beat basis and AV synchronous pacing is restored as soon as possible.
Indications:
chronotropic incompetence due to atrial bradyarrhythmia or AV block
sick sinus syndrome, including brady-tachy syndrome
paroxysmal atrial arrhythmias in patients who require restoration of AV synchrony
Contraindications:
permanent atrial tachyarrhythmias, including atrial fibrillation and flutter
expected aggravation of clinical symptoms (for example angina pectoris) or
congestive heart failure caused by fast heart rates

3.7.2 DDD mode

The pacemaker senses and paces in both the atrium and the ventricle. Sensed atrial events inhibit the atrial channel and start an AV delay. Sensed atrial events conducted to the ventricles before the end of the AV delay inhibit the ventricular channel. Sensed atrial events not conducted before the end of the AV delay trigger the release of a ventricular stimulus (tracking of the atrial rate).
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T-series Reference Manual Section 3.7
Paced atrial events also start an AV delay. Paced atrial events conducted to the ventricles before the end of the AV delay inhibit the ventricular channel. Paced atrial events not conducted before the end of the AV delay trigger the release of a ventricular stimulus.
In the absence of sinus rhythm and spontaneous AV conduction both chambers are paced either at the Flywheel rate or the lower rate (whichever is highest).
In the presence of atrial tachyarrhythmias, Beat-to-Beat mode switching is initiated. The atrial rate is monitored on a beat to beat basis and AV synchronous pacing is restored as soon as possible.
Indications:
intermittent or complete AV block with normal sinus rhythm
sick sinus syndrome, including brady-tachy syndrome
paroxysmal atrial arrhythmias in patients who require restoration of AV synchrony
Contraindications:
permanent atrial arrhythmias, including atrial fibrillation and flutter
expected aggravation of clinical symptoms (for example angina pectoris) or
congestive heart failure caused by fast heart rates

3.7.3 DDIR mode

The pacemaker senses and paces in both the atrium and the ventricle. Atrial inhibition does not trigger an AV delay. In the absence of spontaneous conduction to the ventricle the pacemaker actively resynchronizes the atrium with the ventricle using an atrial synchronization pace (ASP). The pacing rate is dictated by the sensor rate.
Indications:
atrial bradyarrhythmia in patients with paroxysmal atrial tachyarrhythmias, with or
without normal AV conduction
brady-tachy syndrome
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T-series Reference Manual Section 3.7
Contraindications
complete AV block with normal sinus rhythm (allows retrograde P-wave sensing or
continuous atrial synchronization pacing)

3.7.4 DDI mode

The pacemaker senses and paces in both the atrium and the ventricle. Atrial inhibition does not trigger an AV delay. In the absence of spontaneous conduction to the ventricle the pacemaker actively resynchronizes the atrium with the ventricle using an atrial synchronization pace (ASP). The pacing rate is dictated by the programmed lower rate.
Indications:
atrial bradyarrhythmia in patients with paroxysmal atrial tachyarrhythmias, with or
without normal AV conduction
brady-tachy syndrome
Contraindications
complete AV block with normal sinus rhythm (allows retrograde P-wave sensing or
continuous atrial synchronization pacing)

3.7.5 DOO mode

The pacemaker provides asynchronous, AV sequential pacing at the programmed lower rate.
Indications:
intended primarily as a temporary mode to reduce the likelihood of triggering or
inhibition during electrosurgery or electromagnetic interference
Contraindications:
intrinsic cardiac activity at a rate sufficient to cause competitive pacing

3.7.6 VDDR mode

The pacemaker senses in both the atrium and the ventricle but can only pace the ventricle. It tracks spontaneous sinus rhythm and is inhibited by ventricular sensing. In the absence of sinus rhythm, or in the presence of atrial tachyarrhythmias, rate responsive ventricular pacing is initiated.
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Indications:
intermittent or complete AV block with normal sinus rhythm, with or without
paroxysmal atrial tachyarrhythmia
Contraindications:
likelihood of loss of AV synchrony (atrial bradyarrhythmia) and associated
complications (retrograde conduction, anticipated or known pacemaker syndrome)
permanent atrial tachyarrhythmias, including atrial fibrillation and flutter
expected aggravation of clinical symptoms (for example angina pectoris) or
congestive heart failure caused by fast heart rates
inadequate intracavitary atrial complexes

3.7.7 VDD mode

The pacemaker senses in both the atrium and the ventricle but can only pace the ventricle. It tracks spontaneous sinus rhythm and is inhibited by ventricular sensing. In the absence of sinus rhythm, or in the presence of atrial tachyarrhythmias, ventricular (VVI) pacing at the programmed lower rate is initiated.
Indications:
intermittent or complete AV block with normal sinus rhythm, with or without
paroxysmal atrial tachyarrhythmia
Contraindications:
likelihood of loss of AV synchrony (atrial bradyarrhythmia) and associated
complications (retrograde conduction, anticipated or known pacemaker syndrome)
permanent atrial tachyarrhythmias, including atrial fibrillation and flutter
inadequate intracavitary atrial complexes

3.7.8 VVIR mode

The pacemaker senses and paces in the ventricle and is inhibited by sensed ventricular events. In the absence of spontaneous ventricular rhythm, rate responsive ventricular pacing is initiated.
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T-series Reference Manual Section 3.7
Indications:
permanent atrial fibrillation and flutter with symptomatic ventricular bradyarrhythmia
Contraindications:
expected aggravation of clinical symptoms (for example angina pectoris) or
congestive heart failure caused by fast heart rates
anticipated or known pacemaker syndrome
a need for the restoration of AV synchrony

3.7.9 VVI mode

The pacemaker senses and paces in the ventricle and is inhibited by sensed ventricular events. In the absence of spontaneous ventricular rhythm, ventricular pacing at the programmed lower pacing rate is initiated.
Indications:
permanent atrial fibrillation and flutter with symptomatic ventricular bradyarrhythmia
Contraindications:
anticipated or known pacemaker syndrome
a need for the restoration of AV synchrony

3.7.10 VVT mode

The pacemaker paces and senses in the ventricle. Operation is identical to the VVI mode except that events sensed during the ventricular escape interval trigger an immediate pacing pulse.
Indications:
intended as a temporary diagnostic mode, used to verify sensing and evaluate
arrhythmias. This mode may also be useful in preventing inappropriate inhibition in the presence of electromagnetic interference.
Contraindications:
anticipated or known pacemaker syndrome
a need for the restoration of AV synchrony
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T-series Reference Manual Section 3.7

3.7.11 VOO mode

The pacemaker paces in the ventricle at the programmed lower rate (asynchronous ventricular pacing). It is not inhibited by sensed ventricular events.
Indications:
intended primarily as a temporary mode to reduce the likelihood of triggering or
inhibition during electrosurgery or electromagnetic interference
Contraindications:
intrinsic cardiac activity at a rate sufficient to cause competitive pacing

3.7.12 AAIR mode

The pacemaker senses and paces in the atrium and is inhibited by sensed atrial events. In the absence of spontaneous rhythm, rate responsive atrial pacing is initiated.
Indications:
atrial bradyarrhythmia with normal AV conduction
Contraindications:
AV conduction disturbances
atrial fibrillation and flutter
expected aggravation of clinical symptoms (for example angina pectoris) or
congestive heart failure caused by fast heart rates
inadequate intracavitary atrial complexes

3.7.13 AAI mode

The pacemaker senses and paces in the atrium and is inhibited by sensed atrial events. In the absence of spontaneous atrial rhythm, atrial pacing at the programmed rate is initiated.
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T-series Reference Manual Section 3.7
Indications:
atrial bradyarrhythmia with normal AV conduction
Contraindications:
AV conduction disturbances
atrial fibrillation and flutter
inadequate intracavitary atrial complexes

3.7.14 AAT mode

The pacemaker paces and senses in the atrium. Operation is identical to the AAI mode except that events sensed during the atrial escape interval trigger an immediate pacing pulse.
Indications:
intended as a temporary diagnostic mode, used to verify sensing and evaluate
arrhythmias. This mode may also be useful in preventing inappropriate inhibition in the presence of electromagnetic interference.
Contraindications:
inadequate intracavitary atrial complexes

3.7.15 AOO mode

The pacemaker paces in the atrium at the programmed lower rate (asynchronous atrial pacing). It is not inhibited by sensed atrial events.
Indications:
intended primarily as a temporary mode to reduce the likelihood of triggering or
inhibition during electrosurgery or electromagnetic interference
Contraindications:
intrinsic cardiac activity at a rate sufficient to cause competitive pacing
AV conduction disturbances

3.7.16 OOO mode

In the OOO mode pacing is switched off.
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T-series Reference Manual Section 3.7
Indications:
used for diagnostic purposes, such as the analysis of underlying rhythm
Contraindications:
patients with no underlying rhythm
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T-series Reference Manual

4 The programmer

4.1 Introduction

Vitatron T-series pacemakers can be programmed with a Vitatron CareLink programmer with Vitatron T-series software. This manual only describes the software for the Vitatron T-series. For specific programmer information, please refer to the programmer manual which is provided with the programmer.
This chapter describes how to carry out a follow-up session using the programmer.
how to start a programmer session (see Section 4.2)
how to use the cardiac dashboard (see Section 4.3)
how to view diagnostics (see Section 4.4)
how to program parameters (see Section 4.5)
how to start tests (see Section 4.6)
how to enter patient information (see Section 4.7)
how to save and reload data (see Section 4.8)
how to print and set print options (see Section 4.9)
Two sections describe how to change the programmer settings and display.
how to adjust the programmer (see Section 4.10)
how to adjust the ECG display (see Section 4.11)
The last section explains how to perform emergency programming (see Section 4.12).
Notes:
Programmers other than the Vitatron CareLink are not compatible.
When using a second programmer during the same follow-up session, the first
session must be ended before the second begins.
The screens in this chapter show examples based on dual chamber pacemakers,
and are subject to minor changes. The screens for single chamber pacemakers have a simpler layout because many features are not applicable to all models.
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T-series Reference Manual Section 4.1
Warning: Pacemaker programming should be done only after careful study of the Pacemaker Manual and after determination of the appropriate parameter settings. Improper use of the programmer could result in erroneous or inadvertent programming and improper operation of the telemetry and measurement functions.

4.2 How to start a programmer session

After switching the programmer on the Vitatron desktop appears.

Figure 3. The Vitatron desktop

The main parts of the desktop are described briefly in this section. The task bar, which appears above the top line, is described in the programmer manual.
1 Top line – The desktop always shows the Vitatron logo on the top line. During a follow-up session, the patient’s name, the pacemaker model name and number are also shown. The top line is not usually included in the illustrations used in this manual.
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T-series Reference Manual Section 4.2
2 ECG window and controls – While the desktop is active, the ECG window displays the default surface electrocardiogram (ECG lead I, II or III). During a follow-up session, the filtered atrial and ventricular intracardiac electrograms (AEGM and VEGM), marker annotations and marker intervals are also available. For a description of this window, see Section 4.3.1.
The ECG controls on the right allow you to freeze the ECG, adjust the ECG settings and ECG markers or recall previously stored ECGs. For a detailed explanation see Section 4.11.
For instructions on connecting the ECG cable and leads, refer to the programmer manual.
3 Control panel – Pressing one of the control panel icons opens the relevant window in the main window.
4 Main window – At startup the main window always contains the Select Model window. During a follow-up session, the main window contains the cardiac dashboard or one of the detailed windows.
5 Button line – When the desktop is active, the bottom line contains the [Auto Identify] button and a Vitatron to Medtronic switch, which is used to go from Vitatron to Medtronic applications and vice versa. During a follow-up or demonstration session, the bottom line contains buttons that are available in all windows. On some buttons, three dots indicate that pressing the button opens another window in which you can program related parameters.

4.2.1 Starting a demo session

Select a model from the Select Model window and press [Demo] to start a simulated programming session.

4.2.2 Starting a follow-up session

To start automatic pacemaker recognition position the programming head and press [Auto Identify]. This starts initial interrogation of the pacemaker. The cardiac dashboard appears in the main window (see Section 4.3). Press [Stop] to return to the Select Model window.
The [Start] button can only be used to launch applications that are not started with auto identify.
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T-series Reference Manual Section 4.2
Notes:
If the programmer is unable to identify the pacemaker the following message is
displayed: “Position programming head”.
In the unlikely event that more than one pacemaker is in close proximity to the
programming head, the programmer will warn you that more than one pacemaker has been detected. The pacemakers are then listed and you are asked to select the one to be interrogated.

4.2.3 Starting a reloaded data session

Select the “Programmer” icon and choose the reload session data option to reload session data stored on diskette. For more information, see Section 4.8.3.

4.2.4 Starting the Analyzer program

If the Medtronic lead analysis software and hardware are installed on the programmer, the Vitatron desktop will contain the “Analyzer” icon. Clicking the icon starts the analyzer program. After ending the analyzer program the programmer restarts the Vitatron software. For more information about the analyzer please refer to the documentation provided with it.

4.2.5 Adjusting programmer settings

Select the “Programmer” icon to change the programmer time and date, audio or printer options, turn the Therapy Advisor on or off, manage memory contents files or check the software version. See Section 4.10 for more information.

4.3 How to use the cardiac dashboard

When the pacemaker has been identified with [Auto Identify], the programmer starts initial interrogation of the pacemaker. When pacemaker interrogation is complete (indicated by a progress bar), the cardiac dashboard appears. The cardiac dashboard gives an overview of how the pacemaker has performed during the last follow-up period. Therapy Advisor messages and the most important patient and pacemaker information indicate whether the pacemaker may need reprogramming to optimize pacing therapy. If you change pacemaker settings or measurements during the follow-up session, the cardiac dashboard is updated.
You can select the “Dashboard” icon at any time to return to the cardiac dashboard.
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T-series Reference Manual Section 4.3

Figure 4. Cardiac dashboard window

1 Therapy Advisor window – The main Therapy Advisor messages are shown here,
if the Therapy Advisor is switched on. For a description of the Therapy Advisor, see Section 7.2.
2 Dynamic window – Press one of the underlined hyperlinks on the cardiac dashboard to display more detailed information in the dynamic window. If you press a Therapy Advisor hyperlink, details and programming advice appear in this window. If you press a parameter or diagnostic hyperlink, the dynamic window contains a graph showing its history over the previous follow-up periods. The anticoagulation information in the Burden graph comes from details entered in the Patient window.
The graphs are based on the History data in the pacemaker (see Section 6.8 and Section 7.4.2). If any relevant parameter settings were changed between history periods, no trend line will be shown on the graph.
3 Patient summary – This gives a summary of the most important pacing and sensing data during the follow-up period, including notes from the Patient window. The Episodes information applies to data collected during the follow-up period, and does not reflect any episode trigger changes in the current follow-up session.
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T-series Reference Manual Section 4.3
4 Pacemaker information – This contains technical information on parameter settings, battery and lead status, threshold and testing results. If no information is available, “---” is displayed. If “***” is displayed, this means that no senses were detected during a test.
If you change any settings during the follow-up session, the cardiac dashboard will show the new value. At initial interrogation, the P-wave amplitude is derived from the P-wave amplitude histogram. If a P-wave amplitude test is carried out during the follow-up session, the test result replaces the initial value. R-wave information is only available after an R-wave amplitude test has been performed during the follow-up session.
5 Control panel – The control panel icons are used to access stored information and to perform programming and test functions during a follow-up session.
6 Button line – During a follow-up session, the bottom line normally contains three buttons:
The [Emergency] button is always active during a follow-up session. When pressed
it programs the pacemaker to emergency settings (see Section 4.12).
The [Print] button prints the data displayed in the current window (see Section 4.9.1).
The [End Session] button allows you to close the follow-up session (see
Section 4.3.2). There is also an option to save pacemaker data to diskette or the network before closing the session.
Note: You cannot program parameters in this window. Select the “Parameters” icon to change parameter values.
A number of symbols may appear on the cardiac dashboard or in diagnostics and parameter programming windows (see Table 2).

Table 2. Programmer symbols

Symbol
Description
When pressed, shows more detailed information or the history of a parameter in the dynamic window. The last hyperlink pressed changes from green to blue.
When pressed, leaves the cardiac dashboard and jumps directly to the relevant diagnostic, test or therapy programming window.
When pressed, leaves the cardiac dashboard and jumps directly to the stored EGM window of the first episode in the Selected Episodes diary.
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