Follow-up: Programming

Question 1

Programming triggered modes (AAT, VVT) is useful to determine what?

Answer 1

To determine when sensing threshold is achieved.

i.e. At what point during the P-wave does the device register the event.

Question 2

What mode can be programmed to temporarily correct myopotential oversensing and/or noise due to lead failure until a permanent solution can be achieved?

Answer 2

Triggered (AAT/VVT) - Prevents under-pacing due to oversensing. Non-competitive against intrinsic conduction*. Good for non-dependent pts.

Asynchronous (AOO/VOO/DOO) - Paces at programmed rate but will compete against intrinsic conduction. Good for dependent pts.

*Triggered beat will fall within refractory of intrinsic beat - Functional non-capture.

Question 3

How would you reduce safety pacing // functional non sensing in patient with frequent ectopy?

Answer 3

Shorten the ventricular blanking period.

Question 4

List two indicators that show a devices battery has hit ERI.

Answer 4

1. Percent or fixed decrease in pacing rate
2. Change to a simpler pacing mode E.g. DDD to VVI

Question 5

Define the following

• BOL
• ERI
• EOL

Answer 5

• BOL = Beginning of life
• ERI = Electrive replacement indicator
• EOL = End of life

Question 6

What are the 4 types of data one receives when interrogating a device?

Answer 6

1. Administrative data - E.g. Patient details
2. Programmed data - E.g. Mode, Rate
3. Real-time data - E.g. Testing values
4. Stored data - E.g. Events

Question 7

Is the EGM of an event stored in the RAM or the ROM of the device?

Answer 7

EGM is stored on RAM = read and write capabilities.

ROM = installed by manufacturer and can’t be modified.

Question 8

In clinic you are presented with this atrial lead noise. List two ways to program around it.

Answer 8

1. Program the lead uniploar and test via provocation manouvers.
2. P-wave amplitude is considerably larger in amplitude than the noise. Thus decreasing atrial sensetivity (bigger number) to filter out noise while retaining ability to ‘see’ the p-wave may be appropriate.

Question 9

Patient mentions palpitations - what programming changes would you make with relation to Mswitch?

Answer 9

Reduce Mswitch entry criterion & Increase Mswitch exit criterion.

Mswitch resolved inappropriately due to atrial undersensing. By making exit criteria more difficult (more beats necessary at normal rate) undersensing is accounted for to some degree.

Reduce Mswitch entry criteria - this means fewer beats are necessary to enter Mswitch, which means less likely to experience symptoms associated with faster V-pacing rate.

Question 10

You see dropped p-waves on this IEGM, what would you adjust to ensure appropriate sensing?

Answer 10

Increase atrial sensetivity (lower number).

The amplitude of the dropped p-waves is significantly less than the preceeding sensed p-waves. Thus making the atrial channel more sensitive is likely to correct the problem.

Question 11

Would you program a shorter AVD and promote pacing in this patient?

Answer 11

Yes.

Although intrinsic rhythm is generally something to be preserved, an AV delay >450msec is unlikely to promote AV synchrony. Thus it is advisable to program normal physiological AV delays and increase V-pacing.

Question 12

What is the likely programming change seen here?

Answer 12

Both leads have changed from unipolar to bipolar sensing configurations.

Note how ventricular IEGM goes from broad to narrow (represents sensing field of view going from lead tip-can (large) to lead tip-ring (small)).

Note how far-field ventricular signal is removed from the atrial channel.

Question 13

What is the appropriate mode for each number?

Answer 13

1. AAIR
2. DDDR
3. DDDR
4. AAIR

Question 14

What is the appropriate mode for each number?

Answer 14

1. VDD / DDD
2. DDDR
3. VVIR

Question 15

What would be an appropriately programmed output voltage?

Answer 15

1.5V

Double the threshold voltage value = approriate programmed output.

Question 16

Atrial rates above ______bpm will trigger a switch to DDI pacing?

Answer 16

>160bpm.

ATR mode switch rate as illustrated.

Question 17

Yes / No

Would IRS+, MVP, VIP or RYTHMIQ be appropriate for this patient?

Answer 17

No.

These are all algorhythms designed to reduce RV pacing. This patient has CHB as evidenced by 100% RVp. These algorhythms would likely invoke symptoms.

Question 18

Yes / No

Would IRS+, MVP, VIP or RYTHMIQ be appropriate for this patient?

Answer 18

Yes.

These algorhythms aim to reduce RVp% by promoting intrinsic rhythm. This patient is clearly suitable for such treatment as 99% of V-events are sensed - thus evidencing intrinsic conduciton.

Question 19

From the below sensing test what would be the most appropriate mode to program?

Answer 19

DDD.

Rhythm shows good sinus function with 2:1 conduction. DDD will allow for appropriate sinus tracking and AV synchrony.

Question 20

You observe the following, how could one program around this without changing the pacing mode?

Answer 20

Program atrial lead from bipolar to unipolar.

Removing the outter ring conductor (most likely to fracture) will eradicate the noise. However be aware unipolar programming leads to increased risk of oversensing myopotentials. Reprograming the mode to VVI would risk sacrificing AV synchrony should they become dependent and could bring about paceaker syndrome.

Question 21

Yes / No

Would IRS+, MVP, VIP or RYTHMIQ be appropriate for this patient?

Answer 21

No.

These are all algorhythms designed to reduce RV pacing. This patient has CHB as evidenced by ~100% RVp. These algorhythms would likely invoke symptoms.

Question 22

To remove the observed ‘AT’ sensed events, would one increase or decrease sensitivity?

Answer 22

Decrease sensitivity by Increasing the programmed mV number.

Question 23

What would be an appropriately programmed output for this patient?

Answer 23

Double threshold voltage (0.9 x 2) = 1.8V

Question 24

What two programming changes could be made to remove the observed far field atrial sensing?

Answer 24

1. Decrease atrial sensitivity (intrinsic activity appears double the amplitude of the far field signal).
2. Extend the atrial blanking window (Far Field Protection).

Question 25

What programming change was likely made here?

Answer 25

A & V sensing changed from unipolar to bipolar. ## Footnote *Note how A-IEGM no longer senses far-field signals and V-IEGM depicts narrower complexes.*

Question 26

Patient remarks of SOBOE, what would you program to help reduce symptoms?

Answer 26

Rate response. ## Footnote *Note how histos show poor spread, with majority pacing at base rate. Patient is also CHB as evidenced by ~80% Vp - thus rate response would be a good idea for this patient.*

Question 27

This patient shows chronotropic incompetence as evidenced by a lack of HR distribution. However why would one be cautious of programming rate response in this patient?

Answer 27

Patient has intrinsic conduction as shown by 0%Vp. ## Footnote *If patient describes no symptoms then preserving 0% Vp may be of a higher priority. Programming RR will increase Vp which could bring about pacemaker syndrome.*

Question 28

# Yes / No Patient presents at 70% CRT - would programming the device from DDD to VVI improve target CRT?

Answer 28

No. ## Footnote *V events are all sensed, thus Atrial signals that are conducted. The device cannot prevent signals conducting to the ventricles. Best option here is to ablate the AV node to ensure CRT pacing.*

Question 29

# Yes / No Patient complains of palpitations. You see 15 of these examples. Would you program different parameters to BURST ATP?

Answer 29

Yes. ## Footnote *Clearly burst ATP at this setting is ineffective as the tachycardia continues unchanged. Coupling interval, Scan and train length are all settings to be altered.*

Question 30

What pacing output would you program?

Answer 30

Threshold = 0.6V thus output = 1.2V. ## Footnote *Appropriate safety margin is double threshold voltage.*

Question 31

What are the two main differential diagnosis that explain the Ars(FFP) observed?

Answer 31

1. Retrograde P-wave - comes approximately 90msec post LV stim. 2. Crosstalk - Oversensing of ventricular depolarisation / repolarisation.

Question 32

How could you program the device to overcome this?

Answer 32

Oversensing on ventricular lead respondent to noise. Program lead unipolar to remove fractured conductor from circuit. ## Footnote *Patient here has intrinsic rhythm - in a dependent patient this could be catastrophic. Device would withold pacing due to believing the sensed noise to be intrinsic beats. This would result in asystole.*

Question 33

What output would you program?

Answer 33

Threshold is 1.0V - Thus output = 2.0V ## Footnote *Double threshold value to ascertain appropriate safety margin.*

Question 34

Patient remarks of irregular heart beat, what programming changes could you make?

Answer 34

Device is inappropriately exiting Mswitch, eliciting changes in the V-paced rate due to tracking of atrial arrhythmia. Device is Mswitching inappropriately due to atrial undersensing. ## Footnote *Alter atrial sensitivity either by fixing the sensitivity lower or increasing decay rate.* *Program tougher Mswitch exit criterion E.g. from 5/8 beats \<160bpm to 8/8 beats \<160bpm.* *Program VVI depending on whether the AF is chronic \>1yr or not.*

Question 35

# Yes / No Patient asymptomatic. Upon device interrogation you see x10 of these lasting ~5s. VT1 is currently monitor zone. Would you program therapies on for these and why?

Answer 35

No. ## Footnote *VT1 is monitor suggesting primary prevention case under HRS programming. 5sec is very short and causes no symptoms. Prognosis is better if shorter tachycardias self terminate without intervention.*

Question 36

What is the purpose of the programmed algorhythm behaviour seen here?

Answer 36

NCAP - Non Competitve Atrial Pacing. ## Footnote *NCAP ensures a reduced risk of atrial arrhythmia by preventing pacing during the atriums vunerable period.*

Question 37

# DDDR 60/130, AVD 200ms, V-ref 225ms, PVARP 225ms, A = 5.0V, V = 2.0V Programming the following would likely induce: 1. Pacemaker Syndrome 2. Exercise intolerance 3. PMT 4. Crosstalk

Answer 37

3 - PMT.

Question 38

Which of the following discriminators would be most helpful? 'Patient has history of PAF and sustained monomorphic VT'. 1. Rate 2. Stability 3. Onset 4. Sustained high rate

Answer 38

2. Stabililty

Question 39

What rhythm is shown and what programming changes are necessary?

Answer 39

Atrial Fibrillation is being undersensed. Increase atrial sensitivity to ensue device mode switches.

Question 40

Explain the following and their purposes. "AAI safe R or AAI=DDD'

Answer 40

Both forms of RVpacing reduction algorhythms. ## Footnote *Reduced RV pacing leads to a reduction in pacemaker syndrome risk, Chronic AF development etc. Review DAVID 2004 study.*

Question 41

What programming changes would you make to this secondary prevention patient experiencing extended runs of palpitations?

Answer 41

Slow VT below VT1 detect rate is seen - Lower VT1 rate to allow VT detection + therapy if required.

Question 42

You see this in clinic in a dependent patient - what is wrong, how would you program around it?

Answer 42

RV impedance increase consistent with conductor fracture. Program lead from bipolar to unipolar.

Question 43

# Device programmed DOO What is wrong, how would you program around this?

Answer 43

Atrial non-capture. Check threshold and increase atrial output.

Question 44

What is the issue, how do you program around it?

Answer 44

Atrial undersensing. Check lead integrity and increase atrial sensitivity.

Question 45

What programming alterations would you make in this case?

Answer 45

Atrial non capture - Check lead integrity and increase output.

Question 46

How would you program around this?

Answer 46

Example of FFRWS. ## Footnote *Decrease atrial sensitivity - Atrial intrinsic signals are of greater amplitude and FF signals.* *Increase PVAB - Thus placing the FF signals within a blanking zone.*

Question 47

What is the issue, how do you program around it?

Answer 47

Ventricular non-capture. Increase ventricular output.

Question 48

What is the most appropirate programming change? 'Patient presents with occasional palpitations. Device programmed DDD 75bpm'.

Answer 48

Atrial sensitivity increased. ## Footnote *Device is not detecting low amplitude fib waves, thus cannot appropriately Mswitch. Note lack of As events and Ap throughout.*

Question 49

What is the most appropriate programming change?

Answer 49

Increase ventricular sensitivity. ## Footnote *Ventricular undersensing has led to a stim being delivered during ventricular depolarisation.*

Question 50

What is the most likely programming change required here? 1. Turn on Atrial Mode Switch 2. Increase ventricular output 3. Increase atrial sensitivity 4. Decrease atrial sensitivity 5. Increase Max Track Rate

Answer 50

3 - Increase atrial sensitivity. ## Footnote *If the rate is true (~280bpm), there should be significantly more A-sensed events than V-events. The lack of sensed events suggests undersensing in the atrial channel.*

Question 51

What programming change would you make for this patient?

Answer 51

Decrease the AV Delay. ## Footnote *Toward the latter part of the strip you see sensed events. The purpose of BiV is to get as close to 100% pacing as possible. Thus shortening the AVD will prevent any sensed events from arriving ahead of the paced beats.*

Question 52

# Yes / No Doctor requests primary prevention tachy programming - is this correct?

Answer 52

No ## Footnote VF Zone too low / VF Detection too short / VT2 detection too short / VT2 zone too low / VT2 R-S1 interval % too low

Question 53

Doctor requests primary prevention tachy programming - what changes would you make?

Answer 53

* VF Zone: 222bpm > 231bpm * VF Detection: 18/24 > 30/40 * VT2 Detection: 20 > 30 * VT2 Zone: 182bpm > 188bpm * VT2 R-S1 interval: 80% > 88%

Question 54

What programming changes (if any) would you make here?

Answer 54

Turn therapies off ## Footnote Patient is receiving innapropriate shocks due to detected RV noise. Revision of RV lead required immediately.

Question 55

# Yes / No Would you program the following AAI?

Answer 55

No ## Footnote This is 2nd Degree AVB (clear dropped P-waves). Device programming should be DDD.

Question 56

How would you program this device?

Answer 56

LV IEGM shows noise - Prog RV VVI and revise LV lead.

Question 57

Why would you not program this device AAI?

Answer 57

Sinus Rhythm with 1st Degree (~400ms PR Interval). ## Footnote PR intervals >400ms could lead to AV dyssnchrony. Better to program DDD with shorter AVD.

Question 58

# Yes / No Could you appropriately program this device AAI?

Answer 58

Yes. ## Footnote Rhythm shown is Tachy/Brady with no evidence of conduction system disease (dropped beats)

Question 59

# Yes / No Would it be appropriate to program this device AAI?

Answer 59

Yes. ## Footnote Vp events are 4%, indicating a healthy AV conduction system.