Pacemaker Timing and Intervals

Objectives:

 Describe expected pacemaker function based

on the NBG code
 Interpret intervals comprising single and dual
chamber timing
 Recognize various modes of dual chamber
device operation from lower to upper rate
behaviors
 Calculate upper rate behavior based on
programmed parameters
 Identify therapy specific device operations
when presented on patient ECG
 Timing Intervals Are Expressed in
Milliseconds
 One millisecond = 1 / 1,000 of a second
 Converting Rates to Intervals
and Vice Versa
 Rate to interval (ms):
 60,000/rate (in bpm) = interval (in
milliseconds)
 Example: 60,000/100 bpm = 600
milliseconds
 Interval to rate (bpm):
 60,000/interval (in milliseconds) = rate
(bpm)
 Example: 60,000/500 ms = 120 bpm
 NBG Code Review

I II III IV V
Chamber Chamber Response Programmable Antitachy
Paced Sensed to Sensing Functions/Rate Function(s)
Modulation

V: Ventricle V: Ventricle T: Triggered P: Simple P: Pace

programmable
M: Multi-
A: Atrium A: Atrium I: Inhibited S: Shock
programmable

D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S)

O: None O: None O: None R: Rate modulating O: None

S: Single S: Single O: None

(A or V) (A or V)
Single-Chamber Timing
 Single Chamber Timing Terminology
 Lower rate
 Refractory period
 Blanking period
 Upper rate(in rate responsive mode)
 Lower Rate Interval

 Defines the lowest rate the pacemaker will pace

Lower Rate Interval

VP VP
VVI / 60
 Refractory Period

 Interval initiated by a paced or sensed

event
 Designed to prevent inhibition by cardiac
or non-cardiac events
Lower Rate Interval

VP VP
VVI / 60
Refractory Period
 During refractory periods, the pacemaker “sees” but is
unresponsive to any signals.
 This is designed to avoid restarting the lower rate interval
in the event of oversensing.
 T-wave oversensing in VVI and AAI modes will occur if
refractory periods are too short. In the AAI mode, the
pacemaker may even sense the QRS complex (“far-field R
wave”) if the refractory period is not long enough.
 Events that fall into the refractory period are sensed by
the pacemaker (the marker channel will display a “SR”
denoting ventricular refractory or atrial refractory in
single chamber systems) but the timing interval will
remain unaffected by the sensed event.
 A refractory period is started by a non-refractory paced,or
sensed event.
 Blanking Period

 The first portion of the refractory period

 Pacemaker is “blind” to any activity
 Designed to prevent oversensing pacing stimulus

Lower Rate Interval

VP VP
VVI / 60
Blanking Period
Refractory Period
 A paced or sensed event will initiate a blanking
period.
 Blanking is a method to prevent multiple detection
of a single paced or sensed event by the sense
amplifier (e.g., the pacemaker detecting its own
pacing stimuli or depolarization, either intrinsic or
as a result of capture).
 During this period, the pacemaker is "blind" to any
electrical activity.
 A typical blanking period duration in a single-
chamber mode is 100 msec*.
 Upper Sensor Rate Interval
 Defines the shortest interval (highest rate) the pacemaker
can pace as dictated by the sensor (AAIR, VVIR modes)
 The upper sensor rate interval in single chamber pacing is
available only in rate-responsive modes. The upper rate
defines the limit at which sensor-driven pacing can occur.

Lower Rate Interval

Upper Sensor Rate

Interval

VP VP
VVIR / 60 / 120
Blanking Period
Refractory Period
Single Chamber Mode Examples
 VOO Mode
 Asynchronous pacing delivers output regardless of
intrinsic activity

Lower Rate Interval

VP VP
Blanking Period

VOO / 60
 VOO mode paces in the ventricle but will not
sense and, therefore, has no response to cardiac
events.
 Pacemakers programmed to the VVI, VVIR, and
VDD modes will revert to VOO mode upon magnet
application.
 In this example, an intrinsic beat occurs, but it has
no effect on the timing interval and another
ventricular pace is delivered at the programmed
rate.
 No sensing occurs, thus, the entire lower rate
interval is unresponsive to intrinsic activity.
 VVI Mode
 Pacing inhibited with intrinsic activity
 In inhibited modes (VVI/AAI), intrinsic events that occur
before the lower rate interval expires will reset the lower
rate interval, as shown in the example above. As with
paced events, sensed events will also initiate blanking
and refractory periods.

Lower Rate Interval {

VP VS VP
Blanking/Refractory

VVI / 60
 VVIR
 Pacing at the sensor-indicated rate

Lower Rate

Upper Rate Interval

(Maximum Sensor Rate)

VP VP
Refractory/Blanking

VVIR / 60/120
Rate Responsive Pacing at the Upper Sensor Rate
 Single chamber rate-responsive pacing is
identical to non-rate responsive pacing operation,
with the exception that the pacing rate is driven
by a sensor.
 The sensor determines whether or not a rate
increase is indicated, and adjusts the rate
accordingly.
 The highest rate that the pacemaker is allowed to
pace is the upper rate limit or interval.
 In this example, the pacemaker is pacing at the
maximum sensor indicated rate of 120 ppm.
 AAIR
 Atrial-based pacing allows the normal A-V activation
sequence to occur

Lower Rate Interval

Upper Rate Interval
(maximum sensor rate)

AP AP
Refractory/Blanking

AAIR / 60 / 120
(No Activity)
 Although this mode is seldom used , AAI/R pacing is a mode
which, unlike VVI/R, allows for normal AV conduction to occur.
 AAI/R is not often used because of the risk of development of
AV block which can occur over time.
 In this example, the patient received a single chamber device
programmed to the AAIR pacemaker mode due to sick sinus
syndrome and chronotropic incompetence. Presently the
patient is at rest, so the sensor is at the programmed lower
rate. An atrial event (paced or sensed) will initiate a refractory
period including a blanking period.
 In AAI/R, the refractory period must be long enough so that the
far-field R and T waves are ignored. Therefore, the refractory
period must be longer in the AAI/R mode than in the VVI/R
mode—typically 400 msec.
 Atrial events sensed during the refractory period in AAI/R are
marked with an "SR" on the marker channel.
Other Single Chamber Operations
 Hysteresis
 Allows the rate to fall below the programmed lower rate
following an intrinsic beat

Lower Rate Interval-60 ppm Hysteresis Rate-50 ppm

VP VP VS VP
 Hysteresis allows the sensed intrinsic rate to decrease to a value
below the programmed lower rate before pacing resumes.
 Hysteresis provides the capability to maintain the patient's own
heart rhythm as long as possible, while pacing at a faster rate if the
intrinsic rhythm falls below the hysteresis rate.

 The hysteresis rate is always < the lower rate limit.

 The lower rate limit is initiated by a paced event, while the
hysteresis rate is initiated by a non-refractory sensed event.

 In the example above, the lower rate limit is 60 ppm (1000 ms), while
the hysteresis rate is 50 ppm (1200 ms). The patient is paced at 60
ppm until an intrinsic event occurs, and an interval of 1200 ms is
started. This patient did not have another sensed event, so a
ventricular pace was delivered. However, if another sensed event
had occurred, the pacemaker would again have extended the
interval to 1200 ms.
 Noise Reversion
 Continuous refractory sensing will cause pacing at the
lower or sensor driven rate

Lower Rate Interval

Noise Sensed

SR SR SR SR
VP VP

VVI/60
 The portion of the refractory period after the
blanking period ends is commonly called the "noise
sampling period.“
 This is because a sensed event in the noise
sampling period will initiate a new refractory period
and blanking period.
 If events continue to be sensed within the noise
sampling period causing a new refractory period
each time, the pacemaker will asynchronously pace
at the lower rate since the lower rate timer is not
reset by events sensed during the refractory period.
This behavior is known as "noise reversion."
 Note: In rate-responsive modes, noise reversion
will cause pacing to occur at the sensor-driven rate.
 Benefits of Dual Chamber Pacing
 Provides AV synchrony
 Lower incidence of atrial fibrillation
 Lower risk of systemic embolism and stroke
 Lower incidence of new congestive heart failure
 Lower mortality and higher survival rates
Dual-Chamber Timing
 Benefits of Dual-Chamber Pacing

Study Results
Higano et al. 1990 Improved cardiac index during low level
exercise (where most patient activity occurs)
Gallik et al. 1994 Increase in LV filling
Santini et al. 1991 30% increase in resting cardiac output
Rosenqvist et al. 1991 Decrease in pulmonary wedge pressure
Increase in resting cardiac output
Sulke et al. 1992 Increase in resting cardiac output, especially
in patients with poor LV function
Decreased incidence of mitral and tricuspid
valve regurgitation
 Four “Faces” of Dual Chamber Pacing
 Atrial Pace, Ventricular Pace (AP/VP)

AV V-A AV V-A

AP AP
VP VP

Rate = 60 bpm / 1000 ms

A-A = 1000 ms
 Four “Faces” of Dual Chamber Pacing

 Atrial Pace, Ventricular Sense (AP/VS)

AV V-A AV V-A

AP AP
VS VS
Rate = 60 ppm / 1000 ms
A-A = 1000 ms
 Four “Faces” of Dual Chamber Pacing

 Atrial Sense, Ventricular Pace (AS/ VP)

AV V-A AV V-A

AS AS
VP VP

Rate (sinus driven) = 70 bpm / 857 ms

A-A = 857 ms
 Four “Faces” of Dual Chamber Pacing

 Atrial Sense, Ventricular Sense (AS/VS)

AV V-A AV V-A

AS AS
VS VS
Rate (sinus driven) = 70 bpm / 857 ms
Spontaneous conduction at 150 ms
A-A = 857 ms
 Dual Chamber Timing Parameters

 Lower rate
 AV and VA intervals
 Upper rate intervals
 Refractory periods
 Blanking periods
 Lower Rate
 The lowest rate the pacemaker will pace the atrium in
the absence of intrinsic atrial events

Lower Rate Interval

AP AP
VP VP

DDD 60 / 120
 In order to provide optimal hemodynamic benefit
to the patient, dual-chamber pacemakers strive to
mimic the normal heart rhythm.
 In dual-chamber pacemakers, the lower rate is
the rate at which the pacemaker will pace the
atrium in the absence of intrinsic atrial activity.
 Similar to single-chamber timing, the lower rate
can be converted to a lower rate interval (A-A
interval), or the longest period of time allowed
between atrial events.
 AV Intervals
 Initiated by a paced or non-refractory sensed atrial event
 Separately programmable AV intervals – SAV /PAV

Lower Rate Interval

PAV SAV

200 ms 170 ms

AP AS
VP VP
DDD 60 / 120
 The SAV is usually programmed to a shorter duration than the PAV to
allow for the difference in interatrial conduction time between intrinsic
and paced atrial events.
 difference in the activation sequence between a cycle initiated with an
intrinsic atrial event versus a paced atrial event.
 The cycle starting with the intrinsic atrial event will use the normal
conduction pathways between the right atrium and the left atrium. The
cycle starting with the paced atrial beat will not use the normal
interatrial conduction pathways but will instead use muscle tissue,
which takes a little longer to reach the left atrium and causing it to
contract.
 If the AV interval is timed to allow the appropriate amount of time for
left ventricular filling when the cycle is initiated with a sensed atrial
event, the same duration for the PAV may not be the appropriate
amount of time to allow for left ventricular filling when the cycle is
initiated by a paced atrial event.
 Proper LA-LV timing promotes left ventricular filling ("atrial kick") and
prevents regurgitant flow through an open mitral valve. Therefore, it is
beneficial to have separately programmable PAV and SAV intervals.

 In this example, the lower rate interval is terminated by a sensed atrial

event, which initiates a SAV interval (and restarts the the lower rate
interval).
 Atrial Escape Interval (V-A Interval)

 The interval initiated by a paced or sensed ventricular

event to the next atrial event

Lower Rate Interval

200 ms 800 ms

AV Interval VA Interval

AP AP
VP VP
DDD 60 / 120
PAV 200 ms; V-A 800 ms
 Atrial escape interval (AEI)– V-A interval

 The A-V interval is employed to allow the appropriate amount of

time to optimize ventricular filling and mimic the activation
sequence of the normal heart.
 Knowing the lower rate interval and the PAV interval (A-V
interval after a paced atrial event), the V-A interval can be
found:
 V-A interval = lower rate interval minus PAV interval.
 The V-A interval is the longest period that may elapse after a
ventricular event before the atrium must be paced in the
absence of atrial activity.
 The V-A interval is also commonly referred to as the atrial
escape interval.
 Upper Activity (Sensor) Rate

 In rate responsive modes, the Upper Activity Rate

provides the limit for sensor-indicated pacing
Lower Rate Limit

Upper Activity Rate Limit

PAV V-A PAV V-A

DDDR 60 / 120
A-A = 500 ms
AP AP
VP VP
 This upper rate is defined as the upper activity
rate, also known as the upper sensor rate or
maximum sensor rate.
 Before mode switching was available,
pacemakers utilized a separate activity/sensor
rate and upper tracking rate to limit the rate to
which the patient could track (e.g., in the
presence of SVTs), but allow the patient to pace
to higher rates if they were exercising.
 Upper Tracking Rate

 The maximum rate the ventricle can be paced in

response to sensed atrial events
Lower Rate Interval {
Upper Tracking Rate Limit
SAV VA SAV VA

AS AS
VP VP

DDDR 60 / 100 (upper tracking rate)

Sinus rate: 100 bpm
 The sequence of an atrial intrinsic event being
sensed, starting an SAV interval, timing out the
SAV interval, and pacing in the ventricle can be
referred to as "tracking."
 If the atrial rate begins to increase and continues
to increase,it is not desirable to let the ventricle
"track" to extremely high rates.
 to limit the rate at which the ventricle can pace in
the presence of high atrial rates.
 This limit is called the upper tracking rate.
 Refractory Periods

 VRP and PVARP are initiated by sensed or paced

ventricular events
 The VRP is intended to prevent self-inhibition
such as sensing of T-waves
 The PVARP is intended primarily to prevent
sensing of retrograde P waves

AP
A-V Interval Post Ventricular Atrial
(Atrial Refractory) Refractory Period (PVARP)
Ventricular Refractory Period VP
(VRP)
 The Post-Ventricular Atrial Refractory Period (PVARP) is
the period of time after a ventricular pace or sense when
the atrial channel is in refractory.
 In other words, atrial senses outside of blanking that
occur during this period are "seen" (and marked “AR) on
the marker channel), but do not initiate an AV interval.
 The purpose of PVARP is to avoid allowing retrograde P
waves, far-field R waves, or premature atrial
contractions to start an AV interval which would cause
the pacemaker to pace in the ventricle at a high rate.
 The refractory period after a ventricular event (paced or
sensed) is designed to avoid restarting of the V-A
interval due to a T wave. Ventricular sensed events
occurring in the noise sampling portion of the ventricular
refractory period are "seen" but will not restart the V-A
interval.
 The atrial channel is refractory following a paced or
sensed event during the AV interval. This allows atrial
senses occurring in the AV interval to be "seen" but not
restart another AV interval .
 Blanking Periods

 First portion of the refractory period-sensing is disabled

AP AP
VP
Atrial Blanking Post Ventricular Atrial
(Nonprogrammable) Blanking (PVAB)

Post Atrial Ventricular Ventricular Blanking

Blanking (Nonprogrammable)
 DDD/R modes have four types of blanking periods:
 A non-programmable atrial blanking period (varies
from 50-100 msec) is initiated each time the atrium
paces or senses.
 This is to avoid the atrial lead sensing its own pacing
pulse or P wave (intrinsic or captured). In Thera and
Kappa devices, this blanking period is dynamic,
depending on the strength of the paced/sensed signal.
 The PVAB-(Post-Ventricular Atrial Blanking Period) is
initiated by a ventricular pace or sensed event
(nominally set at 220 msec) to avoid the atrial lead
sensing the far-field ventricular output pulse or R
wave.
 In dual-chamber timing, a non-programmable
ventricular blanking period occurs after a ventricular
paced or sensed event to avoid sensing the ventricular
pacing pulse or the R wave (intrinsic or captured). This
period is 50-100 msec in duration and is dynamic,
based on signal strength.
 There also is a ventricular blanking period after an atrial
pacing pulse in order to avoid sensing the far-field atrial
stimulus (crosstalk). This period is programmable (nominally
set at 28 msec).
 This blanking period is relatively short because it is important
not to miss ventricular events (e.g., PVCs) that occur early in
the AV interval.
 Ventricular blanking does not occur coincident with an atrial
sensed event. This is because the intrinsic P wave is relatively
small and will not be far-field sensed by the ventricular lead.
 A note of caution in programming long ventricular blanking
periods after an atrial pace should be mentioned.
 If the ventricular blanking period after an atrial pace is
excessively long, conducted ventricular events may go
unsensed and cause the pacemaker to pace in the ventricle
after the AV interval expires. This pace could occur before the
ventricle has recovered from depolarization and may induce a
ventricular arrhythmia (R on T phenomena).
Upper Rate Behavior
 Upper Rate Behaviors –
Wenckebach and 2:1 Block

Upper rate
Ventricular rate

Atrial
tracking

Lower
rate

Atrial rate
 When the intrinsic atrial rate approaches (and exceeds) the
programmed upper rate (assuming the TARP is less than
the upper rate interval), pacemaker operations will change
from 1:1 tracking operations to blocking operations, which
are designed to prevent tracking atrial arrhythmias which
are too fast, and will likely cause patients to become
symptomatic.
 The jagged line represents Wenckebach operation,
characterized by a lengthening of the A-V interval which
occurs as the atrial rate exceeds the upper rate limit. If the
atrial rate continues to increase, 2:1 block will occur, which
means that every other P wave will fall into refractory and
will not be sensed.
 The ventricular paced rate will typically be half the atrial
rate.
 Total Atrial Refractory Period (TARP)
 Sum of the AV Interval and PVARP
 The Total Atrial Refractory Period (TARP) is equal to the
SAV interval plus the PVARP. The TARP is important to
understand as it defines the highest rate that the
pacemaker will track atrial events before 2:1 block occurs.

Lower Rate Interval

Upper Tracking Rate

AS AS
SAV = 200 ms
PVARP = 300 ms
VP VP
Thus TARP = 500 ms (120 ppm)
SAV PVARP SAV PVARP
DDD
LR = 60 ppm (1000 ms) TARP
{
UTR = 100 bpm (600 ms)
Sinus rate = 66 bpm (900 ms)
P Waves Blocked
 Wenckebach Operation

 Prolongs the SAV until upper rate limit expires

 Produces gradual change in tracking rate ratio

Lower Rate Interval {

Upper Tracking Rate P Wave Blocked (unsensed or unused)

AS AS AR AP
VP VP VP
SAV PVARP SAV PVARP PAV PVARP
TARP TARP TARP
DDD Sinus rate = 109 bpm (550 ms) LR = 60 bpm (1000 ms) UTR = 100 ppm (600 ms)

SAV = 200 ms PAV = 230 ms PVARP = 300 ms

 Pacemaker Wenckebach has the characteristic Wenckebach pattern of the PR
(AV) interval gradually extending beat-to-beat until an atrial event falls into the
PVARP and cannot restart an AV interval. In effect, a ventricular beat is
“dropped”.
 In this graphic, starting from the left side of the ECG, the pacemaker senses an
atrial beat and starts an SAV. Because no ventricular event occurs by the end of
the SAV, a ventricular pace is delivered. Now the pacemaker is looking for a
sensed atrial beat. An atrial beat is sensed outside of the PVARP and starts an
SAV. This time, when the SAV times out, the upper rate interval has not yet
expired. Since the pacemaker can never violate the upper tracking rate, the
ventricular pace has to be delayed until the end of the upper rate interval, at
which time a ventricular pace is delivered.
 This pattern of sensing a P wave, starting an SAV, waiting for the upper rate
interval to time out, and pacing in the ventricle repeats until a P wave falls into
the PVARP and does not start an SAV. The amount of delay created by the time
from the sensed P wave until the upper rate interval expires is a little longer
each time, producing the gradually lengthening of the P wave to ventricular
pace intervals.
 Once a P wave falls into the PVARP and does not initiate an SAV, the
pacemaker looks for the next sensed P wave and the pattern starts all over
again. This is how the classic Wenckebach pattern develops.
 The rate at which the pacemaker will exhibit Wenckebach behavior is at the
upper tracking rate (or upper rate if the pacemaker does not have a separate
upper tracking rate and upper activity rate).
 Wenckebach Operation

DDD / 60 / 120 / 310

 2:1 block
 Pacemaker 2:1 block is characterized by two
sensed P waves per paced QRS complex. This
pattern develops because every other P wave falls
into PVARP.
 The rate at which the pacemaker will exhibit a 2:1
block pattern is determined by the SAV and the
PVARP (or the TARP).
 Atrial rates with a P-P coupling interval shorter
than the TARP will result in 2:1 block.
 To determine at what rate the pacemaker will go
into 2:1 block, the TARP is simply converted from
an interval to a rate. Therefore, the rate the
pacemaker will go into 2:1 block is: 60,000/TARP.
 2:1 Block
 Every other P wave falls into refractory and does not restart the timing interval
 Starting on the left side of this ECG, the sequence begins with a sensed P
wave. This P wave initiates a SAV, followed by a paced ventricular event.
 The next P wave falls into the PVARP, started by the ventricular pace, so no
SAV is initiated. The following P wave is sensed outside of the PVARP, so a
SAV is started. Again, no ventricular event occurs during the SAV, so the
pacemaker paces in the ventricle. In this manner, a 2:1 block pattern is created

Lower Rate Interval {

Upper Tracking Limit

AS AS
AR AR
VP VP
AV PVARP AV PVARP
Sinus rate = 150 bpm (450 ms) TARP TARP
{
PVARP = 300 ms SAV = 200 ms
Tracked rate = 66 bpm (900 ms)
P Wave Blocked
 2:1 Block
DDD / 60 / 120 / 310
 Wenckebach vs. 2:1 Block

 If the upper tracking rate interval is longer

than the TARP, the pacemaker will exhibit
Wenckebach behavior first…
 If the TARP is longer than the upper
tracking rate interval, then 2:1 block will
occur
 Wenckebach vs. 2:1 Block –
What Will Happen First?

What will the upper rate behavior of this pacemaker

be?

Lower rate = 60 ppm

Upper tracking rate = 120 ppm
PAV = 230 ms
SAV = 200 ms
PVARP = 350 ms
 Wenckebach vs. 2:1 Block – Solution

Upper tracking rate = 120 ppm

PVARP = 350 ms
SAV = 200 ms

 Upper tracking rate interval = 60,000/120

ppm = 500 ms
 2:1 block interval = TARP = SAV + PVARP
(200 ms + 350 ms = 550 ms)
 TARP is greater than the upper tracking rate
interval
Thus, 2:1 block will be in effect
 Wenckebach vs. 2:1 Block –
What Will Happen First?

What will the upper rate behavior of this pacemaker

be?

Lower rate = 60 ppm

Upper tracking rate = 110 ppm
PAV = 150 ms
SAV = 120 ms
PVARP = 350 ms
 Wenckebach vs. 2:1 Block – Solution

Upper tracking rate = 110 ppm

PVARP = 350 ms
SAV = 120 ms

 Upper tracking rate interval = 60,000/110 =

545 ms
 2:1 block interval = TARP = SAV + PVARP
(120 ms + 350 ms = 470 ms)
 Upper tracking rate interval is greater than
the TARP
Thus, Wenckebach will be in effect
 Remember:
 1:1 tracking occurs whenever the patient’s
atrial rate is below the upper tracking rate
limit (assuming the TARP is less than the
upper tracking rate limit)
 Wenckebach will occur when the atrial rate
exceeds the upper tracking rate limit (and is
longer than the TARP)
 Atrial rates greater than TARP cause 2:1
block
 What Can We Do to Make Wenckebach Occur
First?

 Going to 2:1 block first without a Wenckebach

period may not be the optimal situation
because many patients do not tolerate a
precipitous drop in ventricular rate well
 Shorten or reduce the TARP by:
 Shortening the PVARP

 Shortening the SAV

 Programming Rate Adaptive-AV (RA-AV)

 Rate-Adaptive AV
 Rate-Adaptive AV (RA-AV) is a shortening of the
A-V interval in the presence of an increased atrial
rate—be it intrinsic or sensor driven
 Pacemaker shortens AV intervals as atrial rates
increase
 Shortened SAV intervals increase the
programmable tracking range
 Shortened PAV intervals increase the
programmable upper activity rate range
 Both permit a longer atrial sensing window
 Both the PAV and the SAV shorten with
increasing rates.
 For the PAV, the adaptation is based on the
sensor-indicated rate.
 For the SAV, the adaptation is based on the
intrinsic atrial rate.
 RA-AV has three programming requirements, in
addition to the SAV and the PAV (at lower rates):
A start rate, which determines when RA-AV
operation begins
 A minimum AV interval, which is the shortest
allowable SAV or PAV value
 A stop rate, which determines the rate where
the minimum SAV and PAV is reached
 Rate-Adaptive AV

240
220
Programmed PAV
200
180 Programmed SAV Ra
te
Ad
160
Ra a pt i
te ve
140 Ad PA
AV Interval (ms)

a pt i V
120 ve
SA Minimum PAV
100 V
80 Minimum SAV
60

40

20

0
50 80 100 150 180
Rate (ppm)
Start Rate Stop Rate
Rate-Adaptive AVI Mimics Intrinsic Response to
Increasing Heart Rates
 In the normal heart, AV conduction times shorten as
heart rates increase; RA-AV mimics this physiologic
response
AS AR
VP
AV PVARP
AV = 200 ms TARP = 500 ms Atrial rate = 450 ms (133 bpm)
PVARP = 300 ms Without RA-AV 2:1 block occurs

AS
VP
AV PVARP AV PVARP
AV = 100 ms TARP = 400 ms Atrial rate = 450 ms (133 bpm)
PVARP = 300 ms 1:1 tracking with RA-AV “on”
 Wenckebach vs. 2:1 Block –
What Will Happen First?

What will the upper rate behavior of this pacemaker

be?

Lower rate = 70 ppm

Upper tracking rate = 130 ppm
Upper activity rate = 130 ppm
PAV = 180 ms
SAV = 150 ms
RA-AV = ON
Start rate = 80 ppm
Stop rate = 120 ppm
Minimum SAV = 100 ms
PVARP = 320 ms
 Wenckebach vs. 2:1 Block – Solution
Upper tracking rate = 130 ppm
SAV = 150 ms
RA-AV = ON
Start rate = 80 ppm
Stop rate = 120 ppm
Minimum SAV = 100 ms
PVARP = 320 ms
 Upper tracking rate interval = 60,000/130
ppm = 462 ms
 TARP = 100 ms + 320 ms = 420 ms
 TARP is less than the upper tracking rate
limit interval
Thus, Wenckebach will be in effect
 Rate Responsive Pacing

 Pacing in DDDR mode can prevent precipitous drops

in heart rate due to upper rate behavior
Lower Rate

Upper Activity (Sensor)

Rate Limit

AS AR AP
VP VP
SAV PVARP PAV PVARP

DDDR 60 / 120 upper activity rate

Sensor-indicated rate = 100 ppm (600 ms)
 A-A Timing
In A-A timing, if a conducted ventricular event occurs during the AV
interval, the ventricular pace is inhibited but the A-A interval remains
consistent and does not exhibit the same shortening in the presence
of AV conduction that V-V timing does. The goal of A-A timing is to
provide for consistent A-A intervals, regardless of ventricular
conduction.

A to A = 1000 ms A to A = 1000 ms

A-A AV = 200 AV = 150 AV = 200

V-A = 800 V-A = 850
Timing

Atrial rate = 60 ppm

Ventricular rate = 63 ppm (first interval); 60 ppm
 V-V Timing
In V-V timing, if a conducted ventricular event occurs during the AV interval,
the ventricular pace is inhibited and a ventricular escape Interval (V-A interval)
is immediately started. This effective shortening of the AV interval causes the
entire V-V interval to be shortened. Therefore, it is possible to be pacing in the
atrium in DDD mode and be at a rate slightly faster than the programmed lower
rate.

A to A = 1000 ms A to A = 950 ms

AV = 200 AV = 150 AV = 200

V-V V-A = 800 V-A = 800
Timing

Atrial rate = 60; 63 ppm

Ventricular rate = 63; 60 ppm
 A-A vs. V-V timing

A to A = 1000 ms A to A = 1000 ms

A-A AV = 200 AV = 150 AV = 200

V-A = 800 V-A = 850
Timing

Atrial rate is held

constant at 60 ppm

A to A = 1000 ms A to A = 950 ms

AV = 200 AV = 150 AV = 200

V-V V-A = 800 V-A = 800
Timing

Atrial rate varies with

intrinsic ventricular conduction
 In this graphic, we can see the difference between A-A timing and V-V timing
schemes. In V-V timing, if a conducted ventricular event occurs during the AV
interval, the ventricular pace is inhibited and a ventricular escape Interval (V-A
interval) is immediately started. This effective shortening of the AV interval
causes the entire V-V Interval to be shortened. Therefore, it is possible to be
pacing in the atrium in DDD mode and be at a rate slightly faster than the
programmed lower rate.
 In A-A timing, if a conducted ventricular event occurs during the AV interval, the
ventricular pace is inhibited but the A-A interval remains consistent and does not
exhibit the same shortening in the presence of AV conduction that V-V timing
does. The goal of A-A timing is to provide for consistent A-A intervals, regardless
of ventricular conduction.
 A-A timing is most important at higher rates. Imagine a pacemaker programmed
to an upper rate of 130 ppm (interval of approximately 460 msec). Now let's say
that there is ventricular conduction and the difference between the programmed
PAV and the ventricular conduction time is 30 msec.
 That means that if the pacemaker were operating under V-V timing rules, the
entire V-V interval at the upper rate would be shortened by 30 msec–equating to a
rate of 140 ppm! This is quite a difference from the intended programmed upper
rate of 130 ppm. If the pacemaker were operating under A-A timing rules, the
entire AV interval would time out regardless of ventricular conduction,
maintaining the intended upper rate of 130 ppm.
Other Dual Chamber Modes
 VDD

 Provides atrial synchronous pacing

 System utilizes a single pass lead

Lower Rate Interval {

Upper Tracking Limit

AS AS
VP VP VP

VDD
LR = 60 ppm
UTR = 120 ppm
Spontaneous A activity = 700 ms (85 ppm); followed by pause
 In the VDD mode, the pacemaker will pace only in the ventricle and will
sense in both chambers.
 In response to sensing in the ventricle, the pacemaker will inhibit. If a P
wave is sensed, an SAV will be triggered. There is no PAV in the VDD
mode because the pacemaker will not pace in the atrium.
 Since the VDD mode does not have the capability to pace in the atrium,
the pacemaker will operate as if in the VVI mode in the absence of
atrial activity faster than the programmed lower rate.
 Therefore, this mode is only appropriate for patients with a normally
functioning, chronotropically competent sinus node and second- or
third-degree heart block.
 In this example, a P wave is sensed and initiates an SAV. Since no
ventricular activity is sensed during the SAV, the pacemaker paces in
the ventricle.
 The V-A interval is then initiated, followed by another sensed atrial and
paced ventricular event. Following this VA interval, no atrial activity is
sensed, and a ventricular pace is delivered at the end of the V-A
interval (lower rate interval).
 DDI/R

 A non-tracking mode
 Provides AV sequential pacing at lower or
sensor indicated rate
Lower Rate
Lower Rate Interval VA Interval

AP AP AS AP
VP VP VP

PAV PVARP PAV PVARP

DDI 60
AV = 200 ms
PVARP = 300 ms
 This is an example of normal DDI/R operation. In the DDI/R
mode, the pacemaker will pace in both chambers and sense
in both chambers.
 In response to sensing, the pacemaker will inhibit, but a
sensed P wave will not trigger an AV Interval (therefore, there
is no SAV Interval in the DDI/R mode). DDI/R pacing can be
thought of as AAI/R with VVI/R backup.
 In this example, since the atrium is paced, a PAV is initiated.
Since no intrinsic ventricular activity occurs, a ventricular
pace is delivered, and a V-A interval is initiated.
 This cycle repeats itself. An intrinsic atrial event occurs.
Since no SAV is initiated, the pacemaker is simply looking
for any ventricular activity to occur in the escape interval-
thus, the sensed atrial event is not tracked. The pacemaker
finally delivers a ventricular pace as the V-A expires (at the
programmed lower rate).
Additional Device Therapies

Issues and Solutions

 Additional Device Therapies

 Ventricular Safety Pacing

 Mode Switching/DDIR with Sensor Varied
PVARP
 PVC Response and PMT Intervention
 Non-Competitive Atrial Pace
 Rate Drop Response
 Sinus Preference
 Sleep Function
 Issue: Crosstalk

 Crosstalk is the sensing of a pacing

stimulus delivered in the opposite
chamber, which results in undesirable
pacemaker response, e.g., false inhibition

DDD / 70 / 120
 Cross talk
 Crosstalk is a phenomenon that occurs when one chamber
senses the output pulse of the other chamber.
 Crosstalk can become a problem when one chamber
senses the output of the other chamber and is inhibited.
 If the ventricular chamber is inhibited by the atrial pacing
pulse, as seen in the third complex above, the ventricular
output is withheld.
 In this particular example, crosstalk inhibition is
intermittent but the outcome could be disastrous if it
occurred with every paced atrial beat.
 If the ventricular lead is "blanked" for an adequate period of
time after the atrial pacing pulse to avoid seeing the atrial
pacing pulse, crosstalk inhibition will not occur.
 Programmable ventricular blanking after an atrial pace is
one method used to address the problem of crosstalk.
Another solution is ventricular safety pacing.
 Solution: Ventricular Safety Pacing

 Following an atrial paced event, a ventricular safety

pace interval is initiated
 If a ventricular sense occurs during the safety
pace window, a pacing pulse is delivered at an
abbreviated interval (110 ms)

PAV Interval

Post Atrial Ventricular Ventricular Safety Pace

Blanking Window
 One method to manage crosstalk is to program Ventricular
Safety Pacing (VSP) ON. If VSP is programmed ON, a ventricular
safety pace window opens up for 110 msec after an atrial pace.
The first portion of this window (about 28 msec) is blanked.
 After the blanking period ends, if a ventricular event is sensed
within 110 msec after the atrial pace, the pacemaker will pace at
the end of the 110 msec window.
 The logic here is that it is assumed that if a sensed event
happens within 110 msec of an atrial pace, it may not have
happened as a result of conduction to the ventricle (i.e., it is not
physiologic), and it may be crosstalk or noise.
 Rather than inhibit the ventricular pace and risk having no
ventricular support, the pacemaker will pace. By pacing at the
end of 110 msec, if the event was truly physiologic, the pace will
fall into the absolute refractory period of the ventricular muscle
tissue.
 Ventricular Safety Pacing is characterized by short (110 msec)
AV intervals.
 On the marker channel, the VSP will be marked by two
downward spikes–one for the ventricular sense and one for the
ventricular pace.
 Ventricular Safety Pacing is designed to minimize the effects of
cross-talk, but it can also occur under other circumstances. If a
ventricular sensed event (e.g., a PVC or a conducted ventricular
event) falls within the first 110 msec after an atrial pace, the
pacemaker may Ventricular Safety Pace.
 Also, if there is an atrial undersensing problem, ventricular
safety pacing may be seen. This happens if a scheduled atrial
pace is delivered shortly after this unsensed P wave. The
scheduled atrial pace initiates a PAV. If the unsensed P wave
conducts to the ventricle within the Ventricular Safety Pace
window, a Ventricular Safety Pace will occur.
 Other names for Ventricular Safety Pacing are "non-physiologic
AV delay" or "110-msec phenomenon". When in effect, the AV
interval will always be shortened.
 Ventricular Safety Pace

AP AP AP

VP VS VP VP

AV PVARP PVARP AV PVARP

110 ms
 Ventricular Safety Pace
Programmed parameters for this strip are: DDD; lower rate 60; upper
rate 120; PAV 150ms; SAV 150 ms.
Ventricular Safety Pace (VSP) ON. VSP occurred due to a PVC falling
in the AV interval.

DDD 60 / 120
 Other Methods for Managing Crosstalk

 Reduce atrial output (amplitude and/or pulse

width)
 Decrease (increase value) ventricular sensitivity
 Program bipolar (if possible)
 Increase the post -atrial ventricular blanking
period
 Issue: Managing PSVTs
 Patients with intermittent atrial arrhythmias may
experience palpitations when episodes occur
 In a tracking mode, high rate pacing will result

DDD / 60 / 140
 Some patients with dual-chamber pacemakers have
intermittent paroxysmal supraventricular
tachycardias (PSVTs) that are not desirable to track
due to non-physiologic high rate pacing in the
ventricle.
 These patients have traditionally been managed by
utilizing TARP (2:1 block) and/or separately
programmable upper rates (e.g., upper tracking rate =
90 ppm, upper sensor rate = 120 ppm) to avoid
tracking SVTs to excessively high rates in the
ventricle.
 Recently, the advent of mode switching has offered
another alternative for the management of SVTs.
 Solution: Mode Switching
 Indicated for patients with 3rd degree heart block
 Mode will switch from tracking mode (DDDR,
DDD) to DDIR (non-tracking mode) when atrial
arrhythmia is detected
 Ventricular pacing is decoupled from atrial
events, but rate responsive pacing is matched
to metabolic needs
 Mode Switch

 The device detects an atrial arrhythmia by

constantly comparing intervals with the
programmed mode switch detection rate

DDD / 60 / 120 Mode Switch ON

 At the onset of an atrial arrhythmia, the
pacemaker compares a mean atrial interval
(which is a running index of the atrial rate) to the
current A-A interval.
 If the A-A interval is shorter than the MAI, the
MAI is shortened by 24 ms.
 If the A-A interval is longer than the MAI, the MAI
is lengthened by 8 ms.
 When the MAI reaches the interval
corresponding to the mode switch detection rate
interval, the pacemaker switches from the DDDR
mode to the DDIR mode.
 DDIR with Sensor Varied PVARP

 Patients who have intact conduction are

better served with the DDIR mode
 Mode switch programmed ON will result
in unnecessary ventricular pacing
 Sensor Varied PVARP will vary the length
of the PVARP based on the sensor-
indicated rate
 DDIR with Sensor Varied PVARP

 Due to the shortening of the AV interval that is required in

conjunction with Mode Switch, it is not optimal to use Mode Switch
in patients with intact AV conduction.
 Using Mode Switch in these patients may force the ventricle to be
paced (rather than conduct) which would almost universally be
viewed as less hemodynamically effective.
 In addition to Mode Switch, another method of managing SVTs is to
use the DDI/R mode.
 The DDI/R mode will pace in both the atrium and the ventricle,
sense in both the atrium and the ventricle, and respond to sensing
by inhibiting but not initiating an SAV.
 By using this mode, atrial arrhythmias are sensed but do not cause
tracking to high pacing rates in the ventricle. In patients with intact
AV conduction, whether the R waves are in a 1:1 ratio with the P
waves is a function of the AV node.
 Sensor-Varied PVARP

 PVARP will shorten as rate increases

Long PVARP with little activity Shorter PVARP with increased activity
(Rate 63 ppm) (Rate 86 ppm)
 In DDI/R with a fixed PVARP, as the sensor-indicated pacing rate
increases, the atrial pacing output gets closer and closer to the
PVARP and may even occur during PVARP.
 If an atrial sense occurs during the PVARP, it does not inhibit the
scheduled atrial pace and competitive atrial pacing may ensue. If
the scheduled atrial pace occurs before the atrium has recovered
from depolarization, a pacemaker-induced atrial tachycardia may
be initiated.
 Some pacemakers have a Sensor Varied PVARP (SV-PVARP)
feature. SV-PVARP is intended to promote AV synchrony by
preventing inhibition of atrial pacing by an atrial sense early in the
V-A interval.
 It also reduces the likelihood of competitive atrial pacing at high
sensor-indicated rates.
 SV PVARP creates a minimum 300 ms buffer period after the end of
PVARP and before the next scheduled atrial pace in dual-chamber
modes.
 At low rates, the SV-PVARP is limited to to 400 ms. At high rates,
the PVARP can never be shorter than the programmed PVAB.
 Issue: Pacemaker Mediated Tachycardia (PMT)
 PMT is a paced rhythm, usually rapid, which is
sustained by ventricular events conducted retrogradely
(i.e., backwards) to the atria
 PMT can occur with loss of AV synchrony caused by:
 PVC
 Atrial non-capture
 Atrial undersensing
 Atrial oversensing
 Even patients who have complete antegrade
block may have the ability to conduct retrograde.
 But having the ability to conduct retrograde is
not enough.
 There must be a situation in which the
conduction pathways have had a chance to
recover when a ventricular contraction occurs.
 Basically, anything that causes a loss of AV
synchrony may promote retrograde conduction
and potentially a PMT.
 All of the above conditions (PVC, atrial non-
capture, atrial undersensing, and atrial
oversensing) cause a loss of AV synchrony and
may promote a PMT.
PMT
 PMT

 A retrograde P wave occurs as a result of the PVC.

 This retrograde P wave is sensed outside of the PVARP and
starts an SAV Interval.
 When the SAV Interval times out, if the Upper Tracking Rate
has not yet expired so the SAV Interval is extended.
 A ventricular pace is delivered at the end of the upper
tracking rate. The AV conduction pathways have recovered
and the ventricular pace causes another retrograde P wave.
 The sequence continues resulting in a sustained Pacemaker
Mediated Tachycardia (PMT).
 Solution: PVC Response

 A sensed ventricular event preceded by another

ventricular event without an intervening atrial event is
defined as a PVC
 PVARP is extended to 400 ms

Lower Rate AV VA AV VA
Interval
Restarts VA Interval

Retrograde
PVC P-Wave
(unused)
AV PVARP PVARP AV PVARP
 One way to prevent sensing retrograde P
waves when they happen due to a PVC is "PVC
Response."
 pacemakers define a PVC as the second of any
two consecutive ventricular events with no
intervening atrial event.
 When PVC Response is programmed ON, a
pacemaker defined PVC starts an extended
PVARP of 400 msec if the programmed PVARP
is less than 400 msec. This extended PVARP
allows retrograde P waves, should they occur,
to fall within the refractory period and,
therefore, does not initiate an SAV.
 PVC Response

This ECG strip illustrates the PVARP extension of 400 ms

following a PVC.

DDD / 60 / 120 / 310

 Solution: PMT Intervention

 Designed to interrupt a Pacemaker-

Mediated Tachycardia

DDD / 60 / 120
 If a PMT is initiated, PMT Intervention may be able to stop
the PMT cycle. If PMT Intervention is programmed ON, the
pacemaker will monitor for a PMT by looking for eight
consecutive VA Intervals that meet all of the following
conditions:
 Duration less than 400 msec
 Start with a ventricular paced event
 End with an atrial sensed event
 If PMT Intervention is ON and the above conditions are met,
the PVARP will be forced to 400 msec after the ninth paced
ventricular event.
 By extending the PVARP, the intent is to interrupt atrial
tracking for one cycle and break the PMT. After an
intervention, PMT Intervention is automatically suspended
for 90 seconds before the pacemaker can monitor for a PMT
again.
 Issue: Atrial Arrhythmias Induced by
Competitive Atrial Pacing
 If an atrial pace falls within the atrium's relative
refractory period, an atrial tachycardia may be
induced.
 This can happen if a P wave falls during the
PVARP (which will not inhibit the scheduled
atrial pace) and then the scheduled atrial pace
occurs shortly after the refractory sensed P wave
and induces an atrial arrhythmia
 Solution: Non-Competitive Atrial Pacing
(NCAP)
 Refractory sensed atrial events initiate a 300 ms NCAP
interval; no atrial pacing may occur within this window
 PAV interval shortens to maintain a stable ventricular
rate

DDDR / 60 / 120 NCAP “ON”

 Non competitive atrial pacing

 Non-Competitive Atrial Pacing (NCAP) can be used in

an effort to prevent atrial pacing from occurring too
close to a refractory sensed event.
 If NCAP is programmed ON, the scheduled atrial pace
will be delayed until at least 300 msec has elapsed
since the refractory sensed P wave occurred.
 The ensuing PAV may then be shortened to keep the
ventricular rate from experiencing the same delay.
 Note: The PAV may never be shorter than 80 ms.
 Issue: Neurocardiogenic Syncope

 Hypersensitive Carotid Sinus Syndrome

 Vasovagal Syncope
Solution: Rate Drop Response Therapy
 Rate Drop Response therapy can be used for CSS and VVS patients for
whom a permanent pacemaker is indicated.
 Rate Drop Response algorithms include three steps:
 (1) the pacemaker looks for a drop in heart rate (a detection cycle),
 (2) the pacemaker looks for that rate to remain low to confirm that it is
indeed a rate drop episode (confirmation cycle), and
 (3) the pacemaker intervenes at a high pacing rate that is separate
from the programmed Lower Rate or Upper Rate (intervention cycle).
 When an episodic drop in heart rate occurs and is detected and
confirmed, Rate Drop Response (RDR) therapy provides an immediate
increase in the pacing rate for a specified period, and then gradually
slows pacing to resynchronize to the sinus rate.
 RDR makes it possible for the pacemaker to differentiate between
episodic drops in heart rate and the slowing of the heart rate after
exercise or circadian slow down as bedtime approaches.
 Issue: Pacing in the Presence of Appropriate
Sinus Rhythm
 The best “sensor” for determining metabolic
need and heart rate is a properly functioning
sinus node
 Solution: Sinus Preference

 Sinus Preference is a programmable feature in the Kappa 400

devices.
 Sinus Preference proactively searches for sinus activity when
sensor-driven pacing overrides the sinus node, and allows for P-
wave tracking even when the sinus rate falls below the sensor rate.
 Sinus Preference is best suited for patients with Chronotropic
Incompetence, with sinus rates that may occasionally exceed
and/or lag closely behind the sensor-indicated rate during exercise.
 In this graphic, Sinus Preference shows how sinus activity is
detected below the sensor rate during a Search Episode. A Sinus
Preference Zone (programmable feature) is selected to determine if
the intrinsic rate lags behind the sensor rate, while the Search
Interval (also programmable) determines how often the search
process will occur.
 After 8 consecutive paced atrial events at the lower limit of the
Sinus Preference Zone, the paced rate will gradually increase until
the sensor-indicated rate is reached.
 Solution: Sinus Preference

 Intrinsic atrial rhythms slower than the

sensor-indicated rate can be tracked
 Sinus Preference
 This graphic illustrates Intrinsic Episode, which permits
tracking of sinus rates that rise above, then drift below
the sensor rate, provided they remain within a
preselected range or zone.
 Termination is the same as with Search Episode.
 It should also be noted that there is a physiologic rate
range above the sensor-indicated rate that is equal to
the Sinus Preference Zone.
 Atrial events that are faster than this range will disable
Sinus Preference until the next Search Interval occurs.
In the event that this occurs, the rate will fall back to
the sensor-indicated rate following termination of
tracking of high atrial events.
 In addition to the benefit of utilizing natural heart rate
reserves, programming Sinus Preference ON may
increase device longevity by pacing less frequently.
Sinus Preference
 Sleep Function
The sleep function suspends the programmed lower rate and
replaces it with a sleep rate (slower than the lower rate) during
a specified sleep period. The slower pacing rate during the
sleep period is intended to reduce the paced rhythm during
sleep for patient comfort.

30 30
mins. mins.
Lower
Rate
Rate

Sleep
Rate

Bed Time Wake Time

Time
 Summary

 Review of NBG codes

 Single and dual chamber timing intervals
 Device operations from lower to upper
rate behavior
 Calculate Wenckebach or 2:1 block
 Therapy specific device operations
Thank you