BASICS OF PACEMAKER

DN
 HISTORY
1958 Senning and Elmqvist
Asynchronous (VVI) pacemaker implanted by
thoracotomy and functioned for 3 hours
Arne Larsson
First pacemaker patient
Used 23 pulse generators and 5 electrode systems
Died 2001 at age 86 of cancer
1960 First atrial triggered pacemaker
1964 First on demand pacemaker (DVI)
1977 First atrial and ventricular demand pacing (DDD)
1981 Rate responsive pacing by QT interval, respiration,
and movement
1994 Cardiac resynchronization pacing
What is a Pacemaker?

A Pacemaker System consists of

a Pulse Generator plus Lead (s)
Implantable Pacemaker Systems Contain the Following
Components:

Pulse generator- power source or

battery
Lead

Leads

Cathode (negative electrode) IPG

Anode (positive electrode)

Anode

Body tissue
Cathode

S
 The Pulse Generator
Contains a battery that provides the
energy for sending electrical
impulses to the heart

Houses the circuitry that controls

pacemaker operations
Circuitry

Battery
Anatomy of a Pacemaker
Resistors

Atrial connector

Connector Ventricular connector

Defibrillation protection

Output capacitors
Hybrid
Clock

Reed (Magnet) switch

Telemetry antenna
Battery
 General Characteristics of Pacemaker
Batteries
Hermeticity, as defined by the pacing industry,
is an extremely low rate of helium gas leakage
from the sealed pacemaker container

low rate of self-discharge

lithium iodine -a long shelf life and high

energy density

DDD drains a battery more rapidly

 Power source

Longevity in single chamber pacemaker is 7 to

12 years.

For dual chamber longevity is 6 to 10 years.

Most pacemakers generate 2.8 v in the

beginning of life which becomes 2.1 to 2.4 v
towards end of life.

9
 Leads

Deliver electrical impulses from

the pulse generator to the heart

Sense cardiac depolarisation Lead

 Lead Characterization
Position within the heart Polarity
Endocardial or transvenous leads Unipolar
Epicardial leads
Bipolar

Fixation mechanism
Active/Screw-in
Passive/Tined Insulator
Silicone
Shape Polyurethane
Straight
J-shaped used in the atrium
 Lead components
Conductor
Connector Pin
Insulation
Electrode
Transvenous Leads - Fixation Mechanisms
 Passive fixation

The tines become lodged in

the trabeculae
 Active Fixation

The helix (or screw) extends into

the endocardial tissue

Allows for lead positioning

anywhere in the hearts chamber
 Myocardial and Epicardial Leads

Leads applied directly to

the heart
Fixation mechanisms
include:
Epicardial stab-in
Myocardial screw-in
Suture-on
 Active Fixation Passive Fixation
Advantages Easy fixation Less expensive & simple
Easy to reposition Minimal trauma to patient
Lower rate of dislodgement Lower thresholds
Removability

Disadvantages More expensive Higher rate of

>Complicated implantation dislodgement (>a/c)
Difficult to remove chronic
lead
 Cathode:-An electrode that is
in contact with the heart

Negatively charged

Anode:-receives the
electrical impulse after
depolarization of cardiac
tissue

Positively charged when Anode

electrical current is flowing

Cathode
 A Unipolar Pacing System

Contains a lead with an electrode in the heart

Flows through the

tip electrode
(cathode)

Stimulates the heart +

Anode

Returns through
body fluid and tissue -
to the PG (anode) Cathode
 A Bipolar Pacing System

Contains a lead with 2 electrodes in the heart

Flows through the
tip electrode
located at the end
of the lead wire

Stimulates the
heart

Returns to the ring Anode

electrode above
the lead tip Cathode
 Unipolar leads
One electrode on the tip & one conductor coil

Conductor coil may consist of multiple strands - (multifilar leads)

Unipolar leads have a smaller diameter than bipolar leads

Unipolar leads exhibit larger pacing artifacts on the surface ECG

 Bipolar leads
Circuit is tip electrode to ring electrode

Two conductor coils (one inside the other)

Inner layer of insulation

Bipolar leads are typically thicker than unipolar leads

Bipolar leads are less susceptible to oversensing noncardiac

signals (myopotentials and EMI)

Coaxial Lead Design

 Unipolar Bipolar
Advantages Smaller diameter No pocket stimulation
Easier to implant Less susceptible to EMI
Large spike Programming flexibility

Disadvantages Pocket stimulation Larger diameter

Far-field oversensing Stiffer lead body
No programming flexibility Small spike
Higher impedance
Voltage threshold is 30%
higher
 Electrodes
Leads have 1/> electrically active surfaces
referred to as the electrodes

Deliver an electrical stimulus, detect intrinsic

cardiac electrical activity, or both

Electrode performance can be affected by

Materials
Polarization
Impedance
Pacing thresholds
Steroids
 Electrode Materials
The ideal material for an electrode
Porous (allows tissue ingrowth)
Should not corrode or degrade
Small in size but have large surface area
Common materials
Platinum and alloys (titanium-coated platinum iridium)
Vitreous carbon (pyrolytic carbon)
Stainless steel alloys such as Elgiloy
 Voltage
Voltage is the force that causes electrons to
move through a circuit
In a pacing system, voltage is:
Measured in volts
Represented by the letter V
Provided by the pacemaker battery
Referred to as amplitude
 Current
The flow of electrons in a completed circuit

In a pacing system, current is:

Measured in mA (milliamps)
Represented by the letter I
Determined by the amount of electrons that move
through a circuit
 Constant-Voltage and Constant-Current Pacing

Most permanent pacemakers are constant-

voltage pacemakers

Voltage and Current Threshold

Voltage threshold is the most commonly used

measurement of pacing threshold
 Pacing Thresholds
Defined as the minimum amount of electrical energy required to
consistently cause a cardiac depolarization

Consistently refers to at least 5 consecutive beats

Low thresholds require less battery energy

Capture Non-Capture
 The Strength-Duration Curve

The strength-duration

Stimulation Threshold (Volts)

2.0
curve illustrates the
relationship of 1.5

amplitude and pulse 1.0

width Capture
.50
Values on or above
.25
the curve will result
0.5 1.0 1.5
in capture Duration
Pulse Width (ms)
 Rheobase- (the lowest point on the curve) by definition is the
lowest voltage that results in myocardial depolarization at
infinitely long pulse duration

Chronaxie(pulse duration time ) by definition, the chronaxie is the

threshold pulse duration at twice the rheobase voltage
 Lessons from SDC
The ideal pulse duration should be greater than the chronaxie
time

Cannot overcome high threshold exit block by increasing the

pulse duration, If the voltage output remains less than the
rheobase

Energy (J) = Voltage (V) Current (mA) Pulse Duration (PD

in ms).

Charge (C) = Current (mA) Pulse Duration (ms).

 At very low pulse width thresholds, the charge is low, but the energy
requirements are high because of elevated current and voltage
stimulation thresholds.

At pulse durations of 0.40.6 ms, all threshold parameters - ideal

At high pulse durations, the voltage and current requirements may be low,
but the energy and charge values are unacceptable
-Safety margins
-When a threshold is determined by decrementing the pulse
width at a fixed voltage

At a given voltage where the pulse width value is < .30 ms:
Tripling the pulse width will provide a two-time voltage
safety margin.

Daily fluctuations in threshold that can occur due to eating,

sleeping, exercise, or other factors

- a/c pacing system - higher safety margin, due to the lead

maturation process- occur within the first 6-8 weeks following
implant.
Changes in stimulation threshold (voltage or current) following implantation
of a standard nonsteroid-eluting electrode
 Impedance

The opposition to current flow

In a pacing system, impedance is

Measured in ohms
Represented by the letter R (W for numerical values)

The measurement of the sum of all resistance to the flow of

current

Resistance is a term used to refer to simple electric circuits without

capacitors and with constant voltage and current

Impedance is a term used to describe more complex circuits with

capacitors and with varying voltage and current
 Impedance

Pacing lead impedance typically stated in broad ranges, i.e.

300 to 1500

Factors that can influence impedance

Resistance of the conductor coils

Tissue between anode and cathode
The electrode/myocardial interface
Size of the electrodes surface area
Size and shape of the tip electrode
Ohms Law is a Fundamental Principle
of Pacing That:
Describes the relationship between voltage,
current, and resistance

V
V=IXR
I=V/R I x R
R=V/I
 Impedance and Electrodes

Large electrode tip

Threshold
Impedance
Polarization

Small electrode tip

Threshold
Impedance
Polarization
 Polarization
After an output pulse, positively charged particles gather near
the electrode.
The amount of positive charge is
Directly proportional to pulse duration
Inversely proportional to the functional electrode size
(i.e. smaller electrodes offer higher polarization)

Polarization effect can represent 3040% of the total pacing impedance

As high as 70% for smooth surface, small surface area electrodes
Within the electrode, current flow is due to movement of electrons (e).
At the electrodetissue interface, the current flow becomes ionic &
(-) vely charged ions (Cl, OH) flow into the tissues toward the anode leaving
behind oppositely charged particles attracted by the emerging electrons.

It is this capacitance effect at the electrode tissue interface, that is the basis
of polarization
 Lead Maturation Process
Fibrotic capsule develops around the electrode following lead
implantation

3 phases
1. A/c phase, where thresholds immediately following implant
are low
2. Peaking phase- thresholds rise and reach their highest
point(1wk) ,followed by a in the threshold over the next 6
to 8 wks as the tissue reaction subsides
3. C/c phase- thresholds at a level higher than that at
implantation but less than the peak threshold

Trauma to cells surrounding the electrode edema and

subsequent development of a fibrotic capsule.

Inexcitable capsule the current at the electrode interface,

requiring more energy to capture the heart.
 Lead Maturation Process
Effect of Steroid on Stimulation Thresholds
5

4 Smooth Metal Electrode

3
Volts

Textured Metal Electrode

2

1
Steroid-Eluting Electrode
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Implant Time (Weeks)
Pulse Width = 0.5 msec
 Sensing
Sensing is the ability of the pacemaker to
detect an intrinsic depolarization

Pacemakers sense cardiac depolarization by

measuring changes in electrical potential of
myocardial cells between the anode and cathode
An Electrogram (EGM) is the Recording of Cardiac
Waveforms Taken From Within the Heart

Intrinsic deflection on
an EGM occurs when
a depolarization wave
passes directly under
the electrodes
Two characteristics of
the EGM are:
Signal amplitude(mv)
Slew rate(v/sec)
 Intrinsic R wave Amplitude

Typical intrinsic R wave amplitude

measured from pacing leads in the Right
Ventricle are more than 5 mV in amplitude
Intrinsic R wave in EGM

The Intrinsic R wave amplitude is usually much greater than the T wave amplitude
Slew Rate of the EGM Signal Measures the Change in
Voltage with Respect to the Change in Time

The longer the signal takes to

move from peak to peak:
The lower the slew rate
The flatter the signal
Change in voltage
Slew rate=
Time duration of
voltage change

Higher slew rates translate to

Voltage
greater sensing Slope

Measured in volts per second

Time

Slew rate measurements at implant should exceed .5 volts per second

for P waves; .75 volts per second for R wave measurements
Factors That May Affect Sensing Are:
Lead polarity (unipolar vs. bipolar)
Lead integrity
Insulation break
Wire fracture
EMI Electromagnetic Interference
 Undersensing . . .
Pacemaker does not see the intrinsic beat,
and therefore does not respond appropriately

Scheduled pace
Intrinsic beat delivered
not sensed

VVI / 60
 Oversensing

...though no
Marker channel activity is present
shows intrinsic
activity...

VVI / 60

An electrical signal other than the intended

P or R wave is detected
 Pacemaker Implantation
Signal Amplitude / Slew Rate
Amplitude Range Slew Rate
Signal (mV) (v/sec)

Acute Atrial EGM 1.5 - 4.0 0.6 - 1.7

Chronic Atrial EGM 1.0 - 3.0 0.5 - 1.5
Acute Ventricular EGM 7 - 15 0.8 - 2.0
Chronic Ventricular EGM 5 - 12 0.6 - 1.5
 NASPE/ BPEG Generic (NBG)
Pacemaker Code
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)
 Pacemaker Timing
Pacing Cycle : Time between two consecutive
events in the ventricles (ventricular only
pacing) or the atria (dual chamber pacing)

Timing Interval : Any portion of the Pacing

Cycle that is significant to pacemaker
operation e.g. AV Interval, Ventricular
Refractory period
Single-Chamber Timing
Single Chamber Timing Terminology
Lower rate
Refractory period
Blanking period
Upper rate
 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
Events sensed in the refractory period do not affect the
Lower Rate Interval but start their own Refractory Periods

Lower Rate Interval

VP VP
VVI / 60
Refractory Period
 Blanking Period
The first portion of the refractory period
Pacemaker is blind to any activity
Designed to prevent oversensing of pacing
stimulus/depolarisation

Lower Rate Interval

VP VP
VVI / 60
Blanking Period
Refractory Period
Physiologic Classification of Sensors- rate adaptive

Primary
Physiologic factors that modulate sinus function
Catecholamine level, Autonomic nervous system activity
Secondary
Physiologic parameters that are the consequence of
exercise
QT, respiratory rate
Minute ventilation,temperature
pH, stroke volume, Preejection interval, SVO2
Peak endocardial acceleration
Tertiary
External changes that result from exercise
Vibration
Acceleration
 Upper Sensor Rate Interval
Defines the shortest interval (highest rate) the
pacemaker can pace as dictated by the sensor (AAIR,
VVIR modes)
Limit at which sensor-driven pacing can occur

Lower Rate Interval

Upper Sensor Rate

Interval

VP VP
VVIR / 60 / 120
Blanking Period
Refractory Period
 Hysteresis
Allows the rate to fall below the programmed
lower rate following an intrinsic beat
lower rate limit is initiated by a paced event, while
the hysteresis rate is initiated by a non-refractory
sensed event.

Lower Rate Interval-60 ppm Hysteresis Rate-50 ppm

VP VP VS VP
 Noise Reversion
Continuous refractory sensing will cause pacing at the
lower rate

Lower Rate Interval

Noise Sensed

SR SR SR SR
VP VP

VVI/60
Modes-SINGLE CHAMBER
AOO & VOO-asynchronous modes
By application of magnet

Useful in diagnosing pacemaker dysfunction

During surgery to prevent interference from

electrocautery
 VOO Mode
Asynchronous pacing delivers output regardless of
intrinsic activity

Lower Rate Interval

VP VP
Blanking Period

VOO / 60
 VOO TIMING

VP VP VP VP VP
 VVI Mode
Pacing inhibited with intrinsic activity

Lower Rate Interval {

VP VS VP
Blanking/Refractory

VVI / 60
 VVI TIMING

VS
VP VP VP VP
 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
 AAI
Useful for SSS with N- AV conduction
Should be capable of 1:1 AV to rates 120-140 b/m
Atrial tachyarrhythmias should not be present
Atria should not be silent
If no A activity, atria paced at LOWER RATE limit (LR)
If A activity occurs before LR,- resetting
Caution- far-field sensing of V activity
 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)
 Single-Chamber Triggered-Mode

Output pulse every time a native event sensed

current drain
Deforms native signal
Prevent inappropriate inhibition from
oversensing when pt does not have a stable
native escape rhythm
 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 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
 AV Delay

The AV delay in the pacemaker timing cycle is

designed to simulate that natural pause
between the atrial and ventricular events by
mimicking the PR interval

Benefits of a properly timed AV delay

Allows optimal time for ventricular filling, which
may contribute to improved cardiac output
Allows sufficient time for proper mitral valve
closure- minimize MR
 AV Intervals
Initiated by a paced or non-refractory sensed atrial
event
Separately programmable AV intervals SAV /PAV
Two things can happen with the AV delay
AV delay times out (and ventricular pacing spike is delivered)
AV delay is interrupted by a sensed ventricular event (and ventricular pacing spike is
inhibited)

Lower Rate Interval

PAV SAV

200 ms 170 ms

AP AS
VP VP
DDD 60 / 120
Paced AV Delay
The time period between
the paced atrial event and
the next paced ventricular
event
The pacemaker spike
initiates the paced AV delay
timing cycle
Programmable value
Sensed AV Delay
The time period between
the sensed atrial event and
the next paced ventricular
event
The pacemaker has to sense
the atrial event before the
timing cycle is initiated
there is usually a slight time
lag
Program the sensed AV
delay to a value slightly
shorter than the paced AV
delay (~ 25 ms)
 Atrial Escape Interval (V-A Interval)

Lower rate interval- AV interval

=V-A 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
 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
 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
 Upper Tracking Rate
The maximum rate the ventricle can be paced in
response to sensed atrial events
Prevents rapid ventricular pacing rates in response to
rapid atrial rates
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
 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)
 Post-Ventricular Atrial Refractory
Period
PVARP is initiated by a ventricular
event(sensed/paced), but it makes the atrial
channel refractory
PVARP is programmable (typical settings
around 250-275 ms)
Benefits of PVARP
Prevents atrial channel from responding to
premature atrial contractions, retrograde P-waves,
and far-field ventricular signals
Can be programmed to help minimize risk of
pacemaker-mediated tachycardias
 PVARP and PVAB
The PVAB is the post-ventricular atrial
blanking period during which time no signals
are seen by the pacemakers atrial channel

It is followed by the PVARP, during which time

the pacemaker might see and even count
atrial events but will not respond to them

PVAB-independently programmable
Typical value around 100 ms
PVAB and PVARP
 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)
 Total Atrial Refractory Period (TARP)
TARP is the timing cycle on the atrial channel during which the
pacemaker will not respond to incoming signals
TARP consists of the AV delay plus the PVARP

TARP = AV delay + PVARP

TARP is not programmable directly -can program the AV delay

and PVARP and thus indirectly control TARP
TARP is important for controlling upper-rate behavior of the
pacemaker
 Total Atrial Refractory Period (TARP)
Sum of the AV Interval and PVARP
defines the highest rate that the pacemaker will
track atrial events before 2:1 block occurs

Lower Rate Interval

Upper Tracking Rate

SAV = 200 ms
PVARP = 300 ms
Thus TARP = 500 ms (120 ppm) AS AS

DDD VP VP
LR = 60 ppm (1000 ms)
UTR = 100 bpm (600 ms) SAV PVARP SAV PVARP
TARP
{
No SAV started for events sensed in the TARP
 Wenckebach
Occurs when the intrinsic atrial rate lies
between the UTR and the TARP rate

Results in gradual prolonging of the AV

interval until one atrial intrinsic event occurs
during the TARP and is not tracked
 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
 Wenckebach Operation

DDD / 60 / 120 / 310

 Fixed Block or 2:1 Block

Occurs whenever the intrinsic atrial rate

exceeds the TARP rate

Every other atrial event falls in the TARP when

the atrial rate exceeds the TARP rate

Results in block of atrial intrinsic events in

fixed ratios
 2:1 Block
Every other P wave falls into refractory and does not restart the
timing interval

Lower Rate Interval {

Upper Tracking Limit

AS AS
AR AR
VP VP
AV PVARP AV PVARP
Sinus rate = 133 bpm (450 ms) TARP TARP
PVARP = 300 ms SAV = 200 ms
{
TARP=500 ms
P Wave Blocked
 2:1 Block

DDD / 60 / 120 / 310

Summary-upper rate behaviours
1:1 tracking occurs whenever the patients atrial rate is
below the upper tracking rate limit

Wenckebach will occur when the atrial rate exceeds the

upper tracking rate limit

Atrial rates greater than TARP cause 2:1 block

 Ventricular Safety Pacing
Crosstalk is the sensing of a pacing stimulus delivered in the opposite
chamber, which results in undesirable pacemaker response, e.g., false
inhibition

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
 Ventricular Safety Pace

DDD 60 / 120
 VDD Mode
Atrial Synchronous pacing or Atrial Tracking Mode
A sensed intrinsic atrial event starts an SAV
The Lower Rate Interval is measured between Vs to Vp or Vp to Vp
If no atrial event occurs at the end of the Lower Rate Interval a Ventricular
pace occurs
Paces in the VVI mode in the absence of atrial sensing
AV block with intact sinus node function (esp useful in congenital AV
block)
 VDD
Provides atrial synchronous pacing
System utilizes a single 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)
 DDD Mode
Chamber paced: Atrium & ventricle

Chamber sensed: Atrium & ventricle

Response to sensing: Triggered & inhibited

An atrial sense:
Inhibits the next scheduled atrial pace
Re-starts the lower rate timer
Triggers an AV interval (called a Sensed AV Interval or SAV)
An atrial pace:
Re-starts the lower rate timer
Triggers an AV delay timer (the Paced AV or PAV)
A ventricular sense:
Inhibits the next scheduled ventricular pace
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
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
 Mode Selection
Symptomatic DDIR DDDR
bradycardia

Y N
Are atrial
Is AV conduction
tachyarrhythmias
intact?
present?

N Y N
Is AV conduction Are they Y VVI
intact? chronic? VVIR

Y N Is SA node function
Is SA node function presently adequate?
presently adequate?
Y N
N (SSS) N
DDD, VDD
DDDR DDDR
AAIR DDDR, DDIR
DDDR
 Optimal Pacing Mode (BPEG)

Sinus Node Disease - AAI (R)

AVB - DDD
SND + AVB - DDDR + DDIR
Chronic AF + AVB - VVI
Thank u
Mode Selection Decision Tree
Symptomatic DDIR with DDDR with
bradycardia SV PVARP MS

Y N
Are atrial
Is AV conduction
tachyarrhythmias
intact?
present?

N Y N
Is AV conduction Are they Y VVI
intact? chronic? VVIR

Y N Is SA node function
Is SA node function presently adequate?
presently adequate?
Y N
N (SSS) N (CSS,
VVS)
DDD, VDD
DDDR DDDR
AAIR DDD, DDI
DDDR with RDR
Pacing Modes

Stuart Allen 06
 Ventricular Demand VVI

AMP

Output circuit

Programmed lower rate 50 mm/s

VVI
Ventricular Demand VVIR

Sensor

AMP

Output circuit

Programmed lower rate 50 mm/s

Sensor indicated
rate Stuart Allen 06
 Atrial Demand AAI

AMP

Output circuit

Programmed lower rate 50 mm/s

AAI

Stuart Allen 06
 Pacing Modes - Summary
Ventricular Demand VVI Atrial Demand AAI

AMP
Output circuit
AMP
Output circuit

Atrial Synchronised VAT Atrial synchronised VDD

Ventricular Inhibited
AMP AMP

AMP

Output circuit Output circuit

A-V Sequential DVI A-V Universal DDD

Output circuit Output circuit
AMP
Timing & Control

AMP AMP
Output circuit Output circuit

Stuart Allen 06