Programming of Bradycardic Parameters. C. W. Israel, M.D. Dept. of Cardiology Evangelical Hospital Bielefeld Germany
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1 Programming of Bradycardic Parameters C. W. Israel, M.D. Dept. of Cardiology Evangelical Hospital Bielefeld Germany
2 Programming of ICD Brady Parameters Conflict of Interest Biotronik Boston-Scientific Medtronic Sorin St. Jude Medical - participation in sponsored studies - speaker s honoraria - participation in sponsored studies - speaker s honoraria - participation in sponsored studies - speaker s honoraria - member of the advisory board - member of the advisory board - participation in sponsored studies - speaker s honoraria
3 Programming of ICD Brady Parameters Aims of Programming ICD Bradycardia Parameters 1. Primary Aim: - Prevention of bradycardia 2. Secondary Aims: - Prevention of unnecessary RV pacing long AV delay whenever intrinsic conduction present - Prevention of (proarrhythmic) dysfunction sufficient sensitivity, sufficient pacing output - optimal hemodynamics eventually change to CRT, AV delay optimization, no VVI in sinus rhythm
4 Programming of ICD Brady Parameters Aims in Single-Chamber ICDs no VVI pacing during sinus rhythm use of hysteresis overdrive in long-qt:? (better: AAI/DDD) rate response in permanent AF
5 Programming of ICD Brady Parameters Aims in Single-Chamber ICDs 48 bpm
6 Programming of ICD Brady Parameters Aims in Single-Chamber ICDs Kudenchuk, Heart Rhythm 2009;6:
7 Programming of ICD Brady Parameters Aims in Single-Chamber ICDs Short-long-short sequences: post-pvc pauses and VVI 40 bpm
8 Programming of ICD Brady Parameters Aims in Dual-Chamber ICDs individual lower rate limit ( don t fix what s not broken ) individual upper tracking rate (ICM: bpm) long AV delay (or algorithm) if intrinsic conduction is present optimal parameters for mode switching (ventricular farfield suppression) PVC reaction, PMT intervention ventricular sensitivity
9 Programming of ICD Brady Parameters DDI versus VAT Pacing 110 ms 190 ms Intrinsic P Wave 100 mm/s 180 ms 250 ms Paced P Wave 100 mm/s
10 Programming of ICD Brady Parameters Lower Rate Limit DDD, 50 bpm
11 Programming of ICD Brady Parameters Lower Rate Limit Lead I A-EGM RV-EGM
12 Programming of ICD Brady Parameters Lower Rate Limit Lead I A-EGM
13 Programming of ICD Brady Parameters Lower Rate Limit DDD, 80 bpm
14 Programming of ICD Brady Parameters Upper Tracking Limit Interlock between upper tracking limit and slow VT zone limitation of upper tracking limit to bpm
15 Programming of ICD Brady Parameters Chronotropic Incompetence in ICD Patients *: Maximum exercise heart rate 0.7 (220 age) Melzer, PACE 2005;28:
16 Programming of ICD Brady Parameters Chronotropic Incompetence in ICD Patients max. sensor rate in ICD patients with ICM limited to bpm Melzer, PACE 2005;28:
17 Programming of ICD Brady Parameters DDD Pacing in Patients Without A Pacing Indication - DAVID DDDR 70 VVI 40 p=0.03 DDDR mode causes more death/heart failure than VVI in ICD patients without pacing indication! Wilkoff JAMA 2002;288:
18 Programming of ICD Brady Parameters DDD Pacing Can Do Better Than This DAVID Post-Hoc Analysis Heart failure/death is caused by ventricular pacing, not by DDD mode itself Sharma AD, Heart Rhythm 2005;2:830-4
19 Programming of ICD Brady Parameters Intrinsic AV Conduction: Which AV Delay Is Necessary After Atrial Pacing? paced AV delay 200 ms paced AV delay 270 ms paced AV delay 300 ms paced AV delay 350 ms
20 Programming of ICD Brady Parameters AV Hysteresis
21 Programming of ICD Brady Parameters Problems of DDD with Long AV Delay limited maximal tracking rate pacemaker syndrome (retrograde P) Endless loop tachycardia (A) pseudopacemaker syndrome (AV delay > 50% of cycle length) (B) repetitive non-reentrant VA synchrony (C) B A C
22 Programming of ICD Brady Parameters Managed Ventricular Pacing : AAI DDD Criteria for switch to DDD(R): - MVP : 2 of 4 P wave not conducted Criteria for switch to AAI(R): - MVP : AV conduction during conduction re-check AAI(R) pacing with ventricular monitor no AV delay, no PVARP, no upper tracking limit, no endless-loop tachycardia,
23 Programming of ICD Brady Parameters MVP Trial 1030 patients with ICD, no bradycardia Sweeney, Heart Rhythm 2010
24 Programming of ICD Brady Parameters Inappropriate Mode Switching
25 Programming of ICD Brady Parameters Inappropriate Mode Switching Postventricular atrial blanking too short (in some ICDs nominally off )
26 Programming of ICD Brady Parameters Lack of Mode Switching 2:1 lock-in of atrial flutter - postventricular atrial blanking too long
27 Programming of ICD Brady Parameters Brady-Programming in ICDs 1. Avoid VVI pacing in sinus rhythm rather oligosymptomatic sinus bradycardia than VVI pause-/bradycardia-dependent VT upgrade to DDD 2. Avoid atrial pacing if no sinus node disease exception: AVjunctional rhythms/af during bradycardia LQTS, bradycardia-dependent VT/VF 3. Upper tracking limit low ( bpm) in ICM 4. Sensor activation (max bpm) only if symptomatic 5. Avoid RV pacing (for intrinsic AV conduction < 270 ms) 6. Optimize mode switching (blanking times, algorithms)
28 Programming of Tachycardia Parameters: Minimise Shocks C. W. Israel, M.D. Dept. of Cardiology Evangelical Hospital Bielefeld Germany
29 General Aims of Programming 1. Primary Goal: - Prevention of sudden cardiac death 2. Secondary Goals: a) prevention of syncope short VT/VF detection/quick therapy b) prevention of (unnecessary) shocks programming of sufficient and successful ATP long VT detection c) prevention VT under-detection sensitivity, slow VT rates d) prevention of inappropriate therapy (esp. shocks) enhanced detection criteria, ATP
30 Guideline for Single-Chamber Programming VT detection rate higher than in dual-chamber ( 170 bpm) activate enhanced detection criteria exception: permanent AV block III VT (-1) zone: if tolerated, prolong detection (e. g. 5 sec), allow ATP (e. g. 2 x 4 ATP of 10 stimuli) Stored EGMs: activate Farfield EGM
31 Causes of Preventable ICD Shock Therapy 1. Fast ventricular tachycardia that could have been pace-terminated 2. Non-sustained ventricular tachycardia 3. Supraventricular tachycardia 4. Ventricular oversensing of cardiac signals 5. Electromagnetic interference 6. Lead fracture
32 Can Fast VT be Pace-Terminated? some devices warn the physician that this programming may prolong detection and/or treatment of VT/VF
33 ATP in the Fast VT Zone PainFREE I Wathen et al., Circulation 2001;28:601-7
34 ATP in the Fast VT Zone VF zone should be programmed to high rates ( bpm) (PainFree II) Wathen et al., Circulation 2004;110:2591-6
35 VF Zone Programming VF zone can safely be programmed to high rates ( 250 bpm) (PREPARE) Wilkoff et al., JACC 2008;52:541-50
36 ATP in the Fast VT Zone 2 bursts ( % of VT CL) followed by max. shock max. shock alone programming 2 ATPs in the Fast VT zone reduces the proportion of patients with shocks in the FVT zone by 73 % Martinez-Sanchez et al., J Am Coll Cardiol 2005;45:460-9
37 ATP During Charge Schwaab et al., J Cardiovasc Electrophys 2009;20:663-6
38 Causes of Preventable ICD Shock Therapy 1. Fast ventricular tachycardia that could have been pace-terminated 2. Non-sustained ventricular tachycardia 3. Supraventricular tachycardia 4. Ventricular oversensing of cardiac signals 5. Electromagnetic interference 6. Lead fracture
39 Lucky Patient with Slow Charge spontaneous termination of fast VT during charge particularly frequent in DCM, LQTS, ARVC, etc.
40 Non-Sustained VT/VF long detection ( 18/24 for VF, 24 for VT) long redetection (? maybe 12 for VT, 12/18 for VF) Wathen et al., Circulation 2004;110:2591-6
41 PREPARE Patients in EMPIRIC and MIRACLE-ICD Wilkoff et al., J Am Coll Cardiol 2008;52:541-50
42 PREPARE Wilkoff et al., J Am Coll Cardiol 2008;52:541-50
43 PREPARE Wilkoff et al., J Am Coll Cardiol 2008;52:541-50
44 Virtual Improvement by High Number of Intervals to Detection (NID)
45 Causes of Preventable ICD Shock Therapy 1. Fast ventricular tachycardia that could have been pace-terminated 2. Non-sustained ventricular tachycardia 3. Supraventricular tachycardia 4. Ventricular oversensing of cardiac signals 5. Electromagnetic interference 6. Lead fracture
46 Causes of Inappropriate 133/600 ICD Therapy patients (22 %) 23% 133/600 patients (22.6 %) 4% 5% 39% Afib Aflut ST SVT 25% 5% NSVT 74 % of inappropriate therapy due to different forms of SVT Weber et al. Z Kardiol 1996;85:809
47 Enhanced Detection Criteria Sudden Onset Activate! - discriminates sinus tachycardia from VT - cave: AFL, AF, AVNRT have also sudden onset - cave: slow VT during sinus tachycardia may be non-sudden Stability Activate! - discriminates atrial fibrillation from VT - cave: sinus tachycardia, AFL, AVNRT also regular - cave: irregular VTs Ventricular EGM Morphology Activate if it works! - cave: SVT with aberrancy Sustained Rate Duration Deactivate (or 5 min)! Activate up to 200 bpm
48 Enhanced Detection Criteria ASTRID Studie, n = 149 Dorian et al., Heart Rhythm 2004;1:540-7
49 VT/SVT Discrimination and Rate 1&1-Studie Bänsch et al., Circulation 2004;110:1022-9
50 Causes of Preventable ICD Shock Therapy 1. Fast ventricular tachycardia that could have been pace-terminated 2. Non-sustained ventricular tachycardia 3. Supraventricular tachycardia 4. Ventricular oversensing of cardiac signals 5. Electromagnetic interference 6. Lead fracture
51 ICD Ventricular Oversensing 1. Cardiac Signals - T Wave Oversensing - R Wave Double Counting - P Wave Farfield Sensing 2. Body Signals - Pectoral Muscle Potentials - Diaphragmatic Potentials 3. Electromagnetic Interference 4. Electrode Fracture/Insulation Defect
52 T Wave Oversensing shock therapy for nsvt combined with T wave oversensing
53 Avoid T Wave Oversensing large R waves at implantation dedicated programming options Sensitivity Threshold after VP Reduction of Sensitivity Threshold: 60 ms Delay Reduction of Sensitivity Threshold: No Delay (nominal) R-T ratio: If stable, may be detected by algorithm
54 Lead-Integrity-Alert - Analysis of peak-to-peak R wave amplitude (farfield EGM), 2 criteria: a. Average of 2 smallest values < 1mV b. Average of 2 smallest amplitudes <1/6 of max. R wave amplitude - Rolling window of 12 cycles - if 3/12 signals classified as noise no therapy
55 Tachycardia Detection: Electrode Fractures Data from 15,970 patients with Sprint Fidelis electrodes (121 fractures) Swerdlow et al., Circulation 2008;118:2122-9
56 Lead-Integrity-Alert 76 % of patients with electrode fracture would have received alert 3 days before inappropriate shock Swerdlow et al., Circulation 2008;118:2122-9
57 Telemonitoring Spencker et al., Europace 2009;11:483-8
58 Summary: Programming Shock Prevention 1. Program VF zone to bpm 2. Apply (several) ATP in the Fast VT Zone 3. Prolong detection (18/24-30/40 cycles instead of 8/12 12/16 cycles) 4. Activate enhanced detection criteria up to 200 bpm and deactivate sustained rate duration 5. Activate algorithms to detect oversensing or lead problems 6. Apply remote monitoring
Inappropriate electrical shocks: Tackling the beast
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