Recognition i i and d Management of Pacemaker-Mediated Tachycardia

Susan L. Song, RN, BSN, FHRS, CCDS D i Coordinator, Device C di t EP Service S i USC Keck School of Medicine

Dr Seymour Furman Dr.

Pioneer in Pacing Coined Term Endless Loop Tachycardia Tachycardia

Pacemaker P k M Mediated di t d Tachycardia

Anyundesiredrapidpacingrateresulting fromventricularstimulationasaresultof triggeringviatheatrialchannelorby interactionbetweenthepulsegeneratorwith thepatient.

Pacemaker k Mediate di Tachycardia: h di DifferentCauses

EndlessLoopTachycardia SensorMediatedTachycardia Atrial i lArrhythmia h h i Myopotential y p Tracking g MagneticResonanceImaging R na a Pacemaker Runaway

Pacemaker k Mediate di Tachycardia: h di DifferentCauses

EndlessLoopTachycardia

SensorMediatedTachycardia AtrialArrhythmia MyopotentialTracking MagneticResonanceImaging RunawayPacemaker

EndlessLoopTachycardia

Thelikelihoodofretrograde g conductionis directlycorrelatedwiththestatusofAVnodal conduction. Inpatientswithsinusnodedysfunctionand ;themajority j ywillalso intactAVnodalconduction; haveintactretrogradeconduction. Theincidenceofretrogradeconductioninthe presenceofcompleteAVblockisverylow
(1020%ofindividuals)

EndlessLoopTachycardia

Endlesslooptachycardiasustained,inpart,bythe presenceof fthe h pacemaker k PMTrequiresthepresenceofretrogradeVA conductionandatriggeringevent

EnabledbylossofAVsynchrony

NotallpatientsareabletohavePMTsbutitis oftenhardtoknowwhoissusceptibleuntilit happens pp PMTscanbeavoidedbyprogramminga sufficientlylongPVARP

EndlessLoopTachycardia
Thep pacemakerisone limbofthereentry circuit AlossofAVsynchrony triggersretrograde conduction(yellow) T i ltriggers Typical i
PVC Lossofatrialcapture Atrialundersensing Prematureatrial contraction Magnetremoval

EndlessLoopTachycardia
Atriggeringevent; event suchasaPVCoccursbutinstead oftravelingforward,itconductsbackward Thiscausesaventricularcontractiontooccur dissociatedfromforwardconduction
Theretrograde(dissociated)Pwavefallsintheatrialalert periodandissensed,whichcausesthepacemakerto pacetheventricleinresponse(atrialtracking)

Thiscreatesanendlessloop:forwardfromatriumand ventriclethenbackwardfromventricletoatrium
EachretrogradePwavetriggersaventricularpaced event

History Symptoms Physicalexamination Deviceexamination Reviewofdailyactivities..activeorsedentary

Symptoms

Palpitations p Lightheadedness Chestdiscomfort Syncope

Ph i lExamination Physical E i i

Confirmationoftachycardia Findings i di onECG: CG

Intermittentorcontinuesventricularpacedatthe upperratelimit.

Check Event Histogram

M.E. Irwin: Presentation Materials

PMTrequiresthepresenceofretrogradeVA conductionandatriggeringeventsuchas
PVC loss l of fAVsynchrony h lossofatrialcaptureleadingtopotentialfor
Lossof Atrial Capture
possible VAC

ATI Heart Rhythm Device Follow-up Volume I

Occurswhenanelectricalimpulseintheheartcan conductbackward(fromventricletoatrium)aswellas forward Notallpatientshavetheabilitytoconductanimpulse retrograde

Retrograde(VA)Conductionis Necessary yforPMTtooccur

Temporarilyprogramthepacemakertoarate thatisabovethepatient patients sintrinsicatrialratein ordertoforceventricularpacing

TemporarilyprogramthemodetoVVI Or,DDDwithsubthresholdatrialoutput

MonitortheatrialrhythmwithasurfaceECGor anatrialEGM L kf Look foratrial t i lsensed devents t d derived i df from ventricularpacedevents M Measure the h RVACi interval l

St. Jude Reference & Research; Presentation Materials

PreventingEndlessLoopTachycardia
Whenpossible,treatthecause
forinstance,atriallossofcapture

MeasuretheRVACandprogramaPVARPvaluethatis equaltotheVAconductiontime
+50ms(safetymargin)

UsePMTdetectionandterminationalgorithms
PVCOptions O ti and dPMTOptions O ti

Preventing gEndlessLoop pTachycardia y

PMTscanbeavoidedbyprogrammingasufficientlylongPVARP

ARP

PVARP

TARP
A S SAV A S SAV A R ARP PVARP

TARP
A S SAV

PostVentricularAtrialRefractoryPeriod (PVARP)
Theperiodafterasensedorpacedventricular eventduringwhichtheatrialsensingcircuitis refractory Anyatrialeventoccurringduringthe refractory. PVARPwillnotbesensedbytheatrialsensing circuit circuit.

TARPisthetimingcycleontheatrialchannel duringwhichthepacemakerwillnotrespondto incomingsignals TARPconsistsoftheAVdelayplusthePVARP

TARP=AVdelay+PVARP

APVCis i ani intrinsic t i i ventricular t i l event tnot t precededbyapacedorsensedatrial event. event

Ifanintrinsicatrialeventissensedduring therelativerefractoryportionofthe PVARP, ,itcountsasavalidatrialevent ifitisfollowedbyanintrinsic ventriculareventwithinthenext280 ms

St. Jude Reference & Research; Presentation Materials

Preventing gEndlessLoop pTachycardia y

PMTscanbeavoidedbyprogrammingasufficientlylongPVARP

ARP

PVARP

TARP
A S SAV A S SAV A R ARP PVARP

TARP
A S SAV

Algorithms g toPreventEndlessLoop p Tachycardia

PMTOptions
PVARPonPVC APace P onPVC 10beats>PMT AutoDetect

Thisautomaticalgorithm g extendsthePVARPvalueto4 480mswhenever thepacemakerdeterminesaPVChasoccurred

AftertheextendedPVARP, PVARP thereisanautomatic330msalertperiod Theatrialescapeintervalisnow480+330(810ms)or72ppm

WhenaPVCoccurs,theatrialchannellaunchesa 480msPVARP Anatrialeventsensedintherelativerefractory periodisconsideredaretrogradePwave IfaretrogradePwaveissensed, sensed anatrialoutputis automaticallydelivered330msafterthatretrograde Pwave

10beats>PMT
10beats>PMTautomaticallyextendsthePVARP whenaPMTisdetected HowthepacemakerdetectsaPMT
APMTdetectionratemustbeprogrammed(90to180ppm) PMTisconfirmedwhenthereare10consecutiveASVPeventsatarate higherthanthePMTdetectionrate Onthe10th suchevent,PVARPisextendedto480msanda330msalert periodisimposed Thisisrepeatedafter256cyclesifthePMTcontinues

St. Jude Reference & Research; Presentation Materials

Detects D t t PMTand dresponds d onthe th 10th cycle l Whenthepatientsintrinsicatrialrateexceeds theprogrammablePMTdetectionrate, rate the pacemakermeasurestheVPASintervalfor eightcycles
Averagesthevalues Compares p theaverage g toeachoftheindividual values IfallVPASintervalsarewithin16msoftheaverage. Di Diagnosis: i PMT Ontheninthcycle,theASVPiseithershortenedor lengthened

IfPMTisconfirmed(VPASintervalsareallwithin16msofthe averageVPASinterval),AutoDetectrespondsonthe10th cycle

Itinhibitsthenextventricularoutputpulse Thep pacemakerp pacestheatrium33 330msafterthesensedatrial event(nextPwave)

Thi is This i followed f ll db byaventricular i l outputpulse l when h the h AVd delay l timesout

St. Jude Reference & Research; Presentation Materials

Pacemaker k Mediate di Tachycardia: h di DifferentCauses

EndlessLoopTachycardia

SensorMediatedTachycardia AtrialArrhythmia MyopotentialTracking MagneticResonanceImaging RunawayPacemaker

S Sensor M Mediated di t dTachycardia T h di

Rapidpacingratefornonphysiologicevent Vibrationsensor Piezocrystal

O Oversensitive iti setting tti result lti inexcessive i pacing i with ith slightmotion

Impedance d Based dsensor MinuteVentilation l

Hyperventilation,electrocautery,electrical interference Recommendationtodisablesensorforpreopsurgery

At i lArrhythmia Atrial A h th i

AtrialfibrillationandAtrialFlutter Trackingrapidatrialrates Programmable bl O Options i

Nontrackingmodes:DDI,VVI EnableModeSwitch

Medications Cardioversions

MyopotentialTracking

Oversensingofmusclepotentialsintheatrial channelresultinginPwavetrackingtotheupper ratelimit. limit Commoninunipolardualchambersystem Programtheatrialsensitivitytoalesssensitive setting.

MRIPacemakerInteractions

TheMRIenvironmentcanleadtorapid ventricularpacingduetotheleadactingasan antennaeforradiofrequencyenergypulsesgiven duringscanning.

RunawayPacemaker

Componentfailureinthepulsegenerator Management
Removal R lpacemaker k and dleads. l d

Somedevicehavearunawayprotectioncircuit withapresetratelimit

Conclusions

Findtheclinicallyappropriatesettingsforeach patientbasedontheirindividualneeds Optimizeforexercisetoleranceand hemodynamicstatus Observethepatientsreallifeactivitiesof dailyliving,and Mostimportantly, p y,diagnose g thespecific p type yp of PMTandreprogramaccordingly