Gene A. Bornzin

A New Automode Switch Algorithm for Supraventricular Tachycardias

Patients with complete heart block on a spontaneous, or iatrogenic basis who also have recurrent supraventricular tachycardias, particularly atrial fibrillation and flutter, are often difficult to manage. Various techniques include: independently programmable maximum tracking and maximum sensor rates, limiting the maximum atrial tracking rate to the sensor response of the pacemaker, or automatically switching from DDDR to VVIR based upon the sensed atrial rate. This article will describe a mode switch algorithm that allows for an independently programmable atrial tachycardia detection rate (ATDR). This allows mode switching to occur only in response to the patients pathological tachyarrhythmia, and not during normal upper rate response. The ATDR is based upon a filtered atrial rate, which will prevent an isolated premature beat from initiating the algorithm. In addition, the unit can be programmed to switch to either DDI, DDIR, VVI, or VVIR. Extensive event counters in the pulse generator allows the system to record and store the number of algorithm activations, the average atrial rate which triggered each mode switch, and the duration of the mode switch. These reports are accessible at each follow‐up visit.

Far-field R-wave reduction with a novel lead design : Experimental and human results

Introduction: The purpose of this study was to examine a bipolar screw‐in lead (NL), specially designed to reduce unwanted far‐field R‐wave (FFRW) signal detection in an acute human setting. The results were compared with animal experiments.

Atrial Evoked Response Integral for Automatic Capture Verification in Atrial Pacing

BORIANI, G., et al.: Atrial Evoked Response Integral for Automatic Capture Verification in Atrial Pacing. Beat‐by‐beat Autocapture is currently limited to operation in the ventricle with bipolar leads. The authors investigated the integral of the negative‐going portion of the atrial evoked response integral (AERI) as a potential resource for verification of atrial capture. Intracardiac electrogram signals were collected from 59 patients (ages 67.8 ± 15.1 years) with bipolar, low polarization atrial leads. The signals were collected over a mean period of 6.1 months (minimum 4 days) after lead implantation. St. Jude Medical Affinity pulse generators were used to perform automatic capture threshold tests while the electrogram signals were recorded by a Model 3510 programming device. These signals were transferred to a personal computer in digital form for later analysis. The AERI was calculated at each programmable pacing voltage until capture was lost. The difference between the polarization integral at loss of capture and evoked response integral with successful capture was sufficient to justify enabling the atrial Autocapture feature in 53 of 59 patients in whom bipolar pacing and unipolar sensing was performed. The authors developed a calibration routine to identify automatically those patients in whom atrial Autocapture could be programmed On, based on the polarization integral at loss of capture, the estimated maximum polarization integral, and the AERI. Preliminary analysis indicated that the AERI is a practical resource for beat‐by‐beat atrial capture detection when used with low polarization leads. (PACE 2003; 26[Pt. II]:248–252)

Autocapture enhancements: unipolar and bipolar lead compatibility and bipolar pacing capability on bipolar leads.

BINNER, L., et al.: Autocapture Enhancements: Unipolar and Bipolar Lead Compatibility and Bipolar Pacing Capability on Bipolar Leads. Beat‐by‐beat Autocapture maximizes device longevity by minimizing stimulus amplitude while assuring patient safety. Currently, Autocapture permits use of only bipolar leads. The authors have devised a detection method that operates with unipolar and bipolar leads and covers all pacing and sensing combinations (but bipolar pace and sense simultaneously). This new detection method for unipolar sensing uses the integral of the negative portion of the unipolar evoked response as a robust capture detection feature. When using bipolar leads, the method provides the flexibility of bipolar or unipolar pacing. In this study, unipolar ventricular intracardiac electrograms (EGMs) were recorded in 71 patients, 73.7 ± 9.9 years of age; 9 with high polarization, 62 with low polarization. High polarization had polished platinum or activated carbon electrodes. Low polarization had TiN, platinized platinum, or IrOx electrodes. The intracardiac EGMs were recorded 544 ± 796 days after implant. The pacemakers performed an automatic capture threshold test while the intracardiac EGM signals were recorded in a programmer. These digitized signals were saved for off‐line analysis. The unipolar evoked response was calculated at up to six (depending on capture threshold) pacing voltages and the polarization integral at 4.5 V and at loss of capture. An automatic calibration algorithm determined if the signal‐to‐noise ratio was adequate for Autocapture operation. Autocapture was possible with 60 of 62 of the low polarizations, and with 6 of 9 of the high polarizations. The average values from the data collected were: average unipolar evoked response ‐ 4.1 ± 2.1  mV , average peak negative voltage ‐ 10.0 ± 3.7  mV , average polarization 0.3 ± 0.34 mV, and average signal‐to‐noise ratio (unipolar evoked response/polarization) 38 ± 71. In all cases the algorithm correctly determined the appropriateness of using Autocapture with the electrodes tested and the unipolar evoked response threshold to be used. (PACE 2003; 26[Pt. II]:221–224)

Enhanced rate response algorithm for orthostatic compensation pacing.

Upon orthostatic stress after a period of rest, the heart rate increases rapidly to maintain cardiac output and minimize the fall in arterial pressure. Pacemaker patients are often prone to a deficient response to orthostatic stress. This may cause lightheadedness and, in rare patients with autonomic dysfunction, syncope. To alleviate these undesirable consequences, an enhanced rate response algorithm was developed using an accelerometer. The pacemaker generates two signals from its accelerometer: instantaneous activity level (Act) and long‐term change in activity level (ActVar). Low values of both Act and ActVar indicate a resting state. An increase in Act while ActVar remains low indicates the onset of motion after prolonged rest. Upon detecting this transition, the algorithm increases the pacing rate to a programmable orthostatic compensation rate for a programmable duration. A taped‐on pacemaker with this algorithm was evaluated in three healthy women and two healthy men, 36 ± 8 years of age. Electrocardiogram and ventricular pacing pulses were recorded by a 24‐hour ambulatory system. Each trigger of the orthostatic compensation rate was verified against a >10 beats/min increase in heart rate, a response classified as appropriate. The overall specificity of the algorithm among the five subjects was 78%. The nocturnal specificity (10 pm to 7 am) was 98%, considerably higher than during daytime (72%). In conclusion, a pacing algorithm to alleviate orthostatic stress was developed, which was highly specific during the night hours.

Blood pressure response to transition from supine to standing posture using an orthostatic response algorithm.

Upon standing from a supine position, the normal response is an increase in heart rate to maintain blood pressure (BP). In patients with chronotropic incompetence, heart rate may not increase upon standing, and they may experience orthostatic hypotension (OH). We evaluated a new orthostatic response (OSR) pacing algorithm that uses an accelerometer signal to detect sudden activity following prolonged rest to trigger a 2 minutes increase in pacing rate to 94 bpm. Ten recipients of DDDR pacemakers which contain the OSR compensation algorithm (mean age = 77 ± 9 years, 8 women) with sick sinus syndrome (n = 6) or atrioventricular block (n = 4) were studied. In all patients BP was measured before and 0.5, 1, 1.5, 2, and 3 minutes after standing at their programmed base rate. A 20 mmHg fall in systolic BP upon standing was observed in five patients (OH patients), while the other five were considered non‐OH patients. The measurements were repeated with the OSR algorithm turned on. Mean BP was defined as 1/3 systolic BP + 2/3 diastolic BP. Baseline heart rate was significantly slower in OH patients (62 ± 2 bpm) than non‐OH patients (71 ± 7 bpm, P < 0.05). In OH patients mean BP increased significantly upon standing (P < 0.05 for all comparisons) with the algorithm ON instead of decreasing with the algorithm OFF, at 1 minute (+3.4 vs −10.3 mmHg), 1.5 minutes (+7.0 vs −4.9 mmHg), 2 minutes (+1.6 vs −6.7 mmHg), and 3 minutes (+2.5 vs −8.5 mmHg). These preliminary results suggest that the OSR algorithm maintains BP upon standing in patients with OH.

Activity-Controlled Circadian Base Rate

The current pacing rates are clustered around a fixed base rate since pacemaker patients are usually sedentary, resting, or sleeping most of the time. This fixed base rate is either too low for daytime hemodynamic support or too high for nighttime rest and recovery. Multiple Holter studies involving normal individuals have suggested that the resting base rate fluctuates during the course of the day. The circadian base rate (CBR) algorithm was designed to provide patients with a circadian change in paced resting rate and a normal rate distribution. The CBR algorithm, using a sophisticated accelerometer sensor, was developed and tested using the downloaded activity data from patients implanted with Trilogy DR+ pacemakers. Twenty‐five patients (19 men, 6 women, age 72 ± 9 years) were studied. Trilogy DR+ is able to record the detailed sensor and system behavior data for a week. During outpatient visits, the pacemaker was interrogated and the data accumulated in the pacemaker memory were downloaded. The CBR algorithm was applied to the activity variance histogram to calculate the base rate and to construct its histogram. The base rates in the CBR histogram are generally below 100 ppm with a distribution that mimics the natural sinus rate distribution of normal subjects. The CBR algorithm provides the highest daytime rates for hemodynamic support and the lowest nighttime rates for cardiac recovery, with a smoothly changing base rate modeling the normal circadian variation in heart rate.

Development of a True Pacemaker Holter

A Holter recording is generally defined as the electrocardiographic registration of all cardiac cycles usually for a period of 24 h. Other monitoring methods cannot be considered true Holter recordings except for intracardiac electrographic (IEGM) data.

Evaluation of the Atrial Evoked Response for Capture Detection with High‐Polarization Leads

AutoCapture™ based on the evoked response can be confounded by electrode polarization. In this study, polarization was measured in human subjects who had chronic atrial leads. The aim of the study was to determine whether electrode polarization can be measured using a time integral atrial evoked‐response integral (AERI) of the negative portion of the atrial paced ER evoked‐response signal and to determine whether high‐polarization atrial leads unsuitable for AutoCapture™ can be identified a priori. Atrial intracardiac‐electrogram (IEGM) signals from 39 patients with implanted pacemakers were recorded and analyzed. The signals were recorded during conventional atrial‐threshold searches. A total of 221 atrial‐capture thresholds were recorded, ranging from 0.25 to 2.75 V with a mean of 0.79 V. Each evoked response was evaluated using the AERI in a 36 ms window following the 0.4 ms atrial stimulus. The polarization was estimated as a linear function of stimulus voltage using the evoked‐response signal integral of captured beats identified on the IEGM. The 221 threshold‐search datasets were obtained using leads with eight different electrode materials. Polarization could be measured using AERI as a function of stimulus voltage. Furthermore, this polarization measure can be used to identify high‐polarization leads, which are ill suited for the atrial AutoCapture™ algorithm.

Transient Overdrive Pacing Upon Standing Prevents Orthostatic Hypotension in Elderly Pacemaker Patients with Chronotropic Incompetence

Background: Elderly pacemaker patients with chronotropic incompetence (CI) may experience orthostatic hypotension (OH) upon standing. The objective of this study was to determine whether a transient increase in heart rate (HR) by overdrive pacing upon standing prevents OH in elderly pacemaker patients.