Follow-up: Programming Flashcards
Provides exposure of various programming scenarios encountered during clinic follow up. Currently weighted 6% in the CCDS exam.
Programming triggered modes (AAT, VVT) is useful to determine what?
To determine when sensing threshold is achieved.
i.e. At what point during the P-wave does the device register the event.
What mode can be programmed to temporarily correct myopotential oversensing and/or noise due to lead failure until a permanent solution can be achieved?
Triggered (AAT/VVT) - Prevents under-pacing due to oversensing. Non-competitive against intrinsic conduction*. Good for non-dependent pts.
Asynchronous (AOO/VOO/DOO) - Paces at programmed rate but will compete against intrinsic conduction. Good for dependent pts.
*Triggered beat will fall within refractory of intrinsic beat - Functional non-capture.
How would you reduce safety pacing // functional non sensing in patient with frequent ectopy?
Shorten the ventricular blanking period.
List two indicators that show a devices battery has hit ERI.
- Percent or fixed decrease in pacing rate
- Change to a simpler pacing mode E.g. DDD to VVI
Define the following
- BOL
- ERI
- EOL
- BOL = Beginning of life
- ERI = Electrive replacement indicator
- EOL = End of life
What are the 4 types of data one receives when interrogating a device?
- Administrative data - E.g. Patient details
- Programmed data - E.g. Mode, Rate
- Real-time data - E.g. Testing values
- Stored data - E.g. Events
Is the EGM of an event stored in the RAM or the ROM of the device?
EGM is stored on RAM = read and write capabilities.
ROM = installed by manufacturer and can’t be modified.
In clinic you are presented with this atrial lead noise. List two ways to program around it.
- Program the lead uniploar and test via provocation manouvers.
- P-wave amplitude is considerably larger in amplitude than the noise. Thus decreasing atrial sensetivity (bigger number) to filter out noise while retaining ability to ‘see’ the p-wave may be appropriate.
Patient mentions palpitations - what programming changes would you make with relation to Mswitch?
Reduce Mswitch entry criterion & Increase Mswitch exit criterion.
Mswitch resolved inappropriately due to atrial undersensing. By making exit criteria more difficult (more beats necessary at normal rate) undersensing is accounted for to some degree.
Reduce Mswitch entry criteria - this means fewer beats are necessary to enter Mswitch, which means less likely to experience symptoms associated with faster V-pacing rate.
You see dropped p-waves on this IEGM, what would you adjust to ensure appropriate sensing?
Increase atrial sensetivity (lower number).
The amplitude of the dropped p-waves is significantly less than the preceeding sensed p-waves. Thus making the atrial channel more sensitive is likely to correct the problem.
Would you program a shorter AVD and promote pacing in this patient?
Yes.
Although intrinsic rhythm is generally something to be preserved, an AV delay >450msec is unlikely to promote AV synchrony. Thus it is advisable to program normal physiological AV delays and increase V-pacing.
What is the likely programming change seen here?
Both leads have changed from unipolar to bipolar sensing configurations.
Note how ventricular IEGM goes from broad to narrow (represents sensing field of view going from lead tip-can (large) to lead tip-ring (small)).
Note how far-field ventricular signal is removed from the atrial channel.
What is the appropriate mode for each number?
- AAIR
- DDDR
- DDDR
- AAIR
What is the appropriate mode for each number?
- VDD / DDD
- DDDR
- VVIR
What would be an appropriately programmed output voltage?
1.5V
Double the threshold voltage value = approriate programmed output.
Atrial rates above ______bpm will trigger a switch to DDI pacing?
>160bpm.
ATR mode switch rate as illustrated.
Yes / No
Would IRS+, MVP, VIP or RYTHMIQ be appropriate for this patient?
No.
These are all algorhythms designed to reduce RV pacing. This patient has CHB as evidenced by 100% RVp. These algorhythms would likely invoke symptoms.
Yes / No
Would IRS+, MVP, VIP or RYTHMIQ be appropriate for this patient?
Yes.
These algorhythms aim to reduce RVp% by promoting intrinsic rhythm. This patient is clearly suitable for such treatment as 99% of V-events are sensed - thus evidencing intrinsic conduciton.
From the below sensing test what would be the most appropriate mode to program?
DDD.
Rhythm shows good sinus function with 2:1 conduction. DDD will allow for appropriate sinus tracking and AV synchrony.
You observe the following, how could one program around this without changing the pacing mode?
Program atrial lead from bipolar to unipolar.
Removing the outter ring conductor (most likely to fracture) will eradicate the noise. However be aware unipolar programming leads to increased risk of oversensing myopotentials. Reprograming the mode to VVI would risk sacrificing AV synchrony should they become dependent and could bring about paceaker syndrome.
Yes / No
Would IRS+, MVP, VIP or RYTHMIQ be appropriate for this patient?
No.
These are all algorhythms designed to reduce RV pacing. This patient has CHB as evidenced by ~100% RVp. These algorhythms would likely invoke symptoms.
To remove the observed ‘AT’ sensed events, would one increase or decrease sensitivity?
Decrease sensitivity by Increasing the programmed mV number.
What would be an appropriately programmed output for this patient?
Double threshold voltage (0.9 x 2) = 1.8V
What two programming changes could be made to remove the observed far field atrial sensing?
- Decrease atrial sensitivity (intrinsic activity appears double the amplitude of the far field signal).
- Extend the atrial blanking window (Far Field Protection).
What programming change was likely made here?
A & V sensing changed from unipolar to bipolar.
Note how A-IEGM no longer senses far-field signals and V-IEGM depicts narrower complexes.
Patient remarks of SOBOE, what would you program to help reduce symptoms?
Rate response.
Note how histos show poor spread, with majority pacing at base rate. Patient is also CHB as evidenced by ~80% Vp - thus rate response would be a good idea for this patient.
This patient shows chronotropic incompetence as evidenced by a lack of HR distribution. However why would one be cautious of programming rate response in this patient?
Patient has intrinsic conduction as shown by 0%Vp.
If patient describes no symptoms then preserving 0% Vp may be of a higher priority. Programming RR will increase Vp which could bring about pacemaker syndrome.
Yes / No
Patient presents at 70% CRT - would programming the device from DDD to VVI improve target CRT?
No.
V events are all sensed, thus Atrial signals that are conducted. The device cannot prevent signals conducting to the ventricles. Best option here is to ablate the AV node to ensure CRT pacing.
Yes / No
Patient complains of palpitations. You see 15 of these examples. Would you program different parameters to BURST ATP?
Yes.
Clearly burst ATP at this setting is ineffective as the tachycardia continues unchanged. Coupling interval, Scan and train length are all settings to be altered.
What pacing output would you program?
Threshold = 0.6V thus output = 1.2V.
Appropriate safety margin is double threshold voltage.
What are the two main differential diagnosis that explain the Ars(FFP) observed?
- Retrograde P-wave - comes approximately 90msec post LV stim.
- Crosstalk - Oversensing of ventricular depolarisation / repolarisation.
How could you program the device to overcome this?
Oversensing on ventricular lead respondent to noise. Program lead unipolar to remove fractured conductor from circuit.
Patient here has intrinsic rhythm - in a dependent patient this could be catastrophic. Device would withold pacing due to believing the sensed noise to be intrinsic beats. This would result in asystole.
What output would you program?
Threshold is 1.0V - Thus output = 2.0V
Double threshold value to ascertain appropriate safety margin.
Patient remarks of irregular heart beat, what programming changes could you make?
Device is inappropriately exiting Mswitch, eliciting changes in the V-paced rate due to tracking of atrial arrhythmia. Device is Mswitching inappropriately due to atrial undersensing.
Alter atrial sensitivity either by fixing the sensitivity lower or increasing decay rate.
Program tougher Mswitch exit criterion E.g. from 5/8 beats <160bpm to 8/8 beats <160bpm.
Program VVI depending on whether the AF is chronic >1yr or not.
Yes / No
Patient asymptomatic. Upon device interrogation you see x10 of these lasting ~5s. VT1 is currently monitor zone. Would you program therapies on for these and why?
No.
VT1 is monitor suggesting primary prevention case under HRS programming. 5sec is very short and causes no symptoms. Prognosis is better if shorter tachycardias self terminate without intervention.
What is the purpose of the programmed algorhythm behaviour seen here?
NCAP - Non Competitve Atrial Pacing.
NCAP ensures a reduced risk of atrial arrhythmia by preventing pacing during the atriums vunerable period.
DDDR 60/130, AVD 200ms, V-ref 225ms, PVARP 225ms, A = 5.0V, V = 2.0V
Programming the following would likely induce:
- Pacemaker Syndrome
- Exercise intolerance
- PMT
- Crosstalk
3 - PMT.
What rhythm is shown and what programming changes are necessary?
Atrial Fibrillation is being undersensed. Increase atrial sensitivity to ensue device mode switches.
What programming changes would you make to this secondary prevention patient experiencing extended runs of palpitations?
Slow VT below VT1 detect rate is seen - Lower VT1 rate to allow VT detection + therapy if required.
You see this in clinic in a dependent patient - what is wrong, how would you program around it?
RV impedance increase consistent with conductor fracture. Program lead from bipolar to unipolar.
Device programmed DOO
What is wrong, how would you program around this?
Atrial non-capture. Check threshold and increase atrial output.
What is the issue, how do you program around it?
Atrial undersensing. Check lead integrity and increase atrial sensitivity.
What programming alterations would you make in this case?
Atrial non capture - Check lead integrity and increase output.
How would you program around this?
Example of FFRWS.
Decrease atrial sensitivity - Atrial intrinsic signals are of greater amplitude and FF signals.
Increase PVAB - Thus placing the FF signals within a blanking zone.
What is the issue, how do you program around it?
Ventricular non-capture. Increase ventricular output.
What is the most appropirate programming change?
‘Patient presents with occasional palpitations. Device programmed DDD 75bpm’.
Atrial sensitivity increased.
Device is not detecting low amplitude fib waves, thus cannot appropriately Mswitch. Note lack of As events and Ap throughout.
What is the most appropriate programming change?
Increase ventricular sensitivity.
Ventricular undersensing has led to a stim being delivered during ventricular depolarisation.
What is the most likely programming change required here?
- Turn on Atrial Mode Switch
- Increase ventricular output
- Increase atrial sensitivity
- Decrease atrial sensitivity
- Increase Max Track Rate
3 - Increase atrial sensitivity.
If the rate is true (~280bpm), there should be significantly more A-sensed events than V-events. The lack of sensed events suggests undersensing in the atrial channel.
What programming change would you make for this patient?
Decrease the AV Delay.
Toward the latter part of the strip you see sensed events. The purpose of BiV is to get as close to 100% pacing as possible. Thus shortening the AVD will prevent any sensed events from arriving ahead of the paced beats.
Yes / No
Doctor requests primary prevention tachy programming - is this correct?
No
VF Zone too low / VF Detection too short / VT2 detection too short / VT2 zone too low / VT2 R-S1 interval % too low
Doctor requests primary prevention tachy programming - what changes would you make?
- VF Zone: 222bpm > 231bpm
- VF Detection: 18/24 > 30/40
- VT2 Detection: 20 > 30
- VT2 Zone: 182bpm > 188bpm
- VT2 R-S1 interval: 80% > 88%
What programming changes (if any) would you make here?
Turn therapies off
Patient is receiving innapropriate shocks due to detected RV noise. Revision of RV lead required immediately.
Yes / No
Would you program the following AAI?
No
This is 2nd Degree AVB (clear dropped P-waves). Device programming should be DDD.
How would you program this device?
LV IEGM shows noise - Prog RV VVI and revise LV lead.
Why would you not program this device AAI?
Sinus Rhythm with 1st Degree (~400ms PR Interval).
PR intervals >400ms could lead to AV dyssnchrony. Better to program DDD with shorter AVD.
Yes / No
Could you appropriately program this device AAI?
Yes.
Rhythm shown is Tachy/Brady with no evidence of conduction system disease (dropped beats)
Yes / No
Would it be appropriate to program this device AAI?
Yes.
Vp events are 4%, indicating a healthy AV conduction system.
