st. jude medical

Folie 1, V 1.1 /TK ECG‘s

St. Jude Medical

Case Studies

Folie 2, V 1.1 /TK ECG‘s

Programmed ParametersMode………………………………………….. VVIBase Rate……………………………………….. 70 ppmMagnet Response…………………….. Battery TestHysteresis Rate………………………………… Off ppm

T Temporary programmed value7 Mar 2000 23:20

1.0 Second

Single Chamber ECG Analysis

ECG #1

Folie 3, V 1.1 /TK ECG‘s

VVI Normal Capture and Sensing

Answer ECG #1

Single Chamber ECG Analysis

Folie 4, V 1.1 /TK ECG‘s

ECG #2

Single Chamber ECG Analysis

Folie 5, V 1.1 /TK ECG‘s

VVI Normal Capture and Sensing with initiation of

Hysteresis

Answer ECG #2

Single Chamber ECG Analysis

Folie 6, V 1.1 /TK ECG‘s

ECG #3

Single Chamber ECG Analysis

Folie 7, V 1.1 /TK ECG‘s

VVI Loss of Ventricular Sensing

Answer ECG #3

Single Chamber ECG Analysis

Folie 8, V 1.1 /TK ECG‘s

1.0 Second

ECG #4

Single Chamber ECG Analysis

Folie 9, V 1.1 /TK ECG‘s

ECG #4

Single Chamber ECG Analysis

Folie 10, V 1.1 /TK ECG‘s

VVI Normal Capture and Sensing

Answer ECG #4

Single Chamber ECG Analysis

Folie 11, V 1.1 /TK ECG‘s

ECG #5

Single Chamber ECG Analysis

Folie 12, V 1.1 /TK ECG‘s

ECG #5

Single Chamber ECG Analysis

Folie 13, V 1.1 /TK ECG‘s

VVI Normal Capture Ventricular Undersensing

Answer ECG #5

Single Chamber ECG Analysis

Folie 14, V 1.1 /TK ECG‘s

ECG #6

Single Chamber ECG Analysis

Folie 15, V 1.1 /TK ECG‘s

ECG #6

Single Chamber ECG Analysis

Folie 16, V 1.1 /TK ECG‘s

VVI Loss of Ventricular Capture Normal Sensing

Answer ECG #6

Single Chamber ECG Analysis

Folie 17, V 1.1 /TK ECG‘s

Base Rate 60 ppm

MTR 120 ppm

AVD 200 ms

PVARP 250 ms

Dual Chamber ECG Analysis

ECG #1

Folie 18, V 1.1 /TK ECG‘s

Loss of Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown

Dual Chamber ECG Analysis

Answer ECG #1

Folie 19, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 75 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #2

Folie 20, V 1.1 /TK ECG‘s

Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown

Answer ECG #2

Dual Chamber ECG Analysis

Folie 21, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #3

Folie 22, V 1.1 /TK ECG‘s

Normal Atrial Capture Possible Psuedofusion on 4th atrial output

Atrial Sensing Unknown Loss of Ventricular Capture Normal Ventricular Sensing

Functional Loss of Ventricular Sensing

Dual Chamber ECG Analysis

Answer ECG #3

Folie 23, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #4

Folie 24, V 1.1 /TK ECG‘s

Normal Atrial CaptureAtrial fusion on 3rd atrial output

Normal Atrial Sensing Normal Ventricular Capture Normal Ventricular Sensing

Answer ECG #4

Dual Chamber ECG Analysis

Folie 25, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #5

Folie 26, V 1.1 /TK ECG‘s

Normal Atrial Capture Atrial Sensing Unknown Normal Ventricular Capture

Fusion on 2nd ventricular output Normal Ventricular Sensing

Answer ECG #5

Dual Chamber ECG Analysis

Folie 27, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #6

Folie 28, V 1.1 /TK ECG‘s

Normal Atrial Capture Atrial Sensing Unknown Normal Ventricular Capture

Fusion on 2nd ventricular output Ventricular Sensing Unknown

Answer ECG #6

Dual Chamber ECG Analysis

Folie 29, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #7

Folie 30, V 1.1 /TK ECG‘s

Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Normal Ventricular Sensing

Dual Chamber ECG Analysis

Answer ECG #7

Folie 31, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #8

Folie 32, V 1.1 /TK ECG‘s

Normal Atrial Capture with one beat showing functional loss of atrial capture

Atrial Undersensing Normal Ventricular Capture Ventricular Sensing Unknown

Answer ECG #8

Dual Chamber ECG Analysis

Folie 33, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #9

Folie 34, V 1.1 /TK ECG‘s

Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Normal Ventricular Sensing

Answer ECG #9

Dual Chamber ECG Analysis

Folie 35, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #10

Folie 36, V 1.1 /TK ECG‘s

Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture with two

beats of functional loss of capture Ventricular Undersensing

Answer ECG #10

Dual Chamber ECG Analysis

Folie 37, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 150 msPV 150 msPVARP 250 ms

ECG #11

Dual Chamber ECG Analysis

Folie 38, V 1.1 /TK ECG‘s

Atrial Capture Unknown Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown

Answer ECG #11

Dual Chamber ECG Analysis

Folie 39, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 88 msPVARP 250 ms

ECG #12

Dual Chamber ECG Analysis

Folie 40, V 1.1 /TK ECG‘s

Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown Initiation of a Pacemaker Mediated

Tachycardia (PMT) with following a PVC

Answer ECG #12

Dual Chamber ECG Analysis

Folie 41, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 88 msPVARP 250 ms

ECG #13

Dual Chamber ECG Analysis

Folie 42, V 1.1 /TK ECG‘s

Loss of Atrial Capture initiating a Pacemaker Mediated Tachycardia (PMT)

Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown

Answer ECG #13

Dual Chamber ECG Analysis

Folie 43, V 1.1 /TK ECG‘s

Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 88 msPVARP 250 ms

Dual Chamber ECG Analysis

ECG #14

Folie 44, V 1.1 /TK ECG‘s

Normal Atrial Capture Atrial Sensing Unknown Normal Ventricular Capture Normal Ventricular Sensing The retrograde P-wave after the PVC is not seen

because it falls in PVARP just like it should

Answer ECG #14

Dual Chamber ECG Analysis

Folie 45, V 1.1 /TK ECG‘s

ICD ECG Analysis

ECG #1

Folie 46, V 1.1 /TK ECG‘s

ICD ECG Analysis

ECG #1

Folie 47, V 1.1 /TK ECG‘s

ICD ECG Analysis

Answer ECG #1

T-Wave sensing longer decay delay Threshold start higher

Folie 48, V 1.1 /TK ECG‘s

Presented with left hemi-diaphragmatic stimulation from atrial lead

Twiddler‘s Syndrome

Folie 49, V 1.1 /TK ECG‘s

Courtesy of Dr. F. Venditti, Lahey Clinic, MA`

Twiddler‘s Syndrome

Folie 50, V 1.1 /TK ECG‘s

Rib-Clavicle Crush

Folie 51, V 1.1 /TK ECG‘s

Rib-Clavicle Crush

Folie 52, V 1.1 /TK ECG‘s

Original lead damaged by rib-clavicle crush.

New lead placed via cephalic vein cutdown

Rib-Clavicle Crush

Folie 53, V 1.1 /TK ECG‘s

Myopotential Oversensing

Folie 54, V 1.1 /TK ECG‘s

Reproduce while monitoring EGM / Event Markers

Try to eliminate with reduced sensitivity

Provocative maneuvers

Evaluation of Oversensing

Folie 55, V 1.1 /TK ECG‘s

Ventricular Fusion

Folie 56, V 1.1 /TK ECG‘s

Ventricular Pseudofusion

Folie 57, V 1.1 /TK ECG‘s

Metabolic abnormalities Hyperkalemia ( K+ )

Congestive Heart Failure Changes in time of day

sleep >> wake Exercise and heart rate Pharmacologic agents

Flecainide

Bipolar VVI with 2nd degree Wenckebach exit-block due to hyperkalemia (serum K 7.3 mEq/L). Upon correction of elevated potassium level, capture threshold was 1.3 V @ 0.8 ms

Loss of Capture due to Intrinsic Rise in Capture Threshold

Folie 58, V 1.1 /TK ECG‘s

Slower rate and pauses ONLY follow native beats

First escape cycle followed by pacing at higher rate

Management Education Disable if causing

problems

ProgrammingBase Rate: 115 ppm

Hysteresis Rate: 65 ppm

Hysteresis