Pitfalls of pacemaker detection of ventricular high-rate events

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Date of download: 6/1/2016 Copyright © The American College of Cardiology. All rights reserved. From: Safety and efficacy of advanced atrial pacing therapies.

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HeartRhythm Case Reports

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Pitfalls of pacemaker detection of ventricular high-rate events Fadi Mansour, MD, Isabelle Greiss, MD, Paul Khairy, MD, PhD HeartRhythm Case Reports Volume 4, Issue 4, Pages 163-165 (April 2018) DOI: 10.1016/j.hrcr.2017.11.012 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 Polymorphic ventricular tachycardia (VT) recorded by telemetry. Shown is a telemetry lead II recording of polymorphic VT post pacemaker implantation. The patient was in slow paroxysmal atrial fibrillation prior to the onset of VT, with occasional ventricular paced beats. The tachycardia lasted 20 seconds, had a cycle length that predominantly ranged between 200 and 240 ms, and terminated spontaneously. HeartRhythm Case Reports 2018 4, 163-165DOI: (10.1016/j.hrcr.2017.11.012) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 Dynamic sensitivity adjustment. After each paced or sensed ventricular beat, automatic sensitivity control (ASC) initiates a detection hold-off period (121 ms for sensed beats; 200 ms for paced beats). For sensed ventricular beats, the subsequent sensing threshold is first set to 50% of the measured peak amplitude within the first 80 ms of this interval. For paced ventricular beats, the subsequent sensing threshold is set to the nominal minimal value (ie, 2 mV for Epyra devices). After a step duration of 125 ms, the threshold is set to 25% of the peak amplitude but never below the minimum threshold of 2.0 mV. This functionality allows signals with varying and small amplitudes to be detected with a 1:4 signal-to-noise ratio. HeartRhythm Case Reports 2018 4, 163-165DOI: (10.1016/j.hrcr.2017.11.012) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 Example of refractory ventricular beats that increase the ventricular high-rate (VHR) counter. Shown is an example of a logged VHR event in a patient with a Medtronic Sensia VVIR pacemaker. The device was set to record a VHR event if at least 5 beats exceeded 180 beats per minute. The ventricular refractory period was programmed at 330 ms. A VHR event was chronicled after 5 successive R-R intervals <330 ms were detected (asterisks). Note how ventricular beats with cycle lengths <330 ms were considered refractory (SR), yet increased the counter for VHR detection. EGM = electrogram; P = paced event; S = sensed event. HeartRhythm Case Reports 2018 4, 163-165DOI: (10.1016/j.hrcr.2017.11.012) Copyright © 2017 Heart Rhythm Society Terms and Conditions