1. Brussels June 24 - 25, 2008 Bianka Halmágyi Statistics. Cylos, Cylos 990, Philos II, Talos.

2. 1 Statistics. Cylos, Cylos 990, Philos II, Talos. General Statistics will be restarted at every reprogramming of the device Long-term trends are 180 days long and rolling (if the trend is longer than 180 days the oldest data will be overwritten) Histograms collect all data as long as the statistics are restarted again Short-term trends collect data for 33.33 hours during interrogation and magnet application the counters/ histograms are not active Programming the rate forecast feature will empty all rate counters/histograms

3. 2 Statistics. Cylos, Cylos 990, Philos II, Talos. Overview Timing Timing events Special events Atrial rate histogram Ventricular rate histogram A/V rate trend Intrinsic AV conduction Far-field histogram Tachyarrhythmias Tachy episode trend AT histogram PAC trend PAC versus atrial rate PAC coupling interval PVC classification PVC versus ventricular rate PVC coupling interval Sensor Rate/sensor trend Sensor gain trend Sensor histogram Activity chart Sensing Statistics P-wave trend short + long R-wave trend short + long Pacing A/V impedance trend (short +long) Vent. pacing amplitude trend Ventricular threshold trend Ventricular pacing amplitude histogram ACC status

4. 3 Statistics. Cylos, Cylos 990, Philos II, Talos. Agenda Timing Atrial arrhythmia Ventricular arrhythmia Sensor Sensing Pacing

5. 4 Statistics. Cylos, Cylos 990, Philos II, Talos. Timing Timing events As-Vs: atrial sense/intrinsic AV conduction Ap-Vs:atrial pace/intrinsic AV conduction As-Vp:atrial sense/paced AV conduction Ap-Vp:atrial pace/paced AV conduction V - V:2 consecutive Vs-Vs/Vs-Vp/Vp-Vs/Vp-Vp PVC As:% + no. of Atrial sense Ars:% + no. of refractory sense in the atrium Ap:% + no. of Atrial pace Vs:% + no. of Ventricular sense Vrs: % + no. of refractory sense in the ventricle Vp:% + no. of Ventricular pace

6. 5 Statistics. Cylos, Cylos 990, Philos II, Talos. Definition – Atrial sensed event Ap BR ARP AVI VRP URI As Vx As: spontaneous atrial event sensed outside the ARP

7. 6 Statistics. Cylos, Cylos 990, Philos II, Talos. Definition – Atrial paced event Ap Vx BR ARP AVI VRP URI As Vx Ap: atrial stimulus at the end of the programmed Basic Rate/ Hysteresis Rate or during Sensor driven atrial stimulation

8. 7 Statistics. Cylos, Cylos 990, Philos II, Talos. Definition – Ventricular sensed event AsAp VpVs ARP AVI VRP BR URI Ap Vp As Vs Vs = spontaneous ventricular event sensed after As or Ap during AVI and Vs after Vx

9. 8 Statistics. Cylos, Cylos 990, Philos II, Talos. Definition – Ventricular refractory sense Ap As Vp PVC ARP AVI VRP URI Ventricular sense during the programmed ventricular refractory period is classified as a Vrs however, not classified as a PVC BR

10. 9 Statistics. Cylos, Cylos 990, Philos II, Talos. Definition – Ventricular Extra Systole event Ap Vp Vs PVC ARP AVI VRP BR URI A spontaneous ventricular event sensed outside the programmed VRP without a previous atrial sense or pace is classified as PVC Ventricular event after Ars is classified as PVC

11. 10 Statistics. Cylos, Cylos 990, Philos II, Talos. Definition – Ventricular paced event AsAp VpVs ARP AVI VRP BR URI Ap Vp As Vs Vp = ventricular stimulus at the end of the AV delay

12. 11 Statistics. Cylos, Cylos 990, Philos II, Talos. Definition – V-V counter ApAp Vs Vx BR ARP AVI VRP URI Vx – Vs = in V-Vcounter As Vrs Vx BR ARP AVI VRP URI Vx - Vrs = not in V-V counter

13. 12 Statistics. Cylos, Cylos 990, Philos II, Talos. Timing Special events * *Just Cylos, Cylos 990, Philos II, Talos All events are counted since the last start of the statistics

14. 13 Statistics. Cylos, Cylos 990, Philos II, Talos. Timing A/V rate trend A/V Trend is programmable As fixed trend (12 min/ resolution 4 sec.) As rolling trend (33 hours/ resolution 512 sec.) The one day trend begins with a resolution of 2 seconds with 120 time intervals The time intervals are compressed continuously Last compression level: resolution of 512 seconds and 180 time intervals. Two trends are simultaneously displayed Atrial & ventricular rate % of atrial & ventricular stimulation

15. 14 Statistics. Cylos, Cylos 990, Philos II, Talos. Timing Atrial rate histogram The events in the Rate Histogram are based on Refractory senses (events in the programmed refractory period) Sensed events (events outside refractory period) Paced events (BR/sensor driven rate) Represents distribution of Rate divided over 16 bins (resolution 10 ppm/bin) Ranging 180 ppm

16. 15 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial rate histogram 1/2 P-P 1,000 ms P-P 1,500 ms Ap Vp PVC ARP AVI VRP BI URI < 40 40-49 Ap < BR

17. 16 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial rate histogram 2/2 P-P 1,000 ms P-P 1,250 ms Ap As Ap Vp PVC ARP AVI VRP BI URI < 40 40-49 50-59 As < BR

18. 17 Statistics. Cylos, Cylos 990, Philos II, Talos. Timing Ventricular rate histogram The events in the ventricular rate histogram are based on Sensed events (events outside refractory period) Paced events (BR/sensor driven rate) Refractory senses (inside refractory period): not considered Represents distribution of Rate divided over 16 bins (resolution 10 ppm/bin) Ranging 180 ppm

19. 18 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular rate histogram 1/2 V-V 1,000 ms V-V 1,090 ms Ap AsAp Vp PVC VRP URI < 40 40-49 50-59 Vs < BR BI ARP AVI

20. 19 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular rate histogram 2/2 V-V 1,000 ms V-V 1,180 ms Ap Vp PVC BI ARP AVI VRP URI < 40 40-49 50-59 Vp < BR

21. 20 Statistics. Cylos, Cylos 990, Philos II, Talos. Timing Intrinsic AV conduction* *Just Cylos and Cylos990 Provides data pertaining to how close intrinsic AV conduction is to the programmed AV interval The histogram (it actually consists of 10 histograms in one figure) shows the following Frequency range (5 vertical "trees": 50 - 70ppm, 70 - 90pmm, 90 - 110ppm, 110 - 130ppm, >130ppm) Conduction sorted by Ap (branches to the left of the tree) and As (branches to the right of the tree) How many milliseconds after the atrial event, a Vs is registered

22. 21 Statistics. Cylos, Cylos 990, Philos II, Talos. Timing Intrinsic AV conduction* EXAMPLE: FREQUENCY RANGE 50 - 70PPM AV Hysteresis interval after Ap AV Hysteresis interval after As Intrinsic AV conduction was registered 210 ms (approx. 60%) and 220 ms (approx. 35%) after Ap and very little (approx. 5%) also after 200 ms AV Delay after Ap AV Delay after As Intrinsic AV conduction registered 200 ms after As (approx. 95%) and very little also after 190 ms (approx. 5%) *Just Cylos and Cylos990

23. 22 Statistics. Cylos, Cylos 990, Philos II, Talos. Timing Far-field histogram* *All except Talos Events detected in the FFB window will be sensed but they will not initiate any timing function The detected events are stored in the Far Field Histogram The first part of FFB (standard 56 ms) FFB is also covered by the atrial CCB. The detection/ sensing function during that time is completely switched off. Therefore there are no events marked in the FFB Histogram

24. 23 Statistics. Cylos, Cylos 990, Philos II, Talos. Far Field Blanking (FFB) Prevents detection of R-waves in the atrial channel FFB is a digital blanking to assure a correct function of the Mode Switching functionality Programmability: 32*,40*, 48*, 56*, 72*, 100, 125, 150, 175, 200. The FFB values in Philos II (see *) are dependent on the programmed value of the Atrial Cross Channel Blanking. Only this related value will be seen on the programmer Cylos does not have this type of dependency FFB values for Axios/Philos/Protos are programmable in the Mode Switching screen FFB values for Philos II and Cylos are programmable in the Parameter screen Senses in the FFB and outside the CCB are visible in the marker channel

25. 24 Statistics. Cylos, Cylos 990, Philos II, Talos. Far Field Blanking (FFB) As Vs Vp Ap In Channel B 125ms A V Noise Interval 125ms FFB 32-200ms Cross Channel B 32-72ms Cross Channel B 16-72ms

26. 25 Statistics. Cylos, Cylos 990, Philos II, Talos. Agenda Timing Atrial arrhythmia Ventricular arrhythmia Sensor Sensing Pacing

27. 26 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial arrhythmia Tachy episode trend Consecutive mode switching events within 45 sec result in one Tachy episode The number of Tachy episodes does not match with the number of mode switches! The last 64 Tachy episodes are listed in the printout The trend shows the last 64 events

28. 27 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial arrhythmia Tachy episode report … Report is visible just on the printout, not on the programmer The report shows the last 64 events, earlier events are deleted …

29. 28 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial arrhythmia AT histogram* NSR = normal sinus rhythm ST = Sinus Tachycardia AT = Atrial Tachycardia AF = Atrial fibrillation Afl = Atrial flutter *All except Talos Is generated by an up-down counter of 4 events Transitions from one zone to the next are counted

30. 29 Statistics. Cylos, Cylos 990, Philos II, Talos. AT definition Two rate limits (Philos/Protos had three) Programmable with the "Adjust" button of the statistics menu

31. 30 Statistics. Cylos, Cylos 990, Philos II, Talos. AT definition Stability criterion 3 of the last 5 P-P intervals do not differ more than 6.25% from each other

32. 31 Statistics. Cylos, Cylos 990, Philos II, Talos. AT definition Sudden Onset The average of the 4 previous atrial events is 25% higher than the average of 4 events prior to current average ASAS ASAS VPVP VPVP ASAS VSVS VPVP ASAS VPVP ASAS VPVP ASAS VPVP ASAS ASAS ASAS VPVP VPVP

33. 32 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial arrhythmia A V AVI AARP PACW Prematurity (e.g., 25%) P-P Interval Atrial senses are registered, but do not change timing Dynamic shortening with rate change Premature Atrial Contraction Window Atrial senses in this window are classified as Atrial Premature beats Prematurity programmable between 5.. (5).. 50% PAC definition Definition Prematurity: PAC is X% shorter than the average of the last 4 P- P intervals The length of the PAC Window (PACW)is limited to 800 ms after the atrial event An atrial event later than 800ms following an atrial event is not considered as PAC

34. 33 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial arrhythmia PAC trend* *All except Talos The one day trend begins with a resolution of 2 seconds with 120 time intervals The time intervals are compressed continuously Last compression level: resolution of 512 seconds and 180 time intervals Maximum PAC per hour

35. 34 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial arrhythmia PAC vs. atrial rate* *All except Talos Number and percentage of PAC versus atrial rate shows at which rate the highest percentage of PAC occur Atrial rate divided over 16 bins (resolution 10 ppm) ranging between 40.. (10).. >180 ppm

36. 35 Statistics. Cylos, Cylos 990, Philos II, Talos. Atrial arrhythmia PAC coupling interval* *All except Talos Counts subsequent Ax - PAC intervals Distribution of PAC coupling interval divided over 16 bins (resolution 62 ms) ranging between 760 ms

37. 36 Statistics. Cylos, Cylos 990, Philos II, Talos. Agenda Timing Atrial arrhythmia Ventricular arrhythmia Sensor Sensing Pacing

38. 37 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular arrhythmia PVC definition The PVC definition of Philos II/Talos/Cylos is made more specific than in Philos/Axios/Protos Smallest Vx - Vs interval: 500 ms no PVC at rates below 120 bpm! (But will be counted as V-V Interval in the event counters) At Vx – Ars – Vs sequences Vs will be classified as PVC only if: Ars – Vs > 300 ms no PVC at transion of atrial Tachycardias to the ventricle

39. 38 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular arrhythmia PVC prematurity P-P 1,000 ms Ap Vp Vs PVC ARP AVI VRP BI URI V-V 490 ms As Vp PVC classification is based on previous P-P interval Example: percentage prematurity = 1,000 ms - 490 / 1,000 x 100 = 51%

40. 39 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular arrhythmia Shows (relative to the heart rate) pre-maturity of PVC Indicates severity of PVC Single PVC: sequence of events A-V-PVC-A Couplets: sequence of events A-V-PVC-PVC-A Triplets: sequence of events A-V-PVC-PVC-PVC-A Note: The PVC – PVC coupling interval must be within 500 ms to be counted and classified PVC classification

41. 40 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular arrhythmia Number and percentage of PVC versus ventricular rate shows at which rate the highest percentage of PVC occur Atrial rate divided over 16 bins (resolution 10 ppm) ranging between 180 ppm PVC vs. ventricular rate

42. 41 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular arrhythmia PVC vs. ventricular rate Ap Vp PVC ARP AVI VRP BI URI Ap Vp PVC < 40 40- 49 50- 59 60- 69 PVC vs. Ventricular rate V-V 1,000 ms V-V 1,500 ms The V-V interval before the PVC occurred is taken as reference

43. 42 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular arrhythmia Counts subsequent Vx – PVC intervals Distribution of PVC coupling interval divided over 7 bins (resolution 49 ms) ranging between <200 / 499 ms PVC coupling interval

44. 43 Statistics. Cylos, Cylos 990, Philos II, Talos. Ventricular arrhythmia PVC coupling interval Ap Vp Vs PVC ARP AVI VRP BI URI Vx- PVC 450 ms As Vp Coupling time between Vx and subsequent PVC

45. 44 Statistics. Cylos, Cylos 990, Philos II, Talos. Agenda Timing Atrial arrhythmia Ventricular arrhythmia Sensor Sensing Pacing

46. 45 Statistics. Cylos, Cylos 990, Philos II, Talos. Sensor Records how often the sensor rate lies in a certain range. The rate recorded depends on the pacing mode: Atrial heart rate : VDD, DDD, AAI … + (RR equiv.) Ventr. heart rate: DDI, DVI, VVI … + (RR equiv.) Sensor histogram Recording in all non-rate responsive modes too The sensor indicated rate is also recorded even if inhibition occurs at a faster rate Distribution of Sensor Rate divided over 16 bins (resolution 10 ppm/bin) ranging between 180 ppm

47. 46 Statistics. Cylos, Cylos 990, Philos II, Talos. Sensor Maximum activity rate: Sensor indicates activity at max. sensor rate Activity: Sensor indicates activity (not at the max. sensor rate) No activity: Sensor does not indicate any activity Values are expressed as percentage since last start of statistics Activity chart

48. 47 Statistics. Cylos, Cylos 990, Philos II, Talos. Sensor Continuously checks whether the rate response optimally meets the patient's needs and makes adjustments to the sensor gain when necessary The automatic sensor gain checks daily whether 90% of the adjusted maximum activity rate (MAR) have been reached for a total of 90 seconds. If this occurs, it decreases the sensor gain by one increment Sensor gain If the "maximum activity rate" is not reached, the current setting will initially remain unchanged If the MAR is not reached within a period of 7 days, sensor gain will be increased by one increment

49. 48 Statistics. Cylos, Cylos 990, Philos II, Talos. Sensor If the sensor gain is automatically adjusted the trend shows changed values The sensor gain can show values between 1.0 and 40 in 32 steps Flat line is shown if Auto Gain is OFF and the sensor gain is programmed to a fix value Sensor gain trend

50. 49 Statistics. Cylos, Cylos 990, Philos II, Talos. Agenda Timing Atrial arrhythmia Ventricular arrhythmia Sensor Sensing Pacing

51. 50 Statistics. Cylos, Cylos 990, Philos II, Talos. Sensing 33 h rolling trend P/R wave trend short

52. 51 Statistics. Cylos, Cylos 990, Philos II, Talos. Sensing 180 days rolling trend Can only be displayed after a recording duration of three days P/R wave trend long

53. 52 Statistics. Cylos, Cylos 990, Philos II, Talos. Agenda Timing Atrial arrhythmia Ventricular arrhythmia Sensor Sensing Pacing

54. 53 Statistics. Cylos, Cylos 990, Philos II, Talos. Pacing To make the trend independent from amplitude and pacing every 1.5 hours a measurement occurs by delivering max. 4 triggered pulses at 4.8 V or higher, depending on the program The lead check works beat to beat in a range of 1.4 V - 5.8 V (Philos/ Protos: 2.4 V - 8.4 V). At lower amplitudes (ACC!) the lead check can not work beat-to beat, just during impedance measurement Range of a valid impedance: 200 Ω (Philos/Protos: 300 Ω) to 3,000 Ω The Impedance Trend is independent from the lead check and is always active (deactivation by code possible) Impedance measurement/lead check

55. 54 Statistics. Cylos, Cylos 990, Philos II, Talos. Pacing Rolling 180 day trend, last compression stage: 1 data point per day (values are averaged!) 33 h rolling trend Both trends based on the 90 min impedance measurement at 4.8 V The long-term trend can only be displayed after a recording duration of three days Impedance trend short/long

56. 55 Statistics. Cylos, Cylos 990, Philos II, Talos. Pacing Long-term 180 days trend last compression stage: 1 data point per day (values are averaged!) Records values between 0 - 10 V At the highest compression level, daily values are averaged Ventricular pace amplitude trend

57. 56 Statistics. Cylos, Cylos 990, Philos II, Talos. Pacing Long-term 180 days trend Records values between 0 - 8 V At the highest compression level, daily values are averaged Ventricular threshold trend

58. 57 Statistics. Cylos, Cylos 990, Philos II, Talos. Pacing Shows the distribution of the pacing amplitude range of 4.5 V in 16 bins of 0.3 V Amplitudes applied during the threshold test are included Ventricular pace amplitude histogram

59. 58 Statistics. Cylos, Cylos 990, Philos II, Talos. Pacing OK: feature works as expected Inactive or disabled: ACC was turned on and deactivated later by the implant Pending: the programmer has not got any status information (telemetry?) High Threshold: calculated pacing amplitude is higher than MaxACC amplitude When status OK a note shows the reason for this Active Capture Control (ACC) status