EHRA Book of Pacemaker ICD CRT Troubleshooting

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The EHRA Book of
Pacemaker, ICD, and
CRT Troubleshooting
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The EHRA Book of
Pacemaker, ICD, and
CRT Troubleshooting
Case-based learning with multiple choice questions
Edited by Co-editors
Haran Burri md Jean-Claude Deharo md Carsten Israel md

EHRA Education Committee Chairman EHRA Accreditation Committee Member EHRA Education Committee Member
Assistant Professor Professor Associate Professor
Electrophysiology Unit Rhythmology Department Evangelical Hospital
Cardiology Service Timone Hospital Bielefeld, Germany
University Hospital of Geneva Marseilles, France
Geneva, Switzerland
3
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To our teachers, who have shown us that knowledge is a gift that should be shared with generosity,
and, most of all, to our loved ones.
Endorsements
Pacemakers, ICDs, and CRT devices are used increasingly in the man- The book by Dr Burri, Dr Israel, and Dr Deharo is a godsend, because trou-
agement of arrhythmias and a number of different cardiac conditions. bleshooting of complicated contemporary heart rhythm devices is difficult.
Specialists, general cardiologists, and general physicians are now close- Only very few recent books have addressed this complex subject compre-
ly involved in managing patients with these devices. The EHRA Book of hensively. The book describes the timing cycles involved in the various cases
Pacemaker, ICD, and CRT Troubleshooting is written by leading special- in a clear way, so that they can be more easily understood and remembered.
ists from Europe and is designed for all physicians looking for a clear and The book is ideally suited for workers preparing for an examination given
comprehensive introduction to the troubleshooting management of these by the European Heart Rhythm Association and the Heart Rhythm Society.
devices. Designed to bring you from your current level of knowledge to a It will also be useful to all health care workers dealing with heart rhythm
level of fully advanced troubleshooting manager, this book features 70 real- devices.
life IPG, ICD, and CRT cases, accompanied by thorough explanations and
S Serge Barold, md
vi analyses. Presented in a clear and casual writing style, the book’s levelled
Clinical Professor of Medicine Emeritus,
approach takes a complex subject and makes it simple. Whether you are an University of Rochester,
EMT, nurse, medical student, or physician wanting to learn or brush up on Rochester, New York, USA
your knowledge of pacemaker, ICD, or CRT troubleshooting, this text will
meet your needs. The text has been created to be continuously useful during
The authors, all noted cardiologists with a special expertise in device man-
your development and is intended to be read and reread, as you advance in
agement, have prepared a unique volume of device (pacemakers, ICDs, and
your knowledge and comfort level with the material.
CRT devices)-based cases that test the clinician’s ability to interpret multiple
Angelo Auricchio, md, phd, fesc facets of device-based therapy. This book is the perfect volume for examina-
Director Clinical Electrophysiology Programme, Division of Cardiology, tion preparation. Many practitioners (cardiac electrophysiologists, cardi-
Fondazione Cardiocentro Ticino, Lugano, Switzerland ologists, nurses, device technicians, cardiac technologists), at all levels of
Co-Director, Center of Computational Medicine in Cardiology, experience and knowledge, will find this volume invaluable for improving
Università della Svizzera Italiana, Lugano, Switzerland their ability to analyse device function and malfunction. The bottom line
Scientific Director, Fondazione Ticino Cuore, Lugano, Switzerland
is this book is a ’must have’ for any clinician who cares for cardiac patients
Professor of Cardiology, University of Magdeburg, Magdeburg, Germany
Immediate Past-President of the European Heart Rhythm Association with implantable devices.
Kenneth A Ellenbogen, md, faha, facc, fhrs
Kontos Professor of Cardiology
Chairman of Cardiology
VCU School of Medicine, Richmond, VA, USA
Foreword
I am very pleased to have been asked to provide a foreword to this first The correct answer is given and the explanations are provided in a few
of several specialist “handbooks”, commissioned by the European Heart sentences relating to specific annotations added to each trace. There are
Rhythm Association (EHRA), and written and overseen by the Education three sections in the book, going from relatively easy and straightforward
Committee of EHRA. The project was originally conceived by Panos examples to much more difficult and puzzling cases. References for further
Vardas, then the President of the EHRA. The subjects are highly technical reading are provided for those who want to dig more deeply.
and very practical. They are specifically designed as teaching aids to This type of educational aid is very well suited to preparing those
assist practitioners to become and remain truly expert in their role. This who would like to take formal assessments of their skills, at national or
particular volume concerns the troubleshooting of cardiovascular implant- international levels. In this case the handbook is very useful for those
able electronic devices (CIEDs), specifically pacemakers, implantable car- intending to take the EHRA accreditation examinations. However, the
dioverter d efibrillators and cardiac re-synchronisation therapy. study of this practical book should be of very great value to all technicians,
The book is authored by three true experts in their field. The concept is physiologists, nurses and doctors who have the responsibility to follow vii
to provide a highly illustrated volume of real cases with technical challenges patients fitted with CIEDs.
drawn from clinical practice. The format is to provide a minimum of
technical information and to present ECG recordings, chest X-rays,
A. John Camm, md, fesc
echocardiograms, pacemaker log data, stored or real time electrograms Professor of Clinical Cardiology, St. George’s University of London,
with the manufacturers’ annotations and other technical outputs in order to Professor of Cardiac Electrophysiology, Imperial College, London, United Kingdom, and
Editor-in-Chief of EP-Europace, the official journal of EHRA
challenge the reader. The test comes in the form of multi-choice questions.
Preface
As the complexity of cardiac rhythm devices grows, so does the necessity to The book is divided into three sections: pacemakers, implantable
understand device behaviour, in order to perform proper follow-up of device cardioverter–defibrillators (ICDs), and cardiac resynchronization ther-
patients. Case-based teaching is an effective way to learn device function. This apy (CRT). Each of these sections comprises cases that are of increasing
book is a collection of teaching cases that have been gathered for over more levels of difficulty. The questions are also structured to build upon the
than a decade. The cases presented here serve to illustrate common problems knowledge acquired from previous cases, so it is recommended to work
that the device specialist may be faced with, or uncommon situations for through them in their given order. The names of device manufacturers
which structured and logical reasoning paves the path to elucidation. are seldom indicated in the cases, as this information is usually irrelevant,
This book is not a technical manual of device algorithms. Algorithms of and it is our wish to transmit principles that are applicable across device
the different device manufacturers are almost impossible to memorize and companies.
may be outdated as soon as new models are introduced. However, under- The aim of this book is to consolidate technical knowledge, sharpen
viii standing the general principles of device function and being able to reason skills of observation, and train logical reasoning to be able to tackle device
in a structured and logical manner when interpreting device tracings is of troubleshooting. Most of all, we wish to stimulate the reader’s interest in
timeless value. The material provided here will assist those studying for the the field of cardiac pacing and give the sense of satisfaction that comes with
European Heart Rhythm Association (EHRA) accreditation exam in car- understanding.
diac pacing, even if the level of complexity of some of the cases may exceed Haran Burri
that which is expected of them to pass the exam. It is also intended to be of Jean-Claude Deharo
use to cardiologists and technical consultants who do not intend to pass the
Carsten Israel
exam but deal with device patients.
Acknowledgements
The cases in this book are all from Dr Haran Burri’s clinical practice,
unless mentioned otherwise. We wish to thank the following colleagues
who let us use their cases for this book:
Dr Michael Anelli-Monti
(Medical University of Graz, Graz, Austria):
Case 21
Mr Thomas Bruggemann
(Biotronik, Berlin, Germany):
Cases 7 and 17
Mr Henny Leersen ix
(St-Jude Medical, St Paul, MN, USA):
Case 29
Dr Andrea Menafoglio
(San Giovanni Hospital, Bellinzona, Switzerland):
Case 18
Dr Sergey Moiseenko
(Minsk, Belarus):
Case 33
Dr Cédric Vuille
(Nyon, Switzerland):
Cases 25 and 31
We also wish to thank Mrs Marta Roca (Medtronic) for proofreading
the manuscript, and Mr Martin Dummann (Biotronik), Mrs Sofia Gago
(Sorin), and Mr Ed Van der Veen (Boston Scientific) for their technical
advice.
Contents
Symbols and abbreviations xiii
Introduction xv
SECTION 1 Pacemakers
Cases 1–35 2
SECTION 2 ICD
Cases 36–53 144
SECTION 3 CRT xi
Cases 54–70 218
Index 287
Symbols and abbreviations
= equal to LOC loss of capture
≥ equal to or greater than LV left ventricular
> greater than LVEF left ventricular ejection fraction
< less than min minute
% per cent mm millimetre
+ plus ms millisecond
± plus or minus MTR maximum tracking rate
AF atrial fibrillation mV millivolt
a.m. ante meridiem (before noon) NIPS non-invasive pacing study
AP atrial pacing PAVB post-atrial ventricular blanking
AR atrial refractory PVAB post-ventricular atrial blanking xiii
AS atrial sensed PVARP post-ventricular atrial refractory period
ATP antitachycardia pacing PVC premature ventricular contraction
AV atrioventricular RBBB right bundle branch block
AVI atrioventricular interval RNRVAS repetitive non-re-entrant ventriculoatrial synchrony
AVNRT atrioventricular nodal re-entrant tachycardia RV right ventricular/right ventricle
AVRT atrioventricular re-entrant tachycardia SVT supraventricular tachycardia
bpm beat per minute TARP total atrial refractory period
CRT cardiac resynchronization therapy TOE transoesophageal echocardiogram
CRT-D cardiac resynchronization therapy defibrillator UTR upper tracking rate
CS coronary sinus V volt
ECG electrocardiogram VA ventriculoatrial
EGM electrogram VF ventricular fibrillation
ER evoked response VP ventricular pacing
FFRW far-field R-wave VPB ventricular premature beat
Hz hertz VRP ventricular refractory period
ICD implantable cardioverter–defibrillator VS ventricular sensed
J joule VT ventricular tachycardia
Introduction
A systematic approach to device electrocardiogram (ECG)/electrogram (EGM) tracings is
proposed as a ten-step process, which will allow the reader to troubleshoot cases in a struc-
Basics of pacemaker troubleshooting
tured manner. Non-pacing (lack of a spike)
Pseudomalfunction: hysteresis, night rate, device algorithm
Systematic device ECG/EGM analysis Oversensing
Battery/circuit problem
1. Which ECG leads/EGM channels (chamber, polarity) are displayed, and what is the
Lead connection problem
scale?
2. What is the baseline rhythm? Non-capture (lack of entrainment of a P-wave or QRS)
3. Is there evidence of intrinsic atrial activity, sensing, pacing, and capture? Threshold rise: infarction, drugs (flecainide)
4. Is there evidence of intrinsic ventricular activity, sensing, pacing, and capture? Lead problem (insulation defect, fracture, displacement, perforation)
5. Are the intervals between the spikes and P/QRS complexes constant? Battery end of life
6. What is the morphology of the paced QRS complex? Programming error xv
7. Evaluation of timing and intervals (AA, VV, AV, VA, etc.).
8. What is the likely pacing mode? Undersensing
9. Is there evidence of malfunction (undersensing, oversensing, non-pacing, non- Lead displacement
capture)? New bundle branch block, infarction
10. Is there evidence of pseudomalfunction (device algorithm, functional undersensing, Premature beat with perpendicular electrogram vector
etc.)? Programming error
‘Physiological undersensing’ during refractory period
Oversensing
Ventricular far-field/T-wave/P- or R-wave double-counting
Lead problem (fracture, connection problem)
Electromagnetic interference
Myopotentials (pectoral/diaphragmatic)
VVI timing cycles and refractory periods Summary of DDD timing cycles
Timing cycles of the VVI pacing mode are shown in the figure. A summary of the DDD pacing mode timing cycle triggers and their typical durations is
shown in the table.
AS AP VS VP Typical duration (ms)

FURTHER INFORMATION
A Blanking ✔ ✔ ✔ ✔ 50–200
A Refractory ✔ ✔ ✔ ✔ 120–150 (post-AP); 250–400 (post-VP)

LRI LRI LRI LRI
V Blanking ✔ ✔ ✔ 20–50 (post-AP); 150–250 (post-VP)
VRP VRP VRP <LRI
URI URI URI VRP VRP V Refractory ✔ ✔ 150–300
URI URI
LRI Lower Rate Interval – defines the minimum heart rate
Definitions:
URI Upper Rate Interval – defines the highest (rate-adaptive) pacing rate
Blanking: signals are not at all detected, independent of their amplitude and the
VRP Ventricular Refractory Period – signals are sensed but do not reset the timing cycles
(e.g. prevents restarting a new LRI when sensing the T wave programming of sensitivity.
Blanking Period – signals are not sensed at all (e.g. blinding to the pacing spike) Refractory: signals are detected but will be ignored for pacing cycles (i.e. the next scheduled
pace will not be reset) and only used for calculation of rate, detection of tachyarrhythmias,
xvi and mode switching.
DDD timing cycles and refractory periods Blanking and refractory periods may vary, according to:
Timing cycles of the DDD pacing mode are shown in the figure. ◆ manufacturer
◆ model
◆ paced or sensed event
◆ programmed pacing polarity.
<AVI <AVI AVI AVI

VA interval <VA interval VA interval VA interval
URI URI URI URI
ARP PVARP ARP PVARP ARP PVARP ARP PVARP
VRP VRP VRP VRP
AB − Atrial PVAB − Post ventricular PVAB − Post ventricular VB − Venticular

blanking atrial blanking atrial blanking blanking
AVI: antrioventricular interval period PVARP: post-ventricular atrial refractory

URI: upper rate interval URI: upper rate interval
ARP: atrial refractory period
VRP: ventricular refractory period
Main marker channel annotations of the different device manufacturers (the list is not exhaustive)
Boston Scientific Sorin
AS Atrial Sense - After Refractory and AFR window VT–1 VT–1 Zone Sense
AS–Hy Atrial Sense - In Hysteresis Offset VT VT Zone Sense
A-A interval
FURTHER INFORMATION
AS–FI Atrial Sense - In AFR window VF VF Zone Sense
(AS) Atrial Sense - During TARP AN Atrial Rate Noise
AP Atrial Pace - Lower Rate RVN Right Ventricular Rate Noise V-V interval
AP Atrial Pace - Rate Smoothing Down LVN Left Ventricular Rate Noise
➝➝
AP Atrial Pace - Rate Smoothing Up ATR Atrial Tachycardia Sense - Count Down
➝➝
AP–FB Atrial Pace - Fallback (in ATR) ATR Atrial Tachycardia Sense - Count Up Ap/A Atrial pacing
AP–Hy Atrial Pace - At Hysteres is Rate ATR–Dur ATR Duration Started As/P Atrial sensing
AP–Sr Atrial Pace - Sensor Rate ATR–FB ATR Fallback Started Ar Atrial refractory sensing
AP➝ Atrial Pace - Inserted after AFR ATR–End ATR Fallback Ended Vs/R Ventricular sensing
AP–Ns Atrial Pace - Noise (asynchronous pacing) FB ATR in Progress Vp Ventricular pacing
AP–Tr Atrial Pace - Trigger Mode RID–TU Rhythm ID Template Update Vr Ventricular refractory sensing
RVS Right Vent Sense - After Refractory RID+ Rhythm ID Correlated bV Biventricular pacing
[RVS] Right Vent Sense - During Blanking RID– Rhythm ID Uncorrelated
RVP Right Vent Pace - Lower Rate or Atrial Tracked C–– RhythmMatchTM Correlated without percentage
RVP Right Vent Pace - Rate Smoothing Down U–– RhythmMatchTM Uncorrelated without percentage
➝➝
RVP Right Vent Pace - Rate Smoothing Up PVP➝ PVARP after PVC
RVP–FB Right Vent Pace - Fallback (in ATR) PMT–B PMT Termination
RVP–Hy Right Vent Pace - At Hysteresis Rate AF–Rhythm AFib Rhythm St-Jude Medical
RVP–Sr Right Vent Pace - Sensor Rate V–Epsd Ventricular Tachy Start Episode
RVP–MT Right Vent Pace - Atrial Tracked at MTR V–EpsdEnd Ventricular Tachy End Episode
RVP–Ns
RVP–Tr
Right Vent Pace - Atrial Tracked at MTR
Right Vent Pace - Trigger Mode
V>A
AFibV
Ventricular Rate Faster than Atrial Rate
V AFib Criteria Met
A refractory
sense
% morphology
match
xvii
RVP–VRR Right Vent Pace - Ventricular Rate Regulation V–Dur Duration Met
LVS Left Vent Sense - After Refractory Stb Stable
[LVS] Left Vent Sense - During Blanking Unstb Unstable
LVP Left Vent Pace - Lower Rate or Atrial Tracked Suddn Sudden Onset Refractory A-A interval
LVP Left Vent Pace - Rate Smoothing Down GradI Gradual Onset periods
➝➝
LVP Left Vent Pace - Rate Smoothing Up V–Detect Ventricular Detection Met A-V interval
LVP–Hy Left Vent Pace - At Hysteresis Rate Chrg Start/End Charge
LVP–Sr Left Vent Pace - Sensor Rate Dvrt Therapy Diverted V-V interval
LVP–MT Left Vent Pace - Atrial Tracked at MTR Shock Shock Delivered
LVP–Ns Left Vent Pace - Noice (asynchronous pacing) SRD Sustained Rate Duration Expired
LVP–Tr Left Vent Pace - Trigger Mode Trigger EGM
LVP–VRR Left Vent Pace - Ventricular Rate Regulation recording
Inh–LVP Left Vent Pace - Inhibited Due to LVPP
PVC PVC after Refractory Biventricular
pacing
Biotronik Medtronic Simultaneous LV first RV first Triggered
As/Ap Atrial sensing/pacing AS/AP Atrial sensing/pacing

Vs/Vp Ventricular sensing/pacing AR Atrial refractory sense AMS Modeswitch
LVp/LVs Left ventricular pacing/sensing Ab Atrial event in blanking period LOC Loss of capture
RVp/RVs Right ventricular pacing/sensing VS/VP Ventricular sensing pacing VPP Ventricular backup pacing
Ars Atrial refractory sensing BV Biventricular pace – Interval that is not binned
Ars (FFP) Ars in far-field protection window VR Ventricular refractory sense VS Binning of interval in Sinus zone
Vrs Ventricular refractory sensing TS Sense in (slow) VT zone T1 Binning of interval in VT1 zone
Aflut Atrial flutter detected T•F Sense in fast VT zone via VT T2 Binning of interval in VT2 zone
Afib Atrial fibrillation detected TF• Sense in fast VT zone via VF F Binning of VF interval
Msw.DDI Modeswitch to DDI FS Sense in VF zone Ventricular F Reconfirmation of VF
Det. VF VF detected TD VT detected safety pacing
Rdt. Redetection criteria are fulfilled TF FVT detected
1:1 1:1 A:V ratio FD VF dected
Charging of the capacitors TP Tachy pace (ATP)
Term. Tachycardia episode has terminated CE Charge end Triggered
Psh. VVI Post shock pacing mode is VVI CD Charge delivered biventricular
pacing
Section 1
PACEMAKERS
Cases 1–35
1–35

CASE 1 Introduction to the case
A patient with paroxysmal complete atrioventricular (AV) block was implanted with a
dual-chamber pacemaker. At follow-up, the real-time electrogram (EGM) strip, shown in
Figure 1.1, was recorded.
Question
Figure 1.1 Real-time EGM recording
CASE 1
A bipolar
V unipolar
3
In what pacing mode is the device programmed?

A VDI
B DDI
C VDD
D DDD
Answer
B DDI
SECTION 1 PACEMAKERS
Figure 1.2 Annotated real-time EGM recording
➊ ➋ ➌ ➊ ➋ ➌
➍ ➍
A bipolar ➎ ➎
4
V unipolar
The baseline rhythm is sinus with complete AV block (Figure 1.2). Atrial pacing (AP) is ➌ AP occurs at the end of the VA interval (800ms in this example, which corresponds to
occurring, so the VDI and VDD modes can be excluded. The device was programmed in the programmed lower ventricular rate interval of 1000ms−the paced AV interval (AVI) of
the DDI mode with a baseline rate of 60bpm. 200ms).
➊ There is loss of AV synchrony with atrial sensed events (AS) at a constant ventricular pacing ➍ AV synchrony is maintained after AP events (the paced AVI was programmed at 200ms
(VP) rate of 60bpm (the VP–VP intervals are labelled at 996–1000ms, due to cycles of the but is labelled here as 195ms, due to the device clock cycles).
device clock). This excludes DDD and VDD pacing modes, which track sensed atrial activity.
➎ The EGM amplitude of AP events is low, due to the autogain function.
➋ In the DDI mode, a ventriculoatrial (VA) interval is triggered after a VP or ventricular
sensed (VS) event. Atrial refractory sensed events (AR) that fall within the post-ventricular
atrial refractory period (PVARP) do not inhibit AP.
Comments
The DDI(R) pacing mode
This patient had paroxysmal AV block, with long AS–VS intervals detected by the device
during 1:1 AV conduction. This was, in part, due to first-degree AV block and partly due
to right bundle branch block (RBBB) (resulting in late sensing of the ventricular EGM
by the right ventricular (RV) lead). In order to avoid having to programme very long AV
delays in the DDD mode, to avoid unnecessary RV pacing*, the device was programmed
in the DDI mode.
This non-tracking mode, shown in Figure 1.2, is most often used with automatic mode
CASE 1
switch during atrial tachyarrhythmias, in order to avoid rapid ventricular pacing. It may
also be used in patients with paroxysmal AV block, but AV synchrony will be lost in case
of AV block with AS events (as in this example). AV synchrony is, however, maintained in
the case of AP such as in patients with sinus dysfunction. The DDI(R) pacing mode with a
long paced AV delay (there is no programmed sensed AV delay) may be considered, if the 5
device does not have specialized algorithms to avoid ventricular pacing.
* This may be ineffective in reducing ventricular pacing, may favour endless-loop tachycardia, and may result in pacing on
the T-wave in case of ventricular premature beats (VPBs) falling in the post-atrial ventricular blanking (PAVB)—see future
cases in this book.
An 82-year-old woman had been implanted with a single-chamber ventricular pacemaker
6 years ago for atrial fibrillation (AF) with symptomatic bradycardia. She presented to the
hospital with shortness of breath and twitching of the left pectoral region. Her pacemaker
follow-up, performed 6 months ago, had been completely normal. The results of the de-
vice follow-up performed at that time are shown in Table 2.1, and the electrocardiogram
(ECG) recorded at admission is shown in Figure 2.1.
Table 2.1 Device settings and tested parameters

Programming
Mode VVIR
Rate 60–110bpm
Pacing output (bipolar) 2.5V/0.4ms
Sensitivity setting (bipolar) 2.8mV
Tests
Battery voltage 2.71V
Battery impedance 1200 ohms
Lead impedance (bipolar) 625 ohms
Capture threshold (bipolar) 1.2V/0.4ms
Sensing threshold (bipolar) 6.8mV

Question
Figure 2.1 ECG recorded at admission
II
CASE 2
What do you observe?
A Ventricular undersensing 7
B Ventricular oversensing
C Ventricular non-pacing
D Both A and C are correct
Answer
A Ventricular undersensing
Figure 2.2 Annotated ECG recorded at admission
➊ ➋
II
8
The pacing spikes in Figure 2.2 occur at exactly 60bpm (the baseline rate), with all spikes spike occurs at, or shortly after, QRS onset, but before the depolarization wavefront has
showing ventricular undersensing and non-capture. This should not be confused with reached the lead dipole. The pacing spike occurs during the myocardial refractory period
non-pacing, which refers to the lack of delivery of a pacing spike where one is expected. and therefore does not capture the ventricle.
➊ This beat could be interpreted as normal device function with pseudofusion, as the ➋ The ventricular spike occurs on the T-wave which may be potentially pro-arrhythmic,
spike occurs almost simultaneously with the QRS complex. With pseudofusion, the pacing but this is not the case here, as there is no capture.
Comments
Subclavian crush
A chest X-ray showed complete lead section due to subclavian crush (Figure 2.3A).
A chest X-ray had been performed shortly before the previous device follow-up by
the patient’s general practitioner for cough and already showed signs of lead damage
(Figure 2.3B).
This case illustrates how normal parameters (including impedance) do not rule out
damage to a lead. This is of particular relevance in pacemaker-dependent patients who
may be experiencing symptoms compatible with device dysfunction and in whom a
CASE 2
chest X-ray and Holter recording should be performed if device interrogation does not
elucidate the problem.
Subclavian crush may result from medial subclavian puncture and may be avoided by
favouring axillary vein puncture or cephalic vein cutdown for lead implantation.
9
Figure 2.3 Chest X-rays showing complete lead section due to subclavian crush (a) and
evidence of lead damage 7 months ago, when device parameters were normal (b).
(a) (b)
An 82-year-old patient with ischaemic heart disease and mildly reduced left ventricular
ejection fraction (LVEF) was implanted, 1 month ago, with a St-Jude Medical single-
chamber pacemaker for AF and symptomatic bradycardia.
The pacemaker was programmed to VVIR 60–110bpm.
The presenting EGM at follow-up is shown in Figure 3.1.
Question
Figure 3.1 Real-time EGM recorded at 1-month follow-up
V EGM
CASE 3
How do you explain pacing below the baseline rate? 11
A Ventricular oversensing
B Rate hysteresis
C Programming error
D Loss of capture
Answer
B Rate hysteresis
Figure 3.2 Annotated real-time EGM recorded at 1-month follow-up
➌ ➊ ➋ ➋ ➌ ➊ ➌
➎ ➎ ➎ ➍ ➍
12
The device was programmed at a baseline rate of 60bpm and with a hysteresis of 50bpm ➌ As soon as there is a VS event, the hysteresis rate is reactivated.
(Figure 3.2).
➍ These two beats with different EGM morphologies correspond to varying degrees of
➊ The VS–VP interval is 1203ms, corresponding to the rate of hysteresis (the interval should fusion between ventricular capture and intrinsic conduction. Pseudofusion would have
be theoretically 1200ms but is slightly different, due to processing by the internal clock). resulted in the same morphology as the intrinsic ventricular EGM.
➋ The VP–VP interval is 996ms (should theoretically be 1000ms; see (1)), corresponding ➎ These three beats correspond to full ventricular capture.
to the baseline rate (the patient is at rest, so the rate is not sensor-driven).
Comments
Rate hysteresis
Hysteresis is useful to avoid unnecessary pacing and is available for single-chamber, as
well as dual-chamber devices. In this case, it was used to minimize ventricular pacing at
rest, in order to avoid an adverse effect on cardiac pump function.
With hysteresis, the intrinsic heart rate is allowed to fall below the baseline rate, as long as
it is above the hysteresis rate. As soon as the hysteresis rate is reached, the device paces at
the baseline rate, until a ventricular event is sensed (i.e. that occurs faster than the baseline
rate) (Figure 3.3).
CASE 3
Some devices allow programming additional hysteresis parameters, e.g. the number of
cycles at which pacing occurs at the hysteresis rate before switching to the baseline rate.
Figure 3.3 Rate hysteresis

13
Heart rate Hysteresis off
Lower rate
Time
Heart rate
Hysteresis on
Lower rate
Hysteresis rate
Time
Spontaneous rhythm Pacing
A 76-year-old man with symptomatic sinus node dysfunction and no other cardiovascular
history, was implanted with a single-chamber pacemaker. At the 1-month follow-up
visit, he complained of worsening dyspnoea, fatigue, and orthostatic dizziness. Device
interrogation showed normal parameters. The presenting ECG is shown in Figure 4.1.
Question
Figure 4.1 Presenting ECG at 1-month follow-up
II
CASE 4
III
15
What is the cause of the patient’s symptoms?
A Pacemaker syndrome
B Inadequate rate response
C AF
D Ventricular systolic dysfunction
Answer
A Pacemaker syndrome
Figure 4.2 Annotated presenting ECG at 1-month follow-up
II ➊
III ➊
16
This patient is in sinus rhythm, with VP and 1:1 retrograde VA conduction (Figure 4.2).
➊ Retrograde P-waves can be visualized after each paced QRS complex.

Comments
Pacemaker syndrome
Although there is no universal definition for pacemaker syndrome, it manifests itself by a
variety of symptoms (fatigue, dyspnoea, dizziness, orthopnoea, fullness in the neck, etc.).
It is believed to be due to AV dyssynchrony in patients with a VVI(R) device in sinus
rhythm, with or without retrograde conduction.1 It may be encountered in up to 26% of
these patients1–3 and usually occurs during the first months following implantation.1,3
Changing to dual-chamber pacing significantly improves symptoms in these patients.3
In this example the ventricular lead was repositioned in the atrium to provide AAIR
CASE 4
pacing, after having tested for normal AV conduction. DDDR pacing is the first choice in
case of sick sinus syndrome4 and is preferable to AAIR pacing.5 However, AAIR pacing is
still an option4 and, in this case, was chosen, in order to be able to use the same generator.
References 17
1. Link MS, Hellkamp AS, Estes NAM 3rd, et al. High incidence of pacemaker syndrome in patients with sinus node
dysfunction treated with ventricular-based pacing in the Mode Selection Trial (MOST). J Am Coll Cardiol 2004;
43: 2066–71.
2. Lamas GA, Lee KL, Sweeney MO, et al. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction.
N Engl J Med 2002; 346: 1854–62.
3. Lamas GA, Orav EJ, Stambler BS, et al. Quality of life and clinical outcomes in elderly patients treated with
ventricular pacing as compared with dual-chamber pacing. Pacemaker Selection in the Elderly Investigators.
N Engl J Med 1998; 338: 1097–104.
4. Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC guidelines on cardiac pacing and cardiac
resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European
Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA).
Europace 2013; 15: 1070–118.
5. Nielsen JC, Thomsen PE, Højberg S, et al. A comparison of single-lead atrial pacing with dual-chamber pacing in
sick sinus syndrome. Eur Heart J 2011; 32: 686–96.
A 72-year-old patient was admitted for stroke. He had been implanted with a dual-chamber
pacemaker 2 months ago for sinus dysfunction. Interrogation of the pacemaker was nor-
mal and did not disclose any atrial arrhythmias that may have explained the neurological
event. A chest X-ray was performed and is shown in Figure 5.1.
Question
Figure 5.1 Postero-anterior (a) and lateral (b) chest X-rays
CASE 5
19
(a) (b)
Where is the ventricular lead positioned?

A RV apex
B Coronary sinus (CS) tributary
C Right ventricle (RV) with situs inversus
D Left ventricle via a patent foramen ovale
Answer
D Left ventricle via a patent foramen ovale
Figure 5.2 Annotated postero-anterior (a) and lateral (b) chest X-rays (c) transthoracic echocardiogram
20 (a) ➊ (b) (c)
An echocardiogram confirmed that the lead was positioned via a patent foramen ovale in the left ventricle
(Figure 5.2 c, arrows).
➊ An apical RV lead would be expected to be situated in a lower position than this.

➋ The lateral chest X-ray shows the ventricular lead to be posterior, whereas an RV lead would be anteriorly
located (Figure 5.3) in a patient implanted with an apical RV lead. An endocardial left ventricular (LV)
lead does not course at the border of the cardiac silhouette, contrary to a CS lead which is epicardial
(Figure 5.3).
Comments
Recognizing ventricular lead position Figure 5.3 Lateral chest X-ray of a patient with an apical RV lead and a CS lead
(a). Morphologies of paced QRS complexes at different sites are shown in (b)
This case illustrates the utility of performing multiple fluoroscopic views
at implantation to rule out malposition of pacing leads. The patient was
anticoagulated, and, because the lead had been very recently implanted, it
was repositioned in the RV after a transoesophageal echocardiogram ruled
out residual thrombi.
LV capture results in a negative QRS in lead I (which may be observed
occasionally also with RV pacing)1 and an RBBB QRS morphology. The
CASE 5
differential diagnosis of an RBBB pattern of a paced QRS complex is:
1 LV endocardial pacing via a patent foramen ovale, an atrial/ventricular

septal defect, or an arterial puncture
2 LV epicardial pacing via a CS tributary (a) 21
3 ventricular perforation
RV apex
4 ventricular fusion/pseudofusion in a patient with pre-existing RBBB and
intrinsic AV conduction
5 ‘pseudo-RBBB’ pattern due to misplacement of V1 and V2 electrodes
above the 4th intercostal space. This is probably the commonest cause of
an RBBB-like pattern of the paced QRS complex.
CS (post-lateral vein)
Reference
1. Burri H, Park C, Zimmermann M, et al. Utility of the surface electrocardiogram for
confirming right ventricular septal pacing: validation using electroanatomical mapping.
Europace 2011; 13: 82–6.
LV (endocardial)
(b)
An atrial threshold test was performed in a patient with sinus node dysfunction and nor-
mal AV conduction. The test was performed by pacing in the AAI mode and decrement-
ing the atrial voltage amplitude at a pulse duration of 0.4ms.
The real-time EGM tracing recorded during the threshold test is shown in Figure 6.1.
Question
Figure 6.1 Real-time EGM recorded during the atrial threshold test
RV
CASE 6
1.0V 1.0V 1.0V 0.9V 0.9V 0.9V 0.8V 0.8V 0.8V 0.7V
23
What is the atrial capture threshold amplitude?

A 1.0V
B 0.9V
C 0.8V
D 0.7V
Answer
A 1.0V
Figure 6.2 Annotated real-time EGM recorded during the atrial threshold test
A ➌ ➋ ➋ ➋ ➋
RV
➊
24 1.0V 1.0V 1.0V 0.9V 0.9V 0.9V 0.8V

➍
0.8V 0.8V
➎
0.7V
Capture threshold refers to the output which results in consistent capture (Figure 6.2).
➊ The absence of a conducted R-wave suggests the loss of atrial capture for the 3rd paced beat at 0.9V (the
previous beats show consistent AV conduction).
➋ Sinus rhythm resumes after loss of atrial capture.

➌ Note that, in this case, the local atrial EGMs, with and without capture, look similar (apart from the
presence or absence of the far-field R-wave (FFRW)).
➍ The AS event resets the A–A timing cycle.

➎ The AS event falls in the refractory period (depicted by [AS]) and therefore does not reset the A–A timing cycle.
Comments
Atrial capture threshold testing 3 evaluation of the atrial EGM for a change in near-field morphology (depicted by * in
Figure 6.3). However, this may not always be reliable (compare with Figures 6.2 and 6.4).
Techniques for performing atrial threshold testing are: 4 in case of 1:1 retrograde VA conduction, atrial threshold testing with DDD pacing will
1 evaluation of the surface ECG P-wave (which is, however, not always well visualized) yield a retrograde P-wave after loss of atrial capture (Figure 6.4).
2 testing in the AAI or AOO mode in case of 1:1 AV conduction, as in this example 5 Pace slightly faster than the sinus rate, and look for intrinsic atrial rhythm at loss of atrial
capture (such as in the present case example). This will, however, give a slightly inaccurate
result if the sinus node recovery time is long.
Figure 6.3 Change in atrial EGM morphology with loss of capture
CASE 6
A * * * *
25
Figure 6.4 Atrial threshold test performed with DDD pacing, showing 1:1 retrograde VA conduction (*) at loss of atrial
capture (LOC). Note that, in this case, the atrial EGM looks identical, with or without atrial capture (circles)
* * * *
A
LOC
1.2V 1.2V 1.1V 1.1V 1.1V 0.9V 0.9V 0.9V 0.8V

A 56-year-old patient was implanted with a dual-chamber pacemaker for complete heart
block. He complained of dyspnoea upon exertion. Device settings are listed in Table 7.1.
Device interrogation during a bicycle exercise test is shown in Figure 7.1.
Table 7.1 Device settings

Pacing mode DDD
Baseline rate 60bpm
Upper tracking rate (UTR) 120bpm
Paced AV delay (adaptive) 170-120ms
AV delay sense offset –30ms
PVARP 250ms
Question
Figure 7.1 Real-time EGM recorded during a bicycle exercise test
A
V
CASE 7
A
27
Courtesy of Mr T Bruggemann
V
25 mm/s 25 mm/s
What can be observed?

A Wenckebach behaviour
B Atrial undersensing
C Mode switch
D Ventricular non-capture
Answer
A Wenckebach behaviour
Figure 7.2 Annotated real-time EGM recorded during a bicycle exercise test
➊ ➊ ➊ ➊
A
V
➋ ➌ ➋ ➌ ➋ ➌ ➋ ➌
28
V
25 mm/s 25 mm/s
A 4:3 Wenckebach response can be observed in Figure 7.2. ➌ . . . the AS event falls into the PVARP, resulting in a refractory AS event. This event does
not trigger an AVI, resulting in a non-tracked P-wave and Wenckebach behaviour.
➊ The sinus rate is about 140bpm (P–P interval of 425ms), which exceeds the
programmed UTR of 120bpm.
➋ Progressive lengthening of the AVI can be observed. This occurs until . . .

Comments
Pacemaker upper rate behaviour
Wenckebach response occurs when the atrial rate exceeds the pro- the AVI+PVARP), 2:1 response occurs (the rate at which this is Â�observed
grammed UTR, and up to the functional upper limit of 1:1 tracking can be calculated by 60,000/TARP). This is why the UTR should Â�always be
(Figure 7.3). Wenckebach response occurs progressively (e.g. with a 5:4, programmed below the 2:1 response rate (the dotted red line in Figure 7.3
then 4:3 then 3:2 response), and is similar to AV Wenckebach block shows rate behaviour in case the UTR is programmed up to the upper
other than the fact that the RR intervals do not progressively decrease limit of 1:1 tracking). If modeswitch is enabled, the device reverts to
(Figure 7.4). Ventricular pacing is delivered constantly at the upper rate a non-tracking mode with ventricular pacing at the lower rate (LR) as
interval (URI), but the average heart rate decreases step-wise as the ratio shown in Figure 7.3, or a sensor-driven rate. The fall in heart rate to the
CASE 7
of non-tracked atrial events (i.e. pauses) increases. Wenckebach response LR at onset of modeswitch is usually gradual thanks to rate-smoothing
therefore avoids a sudden drop in heart rate once the programmed UTR algorithms present in most Â�modern devices. If modeswitch is not enabled,
has been reached. Once the atrial rate exceeds the TARP interval (which is a 3:1, 4:1 etc. response will occur as atrial rate increases (Figure 7.4).
Figure 7.3â•‡ Upper rate behaviour Figure 7.4â•‡ Diagram of tracking response at different atrial rates
The device is programmed with a fixed AVI and PVARP. Note the prolongation of the 29
AVI to avoid violating the programmed maximum ventricular pacing rate (defined
60,000/ by the URI)
TARP
1:1
UTR
Ventricular rate
Ventricular pacing
6:5
1:1 2:1
4:3
LR
Wenckebach Mode- 2:1
window switch
2:1
LR UTR 60,000/TARP 2:1

Atrial rate
3:1
AVI AS AR
PVARP
URI
VP
A 72-year-old patient with permanent AF and bradycardia had a single-chamber pace-
maker implanted. The device was programmed to VVIR 60–120bpm. The rate response
parameters were modified at follow-up, due to persistent breathlessness. She presented
again, due to breathlessness and palpitations. Her rate histograms are shown in Figure 8.1.
Question
Figure 8.1 Ventricular rate histogram
40
Ventricle
Paced
Sensed
%
20
CASE 8
0
<40 130
bpm
230 330 >380
31
What is the problem with the sensor settings?

A No problem, the rate histogram is satisfactory
B The sensor threshold is too low, and the slope too steep
C The sensor threshold is too high, and the slope too steep
D The sensor threshold is too high, and the slope is not steep enough
Answer
B The sensor threshold is too low, and the slope too steep
Figure 8.2 Annotated ventricular rate histogram
40
Ventricle
Paced
➊ Sensed
%
20
32 0
<40 130 230 330 >380
bpm
➊ In Figure 8.2, the rate histogram shows a large proportion of sensor-driven events, i.e. at a rate above the
baseline (resting) rate of 60bpm. This proportion is too high for a patient of this age, implying that the sensor
threshold is too low (i.e. too sensitive). The profile of the histogram shows an increasing proportion of events
at an increasing heart rate, indicating that the sensor slope is too steep.
Comments
Rate response Figure 8.4 Example of sensor threshold programmed too
high (i.e. not sensitive enough)
Basic parameters of sensor settings include the threshold and slope, the functions of
which are displayed in Figure 8.3.
The threshold sensitivity setting determines the activity level required to trigger rate >99
response. The programmed slope will then determine the increase in heart rate for a given
Counts (%)
level of activity. Figure 8.4 shows a case that required lowering the threshold (i.e. making
it more sensitive).
CASE 8
It is usually better to change one single parameter at a time, unless the rate histograms
clearly indicate otherwise, or the device has a modelling feature that allows a simulating 0 <1 <1 0 0 0 0 0
rate response at different settings for recorded sensor data. Patient history is of course 45 60 75 90 105 120 135 150 165 187
essential, as modifying sensor settings is only warranted in case of symptoms. Frequency (min–1)
33
Figure 8.3 Rate response parameters
Threshold Slope
Threshold crossing
Max. sensor rate 5 4
3
Activity
Rate
Threshold
Time Activity
An 80-year-old woman implanted with a VDD pacemaker for complete AV block had
recently undergone a generator replacement. She reported malaise, while carrying her
shopping. The device settings are shown in Table 9.1.

Mode VDD
Baseline rate 50bpm
UTR 120bpm
Atrial sensing (bipolar) 0.2mV
Ventricular sensing (unipolar) 2.5mV
VP (bipolar) 2.5V at 0.35ms
AV delay (adaptive) 80–125ms
Post-ventricular atrial blanking (PVAB) 150ms
Upon device interrogation, multiple ventricular high-rate episodes were retrieved from
the device memory, one of which (lasting 10s) is shown in Figure 9.1.
Question
Figure 9.1 Ventricular high-rate episode retrieved from the device memory (the atrial and
ventricular EGMs are displayed on a single channel)
15 mm/s
CASE 9
35
What is the cause of the patient’s symptoms?

A Ventricular tachycardia (VT)
B AF
C Ventricular non-capture
D Ventricular oversensing
Answer
Figure 9.2 Annotated ventricular high-rate episode retrieved from the device memory
15 mm/s
➊ ➊
36
➌ ➌ ➍ ➍ ➌ ➌ ➌
➎ ➎ ➎
➋ ➋ ➋
➊ High-rate signals can be observed on the EGM channel (Figure 9.2). ➎ These AS events fall in the PVARP and are depicted by a short bar (the event sensed
outside the PVARP are indicated by a long bar).
➋ The markers indicate that the high-rate signals are sensed by the ventricular channel
only. The signals correspond to pectoral myopotentials, resulting from the unipolar sensing ↓ Note that there are only few AS events during ventricular oversensing. This is due to the
configuration (that had been programmed by mistake at generator replacement). This P-waves falling in the PVAB period or possibly also due to atrial undersensing (which is
results in ventricular oversensing which inhibits pacing. relatively frequent with VDD devices due to the floating atrial dipole). The atrial signals are
hidden by the myopotentials, but their likely timing is indicated by the interpolated arrows.
➌ These EGM signals correspond to ventricular capture.
➍ These EGM signals correspond to a ventricular escape rhythm at about 30bpm.
Comments
Pectoral myopotential oversensing
Pectoral myopotential oversensing resulted from the unipolar sensing configuration and
was confirmed by asking the patient to press her hands together (prayer manoeuvre;
Figure 9.3), which reproduced the myopotential artefacts on the real-time EGM.
Ventricular oversensing is a potentially lethal condition in pacemaker-dependent patients
(as it may lead to asystole). The problem was corrected in this case by setting the ventricular
sensing to a bipolar configuration.
CASE 9
Figure 9.3 Prayer manoeuvre to reproduce pectoral muscle oversensing
37
A 72-year-old patient with complete AV block was followed by remote monitoring. Table 10.1 Device settings
The device settings are shown in Table 10.1, and the atrial rate histogram is shown in
Pacing mode DDDR
Figure 10.1. High-rate atrial episodes were recorded, and the EGMs of two such episodes
are shown in Figure 10.2. Lower rate 50bpm
Upper rate 130bpm
Figure 10.1 Atrial rate histogram. The atrium was paced in 4%, and the ventricle in 100%, of Atrial output (bipolar) [email protected]
the time Ventricular output (bipolar) [email protected]
30 Atrial sensitivity (bipolar) 0.2mV
Ventricular sensitivity (bipolar) 2.5mV
Atrium Paced AV delay 180–140ms
Paced Sense compensation –45ms

Detected
%
15 PVAB after ventricular sense 100ms
PVAB after ventricular pace 150ms
PVARP 325ms
Post-PVC PVARP extension 400ms
0 Ventricular blanking after atrial pace 30ms

<40 130 230 330 >380
bpm Ventricular refractory period (VRP) 250ms
Question
Figure 10.2 Atrial high-rate episode EGMs retrieved from the device memory
CASE 10
39
What is the cause of the atrial high-rate episodes?

A Atrial bigeminy
B Atrial tachycardia
C AV crosstalk
D Far-field R-wave (FFRW) oversensing
Answer
D Far-field R-wave (FFRW) oversensing
Figure 10.3 Annotated atrial high-rate episode EGMs retrieved from the device memory
➌ ➌
➊ ➊
➋ ➋
40
This is an example of FFRW oversensing that may cause erroneous diagnosis of atrial high- ➋ The smaller signals are FFRWs that occur at just under 160ms after VP and fall within
rate episodes (Figure 10.3). the PVARP (but after atrial blanking of 150ms).
➊ The sharp signals are the near-field atrial EGM. Note the cyclic variation in amplitude, ➌ Note the variable AVIs, due to the device function in a non-tracking (DDIR) mode as a
due to changes in lead orientation as a result of respiration. result of inappropriate mode switch caused by the FFRW oversensing.
Comments
Far-field R-wave oversensing Figure 10.4 FFRW oversensing occurring before sensing by the RV lead
A number of factors may favour FFRW oversensing: ➊ ➌

◆ proximity of the atrial lead to the ventricle
◆ unipolar sensing configuration
◆ programming a high sensitivity
◆ short PVAB
◆ inter-electrode spacing of the lead (with closer spacing,
CASE 10
resulting in less FFRW oversensing).
It also depends upon the orientation of the vector of the
QRS complex, with respect to the electrodes of the atrial
lead (therefore, amplitudes of the FFRW of paced and ➋
sensed QRS complexes may differ). FFRW oversensing
may cause inappropriate mode switch, as in this example. 41
The easiest way to correct the problem is to lengthen the
PVAB, as was done in this case, from 150ms to 180ms. A
more difficult issue to deal with is sensing of FFRW when
it occurs before ventricular sensing (Figure 10.4). This
occurs in about 25% of patients,1 especially in the setting
of RBBB where the depolarization wavefront is sensed late
into the QRS complex by the RV lead.
Reference
1. Lewalter T, Tuininga Y, Frohlig G, et al. Morphology-enhanced atrial
event classification improves sensing in pacemakers. Pacing Clin Electro-
physiol 2007; 30: 1455–63. ➊ The FFRW is being sensed before the VS event. It is labelled as a refractory event, as it falls within the AVI.
➋ The FFRW is observed to be of low amplitude.
➌ FFRW oversensing is intermittent. Changing the sensitivity level from 0.1mV to 0.4mV corrected the
problem (but changing the PVAB would not have changed anything).
A 76-year-old woman with ischaemic heart disease and 45% LVEF, implanted with a
dual-chamber pacemaker for sinus dysfunction, was admitted with decompensated heart
failure. The pacemaker was interrogated, and the real-time EGM is shown in Figure 11.1.
The device settings are shown in Table 11.1.

Mode DDDR
Baseline rate 60bpm
UTR 130bpm
Paced AV delay 300ms
Sense compensation –20ms
AP output (bipolar) 2.5V/0.4ms
Ventricular output (bipolar) 2.5V/0.4ms
Atrial sensitivity (bipolar) 0.3mV
PVARP Auto
Question
Figure 11.1 Real-time EGM at device interrogation
Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars
Vp Vp Vp Vp Vp Vp Vp Vp Vp Vp Vp Vp Vp
CASE 11
43
What is the most likely reason for the pacing rate?

A Runaway pacemaker
B Inactivated mode switch
C Rate-adaptive pacing
D 2:1 locked-in atrial flutter
Answer
B Inactivation of mode switch
Figure 11.2 Annotated real-time EGM at device interrogation

Ars As Ars
➋ ➌
As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars As Ars
Vp Vp Vp Vp Vp Vp Vp Vp Vp Vp Vp Vp Vp
44
➊
In Figure 11.2, The pacemaker is pacing close to the UTR, due to inactivation of mode switch. ➌ This atrial event is classified as refractory (ARS), as it falls within the AVI and does not
reset the AV timer. The fact that all atrial events are sensed indicates that this is not 2:1
➊ The atrial EGM shows flutter at a cycle length of 230ms (260bpm).
locked-in atrial flutter (where every 2nd atrial event falls into the PVAB period and is not
➋ The AS events (falling outside the PVARP) triggers an AVI with VP. The AVIs had sensed).
been programmed long, in order to favour intrinsic AV conduction.
Comment
Mode switch DDI(R) or VDI(R), when the atrial rate crosses a predefined threshold (e.g. 175bpm) for a
given period of time or a specific number of beats.
Mode switch should be routinely activated in all pacemakers and ICDs, even if the patients
In this patient, mode switch had been unintentionally deactivated, leading to the tracking
do not have a history of atrial arrhythmias, as they are prevalent in this population. The
of atrial flutter and rapid VP with decompensated heart failure. Mode switch was
mode switch function reprogrammes the pacing mode into a non-tracking mode, i.e.
reactivated, with resumption of intrinsic ventricular rhythm (Figure 11.3).
Figure 11.3 Real-time EGM after reactivation of mode switch
Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars Ars
CASE 11
Vs Vs Vs Vs Vs Vs Vs
Vs Vs
45
A Holter recording was performed due to dizziness in a patient with a dual-chamber pace-
maker, implanted for symptomatic paroxysmal AV block. The device settings are shown in
Table 12.1.

Pacing mode DDD
Baseline rate 50bpm
UTR 130bpm
Sensed AV delay 170ms

Question
Figure 12.1 Holter recording
CASE 12
47
What do you observe in Figure 12.1?

A Intermittent atrial undersensing
B AV hysteresis
C Atrial non-capture
D ADI pacing mode
Answer
B AV hysteresis
Figure 12.2 Annotated Holter recording

➊ ➋
48
➌ ➌
Dizziness was attributed to low blood pressure and was unrelated to the phenomenon seen The P-waves are not always visible, as they fall in the preceding T-wave, but are tracked by
here in Figure 12.2, which is normal pacemaker behaviour. the pacemaker.
➊ The 1st five beats show sinus rhythm with intrinsic AV conduction, with first-degree ➌ The sensed AVI reverts to the programmed value of 170ms, due to the absence of AV
AV block and bundle branch block. conduction.
➋ The following four beats show sinus rhythm with ventricular pacing and an extended
AVI, due to repetitive AV hysteresis of 200ms (the sensed AV delay amounts to 370ms).
Comments
Atrioventricular hysteresis
The AV hysteresis algorithm is designed to avoid unnecessary ventricular pacing. An AV
delay extension is programmed for a defined number of beats (200ms for four beats in this
example). If ventricular sensing does not occur, the device reverts to the programmed AV
delay for a defined period of time, at the end of which the AV delay is extended again to
test for resumption of intrinsic AV conduction (Figure 12.3; recorded in another patient).
Figure 12.3 AVI extension with resumption of AV conduction
CASE 12
Markers
➊ ➊ ➊ ➊ ➋
49
Distal Uni. V.
Distal Uni. A
➊ The 1st four beats show DDD pacing, with paced and sensed AV delays of 200ms and 170ms, respectively.
➋ An AV delay extension of 200ms is activated, revealing intrinsic AV conduction, perpetuating the AV delay
extension for the following beats.
A patient was implanted with a dual-chamber pacemaker for symptomatic Wenckebach
AV block. A Holter was performed and is shown in Figure 13.1.
Question
CASE 13
51
How can you explain what is observed?

A ADI/DDD switch
B Ventricular non-capture
C Ventricular oversensing
D Both A and C
Answer
A ADI/DDD switch
Figure 13.2 ADI/DDD switch

➊ ➋ ➌
52
The device in Figure 13.2 is switching from an ADI mode to a DDD mode, following ➊ The device is functioning in an ADI mode. AP with intrinsic AV conduction and
repetitive AV block. This is the only option that explains the shortened AVI of the cycle gradually prolonging PR intervals can be observed.
immediately following each non-conducted P-wave. There are no ventricular spikes
that do not result in capture. Ventricular oversensing would result in resetting of the VA
➋ Wenckebach AV block occurs.
interval and change in the A–A timing, and does not explain the shortened AVI after the ➌ A ventricular backup pace is delivered, and the cycle repeats itself again (the shaded
non-conducted P-waves. zone corresponds to an overlap with the following line).
➍ After blocked P-waves have been detected repeatedly, the device switches to a DDD mode.
Comments
The ADI/DDD algorithm
Several device manufacturers have introduced algorithms (with different names) that
minimize ventricular pacing by allowing isolated blocked P-waves to occur intermittently.
The device functions in an ADI(R) mode, until blocked P-waves occur repeatedly,
resulting in a switch to a DDD mode for a specified duration, after which an AV
conduction check occurs.
Algorithms of different companies have slight differences, but all allow pauses to occur,
CASE 13
with long–short sequences. Although they reduce ventricular pacing effectively and are
well tolerated by the majority of patients, it may be better to avoid this algorithm in:
1 patients with permanent complete AV block
2 patients with symptomatic first-degree AV block (as in the present case)
3 pacemaker-dependent patients who do not tolerate slow rates, and
4 in the case of a long QT interval or history of torsades de pointes (due to the
53
pro-arythmic effect of l ong-short sequences in this patients).
A 72-year-old patient was implanted with a dual-chamber pacemaker for sick sinus syn-
drome, programmed with the ADIR/DDDR algorithm. His LVEF was normal. The device
counters indicated 96% AP and 2% VP. He complained of persistent dyspnoea. A real-time
EGM is shown in Figure 14.1. A transthoracic echocardiogram was performed, and the
transmitral Doppler flow is shown in Figure 14.2.
Figure 14.1 Real-time EGM
RV
Question
Figure 14.2 Pulsed-wave (a) and continuous-wave (b) Doppler of transmitral flow
CASE 14
55
(a) (b)
What needs to be done to improve the patient’s symptoms?

A Programme in the DDDR mode
B Programme in the DDIR mode with a long AV delay
C Programme in the AAIR mode
D Implant a biventricular pacemaker
Answer
A Programme in the DDDR mode
Figure 14.3 Annotated pulsed-wave (a) and continuous-wave (b) Doppler of transmitral flow
➌
56
(a) (b)
The EGM showed atrial pacing with intrinsic AV conduction and prolonged first-degree
AV block, resulting in a ‘P on T’ phenomenon (Figure 14.3).
➊ The transmitral pulsed-wave Doppler shows an E-wave, without an A-wave.

➋ This is due to the P-wave occurring during ventricular systole.
➌ The transmitral continuous-wave Doppler shows diastolic mitral regurgitation, due to
the prolonged PR interval (systolic regurgitation is also visible).
Comments
Consequences of ‘P on T’
The ADI/DDD algorithm tolerates very long AVIs, which may, as in this case, lead to
‘P on T’, with atrial contraction occurring during ventricular systole, as in the pacemaker
syndrome (see Case 4). The detrimental haemodynamic effect of RV pacing in the DDD
mode needs to be balanced against improved AV synchrony. In this case, programming
the pacemaker to the DDD mode revealed improved ventricular filling, with the
appearance of an A-wave, as seen in Figure 14.4A. Also, diastolic mitral regurgitation was
eliminated, although it probably was not the main cause of the patient’s symptoms.
CASE 14
Figure 14.4 Transmitral Doppler flow, following programming to the DDD mode. Note the appearance of an A-wave (b) and disappearance of diastolic
mitral regurgitation (b)
57
E A
(a) (b)
A 68-year-old patient was implanted with a DDDR pacemaker for sick sinus syndrome.
He was asymptomatic. At follow-up, the episode retrieved from the device memory is
shown in Figure 15.1. The device settings are shown in Table 15.1.

Mode ADIR/DDDR
Lower rate 50bpm
Upper rate 120bpm
Adaptive AVI 140–80ms
Paced AV offset +65ms
AVB I switch Rest plus exercise
PR long max 350ms (AS–VS) and 450ms (AP–VS)
PR long min 250ms (AS–VS) and 350ms (AP–VS)
Pause max 3s
Atrial ouput (bipolar) [email protected]
Ventricular output (bipolar) [email protected]
PVAB 150ms
Question
Figure 15.1 Stored EGM episode
25 mm/s
EGM A 8
mV 0
CASE 15
–8
EGM V 16
mV 0
–16
59

A AV hysteresis
B ADIR to DDDR mode due to AVB I
C ADIR to DDDR mode due to AVB II
D ADIR to DDDR mode due to pause
Answer
Figure 15.2 Annotated stored EGM episode
25 mm/s
EGM A 8
mV 0
–8
EGM V 16
60 mV 0
–16
➊ ➋
This is an example (Figure 15.2) of the first-degree AV block criterion of this Sorin device
that is occurring during exercise (as the pacing rate is sensor-driven at 92bpm).
➊ The device detects long AP–VS intervals (the cut-offs are programmable and set, in this
case, to >350–450ms, depending on the sensor-driven rate, and can be measured here at
about 400ms).
➋ The AVI then reverts to the programmed value (which is rate-dependent and measured
here at about 160ms).
Comment
Avoiding ‘P on T’ with the ADI(R)/DDD(R) mode
This device has an evolved AV management algorithm that switches from ADI(R) to
DDD(R), based upon three criteria:
1 AV block (two consecutive or 3/12 blocked P waves)
2 ventricular pause (programmable to 2, 3, or 4s)
3 long PR intervals.
In order to avoid unduly long PR intervals that are usually allowed by the ADI(R)/
CASE 15
DDD(R) mode, this device has a first-degree AV block criterion. A maximum PR interval
can be set (200–450ms, with the default value of 350ms and an additional 100ms for
AP–VS intervals, as in this case). If six consecutive cycles have intervals which are greater
than these thresholds, the device switches from the ADI(R) to the DDD(R) mode, in order
to avoid the ‘P on T’ phenomenon observed in Case 14.
61
The same patient, as for Case 15, had an additional episode stored in the device memory
(shown in Figure 16.1). The counters indicated <1% of VP. The device settings are shown
in Table 16.1.

Mode ADIR/DDDR
Lower rate 50bpm
Upper rate 120bpm
Adaptive AVI 140–80ms
Paced AV offset +65ms
AVB I switch Rest plus exercise
PR long max 350ms (AS–VS) and 450ms (AP–VS)
PR long min 250ms (AS–VS) and 350ms (AP–VS)
Pause max 3s
Atrial ouput (bipolar) [email protected]
PVAB 150ms
Question
Figure 16.1 EGM of stored episode
25 mm/s
EGM A 8
mV 0
–8
EGM V 16
CASE 16
mV 0
–16
63

A ADIR to DDDR mode due to pause
C ADIR to DDDR mode due to AVB III
D ADIR to DDDR mode due to ventricular undersensing
Answer
D ADIR to DDDR mode due to ventricular undersensing
Figure 16.2 Annotated EGM of stored episode

25 mm/s
EGM A 8
mV 0
–8
EGM V 16
➊ ➊
mV 0
64 –16
➋
➊ A ventricular event can be observed on the EGM in these two beats but is not sensed by ➋ After 3/12 undersensed R-waves (a 3rd event occurred before the EGM recording), the
the device (Figure 16.2). The scale is shown on the left and confirms the low amplitude of device switches from an ADIR to a DDDR pacing mode, based upon the AVB II criterion.
the ventricular EGM. R-wave undersensing mimics AVB.
Comments
Misdiagnosis of atrioventricular block by ventricular
undersensing
Ventricular undersensing occurred rarely in this patient (few ADIR/DDDR mode
switches were stored in the device memory, with <1% VP), and the histograms, shown
in Figure 16.3, indicated that R-wave amplitude was usually satisfactory. The R-wave
amplitude during device follow-up was measured at 8.2mV, but nevertheless the
sensitivity was increased slightly from 2.0mV to 1.8mV.
CASE 16
Figure 16.3 Histograms of sensing amplitude for conducted R-waves (a) and PVCs (b)
R waves PVC
n = 3 151 825 n = 303
30 30
65
%
15 15
0 0
1.0 2.0 3.0 4.0 5.0 7.0 9.0 11.0 1.0 2.0 3.0 4.0 5.0 7.0 9.0 11.0
(a) mV (b) mV
Recorded during the last 2 months

Detected signal
Undersensing zone
A patient was implanted with a dual-chamber pacemaker for intermittent AV block. An
ECG was recorded at follow-up and is shown in Figure 17.1. The patient was asympto-
matic. Device settings are shown in Table 17.1.

Mode DDD
Lower rate 60bpm
Upper rate 120bpm
Atrial output (unipolar) [email protected]
Ventricular output (unipolar) [email protected]
Paced AVI 200ms
Sensed AVI 180ms

Question
Figure 17.1 ECG recorded at follow-up
CASE 17
67
25 mm/s
Explain the variable AVIs.

A Sense compensation
B Rate-adaptive AVIs
C Crosstalk
D Ventricular safety pacing
Answer
Figure 17.2 Annotated ECG recorded at follow-up
➊ ➊ ➊ ➋ ➋
68
25 mm/s
➊ The 1st three cycles show usual pacemaker behaviour (Figure 17.2).
➋ The 4th and last cycle show atrial undersensing, with an atrial spike occurring after the
P-wave. There is intrinsic AV conduction, with sensing of the conducted QRS shortly after
the atrial spike in the ventricular safety pacing window. This leads to ventricular safety
pacing at the end of the window of 100ms following AP.
Comments
Ventricular safety pacing
Ventricular safety pacing (Figure 17.3) is a feature designed to avoid the ill effect of AV
crosstalk, which is a potentially lethal condition in pacemaker-dependent patients with
complete heart block. After a paced atrial event (and not an AS event), if ventricular
sensing occurs (after the PAVB) within a window of 90–120ms (depending on the
manufacturer), the device delivers ventricular pacing at the end of the window. This
will ensure the absence of asystole, if crosstalk had indeed occurred. In the event of the
ventricular sensing being due to intrinsic AV conduction (which will not occur usually at
CASE 17
such short intervals, unless there is another problem such as atrial undersensing, as in this
example) or due to a VPB, the ventricular spike will fall during the myocardial refractory
period, resulting in pseudofusion, which is harmless.
Figure 17.3 Schematic representation of ventricular safety

pacing due to noise in the ventricular channel (VS) 69
AP
VS
VP
Paced AVI
PAVB Ventricular safety
pacing window
A patient with chronic AF and bradycardia was implanted with a single-chamber pace-
maker. A ventricular high-rate episode was retrieved from the device memory and is

Pacing mode VVIR
Lower rate 55bpm
Upper rate 130bpm
VRP 330ms
Question
Figure 18.1 Ventricular high-rate episode EGM retrieved from the device memory
V EGM
CASE 18
Courtesy of Dr A Menafoglio
Timing
71
Why does the pacemaker continue to pace during the ventricular high-rate episode?
A Noise reversion
B Ventricular rate smoothing
C Ventricular safety pacing
D Ventricular undersensing
Answer
A Noise reversion
Figure 18.2 Annotated ventricular high-rate episode EGM retrieved from the device memory
V EGM
➋ ➋ ➌ ➌
Courtesy of Dr A Menafoglio
Timing
72 ➊
The EGM in Figure 18.2 shows non-sustained VT with asynchronous ventricular pacing. ➋ Repeated SR events trigger the noise reversion mode, resulting in asynchronous
ventricular pacing at the baseline rate (55bpm).
➊ All sensed ventricular events with a cycle length shorter than 330ms fall within the
VRP and are classified as sensed refractory (SR) events. ➌ Cycles that are longer than 330ms are classified as sensed events (S) and interrupt the
noise reversion mode.
Comments
Ventricular noise reversion
This is a safety feature that is activated in case of repeated detection of ventricular
refractory events or very high-rate atrial events, which may be either tachyarrhythmia or
noise (e.g. electromagnetic interference). In order to protect the patients from asystole,
in the latter case resulting from inhibition of pacing, the device delivers asynchronous
stimuli at the baseline rate. This may be interpreted erroneously as undersensing when
visualizing spikes on the surface ECG. Asynchronous ventricular pacing on the T-wave
may be proarrhythmic. However, noise is usually of short duration, limiting the risk to the
CASE 18
patient.
73
A 72-year-old patient underwent implantation of a DDD pacemaker for paroxysmal
complete AV block. The patient experienced syncope on the ward 30min after the inter-
vention. The rhythm strip during the syncopal event is shown in Figure 19.1. The device
settings are shown in Table 19.1.

Pacing mode DDD
Lower rate 60bpm
Upper rate 120bpm
Atrial output (bipolar) [email protected]
Sense compensation 40ms
PVARP Auto
Question
Figure 19.1 Rhythm strip recorded on the ward during syncope
CASE 19
75
What is the problem?

A Atrial lead dislodged to the ventricle
B Ventricular lead dislodged to the atrium
C Atrial/ventricular lead switch on the header
Answer
C Atrial/ventricular lead switch on the header
Figure 19.2 Annotated rhythm strip recorded on the ward during syncope
➊ ➌
➋
76
➊ The 1st spike, delivered by the atrial channel, entrains the ventricle (Figure 19.2). This P-wave sensed in the ventricular channel will trigger a VA interval, before the end of which
may only result from A or C. a new ventricular sensed event will occur due to the next P-wave).
➋ Ventricular pacing is being inhibited by the P-waves, ruling out B (there needs to be ➌ Inhibition of ventricular pacing by the P-waves is intermittent (and absent here), as the
a lead in the atrium). The P-waves are sensed in the ventricular channel at a rate that is sensitivity setting of the ventricular channel is similar to the amplitude of the P-waves.
faster than the pacing rate, thereby repeatedly inhibiting pacing in both channels (i.e. each
Comments
Accidental atrial/ventricular lead switch
Atrial and ventricular switch on the header is a potentially lethal mistake that may occur,
even to experienced implanters during a moment of distraction (as it did to the cardiac
surgeon who performed this intervention). Operators often leave the atrial and ventricular
crocodile clips fastened to the respective leads after testing and until insertion into the
header, in order to avoid having to identify the leads by their serial numbers. A useful
habit is to check always the rhythm monitor as soon as the leads are connected, in order to
verify proper device function (this will, however, not be useful if the patient is in normal
CASE 19
sinus rhythm). The advent of pacemakers and implantable cardioverter–defibrillators
(ICDs) equipped with wireless telemetry also helps identify this issue per-operatively.
77
A patient implanted with a dual-chamber pacemaker complained of palpitations. During
the atrial threshold test performed in the DDD mode, a tachycardia was triggered that
reproduced the symptoms and is shown in Figure 20.1. The device settings are shown in
Table 20.1.

Mode DDDR
Lower rate 60bpm
UTR 140bpm
Sensed AVI 210ms
Paced AVI 250ms
PVAB 150ms
PVARP 150ms
Question
Figure 20.1 EGM recording during the atrial threshold test
CASE 20
79
What is the mechanism of the tachycardia?
A AV node re-entrant tachycardia (AVNRT)
B Endless loop tachycardia
C AV re-entrant tachycardia (AVRT)
D Atrial tachycardia
Answer
B Endless loop tachycardia
Figure 20.2 Annotated EGM recording during the atrial threshold test
➋ ➌ ➌ ➌ ➌ ➌ ➌ ➌ ➌
80 ➊
The 1st four atrial paced events (Figure 20.2) capture the atrium, with intrinsic AV ➌ Ventricular capture is followed by retrograde conduction, visible on the atrial channel
conduction. and sensed by the device, as it falls outside the PVARP of 150ms. The 1st event is annotated
on the marker channel as ‘PC’ (premature contraction), and the following events as ‘TS’
➊ This atrial paced event results in loss of capture, that is visible on lead I as absence of
(tachycardia sense). These AS events trigger an AVI of 210ms (corresponding to the sensed
a P-wave (a low-amplitude P-wave is visible in the previous cycles). Ventricular pacing
AVI), at the end of which ventricular pacing occurs, resulting again in retrograde VA
occurs at the end of the paced AVI of 250ms.
conduction and perpetuating endless loop tachycardia.
➋ The atrial EGM has a similar morphology, with or without atrial capture in this case,
and is not very useful for determining the threshold here.
Comments
Endless loop tachycardia
Endless loop tachycardia is one form of pacemaker-mediated tachycardia. 3 atrial oversensing (initiating VP that is not preceded by a true atrial
An easy way of testing whether this may be an issue with current settings event, which, in e ssence, is similar to a VPB)
in a device is to programme subthreshold atrial pacing output (or to 4 atrial undersensing (with AP and non-capture shortly after the intrinsic
perform an atrial threshold test, as in this example, although, in some P-wave in a patient with AV block, which equates to a long AVI)
devices, refractory periods are altered during threshold tests). 5 atrial premature beat falling outside the PVARP (with AVI extension
due to the UTR, which also equates to a long AVI).
It requires:
CASE 20
1 a dual-chamber device set in a tracking mode (DDD or VDD) with It may be terminated by:
ventricular capture and sensing of retrograde P-waves 1 magnet application (e.g. with initiation of device interrogation)
2 the presence of VA conduction 2 retrograde block: spontaneous, drugs (e.g. adenosine) or carotid sinus
3 a retrograde conduction interval greater than PVARP. massage
3 undersensing of the retrograde P-wave
It is favoured by: 81
4 ventricular non-capture
1 a short PVARP (more likely to have a retrograde P-wave falling outside 5 atrial premature beat falling in the PVARP (which is therefore not
the PVARP) tracked and results in a refractory atrium with retrograde block)
2 slow retrograde conduction (more likely to have a retrograde P-wave 6 VPB (resulting in retrograde block or resetting of the timing cycles)
falling outside the PVARP) 7 pacemaker algorithms: PVARP extension (Medtronic, Biotronik, Boston
3 high atrial sensitivity (more likely to sense retrograde P-waves) Scientific) or withholding ventricular pacing (St-Jude Medical).
4 low safety margin for atrial capture (leading to atrial non-capture)
5 long programmed AVIs in patients with AV block (this allows the con- It may be prevented by:
duction tissue to recover from the preceding event and be depolarized 1 post-PVC PVARP extension algorithm
by retrograde conduction) 2 atrial pace on PVC algorithm (St-Jude Medical)
6 VDD programming with a sinus rate slower than the baseline rate. 3 undersensing of retrograde P-waves (adjust sensitivity levels)
4 avoiding programming long AVIs in patients with AV block.
It may be initiated by:
1 atrial non-capture (as in this example)
2 VPBs (the most frequent trigger)
A dual-chamber pacemaker was implanted in a patient with sinus node dysfunction. The
EGM recorded on the pre-discharge visit is shown in Figure 21.1. The device settings are
shown in Table 21.1.
Table 21.1â•‡ Device settings

Pacing mode DDDR
Lower rate 60bpm
Upper rate 120bpm

Question
II
CASE 21
Courtesy of Dr M Anelli-Monti
A EGM 83
What is your diagnosis?

A Normal device function
B A/V switch on the header
C Atrial lead dislodged to the ventricle
D Ventricular lead dislodgement
Answer
C Atrial lead dislodged to the ventricle
Figure 21.2 Annotated real-time EGM
II
➍ ➋ ➋ ➋ ➋
➌ ➊ ➊ ➌ ➌ ➌ ➌
84
A EGM ➎ ➎
A number of different elements can be observed in this example (Figure 21.2). ➍ This cycle shows ventricular pseudofusion due to intrinsic AV conduction. Note
that the EGM morphology on the A channel (recording ventricular activity) is different,
➊ Atrial sensing occurs simultaneously with the QRS complex, and none of the P-waves
compared to the cycles with sensed event (even though the surface QRS is identical), due
of the tracing are sensed. Note that ventricular sensing occurs just after ‘atrial’ sensing and
to differences in filter settings with sensed and paced events.
is also simultaneous with the QRS complex. This rules out A/V lead switch.
➎ Varying degrees of ventricular fusion occur during the paced cycles, as can be
➋ AP results in ventricular capture.
appreciated by the slightly different EGM morphology and deeper S-waves of the surface
➌ The marker channel annotation indicates ventricular safety pacing. This occurs due to a QRS of these two cycles (with more contribution of intrinsic conduction, compared to the
VS event being detected in the safety pacing window of 110ms following atrial pacing. Note two cycles in between).
that no ventricular safety pacing occurs in ➊, due to the absence of this feature following
AS events.
Comments
Atrial lead dislodgement
A chest X-ray was performed and confirmed dislodgement of the atrial lead into the
ventricle, as shown in Figure 21.3.
The main differential diagnosis in this case is A/V switch on the header (see Case 19)
where atrial sensed and paced events occur simultaneously with the QRS complex.
However, in this setting, ventricular safety pacing does not occur, as VA conduction takes
longer than the duration of the ventricular safety pacing window, and VS events occur
CASE 21
simultaneously with the P-wave (whereas P-waves are never detected in cases where the
atrial lead has dislodged).
Figure 21.3 Chest X-ray showing atrial lead

dislodgement into the ventricle
85
A 45-year-old male had syncope while driving. Carotid sinus massage revealed a 7s
sinus pause with malaise. Hypersensitive carotid sinus syndrome was diagnosed, and a
dual-chamber pacemaker was implanted. After implantation, carotid sinus massage was
repeated, and the patient remained asymptomatic. The EGM during the manoeuvre is
shown in Figure 22.1.
Question
Figure 22.1 Real-time EGM recorded during a carotid sinus massage
CASE 22
RV
87

A Rate drop response
B Atrial overdrive pacing
C Managed ventricular pacing
D Hysteresis
Answer
A Rate drop response
Figure 22.2 Annotated real-time EGM recorded during a carotid sinus massage
➊ ➋
A
88 RV
This is an illustration of the rate drop response algorithm (Figure 22.2). ➋ Following the drop in heart rate, the device paces at a predetermined rate (here 90bpm)
for a programmable duration.
➊ The device paces at the lower rate (40bpm) for two cycles.
Comments
Rate drop response
Dual-chamber pacemakers are indicated for treatment of hypersensitive carotid sinus
syndrome.1 Specific algorithms detect a sudden fall in heart rate and respond by pacing
at a higher rate (either at a set rate or at an average of previous P–P intervals, depending
upon the model) for a predetermined duration. In the absence of such an algorithm and
in case of persistence of symptoms with standard settings, the device can be programmed
with a rapid baseline rate (e.g. 80bpm) and a hysteresis rate as low as possible (e.g.
30bpm). An inconvenience of these settings is possible rapid pacing during periods of
CASE 22
increased vagal tone, e.g. during sleep, that may cause symptoms. In a small randomized
study in patients with carotid sinus hypersensitivity, no difference in efficacy was found
between pacing at VVI 40bpm or DDDR 60–120bpm, with or without a rate drop
response algorithm.2
References
89
1. Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC guidelines on cardiac pacing and cardiac resyn-
chronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of
Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace
2013; 15: 1070–118.
2. McLeod CJ, Trusty JM, Jenkins SM, et al. Method of pacing does not affect the recurrence of syncope in carotid
sinus syndrome. Pacing Clin Electrophysiol 2012; 35: 827–33.
A 72-year-old man with symptomatic 2:1 AV block was implanted with a dual-chamber
pacemaker. During follow-up, a real-time EGM was printed and is shown in Figure 23.1.

Pacing mode DDD
Lower rate 60bpm
Upper rate 120bpm
Paced AV delay (adaptive) 150–80ms
PVARP 250ms
Ventricular blanking after atrial pace 40ms
VRP 250ms
Question
II
RV
CASE 23
91
Which of the following is NOT observed?

A Atrial undersensing
B Adaptive AVIs
C Atrial-based timing
D Atrial non-capture
Answer
C Atrial-based timing
II
A ➊ ➊ ➊ ➊ ➊
RV
92 ➋ ➋ ➋
➌ ➌ ➌ ➌ ➌ ➌ ➌
A number of different observations can be made in Figure 23.2. ➋ The AVIs are adaptive (and shorter at higher heart rates). In this device, the AVI is
based upon the A–A interval of the preceding cycle.
➊ Atrial undersensing, which is intermittent and observed for these cycles only (the other
cycles have correctly identified AS events). Atrial sensitivity had been left at the nominal ➌ The device is functioning with ventricular-based timing. The V–V intervals correspond
value of 0.75mV (and needs to be increased by programming to, e.g. 0.15mV). All the to the lower rate of 60bpm (i.e. 1000ms), unless timing is reset by atrial sensing. The AP
undersensed atrial events, except for the first cycle, lead to functional atrial non-capture intervals may however vary. Note that for this cycle, the VA interval has reduced to 844ms
(due to the atrium being refractory). in order to accommodate for the increase in AV interval (151ms) and maintain the VP
interval close to 1000ms. The slight differences (993–1003ms) are due to the cycles of the
device clock.
Comments
Atrial- and ventricular-based timing
Devices function with either atrial-based or ventricular-based timing in the DDD(R)
mode, and knowledge of these timing cycles is important for advanced tracing
interpretation. Many devices function with atrial-based timing, with a temporary
switch to ventricular-based timing rules under certain circumstances (e.g. in the case
of a suddenly shortened AVI, VPB, or mode switching). Basically, the Ax–AP intervals
(AS–AP or AP–AP sequences) are constant with the former, and the Vx–VP intervals
(VS–VP or VP–VP sequences) with the latter. Sensing of intrinsic atrial events and VPBs
CASE 23
will reset the timers in both instances. For atrial-based timing, if intrinsic AV conduction
occurs, the VA interval is only triggered at the end of the programmed AVI (versus
directly after the VS event in case of ventricular-based timing). With ventricular-based
timing, VA intervals are constant, as long as the AVIs are not adaptive and the rate is
not sensor-driven. In the present case, the VA intervals are variable, due to the adaptive
AVIs. Differences in these timing functions are illustrated in Figure 23.3. Note that, with 93
atrial-based timing, the ventricular rate may be slightly below the programmed baseline
rate (due to the difference between the sensed and paced AVI). For the same reason, with
ventricular-based timing, the atrial rate may be slightly higher than the ventricular rate.
Figure 23.3 Atrial- and ventricular-based timing

Atrial-based timing Ventricular-based timing
Constant Ax−AP interval Constant Vx−Vp interval
A−A interval = 1000ms A−A interval = 1000ms A−A interval = 950ms A−A interval = 1000ms
AVD AVD AVD AVD AVD AVD
150 200 200 150 200 200
V−A interval = 850ms V−A interval = 800ms
V−A interval = 800ms V−A interval = 800ms
VV interval = 1050ms VV interval = 1000 ms VV interval = 1000ms VV interval = 1000ms
Ventricular rate = 57bpm Ventricular rate = 60bpm Ventricular rate = 60bpm Ventricular rate = 60bpm
(a) (b)
A patient with complete AV block and equipped with a dual-chamber pacemaker was seen
at follow-up. The lower rate was programmed at 60bpm (see device settings in Table 24.1).
The rate histograms are shown in Figure 24.1.

Pacing mode DDDR
Lower rate 60bpm
Upper rate 120bpm

Question
Figure 24.1 Rate histograms
50 Atrial 50 Ventricular Sensed
Paced
40 40
% Events
% Events
30 30
20 20
10 10
0 0
CASE 24
< 40 60 80 100 120 140 160 180 > < 40 60 80 100 120 140 160 180 >
Rate (min–1) Rate (min–1)
How do you explain AP at below the programmed lower rate (red square)?
A Atrial oversensing
B Atrial undersensing 95
C VPBs
D Hysteresis
Answer
C VPBs
➋
II
96
RV
Pacing occurs at a sensor-driven rate of 968ms. This patient had VPBs, shown by the VS ➋ This results in an AP–AP interval of 148 + 593 + (968–148) = 1561ms (which
events at 100bpm on the rate histogram (Figure 24.1), which resulted in low atrial rates on corresponds to a rate of 38bpm).
the histogram.
The paced events at 50–60bpm on the ventricular histogram in Figure 24.1 may be
➊ A VPB occurs (Figure 24.2), resetting the timers and triggering a VA interval of explained by atrial-based timing of the device, resulting in ventricular pacing at slightly
968 – 148 = 820ms. below the baseline rate (Figure 23.3).
Comments
Premature ventricular contractions
PVCs may result in a number of observations of pacemaker behaviour. These include:
1 atrial pacing at below the lower rate limit (as in this example)
2 non-tracking of P-waves (due to post-PVC PVARP extension)
3 ventricular safety pacing (when the PVC closely follows an atrial paced event)
4 endless loop tachycardia
5 VVT response (in some biventricular devices).
CASE 24
A potential risk of PVCs is FFRW oversensing in the atrial channel, with tracking of the
event and ventricular pacing on the T-wave, which may be arrhythmogenic (Figure 24.3).
Figure 24.3 Consequence of programming the PVARP < VRP

in the case of a VPB falling in the VRP (without resetting the
timers) and tracking of FFRW oversensing, resulting in ventricular 97
pacing on the T-wave (a). This is why the PVARP should always be
programmed at least as long as the VRP (b).
VPB VPB
AS AS (FFRW) AS AR (FFRW)
VS VR VP VS VS
ARP PVARP ARP PVARP ARP PVARP
VRP VRP VRP
(a) (b)
An 82-year-old patient with a history of brady–tachy syndrome and implanted with a
DDD pacemaker presented with palpitations. The presenting ECG (Figure 25.1) showed
AF with an irregular paced ventricular rhythm. The device memory revealed a high bur-
den of atrial arrhythmia (Figure 25.2). The device settings are shown in Table 25.1, and a
real-time EGM is shown in Figure 25.3.
Figure 25.1 Presenting ECG showing irregular paced ventricular rhythm
Figure 25.2 History of atrial arrhythmia retrieved from the device memory Table 25.1 Device settings
Evolution of atrial arrhythmia: 175 days with >4 hours of AT/AF Pacing mode DDDR
Hours per day Lower rate 60bpm
24
Upper rate 130bpm
20
16
12
8
Courtesy of Dr C Vuille
4
0 Sense compensation –30ms
10.06 10.07 09.08 08.09 08.10 07.11 07.12
Date (dd.mm) Atrial rate for mode switch 175bpm
Pacing mode during mode switch DDIR
PVARP 310ms
Question
Case 25
99
Why is the ventricular rhythm irregular?

B Mode switch programmed off
C Rate response
Answer
➋
100
The pacemaker is functioning in a tracking mode (DDD), as AS events are followed by VP ➋ The high-rate AS events are too few and far in between to fulfil the criteria for
at the programmed sensed AV delay of 120ms. Mode switch had been programmed on but triggering mode switch. Intermittent atrial sensing results in variable ventricular
was not activated in this instance, due to atrial undersensing (Figure 25.4). pacing rate.
➊ The atrial EGM shows AF with low-amplitude signals (scale of 0.1mV/mm), resulting
in atrial undersensing.
Comments
Pacemaker-mediated tachycardia due to undersensing of atrial
fibrillation
Figure 25.5 Decrease in detected AF burden due to atrial undersensing ❶
Evolution of atrial arrhythmia: 175 days with >4 hours of AT/AF
Hours per day

24
➊
Case 25
20
16
12
8
101
4
0
10.06 10.07 09.08 08.09 08.10 07.11 07.12
Date (dd.mm)
This example shows how intermittent undersensing of AF can lead to irregular ventricular
pacing. In addition to lack of mode switch, these events will not be stored in the device
memory as atrial high-rate episodes. Atrial EGM amplitude tends to decrease, as AF
becomes chronic. In the present case, atrial undersensing resulted in a decrease in the
daily AF burden since a few days before device interrogation (Figure 25.5).
Atrial sensing had already been programmed to its most sensitive value, so continued
undersensing was unavoidable. Due to the unlikely event of the patient reverting to sinus
rhythm, the device was programmed to the VVIR mode.
A 74-year-old patient implanted with a dual-chamber pacemaker for complete AV block
was admitted to the intensive care unit for sepsis. The baseline rate was increased to
80bpm, but an irregular paced rhythm was observed. The real-time EGM strip is shown in
Figure 26.1. Device settings are shown in Table 26.1.

Pacing mode DDD
Lower rate 80bpm
Upper rate 130bpm
Paced AV delay 180–140ms
Atrial high rate for mode switch 180bpm
Pacing mode for mode switch DDIR
Baseline rate during mode switch 90bpm
PVARP Auto
Question
CASE 26
103
25mm/s
How do you explain the irregular ventricular pacing rate?

B Atrial noise reversion
C Mode switch was not programmed on
D Rate stabilization algorithm
Answer
B Atrial noise reversion
➋ ➌ ➍ ➌ ➌ ➌
104
25mm/s
The atrial EGM (Figure 26.2) shows AF, but the device is functioning in a tracking (DDD) VP–VP intervals that are slightly below the baseline rate (at approximately 800ms/75bpm).
mode, due to atrial noise reversion, which is inhibiting mode switch. This is due to atrial-based timing sequences (Figure 23.3).
➊ The atrial EGM shows low-amplitude signals with a very high frequency that are sensed ➍ When noise ends, the sensed atrial events (that are outside the PVARP) are tracked
due to the high sensitivity setting (0.1mV). to the ventricles, resulting in an irregular ventricular rhythm. The sensed AVIs may be
longer than the programmed value (this is apparent for this cycle and the 1st one), due to
➋ Repeated high-rate sensing in the atrial channel is interpreted by the device as noise.
limitation of the UTR at 130bpm, with Wenckebach response.
➌ Due to the noise (occurring repeatedly in windows of 50ms for this device),
asynchronous pacing occurs at the baseline rate. Note that all cycles with atrial pacing have
Comments
Atrial noise reversion due to oversensing of atrial fibrillation
This example shows how an atrial sensitivity level that is set too high can lead to atrial
oversensing, noise reversion, and absence of mode switch, with tracking of atrial events
that fall outside the noise reversion window. A compromise should be made with
sufficient sensitivity to avoid undersensing of AF, but not too high to result in oversensing
(e.g. FFRW oversensing or sensing of fractionated potentials, as in this case). The problem
was corrected by reducing the sensitivity level from 0.1mV to 0.4mV.
CASE 26
Paradoxical atrial undersensing of AF has been shown to occur in 13% of patients
programmed at the maximum atrial sensitivity level1 and may occur due to either noise
reversion or ‘ringing’. The latter entity corresponds to saturation of the sense amplifier
(usually due to atrial arrhythmias with high-amplitude signals) and can be distinguished
from noise reversion by the absence of sense markers.2
105
References
1. Kolb C, Halbfass P, Zrenner B, Schmitt C. Paradoxical atrial undersensing due to inappropriate atrial noise rever-
sion of atrial fibrillation in dual-chamber pacemakers. J Cardiovasc Electrophysiol 2005; 16: 696–700.
2. Van Gelder BM, Van Den Broek W, Bracke FA, Meijer A. Paradoxical atrial undersensing: noise rate reversion or
amplifier ringing? J Cardiovasc Electrophysiol 2006; 17: 1371–4.
A 75-year-old woman in chronic AF had been implanted with a single-chamber pacemaker
2 years ago. The pacemaker was programmed to VVI 60bpm (see settings in Table 27.1).
Device counters revealed 72% VP, and the rate histogram is shown in Figure 27.1. A real-
time EGM recorded at follow-up is shown on in Figure 27.2.

Pacing mode VVI
Lower rate 60bpm
VRP 250ms
Figure 27.1â•‡ Ventricular rate histogram

50%
Sensed Paced
0%
30 50 70 90 100 130 150 170 190
Rates (min–1)
Question
Case 27
107
How do you explain pacing at above the lower rate?

A Rate regularization algorithm
B Sensor-driven rate
C Runaway pacemaker
D Magnet response
Answer
A Rate regularization algorithm
SECTION 1â•‡ PACEMAKERS
Figure 27.3â•‡ Annotated real-time EGM
➊ ➊ ➊ ➊
108
The EGM (Figure 27.3) shows relatively rapidly conducted AF with irregular heart rates.
➊ Ventricular pacing occurs above the baseline rate of 60bpm (here at about 90bpm),
due to the rate regularization (smoothing) algorithm that aims to reduce irregularities in
the heart rate, and thereby improve the patient’s symptoms.
Comments
Pacing at an unexpectedly fast rate
Rate regularization/rate-smoothing algorithms are designed to avoid sudden changes in
the heart rate, especially in the setting of AF, in order to reduce symptoms of arrhythmias
in patients with single- and dual-chamber devices. The upper rates at which these
algorithms can pace may be programmable but never exceed the UTR or sensor-driven
rate. Symptoms may be improved, but at the expense of an increased percentage of pacing.
Causes for pacing at a faster than expected rate are:
Case 27
1 rate-smoothing/rate regularization algorithms
2 rate drop response
3 AP preference algorithms (designed to override the intrinsic atrial activity, in order
to prevent AF, and seldom used nowadays due to lack of efficacy).1 Repetitive
non-re-entrant ventriculoatrial synchrony (RNRVAS)1, 2 may also be observed with
these algorithms 109
4 automatic threshold measurements
5 inadequately programmed sensor (threshold too low or slope too steep)
6 AF/atrial flutter/atrial tachycardia with inactivated mode switch or intermittent atrial
undersensing (see Cases 11 and 25)
7 endless loop tachycardia
8 exposure to magnetic fields (pacing at magnet rate)
9 runaway pacemaker (device dysfunction).
References
1. Healey JS, Connolly SJ, Gold MR, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012;
366: 120–9.
2. Barold SS, Stroobandt RX, Van Heuverswyn F. Pacemaker repetitive nonreentrant ventriculoatrial synchrony.
Why did automatic mode switching occur? J Electrocardiol 2012; 45: 420–5.
An 82-year-old patient with symptomatic sinus node dysfunction and second-degree AV
block was implanted with a biventricular pacemaker. A Holter was performed, due to
dizziness occurring at the same time every afternoon, with the rhythm during symptoms
shown in Figure 28.1. Device follow-up was normal. The device settings are shown in
Table 28.1.

Pacing mode DDDRV
Lower rate 60bpm
Upper rate 120bpm
RV output (bipolar) [email protected]
LV output (bipolar) [email protected]
RV sensitivity (bipolar) 2.5mV
LV sensitivity (bipolar) 2.5mV
Paced AV delay (fixed) 120ms
PVARP 280ms
VRP 250ms
The ‘V’ of DDDRV corresponds to multisite ventricular pacing, according to the NBG code.
Question
CASE 28
111
What is the most likely reason for the bradycardia?

A T-wave oversensing
B Atrial undersensing
C ADI/DDD mode
D Autosensing algorithm
Answer
D Autosensing algorithm
➊ ➊ ➋
➌ ➌
112
The Holter (Figure 28.2) shows an intrinsic rhythm occurring below the programmed preceding paced ventricular events. There is no evidence of atrial pacing during the pause,
lower pacing rate, due to an algorithm sensing intrinsic atrial and ventricular signal which should have occurred with a device programmed with an ADI/DDD algorithm.
amplitude.
➌ These two cycles are sinus beats with intrinsic AV conduction. The other QRS
➊ The first complex is an AS–VP, followed by an AP–VP event, with a pacing rate of 60bpm. complexes (other than those indicated in ➊) are VPBs.
➋ If the reason for the low pacing rate had been T-wave oversensing, one would expect
to have a VP event at approximately this timepoint, based upon the intervals between the
Comments
Unexpectedly slow pacing rates
Symptoms that occur repeatedly at the same time of the day are suggestive of a device
algorithm. In this case, the bradycardia was caused by the pacemaker functioning
temporarily in a DDI mode at a rate of 30bpm, in order to measure daily intrinsic atrial
and ventricular amplitudes. For this model, this takes place on a daily basis at the time
the device was implanted. Timing of this feature varies between models. Other automatic
algorithms that may cause symptoms are automatic threshold tests or lead impedance tests
(with delivery of unipolar pulses that may cause pectoral twitching).
CASE 28
Heart rates that are lower than the programmed lower rate may occur with:
1 ventricular oversensing (T-wave, myopotentials, lead fracture artefacts, electromagnetic
interference, etc.)*
2 rate hysteresis
3 programmed night heart rate
113
4 specific device algorithms (ADI/DDD mode, autosensing algorithm, automatic
threshold algorithms, non-competitive atrial pacing algorithm, etc.)
5 non-capture (threshold rise, lead or generator dysfunction, programming error, etc.).
* Atrial oversensing will result in mode switch and pacing in VDI(R)/DDI(R) or in triggering of an AV delay with
ventricular pacing (and thus there is no bradycardia).
A patient with a dual-chamber pacemaker had a atrial high-rate episode retrieved from
the device memory. The retrieved EGM is shown in Figure 29.1. The device parameters
are listed in Table 29.1.

Pacing mode DDDR
Lower rate 70bpm
Upper rate 120bpm
Atrial output [email protected] (bipolar)
Ventricular output [email protected] (unipolar)
Atrial sensitivity 0.3mV (bipolar)
Ventricular sensitivity 2.0mV (bipolar)

Question
Figure 29.1 EGM of atrial high-rate episode
Case 29
Courtesy of Mr H Leersen
115
What is happening at ‘LOC’ on the upper tracing?

A Loss of ventricular capture due to a premature beat
B Loss of ventricular capture due to fluctuating threshold
C Loss of atrial capture due to a premature beat
D Loss of atrial capture due to fluctuating threshold
Answer
A Loss of ventricular capture due to a premature beat
Figure 29.2 Annotated EGM of atrial high-rate episode
➍ ➎ ➍ ➎ ➍ ➎ ➍ ➎
➊
➋
➍ ➎ ➍ ➎ ➎ ➎
116
➌
This example (Figure 29.2) illustrates the function of an automatic capture algorithm (of ➍ FFRWs of the paced QRS complexes are visible on the atrial EGM but are sensed as
St-Jude Medical) which detects loss of capture on a beat-to-beat basis. atrial refractory events for the 1st two VP cycles only, as the signals of the two following
VP cycles are too small to be sensed.
➊ A VPB occurs by chance simultaneously with atrial pacing and is not sensed, as it falls in
the PAVB (functional undersensing). ventricular pacing occurs at the end of the 300ms paced ➎ Retrograde P-waves are visible. All these events fall in the PVARP and therefore do
AVI, with absence of capture, as the ventricle is refractory after the premature beat. Loss of not reset the timers for AP. There is no capture of the AP events, as the atrial myocardium
capture (LOC) is detected by the device, which then delivers a backup pace at 5V (VPP). is still refractory, following the retrograde P-waves. Notice that the morphology of the
EGM during AP is different here, compared to before the LOC event (when atrial capture
➋ Ventricular capture of the backup pace is not evident on the EGM but does occur, as
occurred).
there is a FFRW visible on the atrial EGM (arrow).
➌ The AVI is extended by 100ms for a single cycle, in order to avoid pseudofusion
(without an evoked potential) that may have led to erroneous diagnosis of loss of capture of
the previous cycle. Capture of this cycle is confirmed (no VPP sequence), with resumption
thereafter of the programmed paced AVI.
Comments
Automatic ventricular capture algorithms
The automatic capture algorithm evaluates the presence of an evoked response (ER)
potential resulting from myocardial capture and has to differentiate it from the
after-potential resulting from the polarization of the tissue–electrode interface
(which may be present also without ventricular capture (Figure 29.3).
It performs beat-to-beat confirmation of ventricular capture, thus allowing the delivery
of pacing at an amplitude slightly above the capture threshold (e.g. 0.25–0.5V). It is
Case 29
particularly useful to save battery drain in case of a high capture threshold (thus avoiding
having to double the programmed amplitude) and also to maintain capture in case of a
rise in threshold.
This feature is currently available on St-Jude Medical, Boston Scientific, and Biotronik
devices. It should be distinguished from automatic threshold tests, which perform
thresholds on a daily basis (and may use this information to adjust the pacing output) but
117
do not verify beat-to-beat capture.
Figure 29.3 Evoked response and polarization

Capture Loss of capture
ER signal = 11.4mV Polarization = 0.39mV Reproduced with permission from St-Jude

Medical (St Paul, MN, USA)
ER sensitivity = 5.7mV
2:1
CASE 30 Introduction to the case Table 30.1 Device settings
Pacing mode DDDRV
A patient implanted with a CRT-P had the incidental finding of spikes on T-waves during Lower rate 60bpm
a Holter recording, shown by the asterisks in Figure 30.1. During device follow-up,
Upper rate 120bpm
the same phenomenon was observed, with the EGM tracing shown in Figure 30.2.
Additionally, the device settings are mentioned in Table 30.1. Atrial output [email protected]
RV output [email protected]
LV output [email protected]
Atrial sensitivity 0.3mV

(bipolar)
*
RV sensitivity 2.5mV
* (bipolar)
LV sensitivity 2.5mV
(bipolar)

(fixed)
Interventricular 20ms
delay (LV first)
PVAB after 150ms

ventricular pace
PVARP 280ms
Post-PVC PVARP 400ms

extension
Ventricular blanking 40ms

after atrial pace
VRP 250ms
Question
aVF *
CASE 30
RV
119
How do you explain the spike on the T-wave (*)?

A Ventricular safety pacing
B Atrial pacing
C Atrial oversensing
D Functional ventricular undersensing
Answer
D Functional ventricular undersensing
aVF *
A ➋
RV ➌ ➍ ➍ ➊➍ ➍ ➌ ➍ ➌ ➍ ➌ ➍
120
This example (Figure 30.3) shows functional undersensing of a VPB. ➍ The automatic gain on the RV channel decreases the scale during ventricular pacing
explaining why the EGM is flat during these events.
➊ A VPB falls coincidentally with an atrial paced event. Due to the PAVB, the premature
beat is not sensed. ➎ As this device has RV-based timing, the Vx–VP cycles are at the baseline/sensor-driven
rate (1000ms for this cycle). The AP timing at 970ms can be explained by the AVI which is
➋ A ventricular spike follows after the atrial paced event and falls on the T-wave.
longer by 30ms for this cycle, compared to the previous one (due to the specific behaviour
➌ These VPBs are properly sensed. of this device, the details of which are not relevant for the purposes of this book).
Comments
Hazards of programming long atrioventricular intervals
In the case of functional undersensing of a ventricular event in patients with a long
programmed AVI (or AV hysteresis), pacing on the T-wave may result, which may be
proarrhythmic. In patients with a shorter AVI, pacing will occur shortly after the QRS
complex, i.e. during the myocardial refractory period, which is not a problem.
Other potential drawbacks with programming long AVIs may be haemodynamic
compromise due to the ‘P on T’ phenomenon (see Case 14), endless loop tachycardia
CASE 30
(see Case 20), and limitation of the maximum 1:1 tracking rate (which is limited by the
TARP, see Case 7).
121
A patient implanted 6 months ago with a dual-chamber pacemaker for intermittent AV
block presented to his cardiologist for follow-up. The ECGs recorded at presentation and
with magnet application are shown in Figure 31.1. The cardiologist faxed the tracings, but
the device settings are unknown.
Question
Figure 31.1 ECG
Presenting ECG
II
25mm/s
Case 31
Magnet application
II
25mm/s 123
What is the cause for the irregular heart rate on the presenting ECG?
A Atrial non-capture
B Upper rate behaviour
C Atrial bigeminy
D Hysteresis
Answer
Figure 31.2 Annotated ECG

Presenting ECG
II
* * *
➊ ➋ ➌
25mm/s
Magnet application
II
* * * *
124 ➍ ➎
25mm/s
➊ A P-wave following the pacing artefact (*) is not visible, indicating atrial non-capture ➍ During magnet application, the pacing mode is DOO 85bpm. The RP interval is longer
(Figure 31.2). The atrial pacing artefact is of low amplitude (bipolar pacing) and is not than during the presenting rhythm, due to the faster pacing rate with decremental VA
always visible (i.e. before the 3rd and 5th cycles of the presenting ECG). conduction, detaching the P-wave from the T-wave and making it more visible (and speaks
against atrial bigeminy). An atrial pacing artefact is not visible but must be occurring
➋ A P-wave is visible at the end of each 2nd T-wave, corresponding to retrograde
simultaneously with the retrograde P-wave (and is hidden by it).
conduction, following the ventricular paced event. This P-wave is tracked and initiates an
AVI, at the end of which ventricular pacing occurs. ➎ Again, a 2:1 VA block occurs during magnet application.
➌ There is no retrograde P-wave visible at the end of this cycle, indicating a 2:1 retrograde
VA block. The cycles then repeat.
Comments
Utility of magnet application
The magnet application was used as an indication of the battery status (by measuring
the magnet pacing rate) and as a rough indication of capture threshold (by decremental
pacing output of consecutive beats). Magnet application is seldom used nowadays since
the advent of modern devices. It nevertheless still has its uses. These include:
1 indication of the battery status and capture thresholds in case a programmer is not
available
Case 31
2 identification of the device manufacturer (company-specific magnet rates)
3 temporary programming in the DOO or VOO mode during surgery to avoid interference
with electrocautery
4 temporary programming in the DOO or VOO mode to elucidate device malfunction
(as in this case)
5 interruption of pacemaker-mediated tachycardia 125
6 bailout solution in case of A/V switch on the header (see Case 19).
A detailed review of the magnet function of pacemakers and ICDs has been published.1
Reference
1. Jacob S, Panaich SS, Maheshwari R, Haddad JW, Padanilam BJ, John SK. Clinical applications of magnets on
cardiac rhythm management devices. Europace 2011; 13: 1222–30.
A patient implanted with a dual-chamber pacemaker for syncopal complete heart block
presented for routine device follow-up. The tracing in Figure 32.1 was observed during the
ventricular threshold test performed in the DDD mode at 75bpm. The pacemaker settings
are shown in Table 32.1.

Pacing mode DDD
Lower rate 50bpm
Upper rate 130bpm
Atrial output (unipolar) [email protected]
Ventricular output (unipolar) [email protected]
PVAB 100ms
PVARP 275ms
Ventricular blanking 12ms
VRP 250ms
Question
Figure 32.1 EGM during a ventricular threshold test
II
CASE 32
A bipolar
Courtesy of Dr C Israel
127
RV tip–can

A AV crosstalk
B FFRW oversensing
C Far-field P-wave oversensing
D Ventricular non-capture
Answer
A AV crosstalk
Figure 32.2 Annotated EGM during the ventricular threshold test
➊ ➊ ➊ ➋ ➋ ➋ ➋ ➋ ➋
II
➌ ➌ ➌ ➌ ➌ ➌
A bipolar
128
Courtesy of Dr C Israel
RV tip–can
This is an illustration (Figure 32.2) of the potentially lethal condition known as crosstalk. ➋ The ventricular threshold test is being performed in DDD 75bpm with delivery of atrial
pacing and atrial capture.
➊ The 1st three cycles before the onset of the ventricular threshold test are in sinus
rhythm with ventricular pacing and ventricular capture. ➌ A VS event occurs 15–24ms after atrial pacing, inhibiting ventricular pacing,
corresponding to AV crosstalk with ventricular asystole.
Comments
Atrioventricular crosstalk
Crosstalk is a potentially lethal condition in patients with complete heart block. It results
from sensing of the pacing spike in one chamber by a lead implanted in another chamber.
It should be distinguished from far-field oversensing (of the R-wave by the atrial lead and,
more rarely, the P-wave by the ventricular lead), although there is some confusion of these
terms in the medical literature.
Crosstalk is favoured by high pacing amplitude/duration, high sensitivity settings,
CASE 32
and short blanking periods. It is, however, seldom observed in modern devices, due to
protection of the phenomenon by blanking periods (PVAB and PAVB), as well as porous
leads which reduce polarization and generators which discharge polarization currents.
Blanking periods are significantly longer in duration (e.g. 40ms) than the pacing spike
duration (e.g. 0.4ms). This is to avoid oversensing of the after-potential (resulting from
polarization at the electrode–tissue interface after delivery of the pacing spike). 129
During threshold tests, blanking and refractory periods may be temporarily modified in
some devices, exceptionally resulting in crosstalk. In this case, the ventricular threshold
test was successfully performed in the VVI mode.
A patient with sick sinus syndrome was implanted with a dual-chamber pacemaker. A
Holter was performed about a year after implantation, due to chest pain while walking.
A strip from the Holter is shown in Figure 33.1. The device parameters are shown in
Table 33.1. Pacemaker follow-up was normal.

Pacing mode ADIR/DDDR
Lower rate 60bpm
Upper rate 130bpm
Atrial sensitivity (bipolar) Auto mV
Ventricular sensitivity (bipolar) Auto mV
Paced AV delay (fixed) 150ms
Non-competitive AP On
PVAB 180ms
PVARP Auto
VRP 230ms
Question
Case 33
131
Courtesy of Dr S Moiseenko
A Non-competitive atrial pacing
B Ventricular safety pacing
C Accelerated ventricular rhythm
D Automatic RV threshold test
Answer
D Automatic RV threshold test

➊ ➋ ➍
➏ ➏
➍ ➍
132
Courtesy of Dr S Moiseenko
➌ ➌ ➌ ➎
The observed sequence (Figure 33.2) of ventricular pacing is due to the Medtronic ➎ The reconstructed pacing artefacts show closely spaced lines, corresponding to atrial
automatic RV threshold test. pacing, followed immediately by ventricular pacing at the test amplitude, which captures
the ventricle. This sequence is followed by a backup spike at 110ms (at the programmed
➊ Pacing is in the ADI mode at the baseline (rest) rate of 60bpm up to this cycle (the PR
interval is much longer than the programmed paced AVI of 150ms). amplitude and pulse width of 1ms).
➋ The automatic threshold test is initiated by DDD pacing. A prolonged A–A interval, ➏ These two cycles show the same sequence of three support cycles, followed by a test
resulting from the non-competitive atrial pacing algorithm (e.g. because of atrial cycle with a longer AP interval. This time, the test spike (invisible) results in loss of capture,
oversensing), would not result in a switch to DDD pacing. with the backup spike (visible due to the 1ms duration) capturing the ventricle.
All the arrows are of the same length. The blue arrows serve to illustrate prolongation of the A–A
➌ The Holter displays reconstructed pacing artefact signals, showing AV pacing at the
programmed AVI of 150ms for three cycles (ventricular safety pacing would result in an interval when there is sudden shortening of the AVI (due to onset of DDD pacing after the 2nd
interval of 110ms). arrow and due to very short AVI with the test cycle after the 5th arrow). The red arrows show that
the V–V intervals are constant, except for the last arrow which shows sudden prolongation of the
➍ The 4th beat does not have a clearly visible P-wave (although the slightly larger R-wave V–V interval. This device functions with atrial-based timing and switches to what is, in essence,
corresponds, in fact, to summation with the onset of the P-wave). ventricular-based timing for the cycles with suddenly shortened AVIs, and it then reverts to atrial-
based timing for cycles with lengthening of the AVI (see Comments in Case 23, p. 93).
Comments
Recognizing patterns to deduce device algorithms
Many modern pacemakers have a number of automatic tests that verify lead impedance,
sensing and pacing thresholds. The details of all these tests (which differ between
manufacturers) are almost impossible to memorize. Nevertheless, intriguing device
behaviour that is observed to be repetitive most often results from one of these automatic
algorithms. The clinician can then refer to the device technical manual or online
resources (e.g. <http://www.medtronicfeatures.com> for this case), in order to identify the
algorithm.
Case 33
This case also illustrates that devices may temporarily function with different timing rules
under certain circumstances. A full understanding of atrial- and ventricular-based timing
explains why A–A or V–V intervals may suddenly change.
133
A patient with a dual-chamber pacemaker (and an atrial lead in the right atrial append-
age) presented with atrial flutter 2 months after radiofrequency pulmonary vein isolation
for paroxysmal AF. The ECG is shown in Figure 34.1. The atrial cycle length was measured
at 280ms, and a non-invasive electrophysiological study (NIPS), with right atrial pacing
via the pacemaker at a cycle length of 260ms, was performed. The real-time EGM at the
end of the atrial burst is shown in Figure 34.2.
Figure 34.1 The 12-lead ECG at presentation
10 11 12 13 14 15 16 17 18
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Question
Figure 34.2 Real-time EGM during the non-invasive electrophysiological study with overdrive atrial pacing
CASE 34
A
500mm/s
135
Which of the following is most likely to be true regarding the flutter circuit?
A Counterclockwise typical flutter
B Clockwise typical flutter
C Left atrial flutter
D Impossible to say
Answer
C Left atrial flutter
Figure 34.3 Annotated real-time EGM during the non-invasive electrophysiological study with overdrive atrial pacing
➊ ➊ ➊ ➊ ➊ ➊ ➊ ➊
➋
A
136
50mm/s
The surface ECG may suggest typical counterclockwise atrial flutter. However, the post- ➋ The post-pacing interval is long (500ms), and significantly longer than the tachycardia
pacing interval performed by overdrive pacing from the right atrial appendage is very long, cycle length (260ms).
suggesting a left atrial circuit (Figure 34.3).
➊ Atrial tachycardia pacing (TP) captures the right atrium, as is apparent from the atrial
EGM.
Comments
Non-invasive pacing studies with pacemakers (1)
The patient underwent a redo radiofrequency ablation procedure, with localization of the
flutter circuit in the left atrium near the ostium of the left inferior pulmonary vein, which
was successfully ablated. It has been shown that entrainment mapping via pacemakers and
ICDs, with a post-pacing interval that is <100ms longer than the tachycardia cycle length,
allows to distinguish right atrial from left atrial circuits.1 Atrial overdrive pacing may also
be used to reduce atrial flutters by applying bursts, and some devices have algorithms that
do this automatically.
CASE 34
Reference
1. Burri H, Zimmermann M, Sunthorn H, et al. Non-invasive pacing study via pacemakers and implantable cardio-
verter defibrillators for differentiating right from left atrial flutter. Heart Rhythm 2015 (in press).
137
A 78-year-old patient with a history of symptomatic sinus node dysfunction was im-
planted with a dual-chamber pacemaker. Upon return to the ward, the patient felt palpita-
tions (which he had previously experienced), and the nurse noted a regular tachycardia at
110bpm, with a left bundle branch block QRS pattern (that was also present at baseline).
Device interrogation was performed, and the real-time EGM is shown in Figure 35.1. A
non-invasive pacing study (NIPS) was performed via the pacemaker, with ventricular
pacing at a cycle length of 500ms (the tachycardia cycle length was measured at 540ms).
The EGM at the end of the pacing sequence is shown in Figure 35.2.

Question
Figure 35.2 Real-time EGM of the non-invasive pacing study (NIPS)
Case 35
V
139
500mm/s

A Pacemaker-mediated tachycardia
C VT
D AVNRT
Answer
D AVNRT
Figure 35.3 Annotated real-time EGM of the NIPS
140
V
➋
500mm/s
Pacemaker-mediated tachycardia is excluded by the fact that there is no pacing during the The following can be observed which confirm the diagnosis of AVNRT:
tachycardia. The pacing manoeuvres led to the diagnosis of AVNRT (Figure 35.3). ◆◆ a ‘VAV’ sequence
➊ Ventricular overdrive pacing results in retrograde conduction to the atrium (with ◆◆ a (stimulation-A)–(VA) interval of 120ms
constant VA intervals). ◆◆ a post-pacing interval—tachycardia cycle length of 160ms.
➋ Tachycardia resumes after interruption of ventricular overdrive pacing.

Comments
Non-invasive pacing studies with pacemakers (2)
AVNRT was confirmed by an electrophysiological study, and radiofrequency modification
of the slow pathway was performed.
NIPS can be useful in case of tachycardias with a 1:1 AV ratio where the differential
diagnosis is atrial tachycardia, AVNRT, and AVRT. Almost all devices allow performing
NIPS, which can use the same criteria for diagnosis as for standard electrophysiological
studies.
Case 35
141
Section 2
ICD
Cases 36–53
A 73-year-old patient with ischaemic heart disease and a history of sustained VT and a
single-chamber ICD presented for follow-up. The patient did not report any complaints.
A stored event was retrieved from the device memory. The tachogram is shown in
Figure 36.1, and the EGM of the event in Figure 36.2.
Figure 36.1 Tachogram of the stored event
[ms] Detection classes

RR intervals VT1
1500
VF
1400
1300
1200
1100
1000
900
800
700
600
500
400
300
200
100
–3861 –3475 –3089 –2703 –2317 –1930 –1544 –1158 –772 –386 0 [RR-No.]
RR intervals prior to detection
Question
Figure 36.2 EGM of stored event
CASE 36
145

A Sinus rhythm with appropriate therapy for VT
B AF with appropriate therapy for VT
C Sinus rhythm with inappropriate therapy for SVT
D AF with inappropriate therapy for SVT
Answer
Figure 36.3 Annotated EGM of stored event
SECTION 2 ICD
➊ ➋
146 ➌
The patient is in AF, with the onset of monomorphic VT that is successfully treated by a ➌ After 20 rapid cycles (the programmed number of intervals to detect VT), an ATP
burst of antitachycardia pacing (ATP) (Figure 36.3). sequence is delivered which successfully interrupts the VT.
➊ The RR intervals are very irregular, indicating AF. ➍ Baseline rhythm resumes (the 1st beat is probably ventricular, due to the different
morphology).
➋ A relatively regular tachycardia (cycle length of 320–345ms) of sudden onset with a
different EGM morphology is indicative of VT.
Comments
Ventricular tachycardia/supraventricular tachycardia
discrimination in single-chamber implantable
cardioverter–defibrillators
In this example, the three discriminatory criteria were fulfilled to distinguish VT from
SVT:
◆◆ sudden onset, which distinguishes sinus tachycardia from VT but will not distinguish
CASE 36
VT from atrial or junctional tachycardia (AVNRT, AVRT)
◆◆ regularity, which distinguishes VT from AF but will not be useful to discriminate VT
from regular SVT (e.g. atrial tachycardia, atrial flutter, or AVNRT)

◆◆ morphology, which will distinguish VT from SVT, unless aberrant intraventricular
conduction is present (e.g. due to rate dependence).

The examples shown in the 1st three cases of this book are taken from older devices, 147
dating from around 2000, and do not reflect modern-day technology and programming.
However, the principles for interpreting tracings remain the same.
A patient with a single-chamber ICD was seen for routine follow-up. He had no
complaints. An episode classified as VT was retrieved from the device memory. The
tachogram of the episode is shown in Figure 37.1, and the EGM of the episode is shown in
Figure 37.2.
Figure 37.1 Tachogram of the stored event

Detection classes
RR intervals VT1
[ms]
VT2
1300 VF
1200
1100
1000
900
800
700
600
500
400
300
200
100
–9100 –8190 –7280 –6370 –5460 –4550 –3640 –2730 –1820 –910 0 [RR-No.]
Question
Figure 37.2 EGM of the stored event
Case 37
149

Answer
Figure 37.3 Annotated EGM of the stored event

SECTION 2 ICD
➊ ➋
150
➌
➍ ➎
The patient had AF, with increasing heart rates which gradually entered the VT zone, ➌ An ATP burst is delivered, because the number of intervals to detect VT was reached
resulting in ATP therapy (Figure 37.3). (which was 16 consecutive intervals in this case) and because therapy was not inhibited by
a VT/SVT discriminatory algorithm.
➊ The RR intervals are very irregular (this can be appreciated by the tachogram on the
preceding page), strongly suggesting underlying AF. ➍ There is a pause after ATP delivery, which is probably due to concealed retrograde
conduction into the AV node, delaying the consecutive anterograde conduction of AF. This
➋ The RR intervals enter the VT zone (400ms), without any change in EGM morphology.
should not be mistaken as being an effective therapy of VT.
Note that the intervals before delivery of ATP are relatively regular (between 360ms and
390ms), despite AF. ➎ This beat with a different EGM morphology could be intraventricular aberration or a VPB.
Comments
Ventricular tachycardia and ventricular fibrillation counters
Inappropriate therapy would probably have been avoided in this case by programming a
morphology discrimination algorithm (unavailable on this device) or by the sudden onset
criterion.As can be appreciated by the tachogram, cycles had already been entering the
VT zone since >2700 RR intervals. However, VT was not detected, due to resetting of the
counters by events slower than the tachy zone. Manufacturers use different criteria for
detecting VT and ventricular fibrillation (VF):
Case 37
◆◆ Biotronik and Medtronic devices require a prespecified number of consecutive intervals
to fall within the VT zone. VF detection, on the other hand, is based upon a sliding
window probabilistic counter (e.g. 24/30 intervals falling in the window)
◆◆ Boston Scientific ICDs require that three consecutive fast intervals be detected, in order
to initiate analysis, with a sliding window probabilistic counter that functions during a
predefined duration of time for tachycardia detection 151
◆◆ Sorin devices also use a sliding window probabilistic counter for the VT and VF zones.
Once this is satisfied, a ‘duration’ counter of intervals is incremented. The probabilistic

and duration counters are programmable. The counters are reset, if slow intervals or
SVT is classified by the discriminatory criteria
◆◆ St-Jude devices use a binning system, in which an interval will be binned (as sinus,
VT, VF, or not binned at all), depending on the average of the current and last three
intervals. VT and VF counters keep on incrementing up to the programmable duration
of numbers of intervals, as long as five sinus intervals are not detected.
Details of these criteria have been published previously in a comprehensive article.1
Reference
1. Mansour F, Khairy P. ICD monitoring zones: intricacies, pitfalls, and programming tips. J Cardiovasc Electrophysiol
2008; 19: 568–74.
A patient with a single-chamber ICD and implanted for the primary prevention of sud-
den death, was followed up at the device clinic. He complained of palpitations without any
malaise. An episode of arrhythmia was retrieved from the device memory. The tachogram
is shown in Figure 38.1, and the EGM in Figure 38.2.
Figure 38.1 Tachogram of the stored episode

Detection classes
RR intervals VT1
[ms] VF
1600
1500
1400
1300
1200
1100
1000
900
800
700
600
500
400
300
200
100
–9137 –8223 –7310 –6396 –5482 –4568 –3655 –2741 –1827 –914 0 [RR-No.]
Question
Figure 38.2 EGM of the stored episode
CASE 38
153

B AF with appropriate therapy for VT (double tachycardia)
C Sinus rhythm with onset of AF and inappropriate therapy
D Sinus rhythm with onset of AVNRT and inappropriate therapy
Answer
C Sinus rhythm with onset of AF and inappropriate therapy
Figure 38.3 Annotated EGM of the stored episode

SECTION 2 ICD
154
➋
The patient was in sinus rhythm, with a sudden onset of AF, which resulted in ➋ VT is classified after eight consecutive intervals in the VT zone, triggering an ATP
inappropriate ICD therapy (Figure 38.3). burst sequence of eight cycles.
➊ An irregular rhythm (cycle length of 375–450ms) is observed, corresponding to AF, ➌ A pause is observed after the ATP sequence, due to slowing of AV conduction by
with rates bordering the VT detection zone of 420ms. Note that the cycles entering the concealed retrograde conduction into the AV node. As in Case 1, this should not be
VT zone (labelled ‘VT1’) are of identical morphology as those labelled as ‘VS’. The EGM interpreted as successful ICD therapy.
recording was not triggered when the patient was still in sinus rhythm, as VT detection
only occurred about 200 RR intervals after the onset of AF.
Comments
Sudden onset tachycardia
Inappropriate therapy would have been avoided by programming a higher gradual onset of sinus tachycardia) but may not discriminate correctly
treatment zone for VT (e.g. >182ms, as in the PREPARE study)1 and with SVT with sudden onset (such as AF or AVNRT) and may withhold
a greater number of intervals for detection (the MADIT-RIT2 trial has therapy in rare cases of VT induced by exercise.
validated a duration of 60s in a VT zone of 170–200bpm). A morphology
discrimination algorithm (unavailable in this device) would also have References
been useful. Even though AF had a sudden onset (as visualized on the 1. Wilkoff BL, Williamson BD, Stern RS, et al. Strategic programming of detection and therapy
parameters in implantable cardioverter-defibrillators reduces shocks in primary prevention
tachogram), the sudden onset criterion would also have avoided therapy,
CASE 38
patients: results from the PREPARE (Primary Prevention Parameters Evaluation) study. J Am
as conducted AF rates were just bordering the VT zone (i.e. entering and Coll Cardiol 2008; 52: 541–50.
exiting the zone without great changes in cycle intervals). Sudden onset 2. Moss AJ, Schuger C, Beck CA, et al. Reduction in inappropriate therapy and mortality
may distinguish sinus tachycardia from VT (see Figure 38.4 showing through ICD programming. N Engl J Med 2012; 367: 2275–83.
Figure 38.4 Gradual onset of sinus tachycardia

155
[ms] Detection classes
RR intervals VT1
1300
VF
1200
1100
1000
900
800
700
600
500
400
300
200
100
–9148 –8233 –7318 –6404 –5489 –4574 –3659 –2744 –1830 –915 0 [RR-No.]
A patient implanted with a cardiac resynchronization therapy defibrillator (CRT-D) for
ischaemic heart disease and a history of sustained VT was admitted after having received
multiple shocks. He had undergone previously AV nodal ablation, due to rapidly con-
ducted paroxysmal AF that was refractory to drug therapy. The device settings are shown
in Table 39.1 and Figure 39.1. The tachogram of one of the stored episodes is displayed in
Figure 39.2, with the EGM at the onset of the arrhythmia in Figure 39.3.
Table 39.1 Device settings Figure 39.2 Tachogram of the stored episode
Zone Slow VT Fast VT VF V-V A-A VF = 270ms FVT = 370ms VT = 570ms
Détection Stop.
Rate (bpm/ms) 105/570 162/370 (via VT) 222/270 Burst B
Interv. (ms)
1500 Ramp 15.9 J
Detection (intervals) 16 18/24 18/24
1200
Redetection (intervals) 12 12/16 12/16
900
SVT/VT discriminators Disabled
600
Therapy Five bursts + four One burst + one Shocks
ramps + shocks ramp + shocks
400
Figure 39.1 Device settings 200
270ms 370ms 570ms

VF
–30 –20 –10 0 10 20 30 40 50 60 70 80 90 * * * *
FVT Duration (s)
VT
Question
Case 39
VT
VT Tt 1 Burst
157
B AVNRT with 2:1 retrograde conduction
C Inappropriate therapy for SVT
D Double tachycardia
Answer

SECTION 2 ICD
158 ➊ ➋ VT
➍ VT Tt 1 Burst
The patient had appropriate therapy for monomorphic slow VT (Figure 39.4). ➌ There are more ventricular than atrial events (V > A) with AV dissociation, confirming
VT.
➊ The rhythm is initially in atrial–biventricular pacing.
➍ The criteria for VT are fulfilled after 16 consecutive intervals falling in the slow VT
➋ The episode starts with a ventricular event that falls in the slow VT zone (TS).
zone, and burst ATP is delivered.
Comments
Inactivation of ventricular tachycardia/supraventricular
tachycardia discrimination algorithms
The only instance where VT/SVT discrimination algorithms may be inactivated is in the
case of permanent complete AV block, as in this patient who had undergone ablation
of the AV node. In this case, it is impossible to have conducted SVT. The aim of these
algorithms is to increase the specificity of ICD therapy, but they may reduce the sensitivity
(i.e. inappropriately withhold therapy). Artefacts or T-waves may, however, be detected as
Case 39
rapid VS events but may be identified as such by other algorithms which should remain
activated (see later cases in this book).
After delivery of the five bursts and four ramps for slow VT, the arrhythmia was
reclassified as fast VT, due to a single beat (in the last eight intervals before detection)
falling in the fast VT zone (➊). This then initiated therapy for fast VT with one burst
(labelled as ‘B’ on the figure) and one ramp sequence, which resulted in a slower VT (➋), 159
which was successfully cardioverted by a 15.9J shock (Figure 39.5).
Some VTs, despite being slow, can be difficult to overdrive with ATP. Due to recurrent VT,
the patient underwent VT ablation.
Figure 39.5 Annotated tachogram of the stored episode

V-V A-A VF = 270ms FVT = 370ms VT = 570ms
Détection Stop.
Interv. (ms) Burst B
1500 Ramp 15.9 J
1200
900
600
400 ➋
➊
200
–30 –20 –10 0 10 20 30 40 50 60 70 80 90 * * * *

Duration (s)
A patient, implanted with a CRT-D for secondary prevention of VT, consulted after hav-
ing received a shock that was preceded by palpitations. The tachogram of the retrieved
episode is shown in Figure 40.1, and the EGM in Figure 40.2. The device settings are
displayed in Table 40.1 and Figure 40.3.
Figure 40.1 Tachogram of the stored episode Table 40.1 Device settings
V-V A-A VF = 330 ms FVT = 260 ms VT = 360 ms Zone Slow VT Fast VT (via VF) VF
Détection Stop.
Burst Rate (bpm/ms) 167/360 231/260 182/330
Interv. (ms)
1500 34.7 J
Detection 100 30/40 30/40
1200
Redetection 12 12/16 12/16
900
600 SVT/VT PR logic on; stability Therapy
discriminators off; sudden onset and
morphology ‘monitor’
400
ATP + shocks ATP + shocks Shocks
200
–20 –10 0 10 20 30 40 50 60 70
Duration (s)
Figure 40.3 Device settings
260ms 330ms 360ms
VF
FVT
VT
Question
Figure 40.2 Stored EGM of the episode
CASE 40
VF 34.7 J
VF Tt 1 Defib
161

Answer
Figure 40.4 Annotated stored EGM of the episode
➊
SECTION 2 ICD
➏
➋
162
➌VF ➍ ➎
34.7 J
VF Tt 1 Defib
This is a case of an inappropriate ICD shock due to rapidly conducted AF, which zone, in this case between 330ms and 260ms) or VF (if >1 of the last eight intervals fall in
cardioverted the AF to sinus rhythm (Figure 40.4). the VF zone, in this case shorter than 230ms).
➊ The atrial EGM shows AF. ➍ The capacitor has reached the end of its charge (CE).
➋ The ventricular channel shows an irregular monomorphic rhythm, corresponding to ➎ Ventricular arrhythmia is reconfirmed at the end of the capacitor charge (>2/5 intervals
rapidly conducted AF that enters the tachycardia zones. faster than the VT zone + 60ms for this model, corresponding to 420ms in this case, i.e.
cycles labelled as 350ms and 320ms), resulting in the delivery of a shock.
➌ The criteria for VF are fulfilled, as ≥1 of the last eight intervals is in the VF zone (FS
210ms) and VF is detected (FD). Note that the detection counters are shared between the ➏ The shock results in cardioversion of AF to sinus rhythm. The ventricular channel
VF and ‘FVT via VF’ zones in Medtronic devices. At detection (i.e. when the counter is shows a short run of ventricular beats (V > A) directly after the shock. Ventricular pacing
full), the device will detect either FVT (if all the last eight intervals were inside the FVT was resumed thereafter.
Comments
Implantable cardioverter–defibrillator capacitor charge durations
The ICD transformers multiply the battery voltage (which is charge had resulted in the abortion of shock delivery (the criterion in
approximately 3V) to charge capacitors, in order to be able to deliver this model being <2/5 cycles within the VT/VF zone + 60ms). Rhythm
shocks of approximately 750V. The charge duration of ICDs reflect the reconfirmation should not be confounded with redetection, which refers
battery status and are usually within 6–10s for a capacitor full-energy to whether an arrhythmia is terminated or not after therapy delivery. Short
charge. In this case, the charge time was very short (<2s), confirmed by the cycles were then detected again, with the arrhythmia being classified as
episode details shown in Figure 40.5. VF this time and reconfirmed, leading to delivery of a 34.7J shock, which
at least had the favourable effect of cardioverting the AF back to sinus
CASE 40
In Figure 40.5a, it can be seen that the arrhythmia was classified initially
rhythm. The charge duration was only 1.33s this time, as the capacitors
as fast VT (FVT), for which three bursts were delivered (Figure 40.5b,
were still charged at 28J. The entire sequence was classified as being a
arrows on the tachogram) with persistence of the arrhythmia, resulting
single episode, as there were never >8 consecutive cycles that were outside
in a charge of the capacitors to 35J in 8.07s. As the first shock of all
the VT/VF zone (each manufacturer has its own specific criterion).
ICDs are ‘non-committed’, verification of the rhythm after the end of the
163
Figure 40.5 Episode details
V-V A-A VF = 330 ms FVT = 260 ms VT = 360 ms
Therapies Delivered Charge Ohms Energy Détection Stop.
Interv. (ms) Burst
Confirmation VT/VF 1500 34.7 J
FVT Tt 1 Burst Seq. 1 to seq. 3 1200
| 900
FVT Tt 2 CV Abandon. 8.07 s 0.0 - 35 J 600
|
VF Tt 1 Defib 34.7 J 1.33 s 50 ohms 28 - 35 J 400
|
Stop 200
(a)
–20 –10 0 10 20 30 40 50 60 70
(b) Duration (s)
A patient implanted with a dual-chamber ICD for ischaemic cardiomyopathy and a
history of VT presented for routine follow-up, without any complaints. An arrhythmic
episode was retrieved from the device memory and is shown in Figure 41.1. The device

Zone VT VF
Rate (bpm/ms) 171/350 214/280
Detection 16 12
(intervals)
Therapy ATP + shocks Shocks
Pacing mode DDD
Lower rate 40bpm
Upper rate 120bpm
Discrimination algorithm (dual-chamber) A:V ratio, onset, stability, morphology

Question
CASE 41
165

A Atrial tachycardia
B AVNRT
C AVRT
D VT
Answer
D VT

SECTION 2 ICD
166
➊ ➋
There are several criteria that identify this arrhythmia as being VT (Figure 41.2). interval is too short (87ms) for AV conduction. An initial V > A ratio can be observed,
confirming VT.
➊ A first VPB precedes (and probably triggers) the arrhythmia. The AS–VS interval is
shorter (47ms) than the interval in sinus rhythm on the top of the strip (141–147ms), ➌ The tachycardia later has a 1:1 AV ratio, due to retrograde VA conduction. The morphology
implying that this is not intrinsic AV conduction. Furthermore, the morphology of the discrimination algorithm indicates 0% resemblance with the stored EGM template in sinus
ventricular EGM is different, compared to that in sinus rhythm. rhythm, which is below the match threshold (and the complexes are therefore labelled as
‘X’). Each rapid cycle (labelled as ‘T’) is then binned in the VT zone.
➋ The 1st beat of the tachycardia is also of different morphology, compared to the
ventricular EGM in sinus rhythm, and again is ventricular in origin, as the AS–VS
Comments Figure 41.4 Morphology discrimination algorithm
Morphology criterion for rhythm discrimination

Template
The arrhythmia was classified correctly as VT, and burst ATP was Arrhythmia
delivered, resulting in a return to sinus rhythm (Figure 41.3).
Morphology discrimination algorithms are used by several manufacturers,
using either the far-field EGM (e.g. can to RV coil), the near-field EGM
(RV tip to RV ring), or a combination of the two. The EGM during
tachycardia is compared to the stored template in normal rhythm
CASE 41
(which is usually updated automatically; Figure 41.4). Errors in rhythm
classification may be induced by rate-dependent aberration, inaccurate
template, alignment errors, EGM truncation, and post-shock EGM
distortion.1
Reference 167
1. Swerdlow CD, Friedman PA. Advanced ICD troubleshooting: Part I. Pacing Clin Match 97% No match 23%
Electrophysiol 2005; 28: 1322–46.
Figure 41.3 Burst ATP, with return to sinus rhythm. After the ATP sequence, morphology discrimination shows a match of
74–97% (labelled with a ✓), compared to the stored template, which exceeds the programmed threshold of 60%.
A 76-year-old patient with a CRT-D implanted for the primary prevention of sudden
death presented for routine follow-up. He had no complaints. An episode classified as
non-sustained VT was retrieved from the device memory and is shown in Figure 42.1.

Zone Slow VT Fast VT (via VF) VF
Rate (bpm/ms) Off 240/250 188/320
Detection (intervals) 30/40 30/40
Redetection (intervals) 12/16 12/16
Therapy 2× bursts + shocks Shocks

Question
CASE 42
169
What is the most likely diagnosis?

A Non-sustained VT
B AVNRT
C Atrial tachycardia
D AVRT
Answer
A Non-sustained VT

SECTION 2 ICD
➋ ➋
170 ➊
This case (Figure 42.2) illustrates several criteria which indicate non-sustained VT and ➋ Longer VV intervals precede longer AA intervals, with relatively constant VA intervals
speaks against atrial tachycardia. AVNRT or AVRT initiated by VPBs are not ruled out but (VA linking).
are unlikely, given the cycle length irregularity.
➌ The episode ends with an atrial event.
➊ The event is initiated by a VPB (the AS–VS interval is too short for intrinsic AV
conduction).
Comments
Clues to differentiate supraventricular tachycardia from
ventricular tachycardia
A summary of the clues that discriminate VT from SVT (several of which have been
covered in the previous examples) are shown in Table 42.2.
Many ICDs use criteria that are in Table 42.2 as discriminatory algorithms. Details of how
these algorithms function for each manufacturer are beyond the scope of this book and
can be found in the device technical manuals, as well as in review articles.1, 2
CASE 42
Table 42.2 Differentiating VT from SVT on EGM tracings
VT SVT
◆ Complete AV block ◆ Gradual onset (! VT induced by exercise)
◆ V>A
◆ Very rapid (e g. >240bpm) and not artefacts
◆ Irregular rhythm (! some VTs may be irregular)
◆ Starts with A
171
◆ EGM morphology very different (! aberration) ◆ EGM is identical to normal rhythm (use all EGMs, also
◆ Starts with V ‘can–RV coil’; ! EGM may change after shock)

◆ V–V irregularities precede A–A irregularities (! may also be ◆ A–A irregularities precede V–V irregularities
seen with AVNRT) ◆ ‘VAAV’ sequence after ineffective ventricular ATP and atrial
◆ Ends with A (! may also be seen with AVNRT or AVRT) reset (→ AT/atypical AVNRT)
◆ ATP is effective (! SVT that can be stopped by ATP: AVNRT,
AVRT, AT if VA conduction; ! AF with post-ATP pause)

AT, atrial tachycardia; AF, atrial fibrillation; ATP, antitachycardia pacing; AVNRT, atrioventricular nodal re-entrant tachycardia; AVRT, atrioventricular
re-entrant tachycardia; EGM, electrogram; caveats are indicated by ‘!’.
References
1. Swerdlow CD, Friedman PA. Advanced ICD troubleshooting: Part I. Pacing Clin Electrophysiol 2005; 28: 1322–46.
2. Swerdlow CD, Friedman PA Advanced ICD troubleshooting: Part II. Pacing Clin Electrophysiol 2006; 29: 70–96.
A 65-year-old male with dilated cardiomyopathy was implanted with a dual-chamber
ICD, following an aborted sudden death with documented VF. Follow-up of the patient
over the next 6 months revealed 46 episodes of asymptomatic tachycardia at a rate of
140/min, interpreted as VT, which were interrupted by ATP. An EGM at the onset of one
of these episodes is shown in Figure 43.1.
Question
Figure 43.1 EGM at onset of the tachycardia
CASE 43
173

A Atrial tachycardia
B AVNRT
C AVRT
D VT
Answer
B AVNRT
Figure 43.2 Annotated EGM at onset of the tachycardia

SECTION 2 ICD
➊ ➋ ➌
174
❹
This is an example (Figure 43.2) of how ventricular ATP may interrupt SVT successfully. ➌ Atrial events thereafter occur almost simultaneously with every ventricular event,
indicating retrograde conduction by the fast pathway. In case of AVRT, the VA interval
➊ The arrhythmia is initiated by atrial premature beats, which suggests SVT. The 1st atrial
would have been longer.
premature beat is tracked to the ventricle by the ICD at the maximum tracking interval and
results in ventricular pacing (indicated by the VP–MT 545 marker). ➍ Atrial sensing occurs intermittently, as most events are hidden in the ventricular
blanking period. The V > A criterion then leads to the (erroneous) diagnosis of VT by the
➋ The 2nd atrial premature beat falls within the PVARP, which is indicated by the (AS)
ICD, leading to the delivery of therapy.
marker, and therefore is not tracked to the ventricle and results in intrinsic AV conduction
with a prolonged AS–VS interval, indicating conduction by the slow pathway.
Comments
Atrioventricular nodal re-entrant tachycardia masquerading as
ventricular tachycardia
A rhythm strip was recorded during patient monitoring and is shown in Figure 43.3.
The patient, in this case example, underwent an electrophysiological study, which
confirmed AVNRT with successful radiofrequency ablation of the slow pathway.
Figure 43.3 Rhythm strip recorded during patient monitoring. (A) Initiation of AVNRT (an atrial premature beat is shown by *). (B) Termination of the
CASE 43
tachycardia by ventricular ATP
175
A 74-year-old patient with ischaemic heart disease had a single-chamber ICD implant
ed 3 years ago for resuscitated VF. He was admitted after having received multiple shocks.
The tachogram is shown in Figure 44.1. The EGM strip preceding one of the shocks is
displayed in Figure 44.2.
Figure 44.1 Tachogram of the stored episode

V-V VF = 330 ms FVT = 250 ms VT = 400 ms
Interv. V-V (ms)
2000 29.5 J 30.8 J 30.5 J
1700 30.5 J 30.8 J 30.5 J
1400
1100
800
600
400
200
-20 -10 0 10 20 30 40 50 60 70 * * *
Time (s) [0 = Detection]
Question
Figure 44.2 EGM of the 3rd shock of the stored episode
P/S
HVA/HVB
CASE 44
177
A Fast VT
B VF
C Lead fracture
D Electromagnetic interference
Answer
C Lead fracture
Figure 44.3 Annotated EGM of the 3rd shock of the stored episode
P/S
SECTION 2 ICD
➊ ➌
HVA/HVB
178
This patient (Figure 44.3) had been implanted with a Medtronic Sprint Fidelis lead, which ➋ A shock is delivered (CD) directly after the charge end (CE) of the capacitor. This
was prone to fracture and has been subject to a recall in 2007. indicates that this was not the 1st shock of this episode, as the shock was ‘committed’, i.e.
the rhythm was not reconfirmed before delivery of the shock. The first shock is always
➊ High-amplitude, erratic artefacts, which suggest lead fracture, are observed on the
‘non-committed’, i.e. tachyarrhythmia needs to be reconfirmed before the shock is
pace–sense (P/S) channel and are absent on the far-field can–RV coil (HVA/HVB) channel,
delivered, whereas subsequent shocks of the same episode are committed.
ruling out electromagnetic interference. The far-field EGM shows a regular rhythm at
100bpm which rules out fast VT or VF. ➌ Artefacts continue to be present after the shock, leading to further shocks.
Comments Figure 44.4 Lead impedance graph
Last session ohms
>3000
Recognizing lead fracture 2000
1500
Lead impedance had risen to abnormal levels
1000
(Figure 44.4), triggering an audible alert that 800
had not been heard by the patient. Remote 600
monitoring would have been useful and may 400
have allowed medical intervention before the 300
delivery of inappropriate shocks. <200

17/04/07 26/06/07 04/09/07 13/11/07 22/01/08 01/04/08 10/06/08 13/08/08 26/08/08
CASE 44
Lead impedance may, however, be normal, 80 last weeks (min/max per week) Last 14 days
despite lead fracture. Algorithms have also been
developed to recognize fracture potentials, Figure 44.5 Lead fracture artefacts (indicated by *)
based upon their very high frequency and also
by comparing near-field and far-field EGM
channels. Fracture artefacts may not always be 179
as easy to recognize, as shown in Figure 44.5. P/S * * * * * * * * *
Fluoroscopy and X-rays are seldom useful for

diagnosing fracture. If the fracture occurs near
the generator, manipulation of the pocket or
pressing the lead at the clavicular region may
trigger artefacts (Figure 44.6).
This manoeuvre may also be useful for diagnosing
lead connection problems (e.g. a loose setscrew or
an incompletely inserted lead in the header).
Figure 44.6 Lead fracture artefacts reproduced by manipulation of the generator pocket
External manipulation of the generator pocket

A 67-year-old patient with dilated cardiomyopathy was implanted with a CRT-D for the
primary prevention of sudden death. The control on the day following the implant was
normal, apart from an R-wave sensing amplitude of 4.2mV in the true bipolar configu-
ration, which increased to 8mV when the sensing configuration was programmed to
integrated bipolar (RV tip to RV coil). At 1-month follow-up, 68 episodes of asymptomatic
non-sustained ventricular arrhythmia were recorded. The EGM of one of these episodes is
shown in Figure 45.1, and the device settings are displayed in Table 45.1.

Zone Slow VT Fast VT (via VF) VF
Rate (bpm/ms) 160/375 250/240 200/300
Therapy None ATP + shocks Shocks
Pacing mode DDDR
Lower rate 60bpm
Upper rate 140bpm
LV output (LV tip–RV coil) [email protected]
RV sensitivity (RV tip–RV coil) 0.45mV

Question
Figure 45.1 EGM of a stored non-sustained high ventricular rate episode
RV
CASE 45
181

A Lead fracture
B Pectoral muscle oversensing
C Diaphragmatic muscle oversensing
Answer
C Diaphragmatic muscle oversensing
Figure 45.2 Annotated EGM of a stored non-sustained high ventricular rate episode
A
SECTION 2 ICD
➊
RV ➌
182
➋
Diaphragmatic myopotential oversensing resulted from the extended bipolar ventricular ➌ Upon close inspection, low-amplitude high-rate artefacts are visible on the ventricular
sensing configuration (Figure 45.2) and was confirmed at follow-up by reproducing the channel (note the scale), which are absent on the tracing to the left of the event. There
artefacts during a Valsalva manoeuvre. is no simultaneous increase in artefacts in the atrial channel, which speaks against
electromagnetic interference. Pectoral myopotentials would not be sensed by the bipolar
➊ The automatic scale is larger for the atrial channel, resulting in the visualization of
sensing configuration. The potentials are of very low amplitude, speaking against fracture
background noise that is constant throughout the tracing (and is not sensed).The scale
artefacts (see Case 44).These artefacts correspond to diaphragmatic myopotentials.
for the right ventricular (RV) channel is however small, and should be taken into account
when interpreting the EGM.
➋ A ventricular high-rate episode is detected by the ICD, according to the marker

channel.
Comments
True bipolar and integrated bipolar implantable
cardioverter–defibrillator leads
True bipolar ICD leads have a separate ring electrode that acts as the anode, whereas
integrated bipolar leads use the RV coil as the anode (Figure 45.3).
This patient had a true bipolar ICD lead, which was programmed to an integrated bipolar
configuration, because of a greater sensed R-wave amplitude. Due to the wider inter-
electrode spacing of the integrated bipolar configuration, there is an increased risk of
CASE 45
diaphragmatic myopotential oversensing. The problem was confirmed at follow-up by
reproducing the phenomenon during a Valsalva manoeuvre. It was resolved easily by
reprogramming the lead to a true bipolar sensing configuration.
Figure 45.3 Differences between true bipolar and integrated bipolar ICD leads
183
True Bipolar Integrated Bipolar

Integrated Bipolar
Adapted from Medtronic Core ICD

Pacing/Sensing Anode
RV High Voltage Coil (HVB)
IS-1BI IS-1BI
DF-1 DF-1
A patient was implanted with a dual-chamber ICD for the primary prevention of sudden
death. An episode of non-sustained ventricular arrhythmia was retrieved at routine device
follow-up and is shown in Figure 46.1.
Question
Figure 46.1 EGM of non-sustained ventricular high-rate episode
CASE 46
185

A Lead fracture
B Pectoral muscle oversensing
C Diaphragmatic oversensing
Answer
Figure 46.2 Annotated EGM of non-sustained ventricular high-rate episode
➊ ❹
SECTION 2 ICD
➌
➊
186
The cause of the external electromagnetic interference could not be determined in this case ➌ Preserved AV conduction is visible during the inhibition of ventricular pacing by
(Figure 46.2), as the patient did not remember his activity at the time of the event. the electromagnetic interference. The pacing mode of the device should be changed to
minimize ventricular pacing (from DDD to, e.g. DDI or ADI/DDD mode).
➊ High-rate artefacts are visible simultaneously on the atrial and ventricular channels,
which indicates electromagnetic interference. Another possibility would be pectoral ➍ FFRWs are visible on the atrial channel but are not sensed, as they fall in the PVAB
myopotentials in a device programmed to unipolar sensing for both the atrial and period.
ventricular channels, but ICDs only sense in the bipolar mode in these channels.
➋ Electromagnetic interference is detected as ventricular events in the VF zone but is too

short in duration to lead to a capacitor charge. Note that the electromagnetic signals are
not sensed in the atrium, probably due to low amplitude and also to PVAB.
Comments
Electromagnetic interference Table 46.1 Distinguishing artefacts on EGM tracings
Most modern ICDs have band filters which reduce the risk of detecting Electromagnetic ◆◆ Usually repetitive and of high rate (e.g. 50Hz)
interference ◆◆ Artefacts visible simultaneously on all channels
external electromagnetic interference emitted by devices such as ◆◆ Amplitude on far-field EGM > near-field EGM*
household appliances, cell phones, etc. The risk of interference will depend
Lead fracture ◆◆ Usually of erratic morphology and high amplitude (channel saturation)
upon factors such as: artefacts ◆◆ Only observed on a single EGM channel (or on the channels of all fractured
leads, but usually not perfectly simultaneously)
◆◆ the frequency of the signal (which will determine attenuation by the ◆◆ May be associated with elevated lead impedance or abnormal thresholds
band filters) (! electrical parameters may be normal!)
CASE 46
May sometimes be provoked by manipulation of the pocket (if the fracture is
◆◆ the signal amplitude
◆◆
in the extrathoracic portion of the lead)

◆◆ the proximity of the source to the device (amplitude decreases with the
Myopotentials Usually of high rate, with sometimes crescendo/decrescendo amplitude
square of the distance) ◆◆
◆◆ Diaphragmatic myopotentials are only observed on the ventricular channel,

◆◆ the orientation of the source with respect to that of the electrode dipole with amplitude on the near-field EGM > far-field EGM*
◆◆ the sensing polarity Pectoral myopotentials may be observed in any lead programmed to unipolar
◆◆
◆◆ the inter-electrode spacing

◆◆
sensing
May be reproduced by provocative manoeuvres (Valsalva manoeuvre, cough; 187
◆◆ the programmed sensitivity. prayer manoeuvre, etc.)
Atrial leads have been shown to be more susceptible to electromagnetic *The far-field EGM (e.g. generator can to RV coil) may be recorded for morphology recognition; the near-field EGM
corresponds to the true or integrated bipolar EGM. Caveats are indicated by ’!’.
interference than ventricular leads.1 Interference detected by the atrial
channel may lead to an inappropriate mode switch or to tracking of the
signals with rapid ventricular pacing. If interference is detected by the
ventricular channel, pacing may be inhibited or inappropriate therapy
may be delivered. Electromagnetic interference may also result in noise
reversion with asynchronous pacing at the baseline rate.
Elements which allow distinguishing between different types of artefacts
are shown in Table 46.1.
Reference
1. Napp A, Joosten S, Stunder D, et al. Electromagnetic interference with implantable cardio-
verter defibrillators at power frequency: an in vivo study. Circulation 2014; 129: 441–50.
A 69-year-old patient with ischaemic heart disease and a history of VT was implanted
with a dual-chamber ICD. He was seen at routine device follow-up, without any cardiac
complaints. An episode classified as SVT was retrieved from the device memory and is

Zone Slow VT Fast VT VF
Rate (bpm/ms) 130/462 185/324 240/250
Detection (intervals) 20 12 6
Therapy ATP + shock ATP + shock Shock
Pacing mode ADI/DDD
Lower rate 40bpm
Upper rate 120bpm
Atrial output [email protected] (bipolar)
RV output [email protected] (bipolar)
Atrial sensitivity 0.2mV (bipolar)
RV sensitivity 0.4mV (bipolar)

Question
Figure 47.1 EGM of SVT episode
A EGM
CASE 47
RV
coil–can
SVT
189

A Lead fracture
B Myopotential oversensing
C Electromagnetic interference
D Normal device function
Answer
D Normal device function
Figure 47.2 Annotated EGM of SVT episode
A EGM
➋
SECTION 2 ICD
➍ ➊ ➊ ➊ ➊
RV
coil–can
190 SVT
This episode had been stored, due to the detection of SVT while the patient was exercising, ➍ The artefacts are due to pectoral myopotentials recorded by the far-field RV coil-can
and the artefacts on the ventricular channel are an incidental finding (Figure 47.2). EGM. This 'unipolar' EGM is displayed to facilitate the interpretation of tracings (as it
resembles a surface ECG). It is, however, the near-field pace/sense (RV tip-RV ring) EGM
➊ High-rate artefacts are visible on the ventricular channel.
that is used by the device for detection, but this channel is not displayed on the recorded
➋ The atrial channel shows no artefacts, pointing against electromagnetic interference. EGM.
➌ The artefacts are not sensed by the device, even though they are of higher amplitude
than the R-wave.
Comments
Bipolar sensing in implantable cardioverter-defibrillators
Atrial and RV sensing (and pacing) can only be programmed in the bipolar mode in
ICDs, in order to avoid oversensing of myopotentials, electromagnetic interference,
T-waves, FFRWs, etc. Many ICD models display a 'far-field' EGM, which is usually the
can-RV coil EGM, as this resembles an ECG signal which facilitates the evaluation of
QRS morphology (and may be used by the device for the morphology discrimination
algorithm). The device model shown in this example is unusual, as only the far-field
EGM is displayed (although only the bipolar EGM is used for rate sensing).
CASE 47
Biventricular devices may have LV sensing programmed to either a unipolar, bipolar, or
to an extended bipolar (LV electrode-RV ring or coil) configuration, but this channel
is not used for VT/VF detection, due to the risk of oversensing (e.g. myopotential
oversensing in the unipolar mode or P-wave oversensing in the case of LV lead
dislodgement into the coronary sinus). 191
A 28-year-old patient with arrhythmogenic RV dysplasia had a single-chamber ICD
implanted for the secondary prevention of sudden death. During physical exertion, he
received 42 ICD shocks and presented to the emergency room. The tachogram is shown in
Figure 48.1, and the stored EGM of one of the shocks is shown in Figure 48.2.
Figure 48.1 Tachogram of one of the stored events

V-V VF = 300 ms FVT = 240 ms VT = 370 ms
V-V Interval (ms)
2000 34.9 J
1700
1400
1100
800
600
400
200
−20 −15 −10 −5 0 5 10 15

Time (sec) [0 = Detection]
Question
CASE 48
193
A VT
B SVT
C R-wave double-counting
D T-wave oversensing
Answer
➊
SECTION 2 ICD
➋ ➍ ➍ ➌
194
The T-waves had increased in amplitude during physical exertion and were sensed by the ➌ A full-energy shock is delivered.
ventricular channel, leading to double-counting of the cycles and multiple inappropriate
➍ The R-waves are sometimes undersensed after sensing of the high-amplitude T-wave,
shocks (Figure 48.3).
due to the adaptive sensitivity.
➊ The T-waves are of high amplitude in this channel which is used for rate sensing.
➋ VF is detected (FD), resulting in capacitor charge.
Comments
Avoiding T-wave oversensing
T-wave oversensing may occur in patients who have low R-wave amplitude Simply reducing the maximum sensitivity would not have solved the
(resulting in sensitive value of the sensing threshold start) or high- problem in this case, due to the amplitude of the T-waves that were even
amplitude T-waves (e.g. patients with Brugada syndrome, hyperkalaemia, higher than the R-waves. The issue was solved by programming sensing to
etc.). It can be recognized on the tachogram by the classical ‘railroad track’ an integrated bipolar configuration, as the T-waves were of low amplitude
appearance of the RR intervals (Figure 48.1). The consequences may be (as seen on the stored EGM 2 ‘V tip to HVB’ in Figure 48.3).Recent devices
dramatic, with multiple inappropriate shocks, as in this patient. have algorithms that avoid T-wave oversensing (Figure 48.4).
CASE 48
Figure 48.4â•‡ Algorithms to avoid T-wave oversensing. (a) Increasing the threshold start level and/or prolonging the decay delay. (b) Recognizing the characteristic
patterns of sensing (‘TW’)
(a) (b)
195
Decay delay
62.5%
50% % threshold start
Max. sensitivity
Courtesy of Marta Roca

A patient implanted with a CRT-D presented for routine follow-up. He had no c omplaints.
Device interrogation revealed 11% RV sensing; the device settings are shown in Table 49.1,
and the rate histogram in Figure 49.1. A real-time EGM was printed during the follow-up
and is shown in Figure 49.2.
Table 49.1 Device settings Figure 49.1 Rate histogram

Zone Slow VT VT VF RV LV
Paced
Rate (bpm/ms) 170/353 220/273 240/250 Sensed
Detection (s) 4s 2.5s 2s VT-1 VT VF

100
Therapy ATP + shocks ATP + shocks Shocks
Pacing mode DDDR
(%)
Lower rate 60bpm
Upper rate 120bpm
AV delay (paced/sensed) 160/140ms 0

≤30 50 70 90 110 130 150 170 190 210 230 ≥250
Atrial output [email protected] Rate (min−1)
RV sensitivity (integrated bipolar) 0.4mV
LV sensitivity (LV tip–RV coil) 2.5mV

Question
Figure 49.2 Real-time EGM recorded at follow-up
RV
CASE 49
tip–coil
197

B Crosstalk
D R-wave double-counting
Answer
Figure 49.3 Annotated real-time EGM recorded at follow-up
A
SECTION 2 ICD
RV
tip–coil ➌ ➊
198
This is one of the rare instances of far-field P-wave oversensing by a ventricular lead, due to ➋ The far-field P-wave is sensed in the RV channel (RVS), inhibiting ventricular pacing,
the integrated bipolar RV sensing configuration (Figure 49.3). and is followed by sensing of the near-field RV signal which occurs after 185ms (and is
labelled as VF); this is then followed by LV sensing (LVS).
➊ A low-amplitude signal is observed in the RV channel at about 100ms after atrial pacing
(which is too long for crosstalk), corresponding to the far-field P-wave which is sensed by ➌ The far-field P-wave is visible during each cycle but is sensed intermittently, due to its
the RV coil straddling the tricuspid annulus. low amplitude.
Comments
Far-field P-wave oversensing by integrated bipolar implantable
cardioverter–defibrillator leads
Far-field P-wave oversensing by the ventricular lead is a much rarer phenomenon than
FFRW oversensing by the atrial lead. It should nevertheless be evaluated at implantation
of integrated bipolar leads, especially if the lead is placed in a mid-ventricular position
(e.g. on the interventricular septum) which leads to the RV coil straddling the tricuspid
annulus and sensing atrial signals. The PAVB period will not solve the problem entirely,
CASE 49
as it is only applied during atrial pacing (and also may not be long enough). The issue was
solved here by reducing the ventricular sensitivity from 0.4mV to 0.6mV.
Other causes of far-field P-wave oversensing by the RV lead include dislodgement of
the lead to near the tricuspid annulus and accidental implantation of the RV lead in the
coronary sinus.
199
A patient with a single-chamber ICD, implanted for the primary prevention of sudden
death, presented after having received a shock. The stored EGM of the event is shown in
Figure 50.1. The device settings are shown in Table 50.1 and Figure 50.2.

Zone Slow VT VT (via VF) VF
Rate (bpm/ms) 160/375 240/250 187/320
Figure 50.2 Device settings
250ms 320ms 375ms
VF
FVT
VT
Question
RV tip-ring
Can-RV coil
CASE 50
201

B T-wave oversensing
D Committed shock
Answer
RV tip-ring
SECTION 2 ICD
Can-RV coil
202
➋ ➌
As shown in Figure 50.3, the patient received a shock after the end of non-sustained VT ➋ The VT has spontaneously stopped before the capacitor charge end (CE).
(SVT is unlikely because of the short cycle length and the different morphology, compared
to normal rhythm).
➌ The shock is non-committed, as it is not delivered immediately at the end of capacitor
charge. There are two short cycles (320ms and 300ms) that fall in the VT zone, fulfilling the
➊ The VT fulfils the detection criteria in the VF zone, triggering capacitor charge. 2/5 fast interval criterion for reconfirmation of arrhythmia before shock delivery.
Comments
Committed and non-committed shocks
The first shock of ICDs is always ‘non-committed’, i.e. persistence of the arrhythmia is
always reconfirmed before delivery of the shock. For the ICD model in this case, the
criterion is 2/5 fast intervals that fall in the VF zone or VT zone + 60ms. Current models
perform rhythm reconfirmation during capacitor charge and with other criteria, which
would have avoided the unnecessary shock in this case. Aborting capacitor charges also
prolongs battery life.
CASE 50
Arrhythmia reconfirmation should be distinguished from redetection. The latter refers
to verification of termination or persistence of an arrhythmia after delivery of therapy
(the criteria, in this example, are shown in Table 50.1). In case the first shock is ineffective
and the arrhythmia is redetected, all subsequent shocks are ‘committed’, i.e. there is no
reconfirmation of arrhythmia during, or at the end of, capacitor charge.
203
A patient implanted with a dual-chamber ICD presented for a shock that was not preceded
by any cardiac complaints. The EGM of the episode is shown in Figure 51.1. The device

Zone Slow VT VT VF
Rate (bpm/ms) 160/375 171/350 214/280
Detection (intervals) 24 18 12
Pacing mode DDD
Lower rate 40bpm
Upper rate 120bpm
AV delay (paced/sensed) 160/140ms
PAVB 45ms
VRP after VS 125ms
VRP after VP 250ms

Question
A
Trigger
CASE 51
RV
205
RV

A Sinus rhythm with R-wave double-counting
B Accelerated ventricular rhythm with R-wave double-counting
C T-wave oversensing
D VT
Answer
B Accelerated ventricular rhythm with R-wave double-counting

A
➋ Trigger
➏
SECTION 2 ICD
➊
RV
206 A
➎
RV
An accelerated ventricular rhythm resulted in R-wave double-counting with inappropriate ➎ The last cycle is probably sinus with AV conduction, whereas the preceding two cycles
shock (Figure 51.2). are VPBs or junctional beats (as they are not preceded by P-waves). Note that these cycles
do not have R-wave double-counting.
➊ R-wave double-counting is seen on the marker channel.
➏ The atrial channel shows retrograde P-waves. These are detected by the device, as
➋ The morphology shows a mismatch with the template (0% resemblance). Due to the
shown by the timing markers labelled 800, 780, 796, etc. The 1st two atrial cycles are
short RR interval, the 2nd event is binned as a VF event.
atrial-paced (A) but are not conducted because the AR intervals are very short due the
➌ The criteria for VF detection are fulfilled. accelerated ventricular rhythm.
➍ A high-energy shock is delivered.

Comments
R-wave double-counting
This is a relatively rare cause of inappropriate shock in current devices. The R-wave
double-counting interval was measured at 132ms, and the issue was resolved by increasing
the VRP after ventricular sensing from 125ms to 157ms.
In case of a very wide QRS complex, the ventricular blanking may not be able to cover
the full interval. If the 2nd component of the ventricular EGM is of low amplitude, the
issue may be resolved by reducing sensitivity levels or by activating algorithms that avoid
CASE 51
T-wave oversensing (such as increasing the threshold start or programming a decay delay;
see Case 48).
207
A 71-year-old patient, implanted with a CRT-D for ischaemic heart disease and the pri-
mary prevention of sudden death, called the device clinic one afternoon, complaining of
fatigue, dyspnoea, and dizziness since 3 days, without any shocks. As the patient was on
remote device management, a patient-initiated interrogation was performed. The print
screen of the diagnostics overview is shown in Figure 52.1, and a strip of the real-time
EGM is displayed in Figure 52.2.
Figure 52.1 Diagnostics overview obtained by remote transmission

Question
Figure 52.2 Remotely transmitted real-time EGM
EGM1: Atip to Aring
CASE 52
EGM2: RVtip to RVring
A-A Interval (ms)
209
Markers
V-V Interval (ms)
What is the patient’s baseline rhythm?

A Sinus rhythm
C Atrial bigeminy
D VT
Answer
D VT
Figure 52.3 Annotated remotely transmitted real-time EGM
➊
SECTION 2 ICD
EGM1: Atip to Aring ➋ ➋
➌ ➌
EGM2: RVtip to RVring
210 A-A Interval (ms)
Markers
V-V Interval (ms)
The device indicated that ventricular pacing was <90%, and that ventricular sensing ➋ There is intermittent VA block (that is rate-dependent). The V > A ratio confirms VT.
occurred during >60s (Figure 52.1). The diagnosis of a slow irregular VT was made by
➌ The short runs are initiated by ventricular events, thereby also confirming VT.
analysing the real-time EGM (Figure 52.3). The VT was not detected by the ICD, because it
was slower than the VT monitoring zone set at 140bpm.
➊ A large FFRW is visible on the atrial channel but is not detected by the ICD, as it falls in
the PVAB period. The 2nd sharp signal is the near-field atrial signal due to retrograde VA
conduction.
Comments
Importance of real-time EGM strips for remote device
management
Upon diagnosis of VT, the patient was immediately admitted to the emergency
room. The VT accelerated (Figure 52.4a) with syncope and multiple shocks, with
almost immediate recurrence of VT after each shock. The patient was intubated and
administered intravenous amiodarone, which allowed the resumption of stable sinus
rhythm (after a total of 32 shocks). Multiple organ failure developed, but the patient
CASE 52
recovered and was discharged on amiodarone after 3 weeks. A remote device follow-up
was performed after 6 months and showed no recurrence of ventricular arrhythmias,
with >99% VP (Figure 52.4b). This example shows the importance of always checking the
real-time EGM that is displayed with remote device transmissions.
Figure 52.4 (a) VT recorded upon admission. (b) Remote device follow-up performed at 6 months, showing the absence of recurrence of ventricular 211
arrhythmias under amiodarone and recovered daily patient activity.
(a) (b)
A patient with ischaemic heart disease was implanted with a dual-chamber ICD for the
primary prevention of sudden death. He was seen at routine follow-up at 2 months after
implantation, without any complaints. Device interrogation revealed high-rate ventricu-
lar episodes, which are shown in Figure 53.1. All electrical parameters were normal. The
device settings are shown in Table 53.1.

Zone Slow VT VT VF
Rate (bpm/ms) 160/375 190/316 240/250
Detection (s) 12 2.5 2
Therapy Monitor ATP + shocks Shocks
Pacing mode DDI
Lower rate 40bpm
RV output (integrated bipolar) [email protected]

Question
Figure 53.1 EGM of high-rate ventricular episode
RV
CASE 53
Shock
213

A Electromagnetic interference
B Lead fracture
C Diaphragmatic myopotential oversensing due to integrated bipolar sensing
D Pectoral myopotential oversensing due to DF-1 switch
Answer
D Pectoral myopotential oversensing due to DF-1 switch
Figure 53.2 Annotated EGM of high-rate ventricular episode
A ➋
SECTION 2 ICD
RV
➊
Shock
214
The following points from Figure 53.2 may be observed. on the shock channel, which is unusual for diaphragmatic myopotentials. A more likely
explanation is pectoral myopotential oversensing due to accidential DF-1 inversion at
➊ High-frequency artefacts are visible on the RV (tip to RV coil) and shock (can to RV
implantation.
coil) EGMs. Lead fracture of the RV coil may produce artefacts on these two channels
in an integrated bipolar lead, but fracture artefacts are usually more erratic, and the ➋ AF is visible on the atrial channel, but there are no artefacts, which rules out
‘crescendo–decrescendo’ aspect suggests myopotentials. The artefacts are of large amplitude electromagnetic interference.
Comments
DF-1 switch
With integrated bipolar leads, the RV coil is used as the anode in the pace/sense circuit,
with an internal Y connection between the RV DF-1 connector and the IS-1 connector
(Figure 53.3a). As the positive DF-1 connector is internally connected to the ICD casing,
accidental inversion of the DF-1 lead terminals will result in the ICD casing becoming
part of the sensing circuit (Figure 53.3d). Therefore, myopotential oversensing may be
present during pectoral muscle contraction (this was confirmed in the device clinic in the
present case). Not only is there a risk of inappropriate shock, but shocks may be ineffective
CASE 53
because of shunting of the current between the SVC coil and the can (Figure 53.3e). This
situation needs to be corrected by reintervening and correcting the DF-1 connections.
DF-1 inversion with true bipolar leads will not result in myopotential oversensing, but the
issue with the shock vectors remains. This issue is avoided with DF-4 leads.
Figure 53.3 Consequences of switching DF-1 pins with integrated bipolar ICD leads
215
Sensing Shock
SVC coil internally connected to the can

+ +
RV high voltage coil (HVB)
pacing/sensing anode
Integrated bipolar
Integrated bipolar
+ –
Adapted from Medtronic CoreICD

(b) – Normal (c) Normal
– +
+
+ +
– Inverted DF-1 Inverted DF-1
(a) (d) (e)
Section 3
CRT
Cases 54–70
A 76-year-old patient with ischaemic cardiomyopathy was implanted with a CRT-D and
followed up 1 month after device implantation. He had no new cardiac complaints, and
electrical parameters were normal. The counters indicated biventricular pacing in 66.6%
of the time only (Figure 54.1). A real-time EGM is shown in Figure 54.2.
Figure 54.1 Ventricular rate histogram (left panel) and

pacing counters (right panel)
100 VS AS–VS 2.5%

VP AS–VP 57.9%
80
Ventricular
AP–VS 0.4%
% of time
60 AS–VP 39.2%
40
VP 66.6%
20
VSR pace 1.8%
0 VS 31.6%
<40 60 80 100 120 140 160 180 200 220>
Ventricular rate (bpm)
Question
CASE 54
219
What is the cause for non-delivery of cardiac resynchronization therapy (CRT)?

A Premature atrial beats
B Premature ventricular beats
C Junctional beats
D Atrial undersensing
Answer
B Premature ventricular beats

SECTION 3 CRT
➊ ➊ ➊ ➊
220
➋ ➋ ➋ ➋
➊ Monomorphic premature beats can be visualized in the ventricular channels (Figure 54.3). ➋ The atrial events fall in the blanking period but are displayed as ‘Ab’ (few manufacturers
These beats are earlier in the LV channel (EGM3) than the RV channel (EGM2) and also occur currently use this denomination). The VS–Ab intervals are slightly variable, which speaks
early with respect to the leadless ECG channel (LECG: can to SVC), implying an LV origin. against junctional beats.
Comments
Loss of cardiac resynchronization therapy delivery due to
ventricular premature beats
Note that the sum of percentages of AS–VP and AP–VP (57.9% + 39.2% = 97.1%) does
not reflect the total percentage of ventricular pacing which is only 66.6%. This is due to
the Vx–VS sequences (i.e. VPBs) which reduce the percentage of ventricular pacing.
The patient refused radiofrequency ablation of the VPBs and was placed on amiodarone
(in addition to the beta-blocker therapy that had been introduced previously). The
CASE 54
number of premature beats fell considerably, with delivery of CRT in 97% of the time.
Frequent VPBs may induce ventricular dysfunction and are also a cause for non-delivery
of CRT. Radiofrequency ablation of VPBs in CRT non-responders has been shown to
improve LVEF in these patients.1
221
Reference
1. Lakkireddy D, Di Biase L, Ryschon K, et al. Radiofrequency ablation of premature ventricular ectopy improves
the efficacy of cardiac resynchronization therapy in nonresponders. J Am Coll Cardiol 2012; 60: 1531–9.
A patient, equipped with a CRT-D, was followed by remote monitoring. An alert message
was received to indicate that biventricular pacing occurred in <85% of the time. The
transmission included the graphs in Figure 55.1, which indicate biventricular pacing as
78% of events and VPBs (Vx–Vx sequences) as 21% of events. An extract of the 30s real-
time periodic EGM is shown in Figure 55.2.
Figure 55.1 Event counter graphs transmitted by remote monitoring

CRT pacing [%] VV sequence (Vx - Vx) [%]
100 100
80 80
60 60
% events
% events
40 40
20 20
0 0
25 28 06 09 12 15 18 21 25 28 févr. 03 06 09 12 15 18 21
24 Jan 2011 Time (days) 24 Feb 2011 24 Jan 2011 Time (days) 24 Feb 2011
Question
Figure 55.2 Real-time EGM obtained by remote transmission
A
RV
LV
LVp
LVp
LVp
LVp
LVp
mV
CASE 55
A
223
RV
LV
–24 –23 –22 –21 –20 –19 –18
Periodic EGM Time (seconds)
What is the reason for the reduction in CRT delivery?

A Frequent VPBs
B Ventricular non-capture
C Prolonged AVI
Answer
Figure 55.3 Annotated real-time EGM obtained by remote transmission
A
SECTION 3 CRT
RV
LV
LVp
LVp
LVp
LVp
LVp
mV
A
➋ ➌ ➋ ➌ ➋
224
➊ ➊ ➊
RV
LV
–24 –23 –22 –21 –20 –19 –18
Periodic EGM Time (seconds)
Atrial undersensing led to the absence of tracking of the P-waves by the device and resulted automatic gain). These events will be counted as VPBs (as there are no AS or AP events
in intrinsic AV conduction (Figure 55.3). preceding them).
➊ Intrinsic ventricular activity is visible on the ventricular channels (note the ➋ An intrinsic atrial event is, however, visible on the atrial channel before each of these
interventricular conduction delay and the difference in EGM morphology with the paced/ beats, but these events are not sensed.
captured ventricular events which are displayed as being of low amplitude due to the
➌ The EGM of the atrial events are sometimes clipped, due to digital processing.
Comments
Loss of cardiac resynchronization therapy delivery due to atrial
undersensing
The remotely transmitted data showed that measured P-wave amplitude bordered the set
sensitivity level of 0.5mV (Figure 55.4).
The patient was summoned to the device clinic where the sensitivity was set to the
maximum level at 0.2mV, with an increase of CRT delivery to >95% thereafter.
CASE 55
Atrial undersensing should be suspected in case of a high count of VPBs by a pacemaker
or ICD, as these are defined by the device as VS events that are not preceded by AS or
AP events (or AR events in some devices). Atrial undersensing may then be confirmed
by evaluating the trends in P-wave sensing amplitudes and by analysing real-time EGM
tracings.
Figure 55.4 Evolution of P-wave detection amplitude

225
Mean RA detection (mV) Min. RA detection (mV)
>5,0
5
Sensing amplitude [mV]
<0,5
25 28 févr. 03 06 09 12 15 18 21
21 Jan 2011 Time (days) 24 Feb 2011
A patient with ischaemic heart disease implanted with a biventricular ICD was placed
on remote device management. An alert message was received by the device clinic.
The patient was contacted by phone and complained of increased dyspnoea. He was
subsequently admitted to the hospital for decompensated heart failure. Elements of the
device interrogation are shown in Figure 56.1.
Question
Figure 56.1 Data from device interrogation after hospital admission
P = Program
I = Interrogate I I I >200
OptiVol 2.0 fluid index
= Remote OptiVol
24 Threshold 160
AT/AF toal hours/day 20
16 120
12
8
4 80
0
100 40
% = Pacing/day
Case 56
75
Atrial
50 Fluid
Remote 0
25 Jan 2012 Mar 2012 May 2012 Jul 2012 Sep 2012
0 >100
Thoracic impendance
>120
Avg V. rate (bpm) (ohms) 90
100
Day Daily
80
Night Reference 80
60
<40 70 227
4
Patient activity 60
3
hours/day
2
50
1
0 40
Jan 2012 Mar 2012 May 2012 Jul 2012 Sep 2012 Jan 2012 Mar 2012 May 2012 Jul 2012 Sep 2012
What does the device indicate?

A Rapidly conducted atrial arrhythmia with non-delivery of CRT
B Reduction in daily patient activity
C Increased lung fluid
D All of the above
Answer
D All of the above
Figure 56.2â•‡ Annotated data from device interrogation after hospital admission
P = Program
I = Interrogate I I I >200
OptiVol 2.0 fluid index
= Remote OptiVol
➍ ➊
SECTION 3â•‡ CRT
24 Threshold 160
AT/AF toal hours/day 20
16
➍
120
12
8 ➋
4 80
0
100 40
% = Pacing/day
75
Atrial
50 Fluid
Remote 0
25 Jan 2012 Mar 2012 May 2012 Jul 2012 Sep 2012
0 >100
Thoracic impendance
>120
228 Avg V. rate (bpm)
Day
100
80
(ohms)
Daily
90
Night Reference 80
60
<40 70
➌
4
Patient activity 60
3
hours/day
2
50
1
0 40
Jan 2012 Mar 2012 May 2012 Jul 2012 Sep 2012 Jan 2012 Mar 2012 May 2012 Jul 2012 Sep 2012
This example (Figure 56.2) shows device parameters that may be analysed to help manage ➌ The Optivol threshold crossing is due to the accumulation of differences between daily
heart failure patients. transthoracic impedances and the moving average values.
➊ Onset of AF is accompanied by a fall in CRT delivery, increase in heart rates, and a ➍ An Optivol ‘false positive’ alert had previously been triggered but had not been
reduction in daily patient activity. accompanied by changes in other risk indicators (AF, heart rate, daily activity, etc.).
➋ The lung fluid indicator (Optivol index of Medtronic) crossed the predefined threshold
of 100 ohm.days. The threshold had been increased previously from the default value of
60 ohm.days, due to ‘false positive’ alerts.
Comments
Integrated heart failure diagnostic tools
Current CRT devices record a wealth of information that may be used to help manage
heart failure patients. These parameters may be used to risk-stratify patients and are
particularly useful in the setting of remote device and patient management, as they
allow the device specialist to get a better picture of the patient being followed remotely.
Parameters that may be used for remote heart failure management in device patients
include: body weight, blood pressure, heart rate, heart rate variability, respiratory rate,
daily activity, atrial and ventricular arrhythmias, percentage of ventricular pacing and
Case 56
lung fluid overload. Combining these parameters is of interest,1 as this strategy allows to
increase the specificity of risk stratification and to reduce ‘false positive’ lung fluid alerts
(which are probably subclinical events).
Reference 229
1. Whellan DJ, Ousdigian KT, Al-Khatib SM, et al. Combined heart failure device diagnostics identify patients at
higher risk of subsequent heart failure hospitalizations: results from PARTNERS HF (Program to Access and
Review Trending Information and Evaluate Correlation to Symptoms in Patients With Heart Failure) study.
J Am Coll Cardiol 2010; 55: 1803–10.
Remote device management was performed in a patient implanted with a CRT-D. The
device counters showed 100% atrial sensing and biventricular pacing. A periodic real-time
EGM was transmitted and is shown in Figure 57.1.
Question
Figure 57.1 Periodic real-time EGM obtained by remote transmission
Case 57
231
What can be observed?
A Loss of RV pacing
B Loss of LV capture
C AV delay programmed too long
Answer
B Loss of LV capture
Figure 57.2â•‡ Annotated periodic real-time EGM obtained by remote transmission

232
➋ ➊ ➋
➊ The LV EGM shows the absence of LV capture (Figure 57.2). There is a delay between ➋ These two cycles show evidence of LV capture (the ventricular potential is seen
pacing (indicated by the blue line) and the ventricular potential in this channel. This delay directly after the spike, with a different morphology, compared to the other cycles
corresponds to the interval between the RV capture (that can be seen in the RV channel) without LV capture).
and interventricular conduction. The LV events are not sensed, due to the interventricular
refractory period.
Comments
Loss of left ventricular capture
Loss of LV capture occurs in approximately 10% of patients with CRT, due to a rise in LV
threshold, lead dislodgement, or lead failure.1 This will result in RV capture only, which
may be detrimental in patients with impaired LV function (and may be worse than no
pacing at all).
Capture thresholds are often higher for the LV than in the RV, possibly due to less intimate
contact of the lead with the myocardium. Day-to-day fluctuations of the LV threshold
Case 57
are also higher, particularly in patients who have a high LV threshold.2 A sufficient
safety margin must therefore be programmed, in order to ensure consistent LV capture.
This may, however, compromise battery longevity or may lead to phrenic nerve capture.
Automatic LV threshold algorithms are particularly useful, as they may allow reducing the
pacing output.
233
References
1. Knight BP, Desai A, Coman J, Faddis M, Yong P. Long-term retention of cardiac resynchronization therapy. J Am
Coll Cardiol 2004; 44: 72–7.
2. Burri H, Gerritse B, Davenport L, Demas M, Sticherling C. Fluctuation of left ventricular thresholds and required
safety margin for left ventricular pacing with cardiac resynchronization therapy. Europace 2009; 11: 931–6.
A patient, who had been implanted 2 months ago with a CRT-D, was admitted for
decompensated heart failure. A rhythm strip of the limb leads was recorded and is
shown in Figure 58.1.
Question
Figure 58.1 ECG strip
Case 58
235

A Intermittent loss of RV capture
B Intermittent loss of LV capture
C Intermittent RV non-pacing
D Intermittent LV non-pacing
Answer
B Intermittent loss of LV capture
Figure 58.2â•‡ Annotated ECG strip
➊ ➊ ➊ ➊ ➊
236
The ECG (Figure 58.2) shows two paced QRS morphologies. feature is available on some models to assist interpretation); otherwise, they would have
been of identical amplitude in all ECG channels (and are smaller in lead II, due to this lead
➊ A wider QRS implies univentricular capture. The fact that this QRS complex is more
being perpendicular to the pacing vector).
positive in lead I than during biventricular capture implies that this is RV capture only (i.e.
the right-to-left electrical forces are more dominant). Intermittent non-pacing due to interventricular crosstalk is rare, because of VRPs or
because the LV channel is not used for sensing in most devices. Intermittent RV non-
The pacing artefacts are of high amplitude in all the cycles, implying that LV pacing (which
pacing is not compatible with the ECG changes (Figure 58.3). Intermittent LV non-pacing
was programmed to an extended bipolar LV tip–RV coil configuration) was delivered each
would have been accompanied by a change in the pacing spike amplitude.
time. In this case, the pacing artefacts are not reconstructed by the electrocardiograph (this
Comments
Identifying intermittent loss of Figure 58.3 ECG changes with different pacing configurations of CRT
ventricular capture of cardiac BV –125° RV –59°
LV BV RV
resynchronization therapy by the ( –151°––99°) (–47°––71°) I
surface electrocardiogram
II
The surface ECG may be useful to identify intermittent
loss of RV or LV capture (due to an increase in LV LV 171°
Reproduced with permission from Ganière et al. Europace 2013.1

(158°––177°)
Case 58
threshold in this patient). Frontal QRS axes during III
different ventricular pacing configurations are shown in
Figure 58.3 (data shown as mean ± 95th confidence QRS width Narrowing Unchanged Widening
interval). A simple algorithm has been described1 aVR
(Figure 58.3) which evaluates the QRS width (a

narrower QRS indicating biventricular capture), with aVL 237
increasing negativity (which is synonymous with Increasing
No Yes Yes No No Yes
negativity lead I
decreasing positivity) in lead I indicating increasing
aVF
contribution of LV capture.
Another useful lead is V1, which shows increasing
LV➔BV RV➔BV BV➔RV BV➔LV
positivity of the QRS complex with greater participation V1
of LV capture (Figure 58.3). This holds true for an LV Geneva ECG algorithm to diagnose intermittent loss of ventricular capture
lead implanted in a (postero-) lateral position; however,
the QRS complex will be negative in lead V1 in the case
of an anterior LV lead.1
Reference
1. Ganière V, Domenichini G, Niculescu V, Cassagneau R, Defaye P, Burri
H. A new electrocardiogram algorithm for diagnosing loss of ventricu-
lar capture during cardiac resynchronisation therapy. Europace 2013; 15:
376–81.
A patient, implanted with a biventricular pacemaker, was seen at follow-up. She com-
plained of breathlessness. The device settings are shown in Table 59.1, and a rhythm
strip with biventricular pacing temporarily inactivated on the right of Figure 59.1.

Pacing mode DDD
Lower rate 50bpm
Upper rate 140bpm
AV delay (paced/sensed) 120ms/60ms
VV delay 20ms (LV first)
Atrial output [email protected]
LV output (extended bipolar) [email protected]

Question
Figure 59.1 Rhythm strip with biventricular pacing, and temporary inactivation of pacing (last three cycles)
CASE 59
239
Which of the following statements is most likely to be true?

A The LV pacing ouput needs to be increased
B The VV delay needs to be decreased
C The atrial sensitivity needs to be increased
D The AV delay needs to be increased
Answer
D The AV delay need to be increased
Figure 59.2 Annotation of rhythm strip with biventricular pacing, and temporary inactivation of pacing (last three cycles)
➋
SECTION 3 CRT
240
This example (Figure 59.2) shows how the surface ECG may indicate inadequate ➋ The paced QRS complex is negative in lead I and narrower than in intrinsic rhythm,
programming of the AV delay. indicating biventricular capture. There is therefore no need to increase the ventricular
output.
➊ The ventricular spikes fall on the peak of the P-waves, implying that the AV delay is
likely to be programmed too short.
Comments
Recognizing a suboptimal atrioventricular delay using the
surface electrocardiogram (1)
It is important that the AV delay is programmed adequately, as, if it is too short,
ventricular filling may be compromised, and, if it is too long, ventricular pseudofusion
may occur. A previous study has shown that ventricular pacing should occur at
approximately 40ms after the end of the intrinsic P-wave.1
Another point that can be discussed in this case is that a negative paced QRS in lead I
CASE 59
implies LV capture.2 One should nevertheless be cautious regarding this observation, as a
negative QRS in this lead may also be observed with RV capture only.3,4,5
References
1. Jones RC, Svinarich T, Rubin A, et al. Optimal atrioventricular delay in CRT patients can be approximated using
surface electrocardiography and device electrograms. J Cardiovasc Electrophysiol 2010: 21: 1226–32. 241
2. Ammann P, Sticherling C, Kalusche D, et al. An electrocardiogram-based algorithm to detect loss of left ventricu-
lar capture during cardiac resynchronization therapy. Ann Intern Med 2005; 142: 968–73.
3. Burri H, Park C, Zimmermann M, et al. Utility of the surface electrocardiogram for confirming right ventricular
septal pacing: validation using electroanatomical mapping. Europace 2011; 13: 82–6.
4. Balt JC, van Hemel NM, Wellens HJ, de Voogt WG.Radiological and electrocardiographic characterization of
right ventricular outflow tract pacing. Europace 2010; 12: 1739–44.
5. Ganière V, Domenichini G, Niculescu V, et al. A new electrocardiogram algorithm for diagnosing loss of ven-
tricular capture during cardiac resynchronisation therapy. Europace 2013; 15: 376–81.
A patient was seen at 1-month follow-up after CRT implantation, complaining of wors-
ening of dyspnoea since the procedure. Device follow-up showed normal thresholds.
The device settings are shown in Table 60.1. Because there were no clues from the device
interrogation as to the reason for worsening of the patient’s symptoms, a transthoracic
echocardiogram was performed. The transmitral pulsed-wave Doppler flow is shown on
Figure 60.1.

Pacing mode DDDR
Lower rate 60bpm
Upper rate 140bpm
LV output (bipolar) [email protected]

Question
Figure 60.1 Pulsed-wave Doppler of transmitral flow
CASE 60
243
Based upon the transmitral Doppler flow, what should be done?

A Increase the AVI
B Decrease the AVI
C Increase the VV interval
D Decrease the VV interval
Answer
A Increase the AVI
Figure 60.2 Annotated pulsed-wave Doppler of transmitral flow

SECTION 3 CRT
244
The transmitral flow was recorded during AV pacing at the out-of-the box AVI of 140ms
(Figure 60.2).
➊ The A-wave is of low amplitude and seems truncated, and ventricular pacing occurs
much earlier than the A-wave. This suggests that the AVI needs to be lengthened. The
transmitral flow does not give any information on whether the VV interval needs to
be adjusted.
Comments
Optimizing atrioventricular delays using echocardiography
There are a number of different techniques for AV optimization by and to limit optimization to those patients who have evidence of A-wave
echocardiography,1 the simplest, and probably most robust one being the truncation.2,3
iterative method. The transmitral flow during AAI pacing is shown in
Figure 60.3a; a large A-wave can be seen that contributes to about a third References
of ventricular filling. The patient’s intrinsic AP–VS delay was measured 1. Burri H, Sunthorn H, Shah D, Lerch R. Optimization of device programming for cardiac
at 340ms, so the AVI was programmed to 300ms and decremented by resynchronization therapy. Pacing Clin Electrophysiol 2006; 29: 1416–25.
20ms steps, with recording the transmitral flow at each step until A-wave 2. Gorcsan J 3rd, Abraham T, Agler DA, et al. Echocardiography for cardiac resynchronization
CASE 60
therapy: recommendations for performance and reporting—a report from the American
truncation was apparent at a programmed AV delay of 240ms (Figure 60.3b).
Society of Echocardiography Dyssynchrony Writing Group endorsed by the Heart Rhythm
The AVI was finally programmed at 260ms (Figure 60.3c), which avoided Society. J Am Soc Echocardiogr 2008; 21: 191–213.
A-wave truncation, while still resulting in biventricular capture (note 3. Daubert J-C., Saxon L, Adamson PB, et al. 2012 EHRA/HRS expert consensus statement on
that the ECG on the rhythm strip is different compared to that with AAI cardiac resynchronization therapy in heart failure: implant and follow-up recommendations
pacing) and was later confirmed by recording a 12-lead ECG. and management. Europace 2012; 14: 1236–86.
245
The patient improved remarkably thereafter.
As it is impractical to perform AV optimization routinely, it may be useful
to perform screening of the transmitral flow after device implantation
Figure 60.3 Transmitral pulsed-wave Doppler during different settings
AAI AVI 240ms AVI 260ms
(a) (b) (c)

A patient implanted with a CRT-D was followed up at the device clinic, complaining of
breathlessness. The device counters revealed 19% AP and 83% RV/LV pacing. The rate
histograms are shown in Figure 61.1. The surface ECG during biventricular pacing and
temporary inactivation of pacing is shown on Figure 61.2.
Figure 61.1 Rate histograms

75
A
% Paced
Sensed
0
<30 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 ≥250
Heart rate (min–1)
50
RV
Paced
Sensed
%
LV
Paced
Sensed
0
<30 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 ≥250
Heart rate (min–1)
Question
Figure 61.2 ECG recorded during biventricular pacing (left) and after temporary inactivation of pacing (arrow)
CASE 61
247
Based upon the information provided, what do you think should be modified in the device settings?
A Decrease the programmed AVI
B Increase the programmed AVI
C Increase the RV output
D Increase the LV output
Answer
A Decrease the programmed AVI
Figure 61.3 Annotated ECG recorded during biventricular pacing (left) and after temporary
inactivation of pacing (arrow)
➊
SECTION 3 CRT
248
➊ The paced QRS complexes are only slightly different in morphology, compared to
those in intrinsic rhythm. This indicates that there is fusion, but with little contribution of
biventricular capture. The slight narrowing of the QRS complex during pacing, compared
to intrinsic rhythm (that shows left bundle branch block), implies that there is LV capture
(there is therefore no need to increase the LV output) (Figure 61.3).
Comments
narrower QRS with a greater degree of contribution of biventricular capture to the fused
Recognizing a suboptimal atrioventricular interval QRS complex (Figure 61.4).
using the surface electrocardiogram (2) An alternative to shortening the AV delay would have been to programme rate-adaptive
This example illustrates how the surface ECG may be used to evaluate pseudofusion or AVIs, as the rate histogram showed that intrinsic AV conduction occurred more frequently
fusion with little contribution of ventricular capture. The AVI was shortened from 140ms at higher heart rates (Figure 61.1). The rate adaptation of AVIs varies, however, between
to 100ms under echocardiographic guidance, using the iterative method, which yielded a different device manufacturers, and a potential risk is truncation of the A-wave in case the
interval is too short at higher heart rates.
Figure 61.4 ECG with biventricular pacing after shortening of the AV delay
CASE 61
249
A patient implanted with a CRT-D for non-ischaemic heart disease was admitted for
decompensated heart failure. A device follow-up was performed and showed normal
parameters (RV threshold was 1.1 [email protected], and LV capture threshold was [email protected]).
A 12-lead ECG was recorded during simultaneous biventricular pacing (BiV0) and uni-
ventricular RV and LV pacing (Figure 62.1).
Question
Figure 62.1 ECG with different pacing configurations
BiV0 RV LV
CASE 62
251
How may one explain the very similar ECG morphology between biventricular pacing
and RV pacing?
A LV latency
B RV anodal capture
C LV anodal capture
D Increase in LV threshold
Answer
A LV latency
Figure 62.2 Annotated ECG with different pacing configurations

BiV0 RV LV LV-20 LV-40 LV-60 LV-80 LV-100
SECTION 3 CRT
252
➊
➋ ➌
In addition to BiV0 and RV and LV pacing, different sequential biventricular pacing ➋ There is an isoelectric interval between the LV pacing spike and onset of the QRS
configurations with LV pre-excitation are shown in Figure 62.2. complex, indicating latency.
➊ LV capture is evident during LV pacing alone, with a QRS morphology indicating a ➌ During sequential BiV pacing with increasing LV pre-excitation, increasing
postero-lateral lead (positive QRS in the right precordial leads, relatively isoelectric QRS in contribution of the LV vector is observed and is best appreciated in the precordial leads.
the inferior leads).
Comments
Left ventricular latency
A delay between the pacing spike and ventricular depolarization is known Sequential CRT with LV pre-excitation by 80ms was programmed, with
as latency and may result from myocardial ischaemia, anti-arrhythmic remarkable improvement in the patient’s symptoms thereafter.
drugs, hyperkalaemia, and pacing at a site of scar.1 A delay of <40ms to the This example illustrates the importance of systematically evaluating ECGs
rapid deflection of the QRS complex may be observed when pacing from in patients with CRT.
a CS tributary, probably due to a delay of activation of the Purkinje fibres.
If the LV pacing lead overlies scar tissue, an initial isoelectric interval in Reference
all 12 leads may be observed. This is an issue with CRT, as contribution of
CASE 62
1. Barold SS, Herweg B. Usefulness of the 12-lead electrocardiogram in the follow-up of patients
ventricular activation from the LV lead will be reduced, as in the present with cardiac resynchronization devices. Part II. Cardiol J 2011; 18: 610–24.
example, and may be corrected by programming sequential biventricular
pacing with LV pre-excitation. LV latency was measured at 84ms in this
patient (Figure 62.3; recorded at 100mm/s during LV pacing).
Figure 62.3 ECG (recorded at 100mm/s) during LV pacing showing evidence of latency
253
Follow-up was performed in a patient implanted with a CRT-D who was complaining
of shortness of breath. A real-time EGM strip was recorded and is shown in Figure 63.1.
Device settings are shown in Table 63.1.

Pacing mode DDDR
Lower rate 60bpm
Upper rate 140bpm
AV delay—fixed (paced/sensed) 250ms/200ms
RV sensitivity (dedicated bipolar) 0.4mV

Question
Figure 63.1 Real-time EGM strip recorded during follow-up
Markers
CASE 63
Atrial
RV
255
Uni. LV
How do you explain the variable AVIs?

A Rate-adaptive AV delays
B Negative AV hysteresis
C Ventricular safety pacing
D Triggered ventricular pacing (VVT mode)
Answer
B Negative AV hysteresis
Figure 63.2 Annotated real-time EGM strip recorded during follow-up

SECTION 3 CRT
Markers ➊
➌ ➍ ➋
Atrial
256
RV
Uni. LV
This patient had frequent VPBs, which led to variable AVIs due to the negative AV ➋ Negative AV hysteresis (set here at a value of –40ms) reprogrammes the AVI to 102ms.
hysteresis algorithm (Figure 63.2).
➌ The AVI at the beginning of the tracing is only 74ms, due to a previous VPB (falling at
➊ A VPB falls in the AVI (at 141ms after AP and after the end of the ventricular safety 114ms after AP).
pacing window). Note that the morphology algorithm shows a mismatch with the stored
➍ Periodic extensions of the AVIs occur to the default value and, if VP occurs, are
template (labelled ‘X’, with 58% similarity).
maintained at this value until the next Ax–VS event.
Comments
Negative atrioventricular hysteresis
This feature is designed to respond to events with intrinsic AV conduction and to
maximize ventricular pacing. It was introduced initially in the era when RV pacing was
believed to be useful in the setting of hypertrophic obstructive cardiomyopathy and
is now mainly used in CRT devices. As AV conduction properties are variable during
the 24-hour period, loss of CRT may be avoided in situations where AV conduction
is facilitated (e.g. during exercise). However, as illustrated in this case, VPBs falling
during the AVI may be interpreted as intrinsic conduction and unduly shorten this
CASE 63
parameter. This may lead to reduced ventricular filling (due to A-wave truncation), with
unfavourable haemodynamic consequences.
The feature was inactivated in this patient, with improvement in symptoms.
257
A patient implanted with a CRT-D presented for follow-up. He complained of dyspnoea
and palpitations. A surface ECG was recorded and is shown in Figure 64.1.
Question
Figure 64.1 Presenting ECG recorded at follow-up
Case 64
259

A Rate-responsive pacing
B Intermittent atrial undersensing of AF
C Intermittent RV non-capture
Answer
Figure 64.2 Annotated presenting ECG recorded at follow-up
➋ ➊ ➋
SECTION 3 CRT
260
The baseline rhythm is AF with intrinsic AV conduction and irregular RR intervals; the contribution of LV capture to the QRS complex (with negativity in lead I). Note that the
device has a VS response algorithm that triggers LV pacing (VVT mode) as soon as an RV first of these two QRS complexes has a slight degree of fusion with intrinsic AV conduction
sensed event occurs, with a pacing spike at the beginning of each QRS complex (Figure 64.2). (the QRS complex is less negative in lead I).
➊ The narrower QRS complexes correspond to fusion between intrinsic AV conduction Ventricular pacing at an irregular rate is always due to tracking (in this case, of the ventricle).
and triggered LV pacing. Intermittent atrial undersensing of AF may indeed also lead to an irregular paced ventricular
rhythm (see Case 25) but does not explain the different QRS morphologies.
➋ The wider QRS complexes occur at longer RR intervals and correspond to biventricular
capture at the lower rate interval (and not to triggered LV pacing), explaining the greater
Comments
Algorithms for enhancing cardiac resynchronization therapy delivery during atrial fibrillation
Triggered LV pacing occurs during RV sensed events in AF (and, in some and showed that there was some LV capture (the QRS complex with VVT
devices, also in sinus rhythm) as an attempt to maintain CRT, despite pacing is slightly narrower, with less positivity in lead I; Figure 64.3).
intrinsic AV conduction. If the patient has a left bundle branch block, with
The patient’s symptoms were due to recent onset of AF (and not the
a wide QRS complex, this may indeed lead to fusion pacing, which may
VVT algorithm), which was subsequently cardioverted electrically.
have some favourable haemodynamic effect. However, in patients with a
narrower QRS or RBBB (in which case ventricular sensing by the RV lead is Another algorithm featured on some devices reacts to conducted AF
delayed with respect to the QRS onset), triggered LV pacing occurs too late by increasing the baseline rate temporarily to override the intrinsic
Case 64
to result in meaningful capture. The algorithm was inactivated temporarily AV conduction.
Figure 64.3 Temporary inactivation of triggered ventricular pacing
261
A patient implanted with a CRT pacemaker presented for follow-up, without complaints.
The counters revealed 100% of RV sensing and 100% of LV pacing. The device settings are
shown in Table 65.1, and a real-time EGM is shown in Figure 65.1.

Pacing mode DDD
Lower rate 50bpm
Upper rate 140bpm
AV delay (paced/sensed) 220ms/180ms
VV delay 0ms
LV output (unipolar) [email protected]

Question
Figure 65.1 Real-time EGM at follow-up
A
RV
RVs
RVs
RVs
RVs
RVs
RVs
RVs
RVs
RVs
LV
LVp
LVp
LVp
LVp
LVp
LVp
LVp
LVp
LVp
CASE 65
A
RV
263
LV

B Triggered LV pacing (VVT pacing)
C Negative AV hysteresis
D Programmed LV pacing only
Answer
B Triggered LV pacing (VVT pacing)
Figure 65.2 Annotated real-time EGM at follow-up
A
SECTION 3 CRT
RV
RVs
RVs
RVs
RVs
RVs
RVs
RVs
RVs
RVs
➊
LV
LVp
LVp
LVp
LVp
LVp
LVp
LVp
LVp
LVp
A
264
RV
LV
➊ RV sensing occurs, due to intrinsic AV conduction. This triggers LV pacing Ventricular safety pacing only occurs after AP events and would have been timed at an
(VVT pacing). The 4ms difference in RV and LV timing of the first cycle is due to AVI of 100ms in this device. Negative AV hysteresis would have led to shortening of the
inaccuracy of the device clock (Figure 65.2). AVI with biventricular pacing. As shown in Table 65.1, the device was programmed to
simultaneous biventricular pacing.
Comments
Triggered left ventricular pacing
Triggered LV pacing in this case led to fusion with intrinsic AV conduction and
substantial LV capture, as evidenced by narrowing of the QRS complex and increasing
negativity in lead I (Figure 65.3).
Fusion pacing was intentional in this patient, in order to allow the longest possible AV
delay to avoid A-wave truncation of the transmitral flow (which was tolerated poorly).
This was due to interatrial conduction delay, as can been appreciated by the notched and
CASE 65
prolonged (140ms) P-wave (best seen in lead II on the right panel of Figure 65.3).
Figure 65.3 Effect of triggered LV pacing with ventricular capture and narrowing of the QRS
VVT on VVT off
265
A patient was implanted with a CRT-D, with an LV lead in the anterior cardiac vein
(Figure 66.1a), and consulted after 3 weeks due to breathlessness. The device counters
showed 100% RV pacing and 100% LV sensing (Figure 66.1b). The programmed settings
are shown in Table 66.1. A real-time EGM is shown in Figure 66.2.
Figure 66.1 Postero-anterior fluoroscopic view showing the LV lead in the anterior cardiac Table 66.1 Device settings
vein (a) and the rate histograms (b)
Pacing mode DDD
50
Lower rate 50bpm
Atrial Upper rate 140bpm

Paced
(%)
Sensed
0 RV output (bipolar) [email protected]
≤30 50 70 90 110 130
50 LV output (extended bipolar) [email protected]
Ventricular Atrial sensitivity (bipolar) 0.3mV

RV LV
(%) RV sensitivity (integrated bipolar) 0.4mV
Paced
Sensed LV sensitivity (bipolar) 2.5mV
0
≤30 50 70 90 110 130
(b)
(a) Rate (min–1)
Question
LV
CASE 66
267
What is the cause for the lack of LV pacing?

A Far-field P-wave oversensing
B FFRW oversensing
Answer
A Far-field P-wave oversensing

SECTION 3 CRT
LV ➊ ➋
268
The far-field P-wave oversensing of the LV lead was due to its basal position in the CS tributary LV pacing but does not reset the timers in this device. RV pacing therefore occurs at the
(Figure 66.3). Dislodgment of the lead into the CS would also result in a similar EGM. end of the programmed AVI.
➊ The 1st potential on the LV EGM corresponds to left atrial activity (and follows too ➋ The 2nd potential on the LV EGM corresponds to local ventricular activity.
shortly after right atrial sensing to correspond to AV conduction). The LVS event inhibits
Comments
Far-field P-wave oversensing of the LV lead
The proximal pole of the LV lead was picking up atrial signals, due to its basal location.
Extending the PAVB would not be useful, as this period is only activated after AP.
Decreasing the sensitivity levels would also not be a solution, as the far-field P-wave
is of greater amplitude than the R-wave. The problem was resolved by eliminating the
LV proximal electrode from the sensing circuit and programming an extended bipolar
configuration (LV tip to RV coil), without any far-field P-wave signal (Figure 66.4).
CASE 66
Figure 66.4 LV EGM after programming sensing to extended bipolar
A
269
LV
A patient implanted with a CRT-D was seen at 2 months’ follow-up, without any
improvement in symptoms. An LV threshold test was performed at 0.4ms pulse width
(with bipolar pacing) and is shown in Figure 67.1.
Question
Figure 67.1 EGM recorded during the LV threshold test
CASE 67
RV
Can–RV coil
271
What is the LV capture threshold amplitude?

A 0.75V
B 1.00V
C 1.25V
D Some other value
Answer
D Some other value
Figure 67.2 Annotated EGM recorded during the LV threshold test

SECTION 3 CRT
➊ ➌
RV
272
Can–RV coil
➋
The patient had left atrial capture during the LV threshold test, due to a dislodged LV lead ➋ The far-field EGM shows that LV pacing results in atrial capture. Also, the QRS
(Figure 67.2). morphology is identical during ventricular pacing and intrinsic rhythm (i.e. the
two previous cycles).
➊ The LV threshold test is initiated with pacing at 1.5V/0.4ms. There is a delay between
LV pacing and the atrial event labelled as Ab (falling in the atrial blanking period). ➌ This cycle corresponds to loss of left atrial capture.
However, this delay is slightly shorter than that of the event in the RV channel, which is
unusual (one would expect the interval of retrograde VA conduction to be longer than that
of interventricular conduction). Also, the RV EGM morphology is identical during LV
pacing compared to during intrinsic rhythm, which points against ventricular capture.
Comments
Left ventricular lead dislodgement with left atrial pacing
This is an example that illustrates the utility of recording a surface ECG during threshold
tests, as issues may be identified more readily than by evaluating the near- or far-field
EGMs.
The LV lead had dislodged to the proximal CS due to Twiddler’s syndrome (Figure 67.3),
and the patient admitted to having flipped the generator in the pocket several times.
Pacing from this lead resulted in left atrial capture during the threshold test. New leads
CASE 67
were implanted due to possible damage, the generator was fixated in a retropectoral
pocket, and the patient was instructed not to manipulate the region anymore.
Figure 67.3 Chest X-ray showing the LV lead dislodged to the proximal
coronary sinus, with twisted leads in the device pocket due to Twiddler’s
syndrome 273
A patient equipped with a CRT-D was followed up at 6 months after device implantation.
The LV threshold had been measured at 2.7V/0.8ms at the 2-month visit. The device
settings are shown in Table 68.1, and the LV threshold test performed at a pulse width of
0.8ms is shown in Figure 68.1.

Pacing mode DDD
Lower rate 50bpm
Upper rate 140bpm
LV sensitivity (LV tip–RV coil) 2.5mV

Question
Figure 68.1 Real-time EGM during the LV threshold test
II
RV
CASE 68
LV
275
What is the LV capture threshold?

A 2.7V
B 2.8V
C 2.9V
D Some other value
Answer
D Some other value
Figure 68.2 Annotated real-time EGM during the LV threshold test
II
SECTION 3 CRT
RV
➋
➊ ➌
276 LV
The LV lead had dislodged, but RV anodal capture resulted from the LV tip–RV coil ➋ The RV EGM shows evidence of RV capture (note the negative deflection).
(extended bipolar) pacing configuration (Figure 68.4).
➌ There is loss of RV anodal capture at 2.7V/0.8ms. The deflection on the LV EGM that
➊ The LV EGM shows two distinct potentials (Figure 68.2). The 1st potential corresponds occurs directly after the pacing spike is due to tissue polarization (after-potential) and is
to RV anodal capture, which is visible because sensing is programmed in the LV tip to RV different in morphology, compared to the 1st potential of the previous complexes (which
coil configuration. The 2nd potential is the local LV depolarization that occurred with are recorded during capture). Note that the RV EGM also shows the absence of capture.
interventricular conduction.
Comments
Anodal capture Figure 68.3 LV threshold test with unipolar pacing, showing absence of
capture (VPBs are annotated by an *)
Total loss of LV capture was confirmed in this patient by performing the threshold test in a
unipolar (LV tip to can) pacing configuration (Figure 68.3). * * *
II
Anodal capture may occur due to a ’virtual cathode’ of negatively charged tissue
surrounding the anode (with higher thresholds, compared to cathodal capture). In CRT,
it occurs when the LV pacing configuration is programmed to an extended bipolar RV
configuration (see Figure 68.4 relating to an LV threshold test in a different patient). It
occurs more commonly with CRT pacemakers than CRT-D, as the RV ring electrode
CASE 68
has a smaller surface area than the RV ICD coil with higher current density (although as
illustrated by the present case, anodal capture with the RV coil is possible). LV
The consequences of anodal capture in CRT include:

◆◆ erroneous LV capture thresholds (as in the present example). The pacing output may be
programmed consequently to a subthreshold value in the LV, resulting in loss of CRT
◆◆ simultaneous biventricular capture despite programming of sequential CRT pacing with 277
LV pre-excitation
◆◆ maintenance of biventricular capture in case the RV lead output is programmed to
subthreshold values.
Figure 68.4 Extended bipolar LV configuration (a), and ECG recorded during an LV threshold test showing initial
biventricular capture due to LV plus RV anodal capture, followed by LV capture only (b)
Extended bipolar LV pacing LV + RV anodal capture LV capture only
(a) (b)
During CRT-D implantation, a change in rhythm was observed on the monitor.
The real-time EGM recorded with wireless telemetry is shown in Figure 69.1.
Question
Figure 69.1 Real-time EGM recorded by wireless telemetry during CRT implantation
Can–RV coil
CASE 69
RV
LV
279
What is the problem?

A VPBs
B Switching of the RV and LV leads
C Switching of the A and RV leads
D Switching of the A and LV leads
Answer
C Switching of the A and RV leads
Figure 69.2 Annotated real-time EGM recorded by wireless telemetry during CRT implantation
Can–RV coil
SECTION 3 CRT
➊
A
➋
RV
➌ ❹ ❺
280 LV
Inadvertent insertion of the A lead into the RV connector, and vice versa, was identified between the LV and RV channels. As the atrial lead is connected to the RV port, an atrial
and corrected immediately during the procedure (Figure 69.2). EGM is visible).
➊ The atrial EGM signal is synchronous with the QRS complex visible on the far-field ➍ The 2nd signal on the LV EGM corresponds to the LV signal. It is not sensed by the
(can–RV coil) channel, implying that the atrial port is connected to one of the ventricular device, due to the VRP.
leads.
➎ Ventricular pacing occurs at the UTR, due to tracking of the preceding AS event.
➋ The RV EGM signal is synchronous with the P-wave, implying that the atrial lead is
➏ This AS event falls in the PVARP and therefore is not tracked. The sequences repeat
connected to this port.
themselves, leading to grouped beating.
➌ An atrial signal is visible on the LV EGM. This is because LV sensing is programmed
to an extended bipolar configuration (i.e. there is an internal connection in the generator
Comments
Lead switch
Another example of A/V lead switch on the header occurring during implantation was
shown in Case 19. The present case illustrates again the importance of verifying the
rhythm after connecting the leads at device implantation. It also shows the utility of
wireless telemetry for rapidly identifying the problem.
With ICDs, another potential mistake is to switch the DF-1 connectors, as shown in Case
53. Yet another possible error with CRT devices is to switch the RV and LV leads. This
CASE 69
may not need to be corrected, unless the LV dislodges or if sensing issues, such as far-field
P-wave oversensing of the LV lead, occurs (see Case 6). The recent advent of IS-4 leads
will avoid switches with an IS-1 RV lead, but there is the potential for switching IS-4 and
DF-4 leads. These two standards, however, have slightly different designs, as the IS-4 pin is
larger than the DF-4 pin and will not fit fully into the header (Figure 69.3). The error can
be identified by measuring high HV impedances at implantation, as there is no electrical 281
connection between the DF-4 header and the IS-4 pin.
Figure 69.3 Differences between DF-4 and IS-4 pins and connectors
DF-4 in DF-4
DF-4
IS-4 in DF-4
IS-4
No high voltage electrical connection

A Holter test was performed in a patient implanted with a CRT-D, due to palpitations
without any recorded arrhythmias. The test revealed periods with frequent VPBs that
coincided with the patient’s symptoms. In addition, an event was recorded while the
patient was sleeping, and is shown in Figure 70.1. The device settings are shown in
Table 70.1.

Pacing mode DDD
Lower rate 50bpm
Upper rate 140bpm
VV delay LV –4ms
RV sensitivity (true bipolar) 0.45mV
LV sensitivity Not available

Question
CASE 70
283
How can one explain the device behaviour?

B Automatic sensing algorithm
C Automatic atrial threshold test
D Automatic ventricular threshold test
Answer
D Automatic ventricular threshold test

SECTION 3 CRT
➋ ➋ ➋ ➋ ➌ ➌ ➊ ➊
➍ ➍
284
The Holter recording (Figure 70.2) shows an automatic LV threshold test being initiated ➍ VPBs are observed. The 1st beat is not detected by the device, as a ventricular spike
and then aborted due to VPBs. can be seen (if the premature beat originates in the LV, detection may be delayed in the
RV lead, and this device does not have LV sensing). The 2nd premature beat is probably
➊ These two complexes show biventricular pacing (narrow paced QRS) with the
detected, as the coupling interval is slightly shorter. As there is an AP–VS event during the
programmed device settings (at 50bpm and a paced AV delay of 140ms).
AV conduction test, the automatic LV threshold test is aborted (Figure 70.3).
➋ The four initial beats show a very wide paced QRS complex at intervals of 740ms.
The blue arrows correspond to AP–AP interval timing during the test. Note that no spike
Theses cycles are AV pacing with an interval of 30ms (the ventricular spike is not
is visible at the end of the 1st arrow, either because of an intrinsic P-wave or because the
reconstructed by the Holter) with univentricular LV pacing for the interventricular
atrial spike is not detected and reconstructed by the Holter. The red arrows correspond to
conduction test (Figure 70.3). Pacing at a faster rate is not observed with options A and B.
VP–VP interval timing.
➌ These two cycles show biventricular pacing at 740ms with a longer AV delay,
corresponding to the AV conduction test (Figure 70.3).
Comments
Automatic LV threshold test The algorithm functions on the principle that the interventricular interval
tends to be shorter than the intrinsic AVI. A captured LV test pace will
Unexpected device behaviour may be explained sometimes by automatic
therefore be sensed in the RV earlier than the conducted VS of a non-
threshold tests (such as seen in Case 33). The details of the function of
captured test pace. The device first evaluates the interventricular conduction
these algorithms vary between manufacturers and are almost impossible
(LVP–RVS interval) and ascertains that AV conduction is sufficiently longer
to remember, but they can be consulted on technical manuals or online
than the interventricular delay (Figure 70.3). If the criteria are fulfilled, a
resources (e.g. <http://www.medtronicfeatures.com>).
threshold test is performed, with loss of capture being defined as an RVS
In this case, the device was a Medtronic model that was performing the LV event that occurs >50 ms after the maximum LVP–RVS interval.
CASE 70
capture management algorithm. The function of this algorithm is detailed
The test is usually performed at 1 a.m. and was done at around midnight
as follows.
in this patient, due to the device being set to winter time.
Figure 70.3 Initiation of the automatic LV threshold test

LV–RV conduction test AV conduction test 285
© Medtronic
Pacing at rate + 15bpm, AVI 30ms
LV–RV success criteria: AV conduction success criteria:
LV–RV variation <= 30ms AVI → LV–RV max + 80ms
LV–RV min >= 60ms, LV-RV max < 270ms No RVS detected
Index
A Atrial noise reversionâ•‡ 105 hazards of programming longâ•‡ 121 post-ventricular atrial blanking
AAIR pacingâ•‡ 17 Atrial pacing (AP) rate-adaptiveâ•‡249 (PVAB)â•‡ xvi, 41, 129
ADI/DDD algorithmâ•‡ 53, 57 below programmed lower rateâ•‡ 95–7 variableâ•‡ 67–9, 255–7 threshold test modificationâ•‡ 129
ADIR/DDDR algorithmâ•‡ 54, 61 left ventricular lead dislodgement with ventricular safety pacing and pacedâ•‡ 69 Boston Scientific devicesâ•‡ xvii, 151
Anodal captureâ•‡ 277 leftâ•‡273 Atrioventricular nodal re-entrant tachycardia Bradycardiaâ•‡ 6, 10, 30, 70, 111–13
Anterior cardiac vein, LV lead positionâ•‡ 266–9 overdriveâ•‡135–7 (AVNRT)â•‡ 141, 147, 175 Brady–tachy syndromeâ•‡ 98
Antitachycardia pacing (ATP)â•‡ 159, 167, Atrial threshold testingâ•‡ 22–5, 78–81 Atrioventricular re-entrant tachycardia Breathlessness/dyspnoea/shortness of breath
172, 175 Atrioventricular (AV) block (AVRT)â•‡147 CRT casesâ•‡ 226, 238, 242, 246, 254, 258
Index
Atrial arrhythmiaâ•‡ 98–101, 105; see also ICD casesâ•‡ 159 Automatic tests ICD cases 208
specific arrhythmias pacemaker cases, see Atrioventricular (AV) lead impedanceâ•‡ 113, 133 pacemaker casesâ•‡ 6, 14, 17, 26, 30, 54
Atrial-based timingâ•‡ 93 block (pacemaker cases) pattern recognition in device algorithm
Atrial blanking (AB)â•‡ xvi see also Heart block, complete deductionâ•‡133 C
post-ventricular (PVAB)â•‡ xvi, 41, 129 Atrioventricular (AV) block (pacemaker thresholdâ•‡ 113, 117, 133, 285 Capacitor charge
Atrial captureâ•‡ 23–5, 273 cases) ventricular capture algorithmsâ•‡ 117 durationâ•‡163
Atrial fibrillation (AF)
CRT casesâ•‡ 261
completeâ•‡ 34, 38, 94, 102; see also Heart
block, complete
A-wave
‘P on T’ consequencesâ•‡ 57
rhythm reconfirmation duringâ•‡ 203
Cardiac resynchronization therapy (CRT) 287
ICD casesâ•‡ 155, 156, 163 misdiagnosis by ventricular truncationâ•‡ 245, 249, 257, 265 CRT pacemakersâ•‡ 262–5, 274–7
pacemaker cases, see Atrial fibrillation undersensingâ•‡65 enhancement during AFâ•‡ 261
(AF) (pacemaker cases) paroxysmal/intermittentâ•‡ 2–5, 46, 66, 74, B loss ofâ•‡ 219–21, 223–5
Atrial fibrillation (AF) (pacemaker cases) 122 Baseline rate, pacing belowâ•‡ 11–13, 95–7 see also Biventricular pacing
oversensing ofâ•‡ 105 second-degree/2:1/Wenckebach 50, 90, 110 Bicycle exercise testâ•‡ 26–9 Cardiac resynchronization therapy
pre-device patient historyâ•‡ 6, 10, 30, 70, Atrioventricular (AV) conduction Biotronic devicesâ•‡ xvii, 151 defibrillator (CRT-D) devices
106, 134 AV conduction testâ•‡ 285 Bipolar sensing/configurationâ•‡ 180–3, 191 in CRT casesâ•‡ 218–25, 230–7, 246–61,
rate regularization/rate smoothing AVI extension with resumption ofâ•‡ 49 extendedâ•‡ 191, 269, 277 266–273, 278–81
algorithmsâ•‡109 negative atrioventricular hysteresis and true/integratedbipolar ICD leadsâ•‡ 183, in ICD casesâ•‡ 156–63, 168–71, 180, 196–9,
undersensing ofâ•‡ 101, 105 intrinsicâ•‡257 199, 215 208–11
with irregular paced ventricular Atrioventricular (AV) crosstalkâ•‡ 69, 129 Biventricular captureâ•‡ 237, 277 problems during implantationâ•‡ 278–81
rhythmâ•‡98–101 Atrioventricular (AV) delayâ•‡ 241, 245, 249 Biventricular pacingâ•‡ 110–13, 218, 222, 230, Cardiomyopathy
Atrial flutterâ•‡ 134–7 Atrioventricular (AV) dyssynchronyâ•‡ 17 238–41, 249–53 dilatedâ•‡ 172, 180
Atrial high-rate episodesâ•‡ 38–41, 73, 114–17 Atrioventricular (AV) hysteresisâ•‡ 49 ECG during biventricular pacing and ischaemicâ•‡164
Atrial intrinsic amplitude measurement, negativeâ•‡257 temporary inactivation of pacingâ•‡ 238– Carotid sinus massageâ•‡ 86–8
dailyâ•‡113 Atrioventricular (AV) nodal ablationâ•‡ 156, 9, 246–7 Charge durations, capacitorâ•‡ 163
Atrial lead 159 loss ofâ•‡ 218–25 Chest X-ray
accidental atrial/ventricular lead Atrioventricular interval (AVI) remote device managementâ•‡ 226–33 atrial lead dislodgementâ•‡ 85
switchâ•‡ 77, 281 atrial-/ventricular-based timing andâ•‡ 93 see also Cardiac resynchronization therapy LV lead dislodgementâ•‡ 273
dislodgementâ•‡85 atrioventricular (AV) delay (CRT) subclavian crush and lead sectionâ•‡ 9
far field R-wave (FFRW) oversensing optimizationâ•‡245 Blanking periodsâ•‡ xvi ventricular lead position recognitionâ•‡ 19–21
byâ•‡199 ECG for recognition of suboptimalâ•‡ 249 crosstalk andâ•‡ 129 Coronary sinus (CS) leadâ•‡ 21
see also Lead damage/failure/fracture/ extension with resumption of AV post-atrial ventricular blanking Counters, VT and VFâ•‡ 151
section; Lead impedance conductionâ•‡49 (PAVB)â•‡ xvi, 69, 129 Crosstalk, atrioventricular (AV)â•‡ 69, 129
D Electrocardiogram (ECG) (pacemaker cases) ventricular high-rate episodesâ•‡ 35–6, 70–2 dual-chamberâ•‡ 172–5, 184–91, 204–7,
DDD pacingâ•‡ 74–7, 98–101 AF with irregular paced ventricular ventricular pacing (VP) rate 212–15
ADI/DDD algorithmâ•‡ 53, 57 rhythmâ•‡98 irregularityâ•‡98–105 single-chamber 144–55, 176–9, 192–5,
atrial threshold testâ•‡ 25, 78–81 asymptomatic follow-upâ•‡ 66–8 ventricular threshold testsâ•‡ 126–8 200–3
timing cyclesâ•‡ xvi atrial threshold testingâ•‡ 25 Electromagnetic interferenceâ•‡ 187, 191 see also Cardiac resynchronization therapy
DDDR pacingâ•‡ 17, 58–65 irregular heart rateâ•‡ 122–4 Endless loop tachycardiaâ•‡ 81 defibrillator (CRT-D) devices
ADIR/DDDR algorithmâ•‡ 54, 61 syncopeâ•‡74–7 Event counter graphsâ•‡ 222 Implantation procedure, problems during
atrial-/ventricular-based timingâ•‡ 93 see also Holter recording; Rhythm strip Evoked responseâ•‡ 117 CRT-Dâ•‡278–81
DDI pacingâ•‡ 113 analysis Integrated bipolar leadsâ•‡ 180–3, 215
DDI(R) pacingâ•‡ xvi, 5, 45 Electrogram (EGM) analysis F far-field P-wave oversensing byâ•‡ 199
Decay delay, prolongingâ•‡ 195, 207 CRT cases, see Electrogram (EGM) Fainting/syncopeâ•‡ 74–6, 86, 126, 211 Interventricular conductionâ•‡ 285
Decompensated heart failureâ•‡ 42–5, 226–9, analysis (CRT cases) Far-field P-wave oversensingâ•‡ 199, 269, 281 IS-4 lead, lead switchâ•‡ 281
234, 250 ICD cases, see Electrogram (EGM) analysis Far-field R-wave (FFRW) oversensingâ•‡ 41, Ischaemic cardiomyopathyâ•‡ 164
DF-1 switchâ•‡ 215, 281 (ICD cases) 97, 191 Ischaemic heart disease/syndrome
DF-4 lead switchâ•‡ 281 pacemaker cases, see Electrogram (EGM) Fatigueâ•‡ 14, 17, 208 CRT caseâ•‡ 226
Diaphragmatic myopotential oversensingâ•‡ 183 analysis (pacemaker cases) Fusion pacingâ•‡ 261, 265 ICD casesâ•‡ 144, 156, 176, 188, 208, 212
Dilated cardiomyopathyâ•‡ 172, 180 systematic device EGM analysisâ•‡ xv pacemaker caseâ•‡ 42
Index
Dizzinessâ•‡ 46, 110, 208 Electrogram (EGM) analysis (CRT cases)

asymptomatic follow-upâ•‡ 218–21, 262–5
G L
orthostaticâ•‡ 14, 17 Generator pocket, manipulation ofâ•‡ 179, 273
Doppler flow, transmitralâ•‡ 54–7, 242–5 dyspnoea presentationâ•‡ 254–7, 266–9 Latency, left ventricularâ•‡ 253
Double-counting, R-waveâ•‡ 207 implantation problemsâ•‡ 278–81 Lead position
Dyspnoea, see Breathlessness/dyspnoea/ LV threshold testâ•‡ 270–7 H atrialâ•‡85
shortness of breath remote monitoringâ•‡ 222–4, 230–3 Heart block LV lead in anterior cardiac veinâ•‡
completeâ•‡ 26, 69, 126, 129
288 Electrogram (EGM) analysis (ICD cases)
asymptomatic stored eventsâ•‡ 144–51, see also Atrioventricular (AV) block
266–9
ventricularâ•‡ 18–21, 199, 233, 273
E 164–70, 172–4, 180–3, 196–9, 212–14 Heart disease Leads
Echocardiography (transthoracic) distinguishing artefacts’ summaryâ•‡ 187 ischaemic, see Ischaemic heart disease/ damage/failure/fracture/sectionâ•‡ 9, 179,
atrioventricular (AV) delay ‘far-field’ EGMâ•‡ 191 syndrome 187, 233
optimizationâ•‡ 245, 249 high-rate ventricular episodesâ•‡ 212–14 non-ischaemicâ•‡250 dislodgementâ•‡ 85, 199, 233, 273
transmitral Doppler flowâ•‡ 54–7, 242–5 history of shock(s)â•‡ 156–8, 176–9, 192–5, Heart failure lead impedance 113, 133, 179
Electrocardiogram (ECG) analysis 200–2, 204–7 decompensatedâ•‡ 42–5, 226–9, 234, 250 lead switchâ•‡ 77, 281
CRT cases, see Electrocardiogram (ECG) palpitationsâ•‡152–5 integrated diagnostic toolsâ•‡ 229 position of, see Lead position
analysis (CRT cases) remote device managementâ•‡ 208–11 High-rate episodes see also specific lead types
pacemaker cases, see Electrocardiogram supraventricular tachycardia (SVT)â•‡ 171, atrialâ•‡ 38–41, 73, 114–17 Left atrial captureâ•‡ 273
(ECG) analysis (pacemaker cases) 188–90 ventricularâ•‡ 34–7, 70–3, 181–2, 185–7, Left bundle branch blockâ•‡ 261
systematic device ECG analysisâ•‡ xv VT/SVT differentiation cluesâ•‡ 171 212–15 Left ventricular (LV) captureâ•‡ 241
see also Holter recording; Rhythm strip Electrogram (EGM) analysis (pacemaker Holter recording loss ofâ•‡ 233, 237, 277, 285
analysis cases) CRT casesâ•‡ 282–4 management algorithmâ•‡ 285
Electrocardiogram (ECG) analysis (CRT asymptomatic follow-upâ•‡ 58–65, 82–4, 90–2 pacemaker casesâ•‡ 46–8, 50–3, 110–12, thresholdâ•‡ 271–2, 275–7
cases) atrial high-rate episodesâ•‡ 38–41, 114–16 118–121, 130–3 triggered LV pacing effectâ•‡ 265
breathlessness presentationâ•‡ 246–9 atrial threshold testingâ•‡ 22–5, 79–80 Hypersensitive carotid sinus syndromeâ•‡ 86–9 Left ventricular (LV) lead
decompensated heart failure bicycle exercise testâ•‡ 27–9 Hysteresis dislodgementâ•‡ 233, 273
presentationâ•‡ 234–41, 250–3 carotid sinus massage (during)â•‡ 86–8 atrioventricular (AV)â•‡ 49 far-field P-wave oversensing ofâ•‡ 269, 281
dyspnoea and palpitations decompensated heart failureâ•‡ 42–5 negative atrioventricularâ•‡ 257 lead switchâ•‡ 281
presentationâ•‡258–61 non-invasive pacing studies (NIPS)â•‡ 134–6, rateâ•‡13 Left ventricular (LV) pacingâ•‡ 250–3
left ventricular latencyâ•‡ 253 138–40 lack ofâ•‡ 267–9
threshold testsâ•‡ 273, 277 pacing above the lower rateâ•‡ 107–8 I triggeredâ•‡ 261, 265
triggered VP temporary inactivationâ•‡ 261 pacing mode identificationâ•‡ 2–5 Implantable cardioverter–defibrillator (ICD) Left ventricular (LV) pre-excitationâ•‡ 253
see also Holter recording; Rhythm strip stored events (asymptomatic)â•‡ 58–65 devices Left ventricular (LV)–right ventricular (RV)
analysis spikes on T-wavesâ•‡ 118–20 biventricularâ•‡226–29 conduction testâ•‡ 285
Left ventricular (LV) threshold Pacing mode R sensing amplitude in true/integrated
loss of LV capture andâ•‡ 233 identification by EGM analysisâ•‡ 3 Radiofrequency ablation bipolar configurationâ•‡ 180–3
testingâ•‡ 270–7, 285 see also specific pacing modes pulmonary veinâ•‡ 134–7 T-wave oversensing andâ•‡ 195
Left ventricular ejection fraction (LVEF)â•‡ 10, Pacing rate ventricular premature beats (VPBs)â•‡ 221 ventricular undersensingâ•‡ 65
42, 221 below the lower rateâ•‡ 11–13, 95–7 Rate drop responseâ•‡ 89
Left ventricular latencyâ•‡ 253 pacemaker upper rate behaviourâ•‡ 29 Rate histogramsâ•‡ 94–6, 196, 246 S
Lower rate, pacing belowâ•‡ 11–13, 95–7 rate drop responseâ•‡ 89 atrialâ•‡ 38, 266 Sensor settings, problem identificationâ•‡ 31–3
Lower rate interval (LRI)â•‡ xvi rate hysteresis effectâ•‡ 13 ventricularâ•‡ 30–3, 106, 218, 266 Sepsisâ•‡102
rate regularization/rate smoothing Rate hysteresisâ•‡ 13 Shock(s)
M algorithmsâ•‡109 Rate regularization algorithmsâ•‡ 109 cases with presenting history ofâ•‡ 156–8,
Magnet applicationâ•‡ 122–5 rate response parametersâ•‡ 30, 33 Rate response parametersâ•‡ 30, 33 176–9, 192–5, 200–2, 204–7
Marker channel annotationsâ•‡ xvii reason forâ•‡ 11–13, 95–7, 43–5, 107–9 Rate smoothing algorithmsâ•‡ 109 committed and non-committedâ•‡ 203
Maximum tracking rate (MTR)â•‡ 29 unexpectedly slowâ•‡ 113 Reconfirmation, rhythmâ•‡ 203 remote device management caseâ•‡ 211
Medtronic devicesâ•‡ xvii, 151, 285 Palpitations Redetection, rhythmâ•‡ 203 Shortness of breath, see Breathlessness/
Mitral regurgitationâ•‡ 57 CRT casesâ•‡ 258, 282 Refractory periodâ•‡ xvi dyspnoea/shortness of breath
Mode switchâ•‡ 45 ICD casesâ•‡ 152, 160, 208–11 post-ventricular atrial (PVARP)â•‡ xvi, 81, 97 Sick sinus syndrome, see Sinus node
absence ofâ•‡ 105 pacemaker casesâ•‡ 30, 78, 98, 138 threshold test modificationâ•‡ 129 dysfunction/sick sinus syndrome
Index
Morphology discrimination algorithmsâ•‡ 167 patient-initiated interrogationâ•‡ 208–11 total atrial (TARP)â•‡ 29 Sinus node dysfunction/sick sinus syndrome
Myopotentialsâ•‡187 Pectoral muscle ventricular (VRP)â•‡ xvi, 97, 207 atrial threshold testâ•‡ 22–5
oversensingâ•‡ 37, 183, 191, 215 myopotential oversensingâ•‡ 37, 215 Remote device managementâ•‡ 208–11, 222–33 biventricular pacemaker forâ•‡ 110–13
twitchingâ•‡ 6, 113 Rhythm strip analysis brady–tachy syndromeâ•‡ 98
N Polarizationâ•‡117 CRT casesâ•‡ 234–41, 245 dual-chamber pacemaker forâ•‡ 17–21, 42–5,
Negative atrioventricular hysteresisâ•‡ 257 ‘P on T’ phenomenonâ•‡ 57, 61 ICD caseâ•‡ 175 54–61, 82–5, 130–3, 138–41
Noise, ventricular channelâ•‡ 69
Noise reversionâ•‡ 105, 187
Post-atrial ventricular blanking (PAVB)â•‡ xvi,
69, 129
pacemaker caseâ•‡ 74–7
see also Electrocardiogram (ECG)
single-chamber pacemaker forâ•‡ 14–17
Sinus tachycardiaâ•‡ 155 289
Non-capture, troubleshooting basicsâ•‡ xv Post-ventricular atrial blanking (PVAB)â•‡ xvi, analysis Sorin devicesâ•‡ xvii, 151
Non-invasive pacing studies (NIPS)â•‡ 134–41 41, 129 Right bundle branch block (RBBB)â•‡ 5, 21, St Jude Medical devicesâ•‡ xvii, 151
Non-ischaemic heart diseaseâ•‡ 250 Post-ventricular atrial refractory period 261 Strokeâ•‡18
Non-pacing, troubleshooting basicsâ•‡ xv (PVARP)â•‡ xvi, 81, 97 far-field R-wave (FFRW) oversensing Subclavian crushâ•‡ 9
Prayer manoeuvreâ•‡ 37 inâ•‡41 Sudden death
O Premature ventricular contractions (PVCs), Right ventricular (RV) capture 233, 241 primary prevention ofâ•‡ 168, 172, 180, 184,
Orthostatic dizzinessâ•‡ 14, 17 see Ventricular premature beats (VPBs)/ intermittent loss ofâ•‡ 237 200, 208, 212
Oversensingâ•‡ xv, 191 premature ventricular contractions (PVCs) Right ventricular (RV) dysplasia, secondary prevention ofâ•‡ 192
atrial fibrillationâ•‡ 105 PR intervalâ•‡ 61 arrhythmogenicâ•‡192 Supraventricular tachycardia (SVT)â•‡ 147,
far-field P-waveâ•‡ 199, 269, 281 Pulmonary vein, radiofrequency Right ventricular (RV) lead 155, 188–90
far-field R-wave (FFRW)â•‡ 41, 97, 191 ablationâ•‡134–7 dislodgement/positioningâ•‡21 inactivation of VT/SVT discrimination
myopotentialâ•‡ 37, 183, 191, 215 P-waves far-field P-wave oversensing byâ•‡ 199 algorithmsâ•‡159
T-waveâ•‡195 far-field P-wave oversensingâ•‡ 199, 269, 281 far-field R-wave (FFRW) oversensing VT differentiation 147, 171
interatrial conduction delay effectâ•‡ 265 byâ•‡41 Syncope/faintingâ•‡ 74–6, 86, 126, 211
P ‘P on T’ phenomenonâ•‡ 57, 61 incorrect implantationâ•‡ 199 Systematic device ECG/EGM analysisâ•‡ xv
Pacemakers sensing amplitudes’ trend evaluationâ•‡ 225 lead switchâ•‡ 281
biventricular/CRT 110–13, 238–41, Right ventricular (RV)–left ventricular (LV) T
262–5, 274–7 Q conduction testâ•‡ 285 Tachogram analysis
dual-chamberâ•‡ 2–5, 18–21, 26–9, 42–69, QRS complex Right ventricular (RV) pacingâ•‡ 21, 57, 250–2, asymptomatic stored eventâ•‡ 144, 148–51
74–97, 102–5, 114–41 AVI shortening effectâ•‡ 249 257 history of shock(s)â•‡ 156–9, 160–3, 176–8,
single-chamberâ•‡ 6–17, 30–7, 70–3, 106–9 morphology in right bundle branch block ‘Ringing’â•‡105 192–5
Pacemaker syndromeâ•‡ 17, 57 (RBBB) 21 Risk stratification, heart failure patientsâ•‡ 229 palpitationsâ•‡ 152–5, 160
Pacemaker troubleshooting negativity/positivityâ•‡ 237, 241, 265 RR intervals, ‘railroad track’ appearanceâ•‡ 195 ‘railroad’ track appearance of RR
basics ofâ•‡ xv triggered LV pacing andâ•‡ 261, 265 R-wave intervalsâ•‡195
see also specific problems widthâ•‡ 237, 261, 265 double-countingâ•‡207 sinus tachycardia gradual onsetâ•‡ 155
Tachycardia T-waves Ventricular fibrillation (VF)â•‡ 151, 163, 172, Ventricular premature beats (VPBs)/
antitachycardia pacing (ATP)â•‡ 159, 167, avoiding oversensingâ•‡ 191, 195 176 premature ventricular contractions
172, 175 ‘P on T’ phenomenonâ•‡ 57, 61 Ventricular high-rate episodesâ•‡ 34–7, 70–3, (PVCs)
atrial threshold testâ•‡ 78–81 spikes onâ•‡ 118–21 181–2, 185–7, 212–15 CRT casesâ•‡ 221–5, 257, 277, 282
atrioventricular nodal re-entrant Twiddler’s syndromeâ•‡ 273 Ventricular intrinsic amplitude pacemaker casesâ•‡ 65, 93, 97
(AVNRT)â•‡ 141, 147, 175 Twitching, of pectoral regionâ•‡ 6, 113 measurement, dailyâ•‡ 113 Ventricular refractory period (VRP)â•‡ xvi,
atrioventricular re-entrant (AVRT)â•‡ 147 Ventricular lead 97, 207
brady–tachy syndromeâ•‡ 98 U accidental atrial/ventricular lead Ventricular safety pacingâ•‡ 69
endless loopâ•‡ 81 Undersensingâ•‡xv switchâ•‡77 Ventricular tachycardia (VT)
non-invasive pacing studies (NIPS)â•‡ 138– atrialâ•‡ 101, 105, 225 far-field P-wave oversensing byâ•‡ 199 atrioventricular nodal re-entrant
41 ventricularâ•‡65 position/dislodgementâ•‡ 18–21, 199, 233, 273 tachycardia (AVNRT) masquerading
sinusâ•‡155 Unipolar sensing/configuration 37, 191, 277 see also Left ventricular (LV) lead; Right asâ•‡175
sudden onsetâ•‡ 155 Upper rate behaviour, pacemakerâ•‡ 29 ventricular (RV) lead fast (FVT)â•‡ 159, 163
supraventricular (SVT), see Upper rate interval (URI)â•‡ xvi Ventricular noise reversionâ•‡ 73 ICD casesâ•‡ 144–51, 155–67, 168–75,
Supraventricular tachycardia (SVT) Upper tracking rate (UTR)â•‡ 29 Ventricular pacing (VP) 188–91
undersensing of atrial fibrillationâ•‡ 101 atrioventricular hysteresis effectâ•‡ 49 inactivation of VT/SVT discrimination
ventricular (VT), see Ventricular V biventricular, see Biventricular pacing algorithmsâ•‡159
Index
tachycardia (VT) VDD pacemaker caseâ•‡ 34–7 electromagnetic interference and remote device management diagnosisâ•‡ 211
Threshold start level, increasingâ•‡ 195, 207 VDI(R) pacingâ•‡ 45 rapidâ•‡187 SVT differentiationâ•‡ 147, 171
Threshold tests Ventricular arrhythmiaâ•‡ 180, 184; see also irregularâ•‡98–105 Ventricular threshold testsâ•‡ 126–9, 270–7,
atrialâ•‡ 22–5, 78–81 specific arrhythmias left, see Left ventricular (LV) pacing 285
automaticâ•‡ 113, 117, 133, 285 Ventricular-based timingâ•‡ 93 low (<1%)â•‡ 62–5 Ventriculoatrial (VA) intervalsâ•‡ 93
ventricularâ•‡ 126–9, 270–7, 285 Ventricular blanking (VB)â•‡ xvi minimizingâ•‡ 49, 53 VVI pacingâ•‡ xvi, 106
290 Timing cyclesâ•‡ xvi, 93
Total atrial refractory period (TARP)â•‡ 29
post-atrial (PAVB)â•‡ xvi, 69, 129
Ventricular capture
right (RV)21, 57, 250–2, 257
safety pacingâ•‡ 69
VVI(R) pacingâ•‡ 17
Transmitral Doppler flowâ•‡ 54–7, 242–5 automatic algorithmsâ•‡ 117 timing ofâ•‡ 241 W
Triggered left ventricular (LV) pacingâ•‡ 261, see also Left ventricular (LV) capture; triggeredâ•‡261 Wenckebach AV blockâ•‡ 50
265 Right ventricular (RV) capture ventricular premature beats (VPBs) Wenckebach responseâ•‡ 29
True bipolar leadsâ•‡ 180–3, 215 Ventricular channel noiseâ•‡ 69 andâ•‡221 Wireless telemetryâ•‡ 278–81

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z.

The EAE Textbook of Echocardiography

The ESC Textbook of Cardiovascular Imaging (Second Edition)

The ESC Textbook of Preventive Cardiology

The EHRA Book of Pacemaker, ICD, and CRT Troubleshooting: Case-based

The ESC Handbook of Preventive Cardiology: Putting prevention into practice

Haran Burri md Jean-Claude Deharo md Carsten Israel md

AS AP VS VP Typical duration (ms)

A Refractory ✔ ✔ ✔ ✔ 120–150 (post-AP); 250–400 (post-VP)

◆ programmed pacing polarity.

<AVI <AVI AVI AVI

VRP VRP VRP VRP

AB − Atrial PVAB − Post ventricular PVAB − Post ventricular VB − Venticular

AVI: antrioventricular interval period PVARP: post-ventricular atrial refractory

As/Ap Atrial sensing/pacing AS/AP Atrial sensing/pacing

In what pacing mode is the device programmed?

Figure 1.2 Annotated real-time EGM recording

Table 2.1 Device settings and tested parameters

Pacing output (bipolar) 2.5V/0.4ms

Sensitivity setting (bipolar) 2.8mV

Battery voltage 2.71V

Battery impedance 1200 ohms

Lead impedance (bipolar) 625 ohms

Capture threshold (bipolar) 1.2V/0.4ms

Sensing threshold (bipolar) 6.8mV

Figure 2.2 Annotated ECG recorded at admission

Figure 3.2 Annotated real-time EGM recorded at 1-month follow-up

Figure 3.3 Rate hysteresis

Figure 4.2 Annotated presenting ECG at 1-month follow-up

➊ Retrograde P-waves can be visualized after each paced QRS complex.

Where is the ventricular lead positioned?

20 (a) ➊ (b) (c)

➊ An apical RV lead would be expected to be situated in a lower position than this.

1 LV endocardial pacing via a patent foramen ovale, an atrial/ventricular

What is the atrial capture threshold amplitude?

24 1.0V 1.0V 1.0V 0.9V 0.9V 0.9V 0.8V

➋ Sinus rhythm resumes after loss of atrial capture.

➍ The AS event resets the A–A timing cycle.

1.2V 1.2V 1.1V 1.1V 1.1V 0.9V 0.9V 0.9V 0.8V

Table 7.1 Device settings

Baseline rate 60bpm

Upper tracking rate (UTR) 120bpm

Paced AV delay (adaptive) 170-120ms

AV delay sense offset –30ms

What can be observed?

➋ Progressive lengthening of the AVI can be observed. This occurs until . . .

LR UTR 60,000/TARP 2:1

What is the problem with the sensor settings?

Figure 8.2 Annotated ventricular rate histogram

Table 9.1 Device settings

Baseline rate 50bpm

Atrial sensing (bipolar) 0.2mV

Ventricular sensing (unipolar) 2.5mV

VP (bipolar) 2.5V at 0.35ms

AV delay (adaptive) 80–125ms

Post-ventricular atrial blanking (PVAB) 150ms

What is the cause of the patient’s symptoms?

Upper rate 130bpm

30 Atrial sensitivity (bipolar) 0.2mV

Ventricular sensitivity (bipolar) 2.5mV

1 LV endocardial pacing via a patent foramen ovale, an atrial/ventricular