upper rate behavior. for internal use only why do we have upper rate responses? reduce incidence of...
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![Page 1: Upper Rate Behavior. for internal use only Why do we have Upper Rate Responses? Reduce incidence of tracking inappropriate rhythm and/or rate](https://reader035.vdocuments.net/reader035/viewer/2022062714/56649d215503460f949f6748/html5/thumbnails/1.jpg)
Upper Rate Behavior
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Why do we have Upper Rate Responses?
Reduce incidence of tracking inappropriate rhythm and/or rate
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Upper Rate Response Initiating Factors
Exercise
Sinus Tachycardia
Atrial Arrhythmia
Sensing of Myopotentials
VA conduction exceeding PVARP
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Upper Rate Response Limit
Fastest Atrial rate at which consecutively paced ventricular complexes maintain 1:1 synchrony
• Also known as:• Ventricular Maximum Rate (VMR)• Maximum Tracking Rate (MTR)
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Max Track Rate / Max Sensor Rate
Definitions
• The Max Track Rate, or Maximum Tracking Rate, is the fastest rate that intrinsic P-waves can be tracked, or followed by paced Ventricular events with a 1:1 ratio.
• The Max Sensor Rate, is the fastest rate the atria and the Ventricles can be paced, based upon sensor input.
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DDD Timing
URI
AVI PVAVI PVARP
VRPBL
PVAB
Atrial Channel
Ventricular Channel
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Max Track Rate
• The fastest rate the Ventricular channel can pace when tracking intrinsic P-waves.
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Max Track Rate
Programmed settings should be based on
• Patient activity levels
• Age (220 – age)
• LV function
• Chest pain
• Tolerance by the Patient if a PMT occurs
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Max Track Rate
Questions to consider
• Can the programmed Max Track Rate be tolerated by the patient for prolonged periods?
• During sinus tachycardia, can a sudden drop in the pacing rate be tolerated?
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Upper Rate Behaviors
Fixed-Ratio block/Multiblock (2:1, 3:1, etc)
Wenckebach behavior (Pseudo, Electronic)
Auto Mode Switch (not in this presentation)
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Upper Rate Behaviors
Depends on programmed values:
• Max Tracking Rate
• Sensed AV Delay
• PVARP
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Upper Rate Behavior
Fixed Ratio Block
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AV PVARP
TARP (Total Atrial Refractory Period)
Fixed-Ratio Block (Multiblock)
Fast Upper Rate Response
Simplest way to control upper rate
• TARP = MTR
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Fixed-Ratio Block
2:1 Block (one v-paced event per two p-waves)
MTR = 115bpm AVD = 160ms PVARP = 360 ms
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PV PVARP
TARP = 440 ms
160 ms + 280 ms
(2:1 block point)
Fixed-Ratio Block
Calculation
• 60,000 / TARP: e.g. 60,000 / 440 ms = 136 BPM
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Fixed-Ratio Block
PV interval always remains constant
May be inappropriate in young or physically active patients due to sudden rate drops
Patient tracks P-waves until the atrial rate gets to the 2:1 block
• The Ventricular rate will suddenly go to half the Atrial rate
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Fixed-Ratio Block
Fall Down Rate
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Atrial
rate
160
140
120
100
14012010080
Stimulatedventricular rate
Sensed Atrial Rate
Ex.: Shipped SettingsPV Delay 150 msPVARP 275 ms2:1-blockpoint 142 min-1
80
60
160
2:1 blocking
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Upper Rate Responses
Wenckebach
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Upper Rate Behavior
Wenckebach block
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Do you remember?
AV Block 2nd degree Mobitz I
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Wenckebach
Max Track (MTR) must be programmed slower than the TARP interval
2:1 fixed-ratio block will occur when the P-P intervals become faster than TARP
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V-A Interval
Base Rate Interval
MTR
PVARP
PV
W-Period
P
P
P
TARP
Wenckebach
P
Ap Vp Ap Vp Vp
AVAV
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Wenckebach behaviour
Look at the VV and AV intervals
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Wenckebach
Provides a smoother transition from 1:1 to 2:1 block
Avoids a sudden reduction of the ventricular pacing rate and maintains some degree of AV synchrony
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Ventricular Rate (paced)
LowerRate
1:1
Wenckebach Plateau
2:1
3:1
. . . ...
.
Atrial Rate (sensed)
MTR TARP ARRP
Wenckebach
Wenckebach response to increasing Atrial rates
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Wenckebach
Example• DDD
• MTR 100 bpm (600 ms)
• AV delay 150 ms
• PVARP 250 ms
• TARP 150 + 250 = 400 ms \150ppm
• Therefore, atrial rates >100 bpm (600 ms) but < 150 bpm will result in Wenckebach behavior
• Max PV delay prolongation is 200 ms (600-400)• PV intervals will vary from 150 - 350 ms
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Wenckebach
Calculation to determine if a Wenckebach is present:
• Programmed MTR minus TARP
• In our example: 600 ms - 400 ms = 200 ms
• We have a 200 ms Wenckebach window
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60 PPM 130 PPM 143 PPM
Base Rate 60 PPMMTR 130 PPMAV delay 170 MSPVARP 250 MS
TARP = PV Delay + PVARP= 170 + 250= 420 ms 143 PPM (2:1 Block Point)
Atrial Rate Continuum
Base Rate (MTR) TARP
DeviceResponse
1:1 Tracking Wenckebach 2:1 Block
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Wenckebach
V-A Interval
Base Rate Interval
MTR
PVARP
PV
W-Period
P
P
P
TARP
P
Ap Vp Ap Vp Vp
AVAV 150 ms
200 ms
600 ms
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Maximum Tracking Rate Interval
A-A
PVARP
VRP
MTRI
AV Delay
Pseudo Wenckebach - Upper Rate Behaviour
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Wenckebach
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 88 msPVARP 250 ms
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Wenckebach
AV PVARP
MTR MTR MTR MTR MTR MTR MTR MTR MTR MTR MTR MTR
AV AV AVPVARP PVARP PVARP PVARP PVARP PVARP PVARP PVARP PVARP PVARP PVARP PVARP
P-wave in alert and sensed
Ventricular pacing at Max Tracking Rate
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 88 msPVARP 250 ms
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Wenckebach
Identification
• Variable PV delays
• Sustained high rate pacing
• Occasional change in the beat to beat ventricular rate
• Long PV intervals may initiate an endless-loop Tachycardia
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Atrial
rate
160
140
120
100
14012010080
Stimulatedventricular rate
Sensed Atrial Rate
80
60
160
Wenckebach and MTR
= Max. Tracking Rate
TARP
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WenckebachFixed-ratioBlock
AMS
AV Delay progressively lengthens
Pauses in pacing operation may be seen
PV Delay constant
AV Delayconstant
until DDI(R)pacing
occurs atthe AMS base rate
Upper Rate Responses
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Atrial
rate
160
140
120
100
14012010080
Stimulatedventricular rate
Sensed Atrial Rate
Ex.: Shipped SettingsPV Delay 150 msPVARP 275 ms2:1-blockpoint 142 min-1
80
60
160
2:1 blocking
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P V
Factors Limiting Upper Rate
PVARPPV Delay
Programmed PV DelayRate Resp. AV/PV DelayShortest AV/PV Delay
Programmed PVARPRate Resp. PVARP/VRPShortest PVARP/VRP
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To mimic normal heart function
SpontaneousPR intervalreduction
70 min-1 130 min-1110 min-1
Tracking with RRAVDenabled
Rate Responsive AV Delay
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Rate Responsive AV/PV Delays and Shortest AV/PV Delay
0
50
100
150
90
95
10
0
11
0
10
5
11
5
12
0
12
5
13
0
13
5
14
0
14
5
15
0
15
5
16
0
16
5
17
0
17
5
18
0
18
5
19
0
19
5
Low, 1 ms min-1
Medium, 2 ms min-1
High, 3 ms min-1
200
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Rate Responsive AV/PV Delays… … and Shortest AV/PV Delay
0
50
100
150
90
95
10
0
11
0
10
5
11
5
12
0
12
5
13
0
13
5
14
0
14
5
15
0
15
5
16
0
16
5
17
0
17
5
18
0
18
5
19
0
19
5
Low, 1 ms min-1
Medium, 2 ms min-1
High, 3 ms min-1
200
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Atrial
rate
160
140
120
100
14012010080
Stimulatedventricular rate
Sensed Atrial Rate
80
60
160
2:1 blocking and RRAVD
Ex.: Shipped SettingsPV Delay 150 msPVARP 275 msWith RRAVD(Low, Medium and High)
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PVARP
VRP
Rate Responsive Refractory Periods
Low, 1 ms min-1
Medium, 2 ms min-1
High, 3 ms min-1
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PVARP
VRP
Rate Responsive Refractory Periods
Low, 1 ms min-1
Medium, 2 ms min-1
High, 3 ms min-1
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PVARP
VRP
Rate Responsive Refractory Periods
Low, 1 ms min-1
Medium, 2 ms min-1
High, 3 ms min-1
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PVARP
VRP
Rate Responsive Refractory Periods
Low, 1 ms min-1
Medium, 2 ms min-1
High, 3 ms min-1
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MTR Intervall MTR Intervall MTR Intervall MTR Intervall
Pseudo Wenckebach Upper Rate Behaviour
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Atrial
rate
160
140
120
100
14012010080
Stimulatedventricular rate
Sensed Atrial Rate
Programmed MTR, too high. Will not limit the rate fall at 2:1 block rate.
80
60
160
2:1 blocking and MTR
= Max. Tracking Rate
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Atrial
rate
160
140
120
100
14012010080
Stimulatedventricular rate
Sensed Atrial Rate
Use of a well tailoredsensor will relieve the problems of a high MTR
80
60
160
2:1 blocking
= Max. Tracking Rate
= Max. Sensor Rate
= Sensor Indicated Rate
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Summary
One to One tracking is the best upper rate behavior
When tracking at this rate is inappropriate, the device may be programmed to exhibit:
• Fixed Ratio Block (Multiblock)
• Wenckebach
• RR AV delay – PVARP/VRP
• DDIR
• Auto Mode Switch
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Summary
When programming
• AV delay
• PVARP
• Max Tracking Rate
Remember
• WenckebachAVD + PVARP < MTR
• 2/1 block (mentioned on Merlin)AVD + PVARP = MTR
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Merlin
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Upper Rate Behavior
Questions