Interrogation and programming workshop part I - … · • Check lead integrity ... “PBL STOP ”...

Interrogation and programming

workshop part I

- Pacemaker follow-up

LING Hon-Lun

Associate Sales Manager

Cardiac Rhythm Disease Management (CRDM)

Interrogation and programming

workshop part II

Hands-on session

Medtronic helpers

Aims Of Pacemaker Follow Up

• Determine battery status

• Check lead integrity

• Check Sensing Threshold

• Check Pacing Threshold

• Analyse diagnostics

• Assess current parameters

• Obtain documentation

Device interrogation

Question?

What is the most important piece attached

to an pacemaker system?

The PatientThe PatientThe PatientThe PatientThe PatientThe PatientThe PatientThe Patient

Treat the patient, not the device

Interrogation

Presenting Rhythm

& Rate

Battery Status

Lead impedance

Threshold

Sensing

Observation

Program & Print

P Presenting Rhythm and Rate

B Battery Status

L Lead Status

S Sensing

T Threshold

O Observation, Data, and Events

P Program & Print

“PBL STOP”

‘PBL STOP’ – Your acronym for

a standardized follow-up

Programming step by step

• Determine battery status

• Check lead integrity

• Check Sensing Threshold

• Check Pacing Threshold

• Analyse diagnostics

• Assess current parameters

• Obtain documentation

Device battery status

Programming step by step

• Determine battery status

• Check lead integrity

• Check Sensing Threshold

• Check Pacing Threshold

• Analyse diagnostics

• Assess current parameters

• Obtain documentation

Check lead integrity

Lead integrity – in office test

Lead integrity – in office test

Programming step by step

• Determine battery status

• Check lead integrity

• Check Sensing Threshold

• Check Pacing Threshold

• Analyse diagnostics

• Assess current parameters

• Obtain documentation

Sensing

Sensing – in office test

Programming step by step

• Determine battery status

• Check lead integrity

• Check Sensing Threshold

• Check Pacing Threshold

• Analyse diagnostics

• Assess current parameters

• Obtain documentation

Threshold

Threshold – in office test

1. Pulse amplitude – the amount of voltage

delivered to the heart by the pacemaker to ensure capture

of the heart (strength of an output pulse)

2. Pulse width – time (duration) of the pacing pulse

2 Settings Used to Ensure Capture

GOAL Find the minimum amount of energy needed to

consistently capture the heart (stimulation threshold).

Amplitude Threshold Testing

Keeping pulse width stable, decrement voltage until loss of

capture

1.5V 1.0V .5V

@ 0.5ms

Pulse Width Threshold TestingKeeping voltage stable, decrement in pulse width

.30ms .20ms .1ms

@ 2 volts

.06ms

Programming step by step

• Determine battery status

• Check lead integrity

• Check Sensing Threshold

• Check Pacing Threshold

• Analyse diagnostics

• Assess current parameters

• Obtain documentation

Analyse diagnostics (Observation)

Analyse diagnostics (Observation)

Programming step by step

• Determine battery status

• Check lead integrity

• Check Sensing Threshold

• Check Pacing Threshold

• Analyse diagnostics

• Assess current parameters

• Obtain documentation

Assess current parameters (Program)

Assess current parameters (Program)

Assess current parameters (Program)

Programming step by step

• Determine battery status

• Check lead integrity

• Check Sensing Threshold

• Check Pacing Threshold

• Analyse diagnostics

• Assess current parameters

• Obtain documentation

“P”

Programming &

Printing Final Reports

(obtain documentation)

Print final report

Printed final report – post f/u parameter

Print Reports

• Print Final Reports

– Sensing test results

– Threshold test results

– Key observations

– Any changes this session noted on final report (initial and

final)

– Documented all tested result and parameters

P Presenting Rhythm and Rate

B Battery Status

L Lead Status

S Sensing

T Threshold

O Observation, Data, and Events

P Program & Print

“PBL STOP”

PBL STOP

P

B

L

OT

P

S

Interrogation and programming

workshop part II

Hands-on session by Ray Chan

Medtronic helpers:

Poly Fu, Ray Chan, Brandon Chen, Chapman Lee, Fayzi Lee, Tina Ling, Shirley Chau, Cristina Leung

Hands-on session

• Hands-on for a pacemaker follow-up

• Divided into 5 groups each of 8-10 persons

• 5 tables of Medtronic simulators

• Two virtual patient A & B

• Each one perform both patient with printed reports

45mins

Post hands-on f/u observation~ 10mins

Patient historyPatient B

• Post implant 1 day

• Implanted with Medtronic dual chamber pacemaker

• RA & RV active fixation leads

• First degree AVB

Patient A

• Replacement done with a Medtronic dual chamber pacemaker over 1 year

• RA & RV old passive leads implanted in 2002

• Syncope, AF, long pause ~ 5 sec

Parameters during replacement

P wave: 2.0mV

R wave: 18mV

Pacing threshold:

RA: 0.5V@0.5ms

RV: 0.7V@0.5ms

Imp:

RA: 688Ω

RV: 1200Ω

Parameters during implant

P wave: 1.8mV

R wave: 10mV

Pacing threshold:

RA: 1.1V@0.5ms

RV: 0.3V@0.5ms

Imp:

RA: 632Ω

RV: 887Ω

Post follow up observation

Patient A Old leads implanted 11yrs

old

RV lead parameters Impedance: 1200 > 4xxΩΩΩΩ

R wave: 18mV > 2.0mV

Threshold ↑↑↑↑ to 5.0V

Conclusion: RV parameters change showing a suspected RV lead insulation break and degradation

Clinical concern:

1. Pacing dependency?

2. Intact AV conduction?

3. RV lead replacement need?

Patient B Post implant one day with new RA &

RV active leads

RA lead parameters Impedance: normal

P wave: ~ 3.0mV (normal? EGM?)

RA threshold: n/a but capture RV@ 5.0V

Conclusion: RA parameters, ECG & EGM signals shown a suspected RA lead dislodgement to RV chamber

Clinical concern:1. RA reposition need

2. Active fixation on alternative RA position?

3. Passive lead?