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Case Studies. St. Jude Medical. Single Chamber ECG Analysis. ECG #1. Programmed Parameters Mode………………………………………….. VVI Base Rate……………………………………….. 70 ppm Magnet Response…………………….. Battery Test Hysteresis Rate………………………………… Off ppm. T Temporary programmed value. 1.0 Second. - PowerPoint PPT Presentation
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Folie 1, V 1.1 /TK ECG‘s
St. Jude Medical
Case Studies
Folie 2, V 1.1 /TK ECG‘s
Programmed ParametersMode………………………………………….. VVIBase Rate……………………………………….. 70 ppmMagnet Response…………………….. Battery TestHysteresis Rate………………………………… Off ppm
T Temporary programmed value7 Mar 2000 23:20
1.0 Second
Single Chamber ECG Analysis
ECG #1
Folie 3, V 1.1 /TK ECG‘s
VVI Normal Capture and Sensing
Answer ECG #1
Single Chamber ECG Analysis
Folie 4, V 1.1 /TK ECG‘s
ECG #2
Single Chamber ECG Analysis
Folie 5, V 1.1 /TK ECG‘s
VVI Normal Capture and Sensing with initiation of
Hysteresis
Answer ECG #2
Single Chamber ECG Analysis
Folie 6, V 1.1 /TK ECG‘s
ECG #3
Single Chamber ECG Analysis
Folie 7, V 1.1 /TK ECG‘s
VVI Loss of Ventricular Sensing
Answer ECG #3
Single Chamber ECG Analysis
Folie 8, V 1.1 /TK ECG‘s
1.0 Second
ECG #4
Single Chamber ECG Analysis
Folie 9, V 1.1 /TK ECG‘s
ECG #4
Single Chamber ECG Analysis
Folie 10, V 1.1 /TK ECG‘s
VVI Normal Capture and Sensing
Answer ECG #4
Single Chamber ECG Analysis
Folie 11, V 1.1 /TK ECG‘s
ECG #5
Single Chamber ECG Analysis
Folie 12, V 1.1 /TK ECG‘s
ECG #5
Single Chamber ECG Analysis
Folie 13, V 1.1 /TK ECG‘s
VVI Normal Capture Ventricular Undersensing
Answer ECG #5
Single Chamber ECG Analysis
Folie 14, V 1.1 /TK ECG‘s
ECG #6
Single Chamber ECG Analysis
Folie 15, V 1.1 /TK ECG‘s
ECG #6
Single Chamber ECG Analysis
Folie 16, V 1.1 /TK ECG‘s
VVI Loss of Ventricular Capture Normal Sensing
Answer ECG #6
Single Chamber ECG Analysis
Folie 17, V 1.1 /TK ECG‘s
Base Rate 60 ppm
MTR 120 ppm
AVD 200 ms
PVARP 250 ms
Dual Chamber ECG Analysis
ECG #1
Folie 18, V 1.1 /TK ECG‘s
Loss of Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown
Dual Chamber ECG Analysis
Answer ECG #1
Folie 19, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 75 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #2
Folie 20, V 1.1 /TK ECG‘s
Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown
Answer ECG #2
Dual Chamber ECG Analysis
Folie 21, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #3
Folie 22, V 1.1 /TK ECG‘s
Normal Atrial Capture Possible Psuedofusion on 4th atrial output
Atrial Sensing Unknown Loss of Ventricular Capture Normal Ventricular Sensing
Functional Loss of Ventricular Sensing
Dual Chamber ECG Analysis
Answer ECG #3
Folie 23, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #4
Folie 24, V 1.1 /TK ECG‘s
Normal Atrial CaptureAtrial fusion on 3rd atrial output
Normal Atrial Sensing Normal Ventricular Capture Normal Ventricular Sensing
Answer ECG #4
Dual Chamber ECG Analysis
Folie 25, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #5
Folie 26, V 1.1 /TK ECG‘s
Normal Atrial Capture Atrial Sensing Unknown Normal Ventricular Capture
Fusion on 2nd ventricular output Normal Ventricular Sensing
Answer ECG #5
Dual Chamber ECG Analysis
Folie 27, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #6
Folie 28, V 1.1 /TK ECG‘s
Normal Atrial Capture Atrial Sensing Unknown Normal Ventricular Capture
Fusion on 2nd ventricular output Ventricular Sensing Unknown
Answer ECG #6
Dual Chamber ECG Analysis
Folie 29, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #7
Folie 30, V 1.1 /TK ECG‘s
Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Normal Ventricular Sensing
Dual Chamber ECG Analysis
Answer ECG #7
Folie 31, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #8
Folie 32, V 1.1 /TK ECG‘s
Normal Atrial Capture with one beat showing functional loss of atrial capture
Atrial Undersensing Normal Ventricular Capture Ventricular Sensing Unknown
Answer ECG #8
Dual Chamber ECG Analysis
Folie 33, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #9
Folie 34, V 1.1 /TK ECG‘s
Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Normal Ventricular Sensing
Answer ECG #9
Dual Chamber ECG Analysis
Folie 35, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 200 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #10
Folie 36, V 1.1 /TK ECG‘s
Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture with two
beats of functional loss of capture Ventricular Undersensing
Answer ECG #10
Dual Chamber ECG Analysis
Folie 37, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 150 msPV 150 msPVARP 250 ms
ECG #11
Dual Chamber ECG Analysis
Folie 38, V 1.1 /TK ECG‘s
Atrial Capture Unknown Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown
Answer ECG #11
Dual Chamber ECG Analysis
Folie 39, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 88 msPVARP 250 ms
ECG #12
Dual Chamber ECG Analysis
Folie 40, V 1.1 /TK ECG‘s
Normal Atrial Capture Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown Initiation of a Pacemaker Mediated
Tachycardia (PMT) with following a PVC
Answer ECG #12
Dual Chamber ECG Analysis
Folie 41, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 88 msPVARP 250 ms
ECG #13
Dual Chamber ECG Analysis
Folie 42, V 1.1 /TK ECG‘s
Loss of Atrial Capture initiating a Pacemaker Mediated Tachycardia (PMT)
Normal Atrial Sensing Normal Ventricular Capture Ventricular Sensing Unknown
Answer ECG #13
Dual Chamber ECG Analysis
Folie 43, V 1.1 /TK ECG‘s
Base Rate 60 ppmMTR 120 ppmAV 200 msPV 150 msMin. PV 88 msPVARP 250 ms
Dual Chamber ECG Analysis
ECG #14
Folie 44, V 1.1 /TK ECG‘s
Normal Atrial Capture Atrial Sensing Unknown Normal Ventricular Capture Normal Ventricular Sensing The retrograde P-wave after the PVC is not seen
because it falls in PVARP just like it should
Answer ECG #14
Dual Chamber ECG Analysis
Folie 45, V 1.1 /TK ECG‘s
ICD ECG Analysis
ECG #1
Folie 46, V 1.1 /TK ECG‘s
ICD ECG Analysis
ECG #1
Folie 47, V 1.1 /TK ECG‘s
ICD ECG Analysis
Answer ECG #1
T-Wave sensing longer decay delay Threshold start higher
Folie 48, V 1.1 /TK ECG‘s
Presented with left hemi-diaphragmatic stimulation from atrial lead
Twiddler‘s Syndrome
Folie 49, V 1.1 /TK ECG‘s
Courtesy of Dr. F. Venditti, Lahey Clinic, MA`
Twiddler‘s Syndrome
Folie 50, V 1.1 /TK ECG‘s
Rib-Clavicle Crush
Folie 51, V 1.1 /TK ECG‘s
Rib-Clavicle Crush
Folie 52, V 1.1 /TK ECG‘s
Original lead damaged by rib-clavicle crush.
New lead placed via cephalic vein cutdown
Rib-Clavicle Crush
Folie 53, V 1.1 /TK ECG‘s
Myopotential Oversensing
Folie 54, V 1.1 /TK ECG‘s
Reproduce while monitoring EGM / Event Markers
Try to eliminate with reduced sensitivity
Provocative maneuvers
Evaluation of Oversensing
Folie 55, V 1.1 /TK ECG‘s
Ventricular Fusion
Folie 56, V 1.1 /TK ECG‘s
Ventricular Pseudofusion
Folie 57, V 1.1 /TK ECG‘s
Metabolic abnormalities Hyperkalemia ( K+ )
Congestive Heart Failure Changes in time of day
sleep >> wake Exercise and heart rate Pharmacologic agents
Flecainide
Bipolar VVI with 2nd degree Wenckebach exit-block due to hyperkalemia (serum K 7.3 mEq/L). Upon correction of elevated potassium level, capture threshold was 1.3 V @ 0.8 ms
Loss of Capture due to Intrinsic Rise in Capture Threshold
Folie 58, V 1.1 /TK ECG‘s
Slower rate and pauses ONLY follow native beats
First escape cycle followed by pacing at higher rate
Management Education Disable if causing
problems
ProgrammingBase Rate: 115 ppm
Hysteresis Rate: 65 ppm
Hysteresis
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