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

Brussels

June 24 - 25, 2008

Bianka Halmágyi

Statistics.Cylos, Cylos 990, Philos II, Talos.

2

Statistics. Cylos, Cylos 990, Philos II, Talos.

General

Statistics will be restarted at every reprogramming of the device

Long-term trends are 180 days long and rolling (if the trend is longer than 180 days the oldest data will be overwritten)

Histograms collect all data as long as the statistics are restarted again

Short-term trends collect data for 33.33 hours

during interrogation and magnet application the counters/ histograms are not active

Programming the rate forecast feature will empty all rate counters/histograms

3


Overview

Timing Timing eventsSpecial eventsAtrial rate histogramVentricular rate histogramA/V rate trend Intrinsic AV conductionFar-field histogram

TachyarrhythmiasTachy episode trendAT histogramPAC trendPAC versus atrial ratePAC coupling intervalPVC classificationPVC versus ventricular ratePVC coupling interval

SensorRate/sensor trendSensor gain trendSensor histogramActivity chart

Sensing StatisticsP-wave trend short + longR-wave trend short + long

PacingA/V impedance trend (short +long)Vent. pacing amplitude trendVentricular threshold trendVentricular pacing amplitude histogramACC status

4


Agenda

Timing

Atrial arrhythmia

Ventricular arrhythmia

Sensor

Sensing

Pacing

5


Timing

Timing events

As-Vs: atrial sense/intrinsic AV conductionAp-Vs: atrial pace/intrinsic AV conduction As-Vp: atrial sense/paced AV conductionAp-Vp: atrial pace/paced AV conduction V - V: 2 consecutive Vs-Vs/Vs-Vp/Vp-Vs/Vp-Vp PVC

As: % + no. of Atrial sense

Ars: % + no. of refractory sense in the atriumAp: % + no. of Atrial pace Vs: % + no. of

Ventricular senseVrs: % + no. of refractory sense in the ventricleVp: % + no. of

Ventricular pace

6


Definition – Atrial sensed event

Ap

BR

ARP

AVI

VRP

URI

As

Vx Vx

As: spontaneous atrial event sensed outside the ARP

7


Definition – Atrial paced event

Ap

Vx

BR

ARP

AVI

VRP

URI

As

Vx

Ap: atrial stimulus at the end of the programmed Basic Rate/ Hysteresis Rate or during Sensor driven atrial stimulation

8


Definition – Ventricular sensed event

As Ap

Vp Vs

ARP

AVI

VRP

BR

URI

Ap

Vp

As

Vs

Vs = spontaneous ventricular event sensed after As or Ap during AVI and Vs after Vx

9


Definition – Ventricular refractory sense

Ap ApAs As

Vp Vp Vp Vp

PVC

ARP

AVI

VRPURI

Ventricular sense during the programmed ventricular refractory period is classified as a Vrs however, not classified as a PVC

BR

10


Definition – Ventricular Extra Systole event

Ap Ap Ap

Vp Vp Vs

PVC

ARP

AVI

VRP

BR

URI

A spontaneous ventricular event sensed outside the programmed VRP without a previous atrial sense or pace is classified as PVC

Ventricular event after Ars is classified as PVC

11


Definition – Ventricular paced event

As Ap

Vp Vs

ARP

AVI

VRP

BR

URI

Ap

Vp

As

Vs

Vp = ventricular stimulus at the end of the AV delay

12


Definition – V-V counter

Ap

Vs

Vx

BR

ARPAVI

VRPURI

Vx – Vs = in V-Vcounter

As

Vrs

Vx

BR

ARPAVI

VRPURI

Vx - Vrs = not in V-V counter

13


Timing

Special events*

*Just Cylos, Cylos 990, Philos II, Talos

All events are counted since the last start of the statistics

14


Timing

A/V rate trend

A/V Trend is programmableAs fixed trend (12 min/resolution 4 sec.)As rolling trend (33 hours/ resolution 512 sec.)

The one day trend begins with a resolution of 2 seconds with 120 time intervalsThe time intervals are compressed continuouslyLast compression level: resolution of 512 seconds and 180 time intervals.Two trends are simultaneously displayed

Atrial & ventricular rate% of atrial & ventricular stimulation

15


Timing

Atrial rate histogram

The events in the Rate Histogram are based on

Refractory senses (events in the programmed refractory period)

Sensed events (events outside refractory period)

Paced events (BR/sensor driven rate)

Represents distribution of

Rate divided over 16 bins (resolution 10 ppm/bin)

Ranging<40 .. (10) .. >180 ppm

16


Atrial rate histogram 1/2

P-P

1,000 ms

P-P

1,500 ms

Ap Ap Ap Ap

Vp Vp Vp Vp

PVC

ARPAVI

VRP

BI

URI

< 40

40-49

Ap < BR

17


Atrial rate histogram 2/2

P-P

1,000 ms

P-P

1,250 ms

Ap ApAs

Ap

Vp Vp Vp Vp

PVC

ARP

AVI

VRP

BI

URI

< 40

40-49

50-59

As < BR

18


Timing

Ventricular rate histogram

The events in the ventricular rate histogram are based on

Sensed events (events outside refractory period)

Paced events (BR/sensor driven rate)

Refractory senses (inside refractory period): not considered

Represents distribution of

Rate divided over 16 bins (resolution 10 ppm/bin)

Ranging <40 .. (10) .. >180 ppm

19


Ventricular rate histogram 1/2

V-V

1,000 ms

V-V

1,090 ms

Ap Ap As Ap

Vp Vp Vp Vp

PVC

VRPURI

< 40

40-49

50-59

Vs < BR

BIARPAVI

20


Ventricular rate histogram 2/2

V-V

1,000 ms

V-V

1,180 ms

Ap Ap Ap Ap

Vp Vp Vp Vp

PVC

BIARPAVI

VRPURI

< 40

40-49

50-59

Vp < BR

21


Timing

Intrinsic AV conduction*

*Just Cylos and Cylos990

Provides data pertaining to how close intrinsic AV conduction is to the programmed AV interval

The histogram (it actually consists of 10 histograms in one figure) shows the following

Frequency range (5 vertical "trees": 50 - 70ppm, 70 - 90pmm, 90 - 110ppm, 110 - 130ppm, >130ppm)

Conduction sorted by Ap (branches to the left of the tree) and As (branches to the right of the tree)

How many milliseconds after the atrial event, a Vs is registered

22


Timing

Intrinsic AV conduction* EXAMPLE: FREQUENCY RANGE

50 - 70PPM

AV Hysteresis interval after Ap

AV Hysteresis interval after As

Intrinsic AV conduction was registered 210 ms (approx. 60%) and 220 ms (approx. 35%) after Ap and very little (approx. 5%) also after 200 ms

AV Delay after Ap

AV Delay after As

Intrinsic AV conduction registered 200 ms after As (approx. 95%) and very little also after 190 ms (approx. 5%)

*Just Cylos and Cylos990

23


Timing

Far-field histogram*

*All except Talos

Events detected in the FFB window will be sensed but they will not initiate any timing function

The detected events are stored in the Far Field Histogram

The first part of FFB (standard 56 ms) FFB is also covered by the atrial CCB. The detection/ sensing function during that time is completely switched off. Therefore there are no events marked in the FFB Histogram

24


Far Field Blanking (FFB)

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

25


Far Field Blanking (FFB)

As

VsVp

Ap

In Channel B 125ms

In Channel B 125ms

A

V

Noise Interval 125ms

Noise Interval 125ms

FFB 32-200msFFB 32-200ms

Cross Channel B 32-72ms

Cross Channel B 16-72ms

26


Agenda

Timing

Atrial arrhythmia


Sensor

Sensing

Pacing

27


Atrial arrhythmia

Tachy episode trend

Consecutive mode switching events within 45 sec result in one Tachy episode

The number of Tachy episodes does not match with the number of mode switches!

The last 64 Tachy episodes are listed in the printout

The trend shows the last 64 events

28


Atrial arrhythmia

Tachy episode report

…

Report is visible just on the printout, not on the programmer

The report shows the last 64 events, earlier events are deleted

…

29


Atrial arrhythmia

AT histogram*

NSR = normal sinus rhythm

ST = Sinus Tachycardia

AT = Atrial Tachycardia

AF = Atrial fibrillation

Afl = Atrial flutter

*All except Talos

Is generated by an up-down counter of 4 events

Transitions from one zone to the next are counted

30


AT definition

Two rate limits (Philos/Protos had three)

Programmable with the "Adjust" button of the statistics menu

31


AT definition

Stability criterion

3 of the last 5 P-P intervals do not differ more than 6.25% from each other

32


AT definition

Sudden Onset

The average of the 4 previous atrial events is 25% higher than the average of 4 events prior to current average

AS AS

VP VP

AS

VS VP

AS

VP

AS

VP

AS

VP

AS AS AS

VPVP

33


Atrial arrhythmia

AV

AVIAARP PACW

Prematurity (e.g., 25%)

P-P Interval

Atrial senses are registered, but do not change timing

Dynamic shorteningwith rate change

Premature Atrial Contraction WindowAtrial senses in this window are classified as Atrial Premature beats

Prematurityprogrammable

between 5 .. (5) .. 50%

PAC definition

Definition Prematurity: PAC is X% shorter than the average of the last 4 P- P intervals

The length of the PAC Window (PACW)is limited to 800 ms after the atrial event

An atrial event later than 800ms following an atrial event is not considered as PAC

34


Atrial arrhythmia

PAC trend*

*All except Talos

The one day trend begins with a resolution of 2 seconds with 120 time intervals

The time intervals are compressed continuously

Last compression level: resolution of 512 seconds and 180 time intervals

Maximum PAC per hour

35


Atrial arrhythmia

PAC vs. atrial rate*

*All except Talos

Number and percentage of PAC versus atrial rate shows at which rate the highest percentage of PAC occur

Atrial rate divided over 16 bins (resolution 10 ppm) ranging between 40 .. (10) .. >180 ppm

36


Atrial arrhythmia

PAC coupling interval*

*All except Talos

Counts subsequent Ax - PAC intervals

Distribution of PAC coupling interval divided over 16 bins (resolution 62 ms) ranging between <200- >760 ms

37


Agenda

Timing

Atrial arrhythmia


Sensor

Sensing

Pacing

38



PVC definition

The PVC definition of Philos II/Talos/Cylos is made more specific than in Philos/Axios/Protos

Smallest Vx - Vs interval: 500 ms no PVC at rates below 120 bpm!(But will be counted as V-V Interval in the event counters)

At Vx – Ars – Vs sequences Vs will be classified as PVC only if: Ars – Vs > 300 ms no PVC at transion of atrial Tachycardias to the ventricle

39



PVC prematurity

P-P1,000 ms

Ap Ap

Vp

Vs

PVC

ARP

AVI

VRP

BI

URI

V-V490 ms

As

Vp

PVC classification is based on previous P-P interval

Example: percentage prematurity = 1,000 ms - 490 / 1,000 x 100 = 51%

40



Shows (relative to the heart rate) pre-maturity of PVC Indicates severity of PVCSingle PVC: sequence of events A-V-PVC-ACouplets: sequence of events A-V-PVC-PVC-ATriplets: sequence of events A-V-PVC-PVC-PVC-ANote: The PVC – PVC coupling interval must be within 500 ms to be counted and classified

PVC classification

41



Number and percentage of PVC versus ventricular rate shows at which rate the highest percentage of PVC occur

Atrial rate divided over 16 bins (resolution 10 ppm) ranging between <40 .. (10) .. >180 ppm

PVC vs. ventricular rate

42



PVC vs. ventricular rate

Ap Ap

Vp Vp

PVC

ARPAVI

VRP

BI

URI

Ap

Vp

PVC

< 40

40-49

50-59

60-69

PVC vs. Ventricular rate

V-V 1,000 ms

V-V1,500 ms

The V-V interval before the PVC occurred is taken as reference

43



Counts subsequent Vx – PVC intervals

Distribution of PVC coupling interval divided over 7 bins (resolution 49 ms) ranging between <200 / 499 ms

PVC coupling interval

44



PVC coupling interval

Ap Ap

Vp

Vs

PVC

ARP

AVI

VRP

BI

URI

Vx- PVC

450 ms

As

Vp

Coupling time between Vx and subsequent PVC

45


Agenda

Timing

Atrial arrhythmia


Sensor

Sensing

Pacing

46


Sensor

Records how often the sensor rate lies in a certain range.

The rate recorded depends on the pacing mode:

Atrial heart rate : VDD, DDD, AAI … + (RR equiv.)

Ventr. heart rate: DDI, DVI, VVI … + (RR equiv.)

Sensor histogram

Recording in all non-rateresponsive modes too

The sensor indicated rate is also recorded even if inhibition occurs at a faster rate

Distribution of Sensor Rate divided over 16 bins (resolution 10 ppm/bin) ranging between < 40 .. (10) .. >180 ppm

47


Sensor

Maximum activity rate: Sensor indicates activity at max. sensor rate

Activity: Sensor indicates activity (not at the max. sensor rate)

No activity: Sensor does not indicate any activity

Values are expressed as percentage since last start of statistics

Activity chart

48


Sensor

Continuously checks whether the rate response optimally meets the patient's needs and makes adjustments to the sensor gain when necessary

The automatic sensor gain checks daily whether 90% of the adjusted maximum activity rate (MAR) have been reached for a total of 90 seconds. If this occurs, it decreases the sensor gain by one increment

Sensor gain

If the "maximum activity rate" is not reached, the current setting will initially remain unchanged

If the MAR is not reached within a period of 7 days, sensor gain will be increased by one increment

49


Sensor

If the sensor gain is automatically adjusted the trend shows changed values

The sensor gain can show values between 1.0 and 40 in 32 steps

Flat line is shown if Auto Gain is OFF and the sensor gain is programmed to a fix value

Sensor gain trend

50


Agenda

Timing

Atrial arrhythmia


Sensor

Sensing

Pacing

51


Sensing

33 h rolling trend

P/R wave trend short

52


Sensing

180 days rolling trend

Can only be displayed after a recording duration of three days

P/R wave trend long

53


Agenda

Timing

Atrial arrhythmia


Sensor

Sensing

Pacing

54


Pacing

To make the trend independent from amplitude and pacing every 1.5 hours a measurement occurs by delivering max. 4 triggered pulses at 4.8 V or higher, depending on the program

The lead check works beat to beat in a range of 1.4 V - 5.8 V (Philos/ Protos: 2.4 V - 8.4 V). At lower amplitudes (ACC!) the lead check can not work beat-to beat, just during impedance measurement

Range of a valid impedance: 200 Ω (Philos/Protos: 300 Ω) to 3,000 Ω

The Impedance Trend is independent from the lead check and is always active (deactivation by code possible)

Impedance measurement/lead check

55


Pacing

Rolling 180 day trend, last compression stage: 1 data point per day (values are averaged!)

33 h rolling trend

Both trends based on the 90 min impedance measurement at 4.8 V

The long-term trend can only be displayed after a recording duration of three days

Impedance trend short/long

56


Pacing

Long-term 180 days trend last compression stage: 1 data point per day (values are averaged!) Records values between 0 - 10 VAt the highest compression level, daily values are averaged

Ventricular pace amplitude trend

57


Pacing

Long-term 180 days trend

Records values between 0 - 8 V

At the highest compression level, daily values are averaged

Ventricular threshold trend

58


Pacing

Shows the distribution of the pacing amplitude range of <0.3 to > 4.5 V in 16 bins of 0.3 V

Amplitudes applied during the threshold test are included

Ventricular pace amplitude histogram

59


Pacing

OK: feature works as expected Inactive or disabled: ACC was turned on and deactivated later by the implant Pending: the programmer has not got any status information (telemetry?)High Threshold: calculated pacing amplitude is higher than MaxACC amplitudeWhen status ≠ OK a note shows the reason for this

Active Capture Control (ACC) status

Documents

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