Basic Concepts

Pacemaker Modes and

Basic Pacemaker Timing

1
Objectives

• Describe the NBG codes

• Measure intervals and convert to rates
• Identify basic dual chamber timing concepts
• Describe how a pacemaker responds to a magnet

2
Pacemaker Mode

To understand, predict and troubleshoot pacemaker

behavior, it is critical that one understands pacemaker
timing and pacemaker modes.

The pacemaker mode:

• Defines the chambers that are paced/sensed
• Defines how the pacemaker will respond to intrinsic events
• Defines if rate modulation is available (i.e., DDDR)

3
NBG Code

I II III IV V
Chamber(s) Chamber(s) Response to Rate Multisite
Paced Sensed Sensing Modulation Pacing
O = None O = None O = None O = None O = None
A = Atrium A = Atrium T = Triggered R = Rate A = Atrium
modulation
V = Ventricle V = Ventricle I = Inhibited V = Ventricle
D = Dual (A + V) D = Dual (A + V) D = Dual (T + I) D = Dual (A + V)
S = Single (A or V) S = Single (A or V)

Examples:
VVI mode indicates that only the ventricle is paced and sensed and that the pacemaker is
inhibited in response to ventricular sensing.
DDD mode indicates that the atrium and ventricle are both paced and sensed and that the
pacemaker both triggers (commonly called tracking) and inhibits pacing in response to
sensing. This concept will be explained further as you review basic pacemaker timing.
NBG Code – The Usual Pacing Modes

I II III IV V
Chamber(s) Chamber(s) Response to Rate Multisite
Paced Sensed Sensing Modulation Pacing
O = None O = None O = None O = None O = None
A = Atrium A = Atrium T = Triggered R = Rate A = Atrium
modulation
V = Ventricle V = Ventricle I = Inhibited V = Ventricle
D = Dual (A + V) D = Dual (A + V) D = Dual (T + I) D = Dual (A + V)
S = Single (A or S = Single (A or V)
V)

Examples of pacing modes which are typically programmed:

DDD VVI DDIR
DDDR VVIR AAIR
Rate and Interval Review

• Calculated on the horizontal axis

– At 25 mm/s speed (standard)
• Each small box = 40 ms
• Each large box = 200 ms

How do you convert intervals to rate?

Click for Answer
60,000 / (Interval in ms) = Rate in bpm
OR
60,000 / (Rate in bpm) = Interval in ms

What is a rate of 100 bpm in ms? Click for Answer

60,000 / (100 bpm) = 600 ms

6
VVI Mode

Chamber Paced Chamber Sensed Response to

Sensing
V = Ventricle V = Ventricle I = Inhibited

– For VVI 60, lower rate timer equals 1000 ms

– Device paces every 1 second if not inhibited

Lower Rate Timer 1000 ms Lower Rate Timer 1000 ms Lower Rate Timer ….

V V V
P P P

7
VVI Mode

Chamber Paced Chamber Sensed Response to

Sensing
V = Ventricle V = Ventricle I = Inhibited

– A ventricular sense will interrupt the pacing interval, reset the lower
rate timer, and inhibit the next scheduled paced (x)

Lower rate timer 1000 ms Lower rate timer 1000 ms

V V V V
P P S P

8
VOO Mode

Chamber Paced Chamber Sensed Response to

Sensing
V = Ventricle O = None O = None

VOO results in fixed-rate pacing in the ventricle. Placing a magnet over the pacemaker will
result in this behavior. Application of a magnet can be used to inhibit oversensing during
surgery, troubleshoot the pacemaker, or asses the device’s battery status.

1000 ms 1000 ms 1000 ms

V V V V
P P P P
The intrinsic ventricular event is not
sensed in this mode, and thus, does not
interrupt the pacing interval.

9
DDD Mode

Chamber Paced Chamber Sensed Response to

Sensing
D = Dual (A+V) D = Dual (A+V) D = Trigger and
Inhibit

– An atrial sense:
• Inhibits the next scheduled atrial pace
• Re-starts the lower rate timer
• Triggers an AV interval (called a Sensed AV Interval or SAV)
– An atrial pace:
• Re-starts the lower rate timer
• Triggers an AV delay timer (the Paced AV or PAV)
– A ventricular sense:
• Inhibits the next scheduled ventricular pace

10
DDD Examples
The Four Faces of DDD

Atrial and ventricular pacing

A V A V
P P P P

– Atrial pace occurs at the lower rate, re-starts the lower rate timer, and
triggers an AV delay timer (PAV)
– The PAV expires without being inhibited by a ventricular sense, and a
ventricular pace is delivered

Why is the pacemaker pacing in the Why does the pacemaker’s AV interval
atrium? Assuming that the device is timer expire without being inhibited? The
sensing appropriately, the patient’s sinus patient may have a heart block. The patient
rate is less than the pacemaker’s may have delayed AV conduction meaning
programmed rate (i.e., sinus bradycardia). that the patient’s P-R interval is longer than
the programmed PAV.

11
DDD Examples
The Four Faces of DDD

Atrial pacing and ventricular sensing

A V A V
P S P S
– Atrial pace occurs at the lower rate, restarts the lower rate timer, and
triggers an AV delay timer (PAV)
– Before the PAV can expire, it is inhibited by an intrinsic ventricular event (R-
wave)

Why is the ventricular pace inhibited? The atrial pace captures the atrium and intrinsic
conduction within the patient’s heart occurs to cause a ventricular contraction. Because this
occurs before the PAV is timed out, the ventricular pace is inhibited.

12
DDD Examples
The Four Faces of DDD

Atrial sensing, ventricular pacing

A V A V
S P S P

– The intrinsic atrial event (P-wave) inhibits the lower rate timer and triggers
an AV delay timer (SAV)

– The SAV expires without being inhibited by an intrinsic ventricular event,

resulting in a ventricular pace
Why is the atrial pace inhibited and ventricular pace delivered? The patient’s intrinsic
sinus rate is faster than the programmed lower rate. The patient’s AV conduction is slower
than the programmed AV interval which causes a ventricular pace. This concept is called
atrial tracking because the ventricule is tracking the atrial rate. Note that there is an upper
limit to this tracking called the upper tracking rate.

13
DDD Examples
The Four Faces of DDD

Atrial and ventricular sensing

A V A V
S S S S

– The intrinsic atrial event (P-wave) inhibits the lower rate timer and triggers
an AV delay timer (SAV)
– Before the SAV can expire, it is inhibited by an intrinsic ventricular event (R-
wave)
In what cases would a pacemaker be sensed in the atrium and ventricle a majority of
the time? The patient may have intermittent, symptomatic sinus bradycardia, intermittent AV
block, symptomatic neurocardiogenic syncope, or another condition which necessitates
pacing support for only a small amount of time. This “non-paced” rhythm is also often found
in ICD patients who have no pacing indication.

14
Mode Selection to Reduce RV Pacing

It has been proven that chronic RV apical pacing

is associated with detrimental effects, especially MVP® mode
for patients with intact or intermittent AV
conduction.1-7 AAI(R)
- Increased risk of heart failure (HF)
hospitalization
and death
- Increased risk of atrial fibrillation (AF) Intact AV Conduction
Conduction Loss
MVP® (Managed Ventricular Pacing) mode
provides AAI(R) pacing during normal AV
conduction and DDD(R) pacing when AV DDD(R)
conduction is lost. Short AV
- MVP is clinically proven to reduce unnecessary
right MVP is primarily an
ventricular pacing by 99%.8,9 AAI mode with backup
1
Wilkoff BL, et al. JAMA. 2002;288:3115-3123.
2
Sweeney MO, et al. Circulation. 2003;107:2932-2937.
V. pacing when needed
3
Connolly SJ, et al. N Engl J Med. 2000;342:1385-1391.
4
Andersen HR, et al. Lancet. 1997;350:1210-1216.
5
Sweeney MO, et al. N Engl J Med. 2007;357:1000-1008.
6
Nielsen JC, et al. J Am Coll Cardiol. 2003;42:614-623.
7
Epstein AE, et al. J Am Coll Cardiol. 2008;51:e1-62.
8
Sweeney MO, et al. J Cardiovasc Electrophysiol. 2005;16:811-817.
9
Gillis AM, et al. Heart Rhythm. 2005;2:S40.
Pacemaker Timing Notes

• Note that in both the single and dual chamber examples:

– When the device paces – for the purposes of timing – capture is
assumed
• Many devices have algorithms to check for capture

– Sensing is critical to timing

• If the device fails to sense (undersensing) it will usually pace
• If it “oversenses,” e.g., senses myopotentials, it will inhibit pacing

16
Magnet Mode

What happens when a magnet is applied over a pacemaker?

• The pacemaker modes temporarily switches to VOO in single chamber
devices and DOO in dual chamber devices.
– Asynchronous pacing delivers output regardless of intrinsic activity
– Pacing rate will be 85 for pacemaker battery levels above ERI (elective
replacement indicator) and 65 for battery levels below ERI*
– Previously programmed mode returns when the magnet is removed*
• Use when:
– Checking pacemaker battery level
– EMI is present (surgery, TENS, etc.)
– Device troubleshooting (breaking a PMT, assessing capture, etc.)

*This operation is guaranteed for Medtronic devices only.

Status Check

• Calculate the atrial rate

• Measure the P-R interval
• Measure the QRS duration

Click for Answer Atrial Rate: 70 bpm (860 ms)

P-R: 120 ms
QRS: About 100 ms

18
Status Check
Which pacemaker mode(s) could be operating on this
strip? Assume normal pacemaker operation Click for Answer

The strip does not show any signs of pacing. Therefore, the device could
A. DDD be programmed in any mode which allows sensing to inhibit pacing. These
modes are DDD, VVI, and AAI. DOO mode does not sense intrinsic
B. VVI activation and would cause pacing at the programmed lower rate
regardless of the patient’s rhythm.
C. AAI
D. DOO

19
Status Check
Which pacemaker modes could be operating on this strip?
• Assume normal pacemaker operation Click for Answer

The strip shows atrial sensing and ventricular pacing. AAI can be ruled out
A. DDD because ventricular pacing is not possible in this mode. DOO mode does not
include atrial sensing which means that the device would not be tracking the
B. VVI atrial events as they are here. The device is most likely programmed to DDD
mode because it is sensing the P waves, starting a PAV, and then pacing the
C. AAI ventricle. VVI is possible because it will allow for ventricular pacing but is
unlikely because it does not provide AV synchrony.
D. DOO

20
Disclosure

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Brief Statement: IPGs and ICDs

Indications
Implantable Pulse Generators (IPGs) are indicated for rate adaptive pacing in patients who
may benefit from increased pacing rates concurrent with increases in activity and increases
in activity and/or minute ventilation. Pacemakers are also indicated for dual chamber and
atrial tracking modes in patients who may benefit from maintenance of AV synchrony. Dual
chamber modes are specifically indicated for treatment of conduction disorders that require
restoration of both rate and AV synchrony, which include various degrees of AV block to
maintain the atrial contribution to cardiac output and VVI intolerance (e.g. pacemaker
syndrome) in the presence of persistent sinus rhythm.
Implantable cardioverter defibrillators (ICDs) are indicated for ventricular antitachycardia
pacing and ventricular defibrillation for automated treatment of life-threatening ventricular
arrhythmias.
Cardiac Resynchronization Therapy (CRT) ICDs are indicated for ventricular antitachycardia
pacing and ventricular defibrillation for automated treatment of life-threatening ventricular
arrhythmias and for the reduction of the symptoms of moderate to severe heart failure
(NYHA Functional Class III or IV) in those patients who remain symptomatic despite stable,
optimal medical therapy and have a left ventricular ejection fraction less than or equal to 35%
and a prolonged QRS duration.
CRT IPGs are indicated for the reduction of the symptoms of moderate to severe heart failure
(NYHA Functional Class III or IV) in those patients who remain symptomatic despite stable,
optimal medical therapy, and have a left ventricular ejection fraction less than or equal to
35% and a prolonged QRS duration.
Brief Statement: IPGs and ICDs
Contraindications
IPGs and CRT IPGs are contraindicated for dual chamber atrial pacing in patients with chronic
refractory atrial tachyarrhythmias; asynchronous pacing in the presence (or likelihood) of
competitive paced and intrinsic rhythms; unipolar pacing for patients with an implanted
cardioverter defibrillator because it may cause unwanted delivery or inhibition of ICD therapy; and
certain IPGs are contraindicated for use with epicardial leads and with abdominal implantation.

ICDs and CRT ICDs are contraindicated in patients whose ventricular tachyarrhythmias may have
transient or reversible causes, patients with incessant VT or VF, and for patients who have a
unipolar pacemaker.

Warnings/Precautions
Changes in a patient’s disease and/or medications may alter the efficacy of the device’s programmed
parameters. Patients should avoid sources of magnetic and electromagnetic radiation to avoid
possible underdetection, inappropriate sensing and/or therapy delivery, tissue damage, induction
of an arrhythmia, device electrical reset or device damage. Do not place transthoracic
defibrillation paddles directly over the device. Additionally, for CRT ICDs and CRT IPGs, certain
programming and device operations may not provide cardiac resynchronization. Also for CRT
IPGs, Elective Replacement Indicator (ERI) results in the device switching to VVI pacing at 65
ppm. In this mode, patients may experience loss of cardiac resynchronization therapy and / or
loss of AV synchrony. For this reason, the device should be replaced prior to ERI being set.
Brief Statement: IPGs and ICDs
Potential complications
Potential complications include, but are not limited to, rejection phenomena, erosion through
the skin, muscle or nerve stimulation, oversensing, failure to detect and/or terminate
arrhythmia episodes, and surgical complications such as hematoma, infection,
inflammation, and thrombosis. An additional complication for ICDs and CRT ICDs is the
acceleration of ventricular tachycardia.

See the device manual for detailed information regarding the implant procedure, indications,
contraindications, warnings, precautions, and potential complications/adverse events. For
further information, please call Medtronic at 1-800-328-2518 and/or consult Medtronic’s
website at [Link].

Caution: Federal law (USA) restricts these devices to sale by or on the order of a
physician.
Brief Statement: Leads
Indications
Medtronic leads are used as part of a cardiac rhythm disease management system. Leads are intended for
pacing and sensing and/or defibrillation. Defibrillation leads have application for patients for whom
implantable cardioverter defibrillation is indicated. The Attain Leads have application as part of a
Medtronic biventricular pacing system.

Contraindications
Medtronic leads are contraindicated for the following:
• Ventricular use in patients with tricuspid valvular disease or a tricuspid mechanical heart valve.
• Patients for whom a single dose of 1.0 mg of dexamethasone sodium phosphate or
dexamethasone acetate may be contraindicated. (includes all leads which contain these steroids)
• Epicardial leads should not be used on patients with a heavily infarcted or fibrotic myocardium.

The SelectSecure Model 3830 Lead is also contraindicated for the following:
• Patients for whom a single dose of 40.µg of beclomethasone dipropionate may be contraindicated.
• Patients with obstructed or inadequate vasculature for intravenous catheterization.

The Attain leads are contraindicated for patients with coronary venous vasculature that is inadequate for
lead placement, as indicated by venogram. For the Model 4193 and 4194 leads, do not use steroid
eluting leads in patients for whom a single dose of 1.0 mg dexamethasone sodium phosphate may be
contraindicated
Brief Statement: Leads
Warnings/Precautions
People with metal implants such as pacemakers, implantable cardioverter defibrillators
(ICDs), and accompanying leads should not receive diathermy treatment. The interaction
between the implant and diathermy can cause tissue damage, fibrillation, or damage to
the device components, which could result in serious injury, loss of therapy, or the need to
reprogram or replace the device.

For the SelectSecure Model 3830 lead, total patient exposure to beclomethasone 17,21-
dipropionate should be considered when implanting multiple leads. No drug interactions
with inhaled beclomethasone 17,21-dipropionate have been described. Drug interactions
of beclomethasone 17,21-dipropionate with the Model 3830 lead have not been studied.

Attain leads, stylets, and guidewires should be handled with great care at all times. When
using a Model 4193 or 4194 lead, only use compatible stylets (stylets with downsized
knobs and are 3 cm shorter than the lead length). Output pulses, especially from unipolar
leads, may adversely affect device sensing capabilities. Back-up pacing should be readily
available during implant. Use of leads may cause heart block. For the Model 4193 and
4194 leads, it has not been determined if the warnings, precautions, or complications
usually associated with injectable dexamethasone sodium phosphate apply to the use of
this highly localized, controlled-release device. For a list of potential adverse effects, refer
to the Physician’s Desk Reference. Patients should avoid diathermy. Previously
implanted pulse generators, implantable cardioverter-defibrillators, and leads should
generally be explanted.
Brief Statement: Leads
Potential Complications
Potential complications related to the use of leads include, but are not limited to the following
patient- related conditions: cardiac dissection, cardiac perforation, cardiac tamponade,
coronary sinus dissection, death, endocarditis, erosion through the skin, extracardiac muscle
or nerve stimulation, fibrillation or other arrhythmias, heart block, heart wall or vein wall
rupture, hemoatoma/seroma, infection, myocardial irritability, myopotential sensing,
pericardial effusion, epicardial or pericardial rub, pneumothorax, rejection phenomena,
threshold elevation, thrombosis, thrombotic or air embolism, and valve damage. Other
potential complications related to the lead may include lead dislodgement, lead conductor
fracture, insulation failure, threshold elevation or exit block.

See the specific device manual for detailed information regarding the implant procedure,
indications, contraindications, warnings, precautions, and potential complications/adverse
events. For further information, please call Medtronic at 1-800-328-2518 and/or consult
Medtronic’s website at [Link].

Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.