Interrogation and programming workshop part I

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 Patient
Treat the patient, not the device
Interrogation
Presenting Rhythm
& Rate
Battery Status
Lead impedance
Threshold
Observation
Sensing
Program & Print
“PBL STOP”
P
B
L
Presenting Rhythm and Rate
Battery Status
Lead Status
S
T
O
P
Sensing
Threshold
Observation, Data, and Events
Program & Print
‘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
2 Settings Used to Ensure Capture
GOAL Find the minimum amount of energy needed to
consistently capture the heart (stimulation threshold).
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
Amplitude Threshold Testing
Keeping pulse width stable, decrement voltage until loss of
capture
@ 0.5ms
1.5V
1.0V
.5V
Pulse Width Threshold Testing
Keeping voltage stable, decrement in pulse width
@ 2 volts
.30ms
.20ms
.1ms
.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
–
–
–
–
“PBL STOP”
P
B
L
Presenting Rhythm and Rate
Battery Status
Lead Status
S
T
O
P
Sensing
Threshold
Observation, Data, and Events
Program & Print
PBL STOP
P
B
L
T
O
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
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•
•
•
•
Post hands-on f/u observation~ 10mins
Patient history
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
Patient B
• Post implant 1 day
• Implanted with
Medtronic dual
chamber pacemaker
• RA & RV active fixation
leads
• First degree AVB
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
Patient B
Old leads implanted 11yrs
old
RV lead parameters
Post implant one day with new RA &
RV active leads
RA lead parameters
Conclusion: RV parameters
change showing a suspected
RV lead insulation break and
degradation
Conclusion: RA parameters, ECG &
EGM signals shown a suspected RA
lead dislodgement to RV chamber
Impedance: normal
P wave: ~ 3.0mV (normal? EGM?)
RA threshold: n/a but capture RV@
5.0V
Impedance: 1200 > 4xxΩ
Ω
R wave: 18mV > 2.0mV
Threshold ↑ to 5.0V
Clinical concern:
1. Pacing dependency?
2. Intact AV conduction?
3. RV lead replacement need?
Clinical concern:
1.
2.
3.
RA reposition need
Active fixation on alternative RA
position?
Passive lead?