St. Jude Medical

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Case Studies
St. Jude Medical
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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
7 Mar 2000 2320
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Single Chamber ECG Analysis
Answer ECG 1

• VVI
• Normal Capture and Sensing

4
Single Chamber ECG Analysis
ECG 2
5
Single Chamber ECG Analysis
Answer ECG 2

• VVI
• Normal Capture and Sensing with initiation of
  Hysteresis

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Single Chamber ECG Analysis
ECG 3
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Single Chamber ECG Analysis
Answer ECG 3

• VVI
• Loss of Ventricular Sensing

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Single Chamber ECG Analysis
ECG 4
1.0 Second
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Single Chamber ECG Analysis
ECG 4
10
Single Chamber ECG Analysis
Answer ECG 4

• VVI
• Normal Capture and Sensing

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Single Chamber ECG Analysis
ECG 5
12
Single Chamber ECG Analysis
ECG 5
13
Single Chamber ECG Analysis
Answer ECG 5

• VVI
• Normal Capture
• Ventricular Undersensing

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Single Chamber ECG Analysis
ECG 6

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Single Chamber ECG Analysis
ECG 6

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Single Chamber ECG Analysis
Answer ECG 6

• VVI
• Loss of Ventricular Capture
• Normal Sensing

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Dual Chamber ECG Analysis
ECG 1
Base Rate 60 ppm MTR 120 ppm AVD 200
ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 1

• Loss of Atrial Capture
• Normal Atrial Sensing
• Normal Ventricular Capture
• Ventricular Sensing Unknown

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Dual Chamber ECG Analysis
ECG 2
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 150 ms Min. PV 75 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 2

• Normal Atrial Capture
• Normal Atrial Sensing
• Normal Ventricular Capture
• Ventricular Sensing Unknown

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Dual Chamber ECG Analysis
ECG 3
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 150 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 3

• Normal Atrial Capture
• Possible Psuedofusion on 4th atrial output
• Atrial Sensing Unknown
• Loss of Ventricular Capture
• Normal Ventricular Sensing
• Functional Loss of Ventricular Sensing

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Dual Chamber ECG Analysis
ECG 4
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 200 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 4

• Normal Atrial Capture
• Atrial fusion on 3rd atrial output
• Normal Atrial Sensing
• Normal Ventricular Capture
• Normal Ventricular Sensing

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Dual Chamber ECG Analysis
ECG 5
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 200 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 5

• Normal Atrial Capture
• Atrial Sensing Unknown
• Normal Ventricular Capture
• Fusion on 2nd ventricular output
• Normal Ventricular Sensing

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Dual Chamber ECG Analysis
ECG 6
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 200 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 6

• Normal Atrial Capture
• Atrial Sensing Unknown
• Normal Ventricular Capture
• Fusion on 2nd ventricular output
• Ventricular Sensing Unknown

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Dual Chamber ECG Analysis
ECG 7
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 200 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 7

• Normal Atrial Capture
• Normal Atrial Sensing
• Normal Ventricular Capture
• Normal Ventricular Sensing

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Dual Chamber ECG Analysis
ECG 8
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 200 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 8

• Normal Atrial Capture with one beat showing
  functional loss of atrial capture
• Atrial Undersensing
• Normal Ventricular Capture
• Ventricular Sensing Unknown

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Dual Chamber ECG Analysis
ECG 9
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 200 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 9

• Normal Atrial Capture
• Normal Atrial Sensing
• Normal Ventricular Capture
• Normal Ventricular Sensing

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Dual Chamber ECG Analysis
ECG 10
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 200 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 10

• Normal Atrial Capture
• Normal Atrial Sensing
• Normal Ventricular Capture with two beats of
  functional loss of capture
• Ventricular Undersensing

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Dual Chamber ECG Analysis
ECG 11
Base Rate 60 ppm MTR 120 ppm AV 150
ms PV 150 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 11

• Atrial Capture Unknown
• Normal Atrial Sensing
• Normal Ventricular Capture
• Ventricular Sensing Unknown

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Dual Chamber ECG Analysis
ECG 12
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 150 ms Min. PV 88 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 12

• Normal Atrial Capture
• Normal Atrial Sensing
• Normal Ventricular Capture
• Ventricular Sensing Unknown
• Initiation of a Pacemaker Mediated Tachycardia
  (PMT) with following a PVC

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Dual Chamber ECG Analysis
ECG 13
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 150 ms Min. PV 88 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 13

• Loss of Atrial Capture initiating a Pacemaker
  Mediated Tachycardia (PMT)
• Normal Atrial Sensing
• Normal Ventricular Capture
• Ventricular Sensing Unknown

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Dual Chamber ECG Analysis
ECG 14
Base Rate 60 ppm MTR 120 ppm AV 200
ms PV 150 ms Min. PV 88 ms PVARP 250 ms
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Dual Chamber ECG Analysis
Answer ECG 14

• 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

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ICD ECG Analysis
ECG 1
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ICD ECG Analysis
ECG 1
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ICD ECG Analysis
Answer ECG 1

• T-Wave sensing
• longer decay delay
• Threshold start higher

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Twiddlers Syndrome
Presented with left hemi-diaphragmatic
stimulation from atrial lead
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Twiddlers Syndrome
Courtesy of Dr. F. Venditti, Lahey Clinic, MA
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Rib-Clavicle Crush
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Rib-Clavicle Crush
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Rib-Clavicle Crush
Original lead damaged by rib-clavicle crush. New
lead placed via cephalic vein cutdown
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Myopotential Oversensing
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Evaluation of Oversensing

• Reproduce while monitoring EGM / Event Markers
• Try to eliminate with reduced sensitivity
• Provocative maneuvers

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Ventricular Fusion
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Ventricular Pseudofusion
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Loss of Capture due to Intrinsic Rise in Capture
Threshold

• Metabolic abnormalities
• Hyperkalemia ( K )
• Congestive Heart Failure
• Changes in time of day
• sleep gtgt 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 _at_ 0.8 ms
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Hysteresis

• Slower rate and pauses ONLY follow native beats
• First escape cycle followed by pacing at higher
  rate
• Management
• Education
• Disable if causing problems

Programming Base Rate 115 ppm Hysteresis
Rate 65 ppm