BASICS OF PACEMAKER

HISTORY
• 1958 – Senning and Elmqvist
– Asynchronous (VVI) pacemaker implanted by
thoracotomy and functioned for 3 hours
– Arne Larsson
• First pacemaker patient
• Used 23 pulse generators and 5 electrode systems
• Died 2001 at age 86 of cancer
• 1960 – First atrial triggered pacemaker
• 1964 – First on demand pacemaker (DVI)
• 1977 – First atrial and ventricular demand pacing (DDD)
• 1981 – Rate responsive pacing by QT interval, respiration,
and movement
• 1994 – Cardiac resynchronization pacing
Implantable Pacemaker Systems Contain the Following Components:

• Pulse generator- power source

or battery
Lead

• Leads

• Cathode (negative electrode) IPG

• Anode (positive electrode)

Anode

• Body tissue
Cathode

S
 The Pulse Generator
• Contains a battery that provides the
energy for sending electrical
impulses to the heart

• Houses the circuitry that controls

pacemaker operations
Circuitry

Battery
Anatomy of a Pacemaker
Resistors

Atrial connector

Connector Ventricular connector

Defibrillation protection

Output capacitors
Hybrid
Clock

Reed (Magnet) switch

Telemetry antenna
Battery
General Characteristics of Pacemaker Batteries

• Hermeticity, as defined by the pacing industry,

is an extremely low rate of helium gas leakage
from the sealed pacemaker container

• low rate of self-discharge

• lithium iodine -a long shelf life and high

energy density

• DDD drains a battery more rapidly

 Power source

• Longevity in single chamber pacemaker is 7 to

12 years.

• For dual chamber longevity is 6 to 10 years.

• Most pacemakers generate 2.8 v in the

beginning of life which becomes 2.1 to 2.4 v
towards end of life.

9
 Leads

• Deliver electrical impulses from

the pulse generator to the heart

• Sense cardiac depolarisation Lead

 Lead Characterization
• Position within the heart • Polarity
– Endocardial or transvenous leads – Unipolar
– Epicardial leads – Bipolar

• Fixation mechanism
– Active/Screw-in • Insulator
– Passive/Tined – Silicone
– Polyurethane
• Shape
– Straight
– J-shaped used in the atrium
 Lead components
• Conductor
• Connector Pin
• Insulation
• Electrode
Transvenous Leads - Fixation Mechanisms
• Passive fixation

– The tines become lodged in

the trabeculae
• Active Fixation

– The helix (or screw) extends into

the endocardial tissue

– Allows for lead positioning

anywhere in the heart’s chamber
 Myocardial and Epicardial Leads

• Leads applied directly to

the heart
– Fixation mechanisms
include:
• Epicardial stab-in
• Myocardial screw-in
• Suture-on
 Active Fixation Passive Fixation
Advantages Easy fixation Less expensive & simple
Easy to reposition Minimal trauma to patient
Lower rate of dislodgement Lower thresholds
Removability

Disadvantages More expensive Higher rate of

>Complicated implantation dislodgement (>a/c)
Difficult to remove chronic
lead
• Cathode:-An electrode that is
in contact with the heart

• Negatively charged

• Anode:-receives the
electrical impulse after
depolarization of cardiac
tissue

• Positively charged when

electrical current is flowing Anode

Cathode
 A Unipolar Pacing System

Contains a lead with an electrode in the heart

• Flows through the

tip electrode
(cathode)

• Stimulates the heart +

Anode

• Returns through
body fluid and tissue -
to the PG (anode) Cathode
 A Bipolar Pacing System

Contains a lead with 2 electrodes in the heart

• Flows through the
tip electrode
located at the end
of the lead wire

• Stimulates the heart

• Returns to the ring

Anode
electrode above the
lead tip Cathode
 Unipolar leads

• One electrode on the tip & one conductor coil

• Conductor coil may consist of multiple strands - (multifilar leads)

• Unipolar leads have a smaller diameter than bipolar leads

• Unipolar leads exhibit larger pacing artifacts on the surface ECG

 Bipolar leads
• Circuit is tip electrode to ring electrode

• Two conductor coils (one inside the other)

• Inner layer of insulation

• Bipolar leads are typically thicker than unipolar leads

• Bipolar leads are less susceptible to oversensing noncardiac

signals (myopotentials and EMI)

Coaxial Lead Design

 Unipolar Bipolar
Advantages Smaller diameter No pocket stimulation
Easier to implant Less susceptible to EMI
Large spike Programming flexibility

Disadvantage Pocket stimulation Larger diameter

s Far-field oversensing Stiffer lead body
No programming flexibility Small spike
Higher impedance
Voltage threshold is 30%
higher
 Electrodes
• Leads have 1/> electrically active surfaces
referred to as the electrodes

• Deliver an electrical stimulus, detect intrinsic

cardiac electrical activity, or both

• Electrode performance can be affected by

– Materials
– Polarization
– Impedance
– Pacing thresholds
– Steroids
 Electrode Materials
• The ideal material for an electrode
– Porous (allows tissue ingrowth)
– Should not corrode or degrade
– Small in size but have large surface area
– Common materials
• Platinum and alloys (titanium-coated platinum iridium)
• Vitreous carbon (pyrolytic carbon)
• Stainless steel alloys such as Elgiloy
 Voltage
• Voltage is the force that causes electrons to
move through a circuit
• In a pacing system, voltage is:
– Measured in volts
– Represented by the letter “V”
– Provided by the pacemaker battery
– Referred to as amplitude
 Current
• The flow of electrons in a completed circuit

• In a pacing system, current is:

– Measured in mA (milliamps)
– Represented by the letter “I”
– Determined by the amount of electrons that move
through a circuit
• Constant-Voltage and Constant-Current Pacing

• Most permanent pacemakers are constant-voltage

pacemakers

• Voltage and Current Threshold

• Voltage threshold is the most commonly used

measurement of pacing threshold
 Pacing Thresholds
• Defined as the minimum amount of electrical energy required to
consistently cause a cardiac depolarization

• “Consistently” refers to at least ‘5’ consecutive beats

• Low thresholds require less battery energy

Capture Non-Capture
 The Strength-Duration Curve

• The strength-duration

Stimulation Threshold (Volts)

2.0
curve illustrates the
relationship of 1.5

amplitude and pulse 1.0

width .50
Capture

– Values on or above
.25
the curve will result
0.5 1.0 1.5
in capture Duration
Pulse Width (ms)
• Rheobase- (the lowest point on the curve) by definition is the
lowest voltage that results in myocardial depolarization at
infinitely long pulse duration

• Chronaxie(pulse duration time ) by definition, the chronaxie is the

threshold pulse duration at twice the rheobase voltage
 Lessons from SDC
• The ideal pulse duration should be greater than the chronaxie
time

• Cannot overcome high threshold exit block by increasing the

pulse duration, If the voltage output remains less than the
rheobase

• Energy (μJ) = Voltage (V) × Current (mA) × Pulse Duration (PD

in ms).

• Charge (μC) = Current (mA) × Pulse Duration (ms).

• At very low pulse width thresholds, the charge is low, but the energy
requirements are high because of elevated current and voltage stimulation
thresholds.

• At pulse durations of 0.4–0.6 ms, all threshold parameters - ideal

• At high pulse durations, the voltage and current requirements may be low,
but the energy and charge values are unacceptable
-Safety margins
-When a threshold is determined by decrementing the pulse
width at a fixed voltage

• At a given voltage where the pulse width value is < .30 ms:
Tripling the pulse width will provide a two-time voltage
safety margin.

–Daily fluctuations in threshold that can occur due to eating,

sleeping, exercise, or other factors

- a/c pacing system - higher safety margin, due to the lead

maturation process- occur within the first 6-8 weeks following
implant.
Changes in stimulation threshold (voltage or current) following implantation
of a standard nonsteroid-eluting electrode
 Impedance

• The opposition to current flow

• In a pacing system, impedance is

– Measured in ohms
– Represented by the letter “R” (W for numerical values)

• The measurement of the sum of all resistance to the flow of current

Resistance is a term used to refer to simple electric circuits without

capacitors and with constant voltage and current

Impedance is a term used to describe more complex circuits with

capacitors and with varying voltage and current
 Impedance

• Pacing lead impedance typically stated in broad ranges, i.e.

300 to 1500 Ω

• Factors that can influence impedance

– Resistance of the conductor coils

– Tissue between anode and cathode
– The electrode/myocardial interface
– Size of the electrode’s surface area
– Size and shape of the tip electrode
 Ohm’s Law is a Fundamental Principle of
Pacing That:
• Describes the relationship between voltage,
current, and resistance

V
V=IXR
I=V/R I x R
R=V/I
 Impedance and Electrodes

• Large electrode tip

– Threshold ↑
– Impedance ↓
– Polarization ↓

• Small electrode tip

– Threshold ↓
– Impedance ↑
– Polarization ↑
 Polarization
• After an output pulse, positively charged particles gather near
the electrode.
• The amount of positive charge is
– Directly proportional to pulse duration
– Inversely proportional to the functional electrode size
(i.e. smaller electrodes offer higher polarization)

Polarization effect can represent 30–40% of the total pacing impedance

As high as 70% for smooth surface, small surface area electrodes
Within the electrode, current flow is due to movement of electrons (e−).
At the electrode–tissue interface, the current flow becomes ionic &
(-) vely charged ions (Cl−, OH−) flow into the tissues toward the anode leaving
behind oppositely charged particles attracted by the emerging electrons.

It is this capacitance effect at the electrode tissue interface, that is the basis
of polarization
 Lead Maturation Process
• Fibrotic “capsule” develops around the electrode following lead
implantation

• 3 phases
1. A/c phase, where thresholds immediately following implant are low
2. Peaking phase- thresholds rise and reach their highest point(1wk)
,followed by a ↓ in the threshold over the next 6 to 8 wks as the
tissue reaction subsides
3. C/c phase- thresholds at a level higher than that at implantation but
less than the peak threshold

• Trauma to cells surrounding the electrode→ edema and subsequent

development of a fibrotic capsule.

• Inexcitable capsule ↓ the current at the electrode interface, requiring

more energy to capture the heart.
 Lead Maturation Process
• Effect of Steroid on Stimulation Thresholds
5

4 Smooth Metal Electrode

3
Volts

Textured Metal Electrode

2

1
Steroid-Eluting Electrode
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Implant Time (Weeks)
Pulse Width = 0.5 msec
 Sensing
• Sensing is the ability of the pacemaker to
detect an intrinsic depolarization

– Pacemakers sense cardiac depolarization by

measuring changes in electrical potential of
myocardial cells between the anode and cathode
An Electrogram (EGM) is the Recording of Cardiac Waveforms Taken From
Within the Heart

• Intrinsic deflection on
an EGM occurs when
a depolarization wave
passes directly under
the electrodes
• Two characteristics of
the EGM are:
– Signal amplitude(mv)
– Slew rate(v/sec)
 Intrinsic R wave Amplitude

• Typical intrinsic R wave amplitude measured

from pacing leads in the Right Ventricle are
more than 5 mV in amplitude
Intrinsic R wave in EGM
Amplitude

The Intrinsic R wave amplitude is usually much greater than the T wave amplitude
Slew Rate of the EGM Signal Measures the Change in Voltage
with Respect to the Change in Time

• The longer the signal takes

to move from peak to peak:
– The lower the slew rate
– The flatter the signal

Change in voltage
Slew rate=
Time duration of
voltage change
• Higher slew rates translate to
greater sensing

Voltage
– Measured in volts per second Slope

Time

Slew rate measurements at implant should exceed .5 volts per second

for P waves; .75 volts per second for R wave measurements
Factors That May Affect Sensing Are:
• Lead polarity (unipolar vs. bipolar)
• Lead integrity
– Insulation break
– Wire fracture
• EMI – Electromagnetic Interference
 Undersensing . . .
• Pacemaker does not “see” the intrinsic beat,
and therefore does not respond appropriately

Scheduled pace
Intrinsic beat delivered
not sensed

VVI / 60
 Oversensing

...though no
Marker channel activity is present
shows intrinsic
activity...

VVI / 60

• An electrical signal other than the intended

P or R wave is detected
 NASPE/ BPEG Generic (NBG) Pacemaker
Code
I II III IV V
Chamber Chamber Response Programmable Antitachy
Paced Sensed to Sensing Functions/Rate Function(s)
Modulation

V: Ventricle V: Ventricle T: Triggered P: Simple P: Pace

programmable
M: Multi-
A: Atrium A: Atrium I: Inhibited S: Shock
programmable

D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S)

O: None O: None O: None R: Rate modulating O: None

S: Single S: Single O: None

(A or V) (A or V)
 Pacemaker Timing
• Pacing Cycle : Time between two consecutive
events in the ventricles (ventricular only
pacing) or the atria (dual chamber pacing)

• Timing Interval : Any portion of the Pacing

Cycle that is significant to pacemaker
operation e.g. AV Interval, Ventricular
Refractory period
Single-Chamber Timing
Single Chamber Timing Terminology
• Lower rate
• Refractory period
• Blanking period
• Upper rate
 Lower Rate Interval

• Defines the lowest rate the pacemaker will pace

Lower Rate Interval

VP VP
VVI / 60
 Refractory Period
• Interval initiated by a paced or sensed event
• Designed to prevent inhibition by cardiac or non-cardiac
events
• Events sensed in the refractory period do not affect the
Lower Rate Interval but start their own Refractory Periods

Lower Rate Interval

VP VP
VVI / 60
Refractory Period
 Blanking Period
• The first portion of the refractory period
• Pacemaker is “blind” to any activity
• Designed to prevent oversensing of pacing
stimulus/depolarisation

Lower Rate Interval

VP VP
VVI / 60
Blanking Period
Refractory Period
Physiologic Classification of Sensors- rate adaptive

Primary 
• Physiologic factors that modulate sinus function
Catecholamine level, Autonomic nervous system activity
Secondary 
• Physiologic parameters that are the consequence of exercise
QT, respiratory rate
  Minute ventilation,temperature
  pH, stroke volume, Preejection interval, SV O2
  Peak endocardial acceleration
Tertiary 
• External changes that result from exercise
Vibration
  Acceleration
 
 Upper Sensor Rate Interval
• Defines the shortest interval (highest rate) the
pacemaker can pace as dictated by the sensor (AAIR,
VVIR modes)
• Limit at which sensor-driven pacing can occur

Lower Rate Interval

Upper Sensor Rate

Interval

VP VP
VVIR / 60 / 120
Blanking Period
Refractory Period
 Hysteresis
• Allows the rate to fall below the programmed
lower rate following an intrinsic beat
• lower rate limit is initiated by a paced event, while
the hysteresis rate is initiated by a non-refractory
sensed event.

Lower Rate Interval-60 ppm Hysteresis Rate-50 ppm

VP VP VS VP
 Noise Reversion
• Continuous refractory sensing will cause pacing at the
lower rate

Lower Rate Interval

Noise Sensed

SR SR SR SR
VP VP

VVI/60
Modes-SINGLE CHAMBER
AOO & VOO-asynchronous modes
• By application of magnet

• Useful in diagnosing pacemaker dysfunction

• During surgery to prevent interference from

electrocautery
 VOO Mode
• Asynchronous pacing delivers output regardless of
intrinsic activity

Lower Rate Interval

VP VP
Blanking Period

VOO / 60
 VOO TIMING

VP VP VP VP VP
 VVI Mode
• Pacing inhibited with intrinsic activity

Lower Rate Interval {

VP VS VP
Blanking/Refractory

VVI / 60
 VVI TIMING

VS
VP VP VP VP
 VVIR
• Pacing at the sensor-indicated rate

Lower Rate

Upper Rate Interval

(Maximum Sensor Rate)

VP VP
Refractory/Blanking

VVIR / 60/120
Rate Responsive Pacing at the Upper Sensor Rate
 AAI
• Useful for SSS with N- AV conduction
• Should be capable of 1:1 AV to rates 120-140 b/m
• Atrial tachyarrhythmias should not be present
• Atria should not be “silent”
• If no A activity, atria paced at LOWER RATE limit (LR)
• If A activity occurs before LR,- “resetting”
• Caution- far-field sensing of V activity
 AAIR
• Atrial-based pacing allows the normal A-V activation
sequence to occur

Lower Rate Interval

Upper Rate Interval
(maximum sensor rate)

AP AP
Refractory/Blanking

AAIR / 60 / 120
(No Activity)
 Single-Chamber Triggered-Mode

• Output pulse every time a native event sensed

• ↑current drain
• Deforms native signal
• Prevent inappropriate inhibition from
oversensing when pt does not have a stable
native escape rhythm
 Benefits of Dual Chamber Pacing
• Provides AV synchrony

• Lower incidence of atrial fibrillation

• Lower risk of systemic embolism and stroke

• Lower incidence of new congestive heart

failure

• Lower mortality and higher survival rates

 Dual Chamber Timing Parameters
• Lower rate
• AV and VA intervals
• Upper rate intervals
• Refractory periods
• Blanking periods
 Lower Rate

• The lowest rate the pacemaker will pace the atrium in

the absence of intrinsic atrial events

Lower Rate Interval

AP AP
VP VP

DDD 60 / 120
 AV Delay

• The AV delay in the pacemaker timing cycle is

designed to simulate that natural pause
between the atrial and ventricular events by
mimicking the PR interval

• Benefits of a properly timed AV delay

– Allows optimal time for ventricular filling, which
may contribute to improved cardiac output
– Allows sufficient time for proper mitral valve
closure- minimize MR
 AV Intervals

• Initiated by a paced or non-refractory sensed atrial

event
– Separately programmable AV intervals – SAV /PAV
• Two things can happen with the AV delay
– AV delay times out (and ventricular pacing spike is delivered)
– AV delay is interrupted by a sensed ventricular event (and ventricular pacing spike is
inhibited)

Lower Rate Interval

PAV SAV

200 ms 170 ms

AP AS
VP VP
DDD 60 / 120
Paced AV Delay Sensed AV Delay
• The time period between • The time period between the
the paced atrial event and sensed atrial event and the
the next paced ventricular next paced ventricular event
event • The pacemaker has to sense
• The pacemaker spike the atrial event before the
initiates the paced AV delay timing cycle is initiated—
timing cycle there is usually a slight time
• Programmable value lag
• Program the sensed AV delay
to a value slightly shorter
than the paced AV delay (~
25 ms)
 Atrial Escape Interval (V-A Interval)

Lower rate interval- AV interval

=V-A interval

The V-A interval is the longest period that may elapse after a ventricular event before the
atrium must be paced in the absence of atrial activity.

The V-A interval is also commonly referred to as the atrial escape interval
 Atrial Escape Interval (V-A Interval)

• The interval initiated by a paced or sensed ventricular

event to the next atrial event

Lower Rate Interval

200 ms 800 ms

AV Interval VA Interval

AP AP
VP VP
DDD 60 / 120
PAV 200 ms; V-A 800 ms
 Upper Activity (Sensor) Rate
• In rate responsive modes, the Upper Activity Rate
provides the limit for sensor-indicated pacing

Lower Rate Limit

Upper Activity Rate Limit

PAV V-A PAV V-A

DDDR 60 / 120
A-A = 500 ms
AP AP
VP VP
 Upper Tracking Rate
• The maximum rate the ventricle can be paced in
response to sensed atrial events
• Prevents rapid ventricular pacing rates in response to
rapid atrial rates
Lower Rate Interval {
Upper Tracking Rate Limit
SAV VA SAV VA

AS AS
VP VP

DDDR 60 / 100 (upper tracking rate)

Sinus rate: 100 bpm
 Refractory Periods
• VRP and PVARP are initiated by sensed or paced
ventricular events
– The VRP is intended to prevent self-inhibition such as
sensing of T-waves
– The PVARP is intended primarily to prevent sensing of
retrograde P waves

AP
A-V Interval Post Ventricular Atrial
(Atrial Refractory) Refractory Period (PVARP)
Ventricular Refractory Period VP
(VRP)
 Post-Ventricular Atrial Refractory Period

• PVARP is initiated by a ventricular

event(sensed/paced), but it makes the atrial
channel refractory
• PVARP is programmable (typical settings
around 250-275 ms)
• Benefits of PVARP
– Prevents atrial channel from responding to
premature atrial contractions, retrograde P-waves,
and far-field ventricular signals
– Can be programmed to help minimize risk of
pacemaker-mediated tachycardias
 PVARP and PVAB
• The PVAB is the post-ventricular atrial blanking
period during which time no signals are “seen”
by the pacemaker’s atrial channel

• It is followed by the PVARP, during which time

the pacemaker might “see” and even count
atrial events but will not respond to them

• PVAB-independently programmable
– Typical value around 100 ms
PVAB and PVARP
 Blanking Periods
• First portion of the refractory period-sensing is disabled

AP AP
VP
Atrial Blanking Post Ventricular Atrial
(Nonprogrammable) Blanking (PVAB)

Post Atrial Ventricular Ventricular Blanking

Blanking (Nonprogrammable)
 Total Atrial Refractory Period (TARP)
• TARP is the timing cycle on the atrial channel during which the
pacemaker will not respond to incoming signals
• TARP consists of the AV delay plus the PVARP

TARP = AV delay + PVARP

• TARP is not programmable directly -can program the AV delay

and PVARP and thus indirectly control TARP
• TARP is important for controlling upper-rate behavior of the
pacemaker
 Total Atrial Refractory Period (TARP)
• Sum of the AV Interval and PVARP
• defines the highest rate that the pacemaker will
track atrial events before 2:1 block occurs

Lower Rate Interval

Upper Tracking Rate

SAV = 200 ms
PVARP = 300 ms
Thus TARP = 500 ms (120 ppm) AS AS

DDD VP VP
LR = 60 ppm (1000 ms)
UTR = 100 bpm (600 ms) SAV PVARP SAV PVARP
TARP
{
No SAV started for events sensed in the TARP
 Wenckebach
• Occurs when the intrinsic atrial rate lies
between the UTR and the TARP rate

• Results in gradual prolonging of the AV

interval until one atrial intrinsic event occurs
during the TARP and is not tracked
 Wenckebach Operation
• Prolongs the SAV until upper rate limit expires
– Produces gradual change in tracking rate ratio

Lower Rate Interval {

Upper Tracking Rate P Wave Blocked (unsensed or unused)

AS AS AR AP
VP VP VP
SAV PVARP SAV PVARP PAV PVARP
TARP TARP TARP
 Wenckebach Operation

DDD / 60 / 120 / 310

 Fixed Block or 2:1 Block

• Occurs whenever the intrinsic atrial rate

exceeds the TARP rate

• Every other atrial event falls in the TARP when

the atrial rate exceeds the TARP rate

• Results in block of atrial intrinsic events in

fixed ratios
 2:1 Block
• Every other P wave falls into refractory and does not restart the
timing interval

Lower Rate Interval {

Upper Tracking Limit

AS AS
AR AR
VP VP
AV PVARP AV PVARP
Sinus rate = 133 bpm (450 ms) TARP TARP
{
PVARP = 300 ms SAV = 200 ms
TARP=500 ms
P Wave Blocked
 2:1 Block

DDD / 60 / 120 / 310

Summary-upper rate behaviours
– 1:1 tracking occurs whenever the patient’s atrial rate is
below the upper tracking rate limit

– Wenckebach will occur when the atrial rate exceeds the

upper tracking rate limit

– Atrial rates greater than TARP cause 2:1 block

 Ventricular Safety Pacing
• Crosstalk is the sensing of a pacing stimulus delivered in the opposite
chamber, which results in undesirable pacemaker response, e.g., false
inhibition

• Following an atrial paced event, a ventricular safety pace interval is

initiated
– If a ventricular sense occurs during the safety pace window, a pacing pulse is delivered
at an abbreviated interval (110 ms)

PAV Interval

Post Atrial Ventricular Ventricular Safety Pace

Blanking Window
 Ventricular Safety Pace

DDD 60 / 120
 VDD Mode
• Atrial Synchronous pacing or Atrial Tracking Mode
• A sensed intrinsic atrial event starts an SAV
• The Lower Rate Interval is measured between Vs to Vp or Vp to Vp
• If no atrial event occurs at the end of the Lower Rate Interval a Ventricular
pace occurs
• Paces in the VVI mode in the absence of atrial sensing
• AV block with intact sinus node function (esp useful in congenital AV
block)
 VDD
• Provides atrial synchronous pacing
– System utilizes a single lead

Lower Rate Interval {

Upper Tracking Limit

AS AS
VP VP VP

VDD
LR = 60 ppm
UTR = 120 ppm
Spontaneous A activity = 700 ms (85 ppm)
 DDD Mode
• Chamber paced: Atrium & ventricle

• Chamber sensed: Atrium & ventricle

• Response to sensing: Triggered & inhibited

– 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
Four “Faces” of Dual Chamber Pacing
• Atrial Sense, Ventricular Sense (AS/VS)

AV V-A AV V-A

AS AS
VS VS
Rate (sinus driven) = 70 bpm / 857 ms
Spontaneous conduction at 150 ms
A-A = 857 ms
Four “Faces” of Dual Chamber Pacing
• Atrial Pace, Ventricular Pace (AP/VP)

AV V-A AV V-A

AP AP
VP VP

Rate = 60 bpm / 1000 ms

A-A = 1000 ms
Four “Faces” of Dual Chamber Pacing
• Atrial Pace, Ventricular Sense (AP/VS)

AV V-A AV V-A

AP AP
VS VS
Rate = 60 ppm / 1000 ms
A-A = 1000 ms
Four “Faces” of Dual Chamber Pacing
• Atrial Sense, Ventricular Pace (AS/ VP)

AV V-A AV V-A

AS AS
VP VP

Rate (sinus driven) = 70 bpm / 857 ms

A-A = 857 ms
 Mode Selection
Symptomatic DDIR DDDR
bradycardia

Y N
Are atrial
Is AV conduction
tachyarrhythmias
intact?
present?

N Y N
Is AV conduction Are they Y VVI
intact? chronic? VVIR

Y N Is SA node function
Is SA node function presently adequate?
presently adequate?
Y N
N (SSS) N
DDD, VDD
DDDR DDDR
AAIR DDDR, DDIR
DDDR
 Optimal Pacing Mode (BPEG)

• Sinus Node Disease - AAI (R)

• AVB - DDD
• SND + AVB - DDDR + DDIR
• Chronic AF + AVB - VVI
Thank u
Mode Selection Decision Tree
Symptomatic DDIR with DDDR with
bradycardia SV PVARP MS

Y N
Are atrial
Is AV conduction
tachyarrhythmias
intact?
present?

N Y N
Is AV conduction Are they Y VVI
intact? chronic? VVIR

Y N Is SA node function
Is SA node function presently adequate?
presently adequate?
Y N
N (SSS) N (CSS,
VVS)
DDD, VDD
DDDR DDDR
AAIR DDD, DDI
DDDR with RDR
Pacing Modes

Stuart Allen 06
 Ventricular Demand VVI

AMP

Output circuit

Programmed lower rate 50 mm/s

VVI
Ventricular Demand VVIR
Pacing Modesp

Sensor

AMP

Output circuit

Programmed lower rate 50 mm/s

Sensor indicated
rate Stuart Allen 06
 Atrial Demand AAI

AMP

Output circuit

Programmed lower rate 50 mm/s

AAI

Stuart Allen 06
 Pacing Modes - Summary
Ventricular Demand VVI Atrial Demand AAI

AMP
Output circuit
AMP
Output circuit

Atrial Synchronised VAT Atrial synchronised VDD

Ventricular Inhibited
AMP AMP

AMP

Output circuit Output circuit

A-V Sequential DVI A-V Universal DDD

Output circuit Output circuit
AMP
Timing & Control

AMP AMP
Output circuit Output circuit

Stuart Allen 06