We found the following characteristics predictive of CI in this pacemaker patient population: VO(2) max, existence of coronary artery disease or acquired valvular heart disease, previous cardiac surgery, as well as medication with digitalis, beta blockers, and amiodarone.
This study was undertaken to develop and test a morphology-based adaptive algorithm for real-time detection of P waves and far-field R waves (FFRWs) in pacemaker patient atrial electrograms. Cardiac event discrimination in right atrial electrograms has been a problem resulting in improper atrial sensing in implantable devices; potentially requiring clinical evaluation and device reprogramming. A morphology-based adaptive algorithm was first evaluated with electrograms recorded from 25 dual chamber pacemaker implant patients. A digital signal processing (DSP) system was designed to implement the algorithm and test real-time detection. In the second phase, the DSP implementation was evaluated in 13 patients. Atrial and ventricular electrograms were processed in real-time following algorithm training performed in the first few seconds for each patient. Electrograms were later manually annotated for comparative analysis. The sensitivity for FFRW detection in the atrial electrogram during off-line analysis was 92.5% (+/- 10.9) and the positive predictive value was 99.1% (+/- 1.8). Real-time P wave detection using a DSP system had a sensitivity of 98.9% (+/- 1.3) and a positive predictivity of 97.3% (+/- 3.5). FFRW detection had a sensitivity of 91.0% (+/- 12.4) and a positive predictivity of 97.1% (+/- 4.2) in atrial electrograms. DSP algorithm tested can accurately detect both P waves and FFRWs in right atrium real-time. Advanced signal processing techniques can be applied to arrhythmia detection and may eventually improve detection, reduce clinician interventions, and improve unipolar and bipolar lead sensing.
Chronotropic incompetence (CI), which has not been systematically examined in the ICD patient population, may have implications for device programming. A total of 123 ICD patients were classified into three groups: single-chamber ICD with sinus rhythm, dual-chamber ICD with sinus rhythm, and single-chamber ICD with permanent atrial fibrillation. Heart rate response, maximum oxygen uptake, and oxygen uptake at the anaerobic threshold were measured during treadmill exercise testing. In addition, clinical variables such as antiarrhythmic drug therapy, underlying heart disease, and left-ventricular (LV) ejection fraction were recorded. Of the patients studied, 38% were chronotropically incompetent (47/123). Significant predictors of CI were as follows: presence of a coronary disease (P = 0.036), prior cardiac surgery (P = 0.037), chronic drug therapy with beta-blockers (P = 0.032), administration of amiodarone (P = 0.025), and a combination of these two forms of treatment (P = 0.01). Spiroergometry revealed reduced exercise capacity (P = 0.041) and lessened VO2max (P = 0.034) among chronotropically incompetent patients. A large percentage of ICD patients demonstrates CI with subsequently reduced physical stress tolerance. In light of the DAVID study, we believe that a closer examination of rate-adaptive modes for ICD patients is warranted under enhanced conditions: (1) optimized AV interval programming; (2) utilization of new algorithms to reduce ventricular pacing in combination with rate-adaptive atrial pacing, with the goal of addressing CI while minimizing ventricular pacing; and (3) an optimized upper heart-rate limit.
Conventional Holter monitoring is of limited benefit in patients with infrequent symptoms suspected to be related to arrhythmia. A small recorder implanted subcutaneously might obviate many limitations of conventional monitoring. To determine the feasibility of obtaining adequate electrocardiographic signals from such a device, a prototype was temporarily implanted in 17 patients undergoing pacemaker implantation. The prototype contained four disc-shaped titanium electrodes, 0.21 inches in diameter embedded in epoxy. The four electrodes were in a square configuration spaced 0.72 inches center to center and were placed face down in a subcutaneous pocket in the left pectoral region. Bipolar recordings were made from a horizontal pair, a vertical pair, and both diagonal paris of electrodes (interelectrode distance 1.02 inches) and recorded on electromagnetic tape after filtering at 0.5-250 Hz. The mean peak-to-peak amplitude in each configuration was determined over a five-beat interval. Clear recordings were obtained from all 17 patients with recognizable P, QRS, and T waves. The amplitude of the signals obtained from the diagonal pairs of electrodes (175 +/- 51 and 170 +/- 54 microV) were greater than obtained from either the vertical pair (142 +/- 62 microV, P = 0.08 compared to diagonal electrodes) or the horizontal pair of electrodes (105 +/- 54 microV, P < 0.01). The maximum amplitude recorded from any configuration was 189 +/- 54 microV. In six patients the device was also tested with the electrodes face up in the subcutaneous pocket.(ABSTRACT TRUNCATED AT 250 WORDS)
Previous studies with activity-based rate adaptive pacemakers have shown a somewhat paradoxical response when comparing ascending stairs to descending stairs. The objective of this investigation was to measure dual-sensor rate response provided by activity and minute ventilation (MV) compared with activity alone, and with a control group, during ascending and descending stairs. For dual sensor mode, measured mean peak pacing rate with 72 (92) steps per minute was 111 +/- 13 beats/min (124 +/- 14 beats/min) ascending stairs and 81 +/- 7 beats/min (97 +/- 13 beats/min) for descending. For activity mode alone, mean peak pacing rate was 90 +/- 12 beats/min (108 +/- 19 beats/min) ascending stairs and 97 +/- 12 beats/min (123 +/- 17 beats/min) descending. The mean peak control group heart rate ascending stairs for a step rate of 72 (92) steps/min were 116 +/- 11 beats/min (127 +/- 14 beats/min) ascending stairs and for descending 89 +/- 12 beats/min (95 +/- 11 beats/min). While for dual sensor controlled pacing there was a significant difference for ascending and descending stairs at both step rates, there was no difference between going upstairs and downstairs for activity mode alone. Rates with dual sensor did not significantly differ from respective rates of the control group. The mean correlation coefficient between MV and paced rate was 0.85. Pacing heart rates delivered by the dual sensor mode were appropriate for ascending and descending stairs. In contrast to activity mode alone, the peak heart rates for dual sensor mode are higher during ascending than during descending stairs.
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