CA2514306A1 - Synchronized atrial anti-tachy pacing system and method - Google PatentsSynchronized atrial anti-tachy pacing system and method
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- CA2514306A1 CA2514306A1 CA 2514306 CA2514306A CA2514306A1 CA 2514306 A1 CA2514306 A1 CA 2514306A1 CA 2514306 CA2514306 CA 2514306 CA 2514306 A CA2514306 A CA 2514306A CA 2514306 A1 CA2514306 A1 CA 2514306A1
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
- A61N1/00—Electrotherapy; Circuits therefor
- A61N1/18—Applying electric currents by contact electrodes
- A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
- A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
- A61N1/362—Heart stimulators
- A61N1/3621—Heart stimulators for treating or preventing abnormally high heart rate
- A61N1/3622—Heart stimulators for treating or preventing abnormally high heart rate comprising two or more electrodes co-operating with different heart regions
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
- A61N1/00—Electrotherapy; Circuits therefor
- A61N1/18—Applying electric currents by contact electrodes
- A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
- A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
- A61N1/362—Heart stimulators
- A61N1/3621—Heart stimulators for treating or preventing abnormally high heart rate
- A61N1/3624—Heart stimulators for treating or preventing abnormally high heart rate occurring in the atrium, i.e. atrial tachycardia
SYNCHRONIZED ATRIAL ANTI-TACHY PACING SYSTEM AND
This application claims priority to provisional U.S. Application No.
60/439,460 ftled 13 January 2003.
This invention relates to implantable cardiac pacing devices that incorporate atrial anti-tachycardia control, and in particular dual chamber pacing devices with atrial anti-tacky control that optimize synchronous ventricular pacing.
Modern implantable cardiac pacing devices are designed for efficient dual or multiple chamber pacing as well as detection and treatment of dangerous cardiac arrhythmias. A dual chamber pacing device provides the capability of synchronous pacing, whereby the ventricle is paced in synchrony with the just preceding atrial beat (intrinsic or paced), thereby approximating the normal healthy coordination between the atrium and the ventricle and thus optimizing cardiac output. However, if the atrium is seized with an arrhythmia, such synchronous pacing cannot be resumed until after the arrhythmia abates or is somehow reverted. In the case of atrial tachycardia (AT), a malignant arrhythmia, pacemakers can respond with normally effective atrial pacing schemes to arrest or stop the AT, after which the pacemaker can resume synchronous pacing when the cardiac condition is stabilized. The problem is that the atrium remains vulnerable to a recurring episode of tachycardia following AT treatment, particularly if the two chambers are not operating in an efficient synchronous manner. What is important, then, and a main feature of this invention, is enabling the pacemaker or other implantable device (ipg) to resume such synchronous pacing as quickly as possible after the conclusion of,the.AT response.
The advantage of synchronous pacing is well established. For a patient at rest, AV
synchrony improves cardiac output by about 20-25%; the improvement decreases with exercise. The intrinsic atrial rate, however, is not always reliable for control of ventricular pacing. Pacemaker patients are, by definition, in a class that is subject to cardiac abnormalities. In particular, AT is a concern, and the pacemaker or ipg must be able to detect AT and provide an appropriate response to terminate the AT. As used here, AT
means an abnormally high atrial rate, e.g., a rate of intrinsic atrial beats above 120-150 bpm. The definition of AT may be programmed into the device by a physician, and may be set at a value within a range of, for example, 100-180 bpm. Most pacing devices have a programmable upper rate limit above which the ventricle will not be paced, and this limit may serve to define tacky senses. In a typical arrangement, when such high rate tacky senses occur consecutively or in predominance over a given time period, AT is recognized and an anti-tacky pacing (ATP) mode automatically takes over to stop the AT.
There are many different ATP schemes illustrated in the patent art. Table 1 below lists representative patent and literature references that show different forms of ATP.
Table 1 PatentlDoc. No. hzventor(s) IssuelPub Date 4,280,502 Baker, Jr. et al. July 28, 1981 4,390,021 Spurrell et al. June 28, 1983 4,398,536 Nappholz et al. Aug. 16, 1983 4,406,287 Nappholz et al. Sept. 27, 1983 4,408,606 Spurrell et al. Oct. 11, 1983 4,467,810 Vollmann Aug. 28, 1984 4,574,437 Segerstad et al. March 1 l, 1986 4,577,633 Berkovitz et al. March 25, 1986 4,587,970 Holly et al. May 13, 1986 4,593,695 Wittkampf June 10, 1986 4,491,471 Mehra July 17, 1990 All patents listed in Table 1 above are hereby incorporated by reference herein in their respective entireties. As those of ordinary skill in the art will appreciate readily upon reading the Summary of the Invention, Detailed Description of the Preferred Embodiments and Claims set forth below, many of the devices and methods disclosed in the patents of Table 1 may be modified advantageously by using the teachings of the present invention.
A common form of ATP is to deliver a train of pulses to the atrium immediately after AT
is declared. In delivering an ATP train, or burst, different sequences of atrial pulses can be used, with the timing being adjusted for maximum interruption of the tachycardia. Atrial tachycardia is thought to be, characterized by a re-entry feedback loop in the atrium, whereby each atrial conduction induces another beat before the natural pacemaker triggers the next normal beat. The timing of the feedback conduction can be variable, such that it is difficult to determine the best time to deliver a reverting pulse that can interrupt the arrhythmia. The basic idea of the train is to deliver a series of pulses before the next tachy occurrence, to enhance the possibility of interruption. It is thought that each successive pulse of the sequence enlarges the area of the atrium that is conditioned to respond to a pacing pulse, such that by the end of the train the entire atrium is in condition to be captured by an atrial pulse (AP). The sequence, whether called a train or burst or whatever, can be programmed for each patient, and may even vary based on history. As used herein, ATP refers to any sequence of atrial pulses delivered for the purpose of interrupting atrial tachycardia or like arrhytlnnias. However, the various ATP
trains have in common the features that atrial sensing is abolished while the ATP pulses are being delivered, and once the train is started the order and timing of the ATP
pulses is set, i.e., the train is irrevocable.
As stated above, it is important to continue with synchronous pacing as soon as possible after an AT episode. In fact, establishing synchronous pacing quickly after an abnormal episode is crucial, due to the possibility of mediating or permitting re-establishment of the tachycardia. By way of example, following a premature atrial contraction (PAC) it is known to deliver an atrial sync pulse (ASP) that is timed to enable the pacer to re-establish snychrony with the next delivered ventricular pulse.
This is done in order to prevent pacemaker mediated tachycardia. Likewise, following an AT
episode, there is a danger of a new AT episode if the next ventricular pace pulse is not synchronized to the last atrial pulse of the ATP. An asynchronous ventricular pulse could put stress on the atrium, which increases the vulnerability to AT or AF. Or, such an asynchronous pulse could lead to retrograde conduction back to the atrium which could induce AT or AF. Moreover, these two mechanisms could stimulate the localized source of polarization that gave rise to the AT or AF in the first place. Thus, while the ATP has"
presumably stopped the feedback mechanism in the atrium that was admitting the AT, the atrium remains vulnerable following AT and a following asynchronous ventricular pulse can cause either electrical or mechanical interference capable of destabilizing the atrial tissue. This presents a serious problem that has not been addressed by the pacemaker art.
It is an object of the invention to provide an implantable pacing device, and method of operation, that can sense and respond to atrial tachycardias, deliver an ATP
train of atrial pulses, and deliver the next ventricular pulse in synchrony with the last atrial pulse of the train.
It is another object of the invention to provide an implantable pacing system capable of detecting a high rate atrial arrhythmia and responding to such arrhythmia with a fixed sequence of atrial pulses designed to revert the arrhythmia, and to deliver the very next ventricular pacing pulse that is due following the sequence in synchrony with the last atrial pulse of such sequence.
It is another object of the invention to provide a method of responding to a sensed atrial tachycardia or the like by delivering a planned ATP scheme of atrial pulses while delivering ventricular pulses without interruption and regaining synchronous ventricular pacing directly after such delivery.
In accord with the above objectives, there is provided a pacing system and method adapted for an implanted cardiac device, whereby an atrial anti-tachy pacing sequence is delivered to the patient's atrium upon sensing of AT, and where the next ventricular beat that follows the ATP is synchronized to the last atrial beat of the sequence.
When AT is declared by the system, timing of an ATP is initiated referenced to the atrial sense (AS).
At the same time, the pacing system determines whether the first ventricular pacing pulse after the end of the sequence can be delivered at the current ventricular pacing interval (PI) with an acceptable AV interval. If so, the ventricular pacing interval is not changed. If not, then the pacing system determines whether PI can be adapted to a value within predetermined maximum and minimum criteria in order to provide a ventricular pacing pulse with an acceptable AV interval following the last atrial pulse of the sequence. If so, the PI is lengthened or shortened appropriately. Upon determination of an acceptable ventricular PI, one or more ventricular pacing pulses may be delivered asynchronously during the duration of the ATP sequence, and the first ventricular pacing pulse after the end of the ATP train is delivered at an acceptable AV delay following the last atrial pulse of the sequence. In the event that the ventricular PI cannot be so adapted for synchrony when the determinations are first made, the system waits for the next atrial sense, determines a workable PI, and then delivers the ATP train and adapts ventricular PI
In carrying out the method of the invention, the ATP sequence is delivered followed by a ventricular pacing pulse that is synchronized to the last atrial pulse. The prior ventricular PI is then restored, and the device determines whether the atrial rhythm is a normal sinus rhythm, i.e., whether AT has been reverted. If AT is again detected, the device repeats delivery of the ATP in the same manner until sinus rhythm is detected, again adapting ventricular PI in order to synchronize the ventricular pulse following the ATP sequence. Ventricular pacing is not interrupted, since one or more ventricular pace pulses, depending on the length of the ATP sequence, will be delivered asynchronously during the ATP sequence. But as soon as the ATP sequence is finished, and a normal sinus rhythm hopefixlly restored, ventricular pacing is immediately restored in a synchronous mode.
Figure 1 is a simplified schematic view of one embodiment of an implantable medical device that can be employed in the present invention.
Figure 2 is a graphic representation of an implantable medical device interconnected with a human or mammalian heart, illustrating the device connector portion and the leads between the device and the heart.
Figure 3 is a functional schematic diagram showing the primary constituent components of an implantable medical device in accordance with an embodiment of this invention.
Figure 4 is a graphic representation of an embodiment of this invention showing an implantable PCD device interconnected with a heart, the system of this embodiment providing pacing, cardio version and defibrillation.
Figure 5 is a functional schematic diagram of an implantable PCD embodiment of this invention.
Figure 6A is a timing diagram illustrating an ATP sequence and ventricular pacing with an unchanged ventricular pacing interval.
Figure 6B is a timing diagram illustrating an ATP sequence and ventricular pacing with a shortened ventricular pacing interval.
Figure 6C is a timing diagram illustrating an ATP sequence and ventricular pacing with a lengthened ventricular interval.
Figure 7 is a flow diagram showing the primary steps taken by the system of the invention in responding to sensed AT, adapting ventricular pacing interval as necessary, delivering an ATP sequence, pacing the ventricle asynchronously during the ATP
sequence and following the sequence with a ventricular pace pulse synchronously timed to the last atrial pulse of the ATP sequence.
Figure 8 is a flow diagram illustrating the preferred algorithm for determining the best ventricular pacing interval for use with an ATP sequence.
Figure 1 is a simplified schematic view of one embodiment of implantable medical device ("IMD") 10 of the present invention. IMD 10 shown in Figure 1 is a pacemaker comprising at least one of pacing and sensing leads 16 and 18 attached to hermetically sealed enclosure 14 and implanted near human or mammalian heart 8. Pacing and sensing leads 16 and 18 sense electrical signals attendant to the depolarization and re-polarization of the heart 8, and further provide pacing pulses for causing depolarization of cardiac tissue in the vicinity of the distal ends thereof. Leads 16 and 18 may have unipolar or bipolar electrodes disposed thereon, as is well known in the art. Examples of IMD 10 include implantable cardiac pacemakers disclosed in U.S. Patent No. 5,158,078 to Bennett et al., U.S.
5,312,453 to Shelton et al. or U.S. Patent No. 5,144,949 to Olson, all hereby incorporated by reference herein, each in its respective entirety.
Figure 2 shows connector module 12 and hermetically sealed enclosure 14 of IMD
10 located in and near human,or mammalian heart 8. Atrial and ventricular pacing leads 16 and 18 extend from connector header module 12 to the right atrium and ventricle, respectively, of heart 8. Atrial electrodes 20 and 21 disposed at the distal end of atrial pacing lead 16 are located in the right atrium. Ventricular electrodes 28 and 29 at the distal end of ventricular pacing lead 18 are located in the right ventricle.
Figure 3 shows a block diagram illustrating the constituent components of lMD
10 in accordance with one embodiment of the present invention, where I1VID 10 is pacemaker having a microprocessor-based architecture. IMD 10 is shown as including activity sensor or accelerometer 11, which is preferably a piezoceramic accelerometer bonded to a hybrid circuit located inside enclosure 14. Activity sensor 11 typically (although not necessarily) provides a sensor output that varies as a function of a measured parameter relating to a patient's metabolic requirements. For the sake of convenience, IMD 10 in Figure 3 is shown with lead 18 only connected thereto; similar circuitry and connections not explicitly shown in Figure 3 apply to lead 16.
IMD 10 in Figure 3 is most preferably programmable by means of an external programming unit (not shown in the Figures). One such programmer is the commercially available Medtronic Model 9790 programmer, which is microprocessor-based.and provides a series of encoded signals to IMD 10, typically through a programming head which transmits or telemeters radio-frequency (RF) encoded signals to IMD 10. Such a telemetry system is described in U.S. Patent No. 5,312,453 to Wyborny et al., hereby incorporated by reference herein in its entirety. The programming methodology disclosed in Wyborny et al.'s '453 patent is identified herein for illustrative purposes only. Any of a number of suitable programming and telemetry methodologies known in the art may be employed so long as the desired information is transmitted to and from the pacemaker.
As shown in Figure 3, lead 18 is coupled to node 50 in 1MD 10 through input capacitor 52. Activity sensor or accelerometer 11 is most preferably attached to a hybrid circuit located inside hermetically sealed enclosure 14 of IMD 10. The output signal provided by activity sensor 11 is coupled to input/output circuit 54.
Input/output circuit 54 contains analog circuits for interfacing to heart 8, activity sensor 11, antenna 56 and circuits for the application of stimulating pulses to heart 8. The rate of heart 8 is controlled by software-implemented algorithms stored in microcomputer circuit 58. ' Microcomputer circuit 58 preferably comprises on-board circuit 60 and off board circuit 62. Circuit 58 may correspond to a microcomputer circuit disclosed in U. S. Patent No. 5,312,453 to Shelton et al., hereby incorporated by reference herein in its entirety. On-board circuit 60 preferably includes microprocessor 64, system clock circuit 66 and on-board RAM 68 and ROM 70. Off board circuit 62 preferably comprises a RAM/ROM unit.
On-board circuit 60 and off board circuit 62 are each coupled by data communication bus 72 to digital controller/timer circuit 74. Microcomputer circuit 58 may comprise a custom integrated circuit device augmented by standard RAMIROM components.
Electrical components shown in Figure 3 are powered by an appropriate implantable battery power source 76 in accordance with common practice in the art. For the sake of clarity, the coupling of battery power to the various components of IMD 10 is not shown in the Figures. Antenna 56 is connected to input/output circuit 54 to permit uplink/downlink telemetry through RF transmitter and receiver telemetry unit 78. By way of example, telemetry unit 78 may correspond to that disclosed in U.S. Patent No.
4,566,063 issued to Thompson et al., hereby incorporated by reference herein in its entirety, or to that disclosed in the above-referenced '453 patent to Wyborny et al. It is generally preferred that the particular programming and telemetry scheme selected permit the entry and storage of cardiac rate-response parameters. The specific embodiments of antenna 56, input/output circuit 54 and telemetry unit 78 presented herein are shown for illustrative purposes only, and are not intended to limit the scope of the present invention.
Continuing to refer to Figure 3, VHF and Bias circuit 82 most preferably generates stable voltage reference and bias currents for analog circuits included in input/output circuit 54. Analog-to-digital converter (ADC) and multiplexer unit 84 digitizes analog signals and voltages to provide "real-time" telemetry intracardiac signals and battery end-of life (EOL) replacement functions. Operating commands for controlling the timing of ILVII?
10 are coupled by data bus 72 to digital controller/timer circuit 74, where digital timers and counters establish the overall escape interval of the IMD 10 as well as various refractory, blanking and other timing windows for controlling the operation of peripheral components disposed within input/output circuit 54.
Digital controller/timer circuit 74 is preferably coupled to sensing circuitry, including sense amplifier 88, peak sense and threshold measurement unit 90 and comparator/threshold detector 92. Circuit 74 is further preferably coupled to electrogram (EGM) amplifier 94 for receiving amplified and processed signals sensed by lead 18. Sense amplifier 88 amplifies sensed electrical cardiac signals and provides an amplified signal to peak sense and threshold measurement circuitry 90, which in turn provides an indication of peak sensed voltages and measured sense amplifier threshold voltages on multiple conductor signal path 67 to digital controller/timer circuit 74. An amplified sense amplifier signal is then provided to' comparator/threshold detector 92. By way of example, sense amplifier 88 may correspond to that disclosed in U.S. Patent No. 4,379,459 to Stein, hereby incorporated by reference herein in its entirety.
The electrogram signal provided by EGM amplifier 94 is employed when IMD 10 is being interrogated by an external programmer to transmit a representation of a cardiac analog electrogram. See, for example, U.S. Patent No. 4,556,063 to Thompson et al., hereby incorporated by reference herein in its entirety. Output pulse generator 96 provides pacing stimuli to patient's heart 8 through coupling capacitor 98 in response to a pacing trigger signal provided by digital controller/timer circuit 74 each time the escape interval times out, an externally transmitted pacing command is received or in response to other stored commands as is well known in the pacing art. By way of example, output amplifier 96 may correspond generally to an output amplifier disclosed in U.S. Patent No. 4,476,868 to Thompson, hereby incorporated by reference herein iii its entirety.
The specific embodiments of input amplifier 88, output amplifier 96 and EGM
amplifier 94 identified herein are presented for illustrative purposes only, and are not intended to be limiting in respect of the scope of the present invention. The specific embodiments of such circuits may not be critical to practicing some embodiments of the present invention so long as they provide means for generating a stimulating pulse and are capable of providing signals indicative of natural or stimulated contractions of heart 8.
In some preferred embodiments of the present invention, IMD 10 may operate in various non-rate-responsive modes, including, but not limited to, DDD, DDI, WI, VOO
modes. In other preferred embodiments of the present invention, IMD 10 may operate in various rate-responsive, including, but not limited to, DDDR, DDIR, WIR, VOOR
and WTR modes. Some embodiments of the present invention are capable of operating in both non-rate-responsive and rate responsive modes. Moreover, in various embodiments of the present invention IMD 10 may be programmably configured to operate so that it varies the rate at which it delivers stimulating pulses to heart 8 only in response to one or more selected sensor outputs being generated. Numerous pacemaker features and functions not explicitly mentioned herein may be incorporated into IMD 10 while remaining within the scope of the present invention.
The present invention is not limited in scope to single-sensor or dual-sensor pacemakers, and is not limited to IMD's comprising activity or pressure sensors only. Nor is the present invention limited in scope to single-chamber pacemakers, single-chamber leads for pacemakers or single-sensor or dual-sensor leads for pacemakers. Thus, various embodiments of the present invention may be practiced in conjunction with more than two leads or with multiple-chamber pacemakers, for example. At least some embodiments of the present invention may be applied equally well in the contexts of single-, dual-, triple- or quadruple- chamber pacemakers or other types of IIVID's. See, for example, U.S. Patent No.
5,800,465 to Thompson et al., hereby incorporated by reference herein in its entirety, as are all U.S. Patents referenced therein.
IMD 10 may also be a pacemaker-cardioverter- defibrillator ("PCD") corresponding to any of numerous commercially available implantable PCD's.
Various 5 embodiments of the present invention may be practiced in conjunction with PCD's such as those disclosed in U.S. Patent No. 5,545,186 to Olson et al., U.S. Patent No.
5,354,316 to Keimel, U.S. Patent No. 5,314,430 to Bardy, U.S. Patent No. 5,131,388 to Pless and U.S.
Patent No. 4,.821,723 to Baker et al., all hereby incorporated by reference herein, each in its respective entirety.
10 Figures 4 and 5 illustrate one embodiment of IMD 10 and a corresponding lead set of the present invention, where IMD 10 is a PCD. In Figure 4, the ventricular lead takes the form of leads disclosed in U.S. Patent Nos. 5,099,838 and 5,314,430 to Bardy, and includes an elongated insulative lead body 1 carrying three concentric coiled conductors separated from one another by tubular insulative sheaths. Located adjacent the distal end of lead 1 are ring electrode 2, extendable helix electrode 3 mounted retractably within insulative electrode head 4 and elongated coil electrode 5. Each of the electrodes is coupled to one of the coiled conductors within lead body 1. Electrodes 2 and 3 are employed for cardiac pacing and for sensing ventricular depolarizations. At the proximal end of the lead is bifurcated connector 6 which carries three electrical connectors, each coupled to one of the coiled conductors. Defibrillation electrode 5 may be fabricated from platinum, platinum alloy or other materials known to be usable in implantable defibrillation electrodes and may be about 5 cm in length.
The atrial/SVC lead shown in Figure 4 includes elongated insulative lead body carrying three concentric coiled conductors separated from one another by tubular insulative sheaths corresponding to the structure of the ventricular lead.
Located adjacent the J-shaped distal end of the lead are ring electrode 9 and extendable helix electrode 13 mounted retractably within an insulative electrode head 15. Each of the electrodes is coupled to one of the coiled conductors within lead body 7. Electrodes 13 and 9 are employed for atrial pacing and for sensing atrial depolarizations. Elongated coil electrode 19 is provided proximal to electrode 9 and coupled to the third conductor within lead body 7. Electrode 19 preferably is 10 cm in length or greater and is configured to extend from the SVC toward the tricuspid valve. In one embodiment of the present invention, approximately 5 cm of the right atrium/SVC electrode is located in the right atrium with the remaining 5 cm located in the SVC. At the proximal end of the lead is bifurcated coimector 17 carrying three electrical connectors, each coupled to one of the coiled conductors.
The coronary sinus lead shown in Figure 4 assumes the form of a coronary sinus lead disclosed in the above cited '838 patent issued to Bardy, and includes elongated insulative lead body 41 carrying one coiled conductor coupled to an elongated coiled defibrillation electrode 21. Electrode 21, illustrated in broken outline in Figure 4, is located within the coronary sinus and great vein of the heart. At the proximal end of the lead is connector plug 23 carrying an electrical connector coupled to the coiled conductor.
The coronary sinus/great vein electrode 41 may be about 5 cm in length.
Implantable PCD 10 is shown in Figure 4 in combination with leads 1, 7 and 41, and lead connector assemblies 23, 17 and 6 inserted into connector block 12.
~ptionally, insulation of the outward facing portion of housing 14 of PCD 10 may be provided using a plastic coating such as parylene or silicone rubber, as is employed in some unipolar cardiac pacemakers. The outward facing portion, however, may be left uninsulated or some other division between insulated and uninsulated portions may be employed. The uninsulated portion of housing 14 serves as a subcutaneous defibrillation electrode to defibrillate either the atria or ventricles. Lead configurations other that those shown in Figure 4 may be practiced in conjunction with the present invention, such as those shown in U.S. Patent No. 5,690,686 to Min et al., hereby incorporated by reference herein in its entirety.
Figure 5 is a functional schematic diagram of one embodiment of implantable PCD
10 of the present invention. This diagram should be taken as exemplary of the type of device in which various embodiments of the present invention may be embodied, and not as limiting, as it is believed that the invention may be practiced in a wide variety of device implementations. IMD 10 is provided with an electrode system. If the electrode configuration of Figure 4 is employed, the correspondence to the illustrated electrodes is as follows. Electrode 25 in Figure 5 includes the uninsulated portion of the housing of PCD 10. Electrodes 25, 15, 21 and 5 are coupled to high voltage output circuit 27, which includes high voltage switches controlled by CV/defib control logic 29 via control bus 31.
Switches disposed within circuit 27 determine which electrodes are employed and which electrodes are coupled to the positive and negative terminals of the capacitor bank (which includes capacitors 33 and 35) during delivery of defibrillation pulses.
Electrodes 2 and 3 are located on or in the ventricle and are coupled to the R-wave amplifier 37, which preferably takes the form of an automatic gain controlled amplifier providing an adjustable sensing threshold as a function of the measured R-wave amplitude. A signal is generated on R-out line 39 whenever the signal sensed between electrodes 2 and 3 exceeds the present sensing threshold.
Electrodes 9 and 13 are located on or in the atrium and are coupled to the P-wave amplifier 43, which preferably also takes the form of an automatic gain controlled amplifier providing an adjustable sensing threshold as a function of the measured P-wave amplitude. A signal is generated on P-out line 45 whenever the signal sensed between electrodes 9 and 13 exceeds the present sensing threshold. The general operation of R-wave and P-wave amplifiers 37 and 43 may correspond to that disclosed in I_T.S. Pat. No.
5,117,824, by Keimel et al., issued Jun. 2, 1992, for "An Apparatus for Monitoring Electrical Physiologic Signals", hereby incorporated by reference herein in its entirety.
Switch matrix 47 is used to select which of the available electrodes are coupled to wide band (0.5-200 Hz) amplifier 49 for use in digital signal analysis. Selection of electrodes is controlled by the microprocessor 51 via data/address bus 53, which selections may be varied as desired. Signals from the electrodes selected for coupling to bandpass amplifier 49 are provided to multiplexer 55, and thereafter converted to multi-bit digital signals by A/D converter 57, for storage in random access memory 59 under control of direct memory access circuit 61. Microprocessor 51 may employ digital signal analysis techniques to characterize the digitized signals stored in random access memory 59 to recognize and classify the patient's heart rhythm employing any of the numerous signal processing methodologies known to the art.
The remainder of the circuitry is dedicated to the provision of cardiac pacing, cardioversion and defibrillation therapies, and, for purposes of the present invention may correspond to circuitry knomn to those skilled in the art. The following exemplary apparatus is disclosed for accomplishing pacing, cardioversion and defibrillation functions. Pacer timing/control circuitry 63 preferably includes programmable digital counters which control the basic time intervals associated with DDD, WI, DVI, VDD, AAI, DDI and other modes of single and dual chamber pacing well known to the art.
Circuitry 63 also preferably controls escape intervals associated with anti-tachyarrhythmia pacing in both the atrium and the ventricle, employing any anti-tachyarrhythmia pacing therapies known to the art.
Intervals defined by pacing circuitry 63 include atrial and ventricular pacing escape intervals, the refractory periods during which sensed P-waves and R-waves are ineffective to restart timing of the escape intervals and the pulse widths of the pacing pulses. The durations of these intervals are determined by microprocessor 51, in response to stored data in memory 59 and are communicated to pacing circuitry 63 via address/data bus 53.
Pacer circuitry 63 also determines the amplitude of the cardiac pacing pulses under control of microprocessor 51.
During pacing, escape interval counters within pacer timing/control circuitry 63 are reset upon sensing of R-waves and P-waves as indicated by a signals on lines 39 and 45, and in accordance with the selected mode of pacing on time-out trigger generation of pacing pulses by pacer output circuitry 65 and 67, which are coupled to electrodes 9, 13, 2 and 3. Escape interval counters are also reset on generation of pacing pulses and thereby control the basic timing of cardiac pacing functions, including anti-tachyarrhythmia pacing. The durations of the intervals defined by escape interval timers are determined by microprocessor 51 via data/address bus 53. The value of the count present in the escape interval counters when reset by sensed R-waves and P-waves may be used to measure the durations of R-R intervals, P-P intervals, P-R intervals and R-P intervals, which measurements are stored in memory 59 and used to detect the presence of tachyarrhythmias.
Microprocessor 51 most preferably operates as an interrupt driven device, and is responsive to interrupts from pacer timing/control circuitry 63 corresponding to the occurrence sensed P-waves and R-waves and corresponding to the generation of cardiac pacing pulses. Those interrupts are provided via data/address bus 53. Any necessary mathematical calculations to be performed by microprocessor 51 and any updating of the values or intervals controlled by pacer timing/control circuitry 63 take place following such interrupts.
Detection of atrial or ventricular tachyarrhythmias, as employed in the present invention, may correspond to tachyarrhythmia detection algorithms known in the art. For example, the presence of an atrial or ventricular tachyarrhythmia may be confirmed by detecting a sustained series of short R-R or P-P intervals of an average rate indicative of tachyarrhythmia or an unbroken series of short R-R or P-P intervals. The suddenness of onset of the detected high rates, the stability of the high rates, and a number of other factors known in the art may also be measured at this time. Appropriate ventricular tachyarrhythmia detection methodologies measuring such factors are described in U.S.
Pat. No. 4,726,380 issued to Vollmann, U.S. Pat. No. 4,880,005 issued to Pless et al. and U.S. Pat. No. 4,830,006 issued to Haluska et al., all incorporated by reference herein, each in its respective entirety. An additional set of tachycardia recognition methodologies is disclosed in the article "Onset and Stability for Ventricular Tachyarrhythmia Detection in an Implantable Pacer-Cardioverter-Defibrillator" by Olson et al., published in Computers in Cardiology, Oct. 7-10, 1986, IEEE Computer Society Press, pages 167-170, also incorporated by reference herein in its entirety. Atrial fibrillation detection methodologies are disclosed in Published PCT Application Ser. No. US92/02829, Publication No.
W092/18198, by Adams et al., and in the article "Automatic Tachycardia Recognition", by Arzbaecher et al., published in PACE, May-June, 1984, pp. 541-547, both of which are incorporated by reference herein in their entireties.
In the event an atrial or ventricular tachyarrhytlnnia is detected and an anti-tachyarrhythmia pacing regimen is desired, appropriate timing intervals for controlling generation of anti-tachyarrhythmia pacing therapies are loaded from microprocessor 51 into the pacer timing and control circuitry 63, to control the operation of the escape interval counters therein and to deEne refractory periods during which detection of R-waves and P-waves is ineffective to restart the escape interval counters.
Alternatively, circuitry for controlling the timing and generation of anti tachycardia pacing pulses as described in U.S. Pat. No. 4,577,633, issued to Berkovits et al. on Mar. 25, 1986, U.S. Pat. No. 4,880,005, issued to Pless et al. on Nov.
14, 1989, U.S.
Pat. No. 4,726,380, issued to Vollmann et al. on Feb. 23, 1988 and U.S. Pat.
4,587,970, issued to Holley et al. on May 13, 1986, all of which are incorporated herein by reference in their entireties, may also be employed.
In the event that generation of a cardioversion or defibrillation pulse is required, microprocessor 51 may employ an escape interval counter to control timing of such cardioversion and defibrillation pulses, as well as associated refractory periods. In response to the detection of atrial or ventricular fibrillation or tachyanhythmia requiring a cardioversion pulse, microprocessor 51 activates cardioversion/defibrillation control circuitry 29, which initiates charging of the high voltage capacitors 33 and 35 via charging circuit 69, under the control of high voltage charging control line 71. The voltage on the high voltage capacitors is monitored via VCAP line 73, which is passed through multiplexer 55 and in response to reaching a predetermined value set by microprocessor 51, results in generation of a logic signal on Cap Full (CF) line 77 to terminate charging.
Thereafter, timing of the delivery of the defibrillation or cardioversion pulse is controlled by pacer timing/control circuitry 63. Following delivery of the fibrillation or tachycardia therapy microprocessor 51 returns the device to a cardiac pacing mode and awaits the next 10 successive interrupt due to pacing or the occurrence of a sensed atrial or ventricular depolarization.
Several embodiments of appropriate systems for the delivery and synchronization of ventricular cardioversion and defibrillation pulses and for controlling the timing functions related to them are disclosed in U.S. Patent No. 5,188,105 to Keirnel, U.S. Pat.
15 No. 5,269,298 to Adams et al. and U.S. Pat. No. 4,316,472 to Mirowski et al., hereby incorporated by reference herein, each in its respective entirety. Any known cardioversion or defibrillation pulse control circuitry is believed to be usable in conjunction with various embodiments of the present invention, however. For example, circuitry controlling the timing and generation of cardioversion and defibrillation pulses such as that disclosed in U.S. Patent No. 4,384,585 to Zipes, U.S. Patent No. 4,949,719 to Pless et al., or U.S.
Patent No. 4,375,817 to Engle et al., all hereby incorporated by reference herein in their entireties, may also be employed.
Continuing to refer to Figure 5, delivery of cardioversion or defibrillation pulses is accomplished by output circuit 27 under the control of control circuitry 29 via control bus 31. Output circuit 27 determines whether a monophasic or biphasic pulse is delivered, the polarity of the electrodes and~which electrodes are involved in delivery of the pulse.
Output circuit 27 also includes high,voltage switches which control whether electrodes are coupled together during delivery of the pulse. Alternatively, electrodes intended to be coupled together during the pulse may simply be permanently coupled to one another, either exterior to or interior of the device housing, and polarity may similarly be pre-set, as in current implantable defibrillators. An example of output circuitry for delivery of biphasic pulse regimens to multiple electrode systems may be found in the above cited patent issued to Mehra and in U.S. Patent No. 4,727,877, hereby incorporated by reference herein in its entirety.
An example of circuitry which may be used to control delivery of monophasic pulses is disclosed in U.S. Patent No. 5,163,427 to Keimel, also incorporated by reference herein in its entirety. Output control circuitry similar to that disclosed in U.S. Patent No.
4,953,551 to Mehra et al. or U.S. Patent No. 4,800,883 to Winstrom, both incorporated by reference herein in their entireties, may also be used in conjunction with various embodiments of the present invention to deliver biphasic pulses.
Alternatively, IMD 10 may be an implantable nerve stimulator or muscle stimulator such as that disclosed in U.S. Patent No. 5,199,428 to Obel et al., U.S. Patent No. 5,207,218 to Carpentier et al. or U.S. Patent No. 5,330,507 to Schwartz, or an implantable monitoring device such as that disclosed in U.S. Patent No.
5,331,966 issued to Bennet et al., all of which are hereby incorporated by reference herein, each in its respective entirety. The present invention is believed to find wide application to any form of implantable electrical device for use in conjunction with electrical leads.
As used in this specification and the appended claims, the term "ATP train"
refers to a sequence of pulses delivered to the patient's atrium for the purpose of interrupting, or stopping a detected episode of atrial tachycardia. Techniques of detecting AT
and delivering ATP trains are well known in the art, as discussed above.
The algorithm used to provide for AV synchrony following an ATP train can be understood with reference to the timing diagram of Figure 6A, and the following definitions in the table below.
Table 2 Term Defzraitiof2 ATP interval (duration between y seconds pulses of the train) ATP trains total duration of an ATP
train (nominally n*y, where the train has n intervals) Pacing Interval the current ventricular cycle length Minimum pacing intervalthe minimum allowed cycle length to obtain resynchronization Maximum pacing intervalthe maximum allowed cycle length to obtain resynchronization AV min the minimum allowed AV
AV max the maximum allowed AV
delay V ATPi the interval between the last ventricular event and the atrial tachy sense i X round up [(V ATPi + ATP
trains + AV min)/ Pacing Interval, where any fractional value is rounded up to the next integer Figure 6A illustrates a series of high rate atrial senses, with ventricular pace pulses being delivered at a certain pacing interval. In a conventional detection algorithm, AT is deemed to be sensed when a given number of senses occur at a rate above a tachy thershold and continue over a given duration of senses or time. As illustrated, AT is declared at Atrial Tachy Sense i, which occurs V ATPi after the last ventricular pace pulse. In this situation if the temporary PI is maintained as the current PI, a ventricular pace pulse would be scheduled for delivery following the last pulse of the ATP
train by more than AV min but less than AV max. Any ventricular pulse delivered within this timeframe would be properly synchronized, as seen in Figure 6A. Thus, the first step of the sync algorithm is to determine if this condition is met: IF (X*pacing interval - V ATPi is <=(ATP Trains + AV max), then deliver the ATP train and set the temporary (adapted) pacing interval to Pacing Interval (the current PI). This will achieve re-synchronization since the next VP will fall between AV min and AV max after the end of the train. In this situation, then, the PI remains unchanged.
If the above condition is not met, then it must be determined whether the ATP
train can be delivered along with an adapted pacing interval that will permit the desired synchronous pacing after the end of the ATP train. Figure 6B illustrates a Short Pacing Interval, and Figure 6C illustrates a Long Pacing Interval, as determined in accord with this invention. The logic is:
ELSE, Check if an ATP train can be delivered with an adapted Pacing Interval.
Short Pacing Interval = (V ATPi +ATP trains+AV max) / X
Long Pacing Interval = (V ATPi + ATP trains - AV min) / (X -1) IF (Short Pacing Interval >= Mininum Pacing Interval) AND (Long Pacing Interval <_ Maximum Pacing Interval), Deliver ATP train;
IF (Pacing Interval - Short Pacing Interval ) < (Long Pacing Interval - Pacing Interval) Set Temporary Pacing Interval = Short Pacing Interval ELSE, Set Temporary Pacing Interval = Long Pacing Interval ENDIF
ELSEIF (Short Pacing Interval >= Minimum Pacing Interval), Deliver ATP Train, Temporary Pacing Interval = Short Pacing Interval ELSEIF (Long Pacing Interval <= Maximum Pacing Interval) Deliver ATP Train, Temporary Pacing Interval = Long Pacing Interval ELSE
Wait for the next atrial tacky sense, and repeat the search for a suitable Pacing Interval for re-synchronization.
Examples of selecting short and long Pacing Intervals are seen in Figures 6B
and 6C respectively. If both short and long pacing intervals qualify, the one that places the temporary Pacing Interval closest to the initial Pacing Interval is chosen.' If only the short Pacing Interval qualifies, it is selected. Figure 6B illustrates a Short Pacing Interval, where the first ventricular pulse after the end of the train occurs just before the time corresponding to AV max. In Figure 6C, the Long Pacing Interval produces a ventricular pace pulse at an AV delay that follows the end of the train by just about AV
min. In both cases, the ventricular pacing Interval then returns to Pacing Interval, and synchronous pacing is continued (assuming a normal sinus rhythm).
Figure 7 is a flow diagram showing the primary steps taken in carrying out the specific features of this invention. At block 301, the sinus rhythm is examined, by looking at successive intervals between sinus (atrial) beats. The sinus beats, or atrial senses, are determined in a well known manner. An example of an over-all flow diagram for event determination in a dual chamber pacemaker, including determining atrial senses, is presented at Figure 4, U.S. Patent No. 6,029, 087, assigned to the assignee of this invention and incorporated herein by reference. See also Fig. 2 of U.S. Patent No.
6,128,532, also incorporated herein by reference in its entirety. As stated above, in a typical tacky detection scheme, senses are classified as tacky senses if the rate corresponding to the interval is above a predetermined threshold. If such tacky beats are sensed, at block 302 the pacemaker monitors to see if the tacky beats continue for a duration as to constitute AT. If so, AT is determined, and an atrial tacky sense i (as seen in Figures 6A -C) signal is sent to block 303. At block 303 the implanted device performs the above logic steps to determine if an ATP train can be delivered along with a Pacing Interval adapted to resynchronize after the train. If not, which is statistically not probable but will occur occasionally, the pacer waits, returning to block 302 where upon the next atrial beat an Atrial Tacky Sense i signal is generated and sent to decision block 303.
Upon determining an available temporary Pacing Interval (the current PI, Short PI or Long PI), the Pacing Interval is adapted as shown at block 305. At 306, the ATP
train is delivered while ventricular pacing is continued asynchronously. At the end of the ATP
train, the pacer waits to deliver the next ventricular pulse, as shown at block 308. After such synchronous delivery, the ventricular pacing interval is restored to Pacing Interval.
At 310, the pacer determines whether the atrial rhythm is a normal sinus rhythm or a tachycardia. If a normal sinus rhythm is detected, the pacer goes back to examining the sinus rhythm, as at block 301. However, if the AT has not been interrupted, the pacer returns to decision block 303, and prepares to deliver another ATP train along with an 10 adapted Pacing Interval.
The logic steps that are carried out at decision block 303 are illustrated in the sub-routine of Figure 8. At 401, it is determined whether the temporary Pacing Interval (TPI) can be maintained as the current Pacing Interval, by the comparison shown. If yes, at block 402 (part of block 305 in Figure 7), TPI = PI and the device proceeds to block 306 15 (Figure 7) to deliver the ATP train. But if no, then at block 410 the Short Pacing Interval (SPI) and Long Pacing Interval (LPI) are calculated. At 412, it is determined if SPI >_ Minimum Pacing Interval AND LPI is <= Maximum Pacing Interval. If yes, at 414 it is determined whether (PI - SPI) < (LPI - PI). If no, TPI is set = LPI at block 416; if yes, then TPI is set = SPI at block 415. Following this, the routine goes to block 306 where the 20 ATP train is delivered.
Returning to block 412, if the answer is NO, the routine goes to block 420 and determines if SPI >= Minimum PI. If YES, TPI is set = SPI at block 421.
However, if NO
then the routine goes to block 424and determines if LPI <= Maximum PI. If yes, then TPI
is set = LPI at block 425. But if NO, then the train cannot be delivered, and the routine returns to block 302 to wait for the next Atrial Tachy Sense i, after which the sub-routine of Figure 8 is again entered.
The preferred embodiment of the invention as described meets the objects set forth above, namely to provide re-synchronization of ventricular pacing following delivery of an anti-tachy scheme of atrial pulses designed to interrupt the AT and return the atrium to a normal sinus rhytlmn. During the ATP sequence, any ventricular pulse that is delivered is an asynchronous pulse at a V-V interval determined by the algorithm. The first ventricular pulse after the end of the train or other ATP scheme follows the last ATP pulse by a delay within the range AV min to AV max, and thus is accurately synchronized. It is an important feature of this invention that ventricular pacing is maintained at a rate that meets the criteria that it can't be too slow or too fast. Re-synchronization as such could theoretically be achieved by the simple expedient of timing out a suitable AV
delay following the last atrial pulse of the ATP train. However, depending on the timing of the ventricular pace pulses and the duration of the ATP train this would usually result in a V-V interval that was unacceptably short or long. The invention, as seen above, provides for asynchronous pacing at an acceptable rate as well as re-synchronization immediately after the end of the ATP train, thus optimizing conditions for stabilizing the atrium and preventing return of AT or another dangerous atrial arrhythmia. Following re-synchronization, and in the absence of continued AT, the pacing device resumes normal synchronous pacing.
The preceding specific embodiments are illustrative of the practice of the invention. It is to be understood, therefore, that other expedients known to those skilled in the art or disclosed herein, may be employed without departing from the invention or the scope of the appended claims. The present invention is not limited to any particular combination of hardware and software per se, but may find application with any form of software supplementing hardware. Of course, the calculation of a temporary pacing interval is most suitably done with a microprocessor. In the claims, means-plus-function clauses are intended to cover the structures described herein as performing the recited function and not only structural equivalents but also equivalent structures.
Thus, although a nail and a screw may not be structural equivalents in that a nail employs a cylindrical surface to secure wooden parts together, whereas a screw employs a helical surface, in the environment of fastening wooden parts a nail and a screw are equivalent structures.
ventricular pacing means for pacing the patient's ventricle with pace pulses at an adaptable pacing interval;
AT means for determining AT and for determining the timing of the start of an AT
train means for delivering an ATP train in fixed relation to said AT start;
algorithm means activated at said start of an AT episode for determining if ventricular pace pulses can be delivered following a said AT start with an adapted pacing interval whereby a synchronized ventricular pace pulse will be delivered synchronized to the last atrial pulse of a said AT train that has been delivered, said determining including determining said adapted pacing interval subject to predetermined pacing interval and AV
temporary means for temporarily changing the pacing interval to said adapted value when it is determined that a said adapted pacing interval can be determined; and ;
initiating means for initiating said train means to deliver a said ATP train upon a said pacing interval determination that a synchronized ventricular pace pulse can be delivered.
ventricular pacing means for pacing the patient's ventricle with pace pulses delivered at an adaptable pacing interval;
AT means for determining the occurrence of AT and for determining a designated time of start of AT;
train means for delivering an ATP train of atrial pulses in fixed relation to said AT start;
and adapting means for adapting the pacing interval of said ventricular pacing means so that the next ventricular pace pulse delivered after the end of said AT train is re-synchronized to the last atrial pulse of said AT train.
start can be maintained and provide for said re-synchronized pulse.
determining the existence of aerial tachycardia (AT) and designating a start of said AT;
storing data concerning an ATP sequence of atrial pulses to be delivered to interrupt an AT;
determining a temporary pacing interval for asynchronously pacing the ventricle after start of AT, wherein said temporary pacing interval meets predetermined rate criteria and is calculated to provide for re-synchronization after the last atrial pulse of said ATP
delivering said ATP sequence in timed relation to said AT start;
delivering ventricular pace pulses at said temporary pacing interval through the duration of said sequence; and delivering the next ventricular pulse following the end of said sequence at said temporary pacing interval, whereby said next ventricular pulse is synchronized to the last atrial pulse of said ATP sequence, thereby re-synchronizing ventricular pacing.
AT means for delivering an ATP train of a fixed sequence of pulses to the patient's atrium; and temporary means for delivering asynchronous ventricular pacing pulses at a temporary pacing interval to the patient's ventricle during said ATP train and for the next ventricular pacing pulse after the last pulse of said sequence, whereby said next ventricular pacing pulse is synchronously timed with respect to said last sequence pulse.
criteria, and delay means for delaying the operation of said AT means and said temporary means until said calculating means can calculate a temporary pacing interval that meets said stored PI criteria.
detecting atrial tachycardia and preparing delivery of an ATP sequence to the patient's atrium;
calculating a temporary pacing interval for asynchronous pacing of the patient's ventricle while said ATP sequence is delivered and which will enable delivery of a next ventricular pace pulse after the end of said sequence that is synchronously timed in relation to the end of the ATP sequence; and delivering said ATP sequence and asynchronously pacing the ventricle at said temporary pacing interval through and including delivery of a synchronous pace pulse to the ventricle after the end of said sequence.
range following the end of said ATP sequence.
AT means for detecting the presence of AT;
ATP means for delivering an ATP sequence of atrial pulses to the patient's atrium in response to detected AT;
ventricular pacing means for pacing the patient's ventricle;
rate criteria means for limiting the rate of ventricular pacing; and control means for controlling said ventricular pacing means to deliver ventricular pace pulses during said ATP sequence and for a next ventricular pace pulse after the end of said sequence at a rate that meets said rate criteria and provides that said next ventricular pace pulse is in cardiac synchrony with the last atrial pulse of said sequence.
means for storing a range of acceptable AV delay values and calculating means for calculating a temporary pacing interval that meets said rate criteria and also provides that said next ventricular pace pulse is delivered following said last atrial pace pulse by an AV
interval that is within said range.
Priority Applications (5)
|Application Number||Priority Date||Filing Date||Title|
|US10435071 US7162300B2 (en)||2003-01-13||2003-05-12||Synchronized atrial anti-tachy pacing system and method|
|PCT/US2004/000652 WO2004062726A8 (en)||2003-01-13||2004-01-12||Synchronized atrial anti-tachy pacing system and method|
|Publication Number||Publication Date|
|CA2514306A1 true true CA2514306A1 (en)||2004-07-29|
Family Applications (1)
|Application Number||Title||Priority Date||Filing Date|
|CA 2514306 Abandoned CA2514306A1 (en)||2003-01-13||2004-01-12||Synchronized atrial anti-tachy pacing system and method|
Country Status (5)
|US (1)||US7162300B2 (en)|
|EP (1)||EP1850908B1 (en)|
|CA (1)||CA2514306A1 (en)|
|DE (1)||DE602004019713D1 (en)|
|WO (1)||WO2004062726A8 (en)|
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Also Published As
|Publication number||Publication date||Type|
|US7266409B2 (en)||Method and apparatus for determining oversensing in a medical device|
|US5741310A (en)||System and method for hemodynamic pacing in ventricular tachycardia|
|US5193536A (en)||Paced cardioversion|
|US7027862B2 (en)||Apparatus and method for transmitting an electrical signal in an implantable medical device|
|US7333855B2 (en)||Method and apparatus for determining oversensing in a medical device|
|US5601609A (en)||Implantable cardiac stimulating device and method for administering synchronized cardioversion shock therapy to provide preemptive depolarization|
|US5643326A (en)||Dual chamber pacing with atrial and ventricular independence|
|US7248924B2 (en)||Self limited rate response|
|US6330477B1 (en)||Ventricular synchronized atrial pacing mode of implantable cardioverter/defibrillator|
|US7277757B2 (en)||Respiratory nerve stimulation|
|US6195584B1 (en)||Method and apparatus for determining atrial lead dislocation|
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