PACEMAKER WITH DETERMINATION OF THE DEPENDENCY OF CARDIAC OUTPUT ON THE AV-DELAY

Abstract: A pacemaker comprises a pulse generating means (12) for delivering stimulation pulses to a patient's heart and a controlling means (8) for controlling the delivery of stimulation pulses from said pulse-generating means. The controlling means comprises an altering means (10) for altering the AV-delay from a predetermined first AV-delay value to a predetermined second AV-delay value, and back to said first AV-delay value. A sensor (2) is provided to measure a parameter related to cardiac output of the patient. The sensor is adapted to measure the parameter in a time window inside a time of operation with said predetermined first AV-delay value, in a time window inside a time of operation with said predetermined second AV-delay value and in a time window inside a time of operation after the return back to said first AV-delay value. A determining means comprises a calculation means (6) for calculating an average value of the measured parameter during each of said time windows and the determining means uses said average values in determining which one of the AV-delay values results in a higher cardiac output.

Description: Pacemaker with determination of the dependency of cardiac output on the AV-delay. Technical field The present invention relates to a pacemaker comprising a pulse gener- ating means for delivering stimulation pulses to a patient's heart and a controlling means for controlling the delivery of stimulation pulses from said pulse generating means, said controlling means comprising an altering means for altering the AV- delay from a predetermined first AV-delay value to a predetermined second AV- delay value, and back to said first AV-delay value, a sensor being provided to measure a parameter related to cardiac output of the patient. Background The PV-interval between the occurrence of an intrinsic P-wave and the application of a cardiac stimulation pulse can be different from the AV-interval between consecutive cardiac stimulation pulses to the atrium and the ventricle. By the expression AV delay is meant in the following the interval between the occurrence of a paced or an intrinsic P-wave and the application of a cardiac stimulation pulse to the ventricle of the heart. It is well known that cardiac output of a human being is depending on the AV-delay, see e.g. US 5,024,222, US 5,487,752, US 5,540,727, US 5,643,327 and US 5,891 ,176. In all these documents techniques are described for studying the variation of a cardiac performance parameter of the heart as a function of ao AV- delay in order to optimise the cardiac output. Thus US 5,487,752 discloses a cardiac stimulator system including means for monitoring and pacing two chambers of the heart with pulses providing predetermined AV intervals. One of the AV intervals represents a base line value and the system is operated with this AV interval for a relatively long time, e.g. during 20 beats. The AV interval is changed for relatively few beats, e.g. 5 beats, and is then allowed to return to the base line value. A cardiac performance parameter is measured during these times of different AV intervals and from these measurements it is determined whether an improvement in said cardiac performance parameter over the base line value occurs when the AV interval is changed. By performing this procedure for different AV intervals an optimum AV interval can be determined. Figure 1 shows experimental data obtained from an animal study and illustrates the dependence of several cardiac performance parameters on the AV delay (or PV delay). The AV delay was altered between 80 and 130 msec, see curve a. 15 changes were performed during a period of 16 minutes while monitor- ing the sinus rate, curve b, the heart rate variability (HRV), curve c, the mean artery pressure, curve d, the mean carotid flow, curve e, the central venous pressure (CVP), curve f, the right atrial oxygen pressure (pO2), curve g, and oxygen saturation (SO2), curve h. A very pronounced correlation between the AV-delay, curve a, and some of the measured parameters like heart rate variability (HRV), curve c, mean artery pressure, curve d, mean carotid flow, curve e, and central venous pressure (CVP), curve f, is noticed. Corresponding variations in the oxygen pressure (pO2), curve g, and oxygen saturation (SO2), curve h, are less pronounced. The purpose of the present invention is to improve the possibilities of determining the dependence of different cardiac performance parameters on the AV delay, such that significant information can also be extracted from such parameters as the oxygen pressure (pO2) and oxygen saturation (SO2). Disclosure of the invention This purpose is obtained by a pacemaker of the kind set forth in the intro- ductory portion of the description and having the characterising features of claim 1. With a pacemaker deviced according to the invention the atrial or ventricular pO2 or SO2 can be used for determining the dependency of cardiac output on the AV-delay. This is an important advantage since especially the pO2 sensor has appeared to be especially suitable to use for this kind of measurements. The technique according to the invention can of course also be applied on other meas- - ured parameters, cf. Figure 1 , in order to get more distinct results, in particular if the measurement signals are affected by disturbances in one way or the other. According to an advantageous embodiment of the pacemaker according to the invention said calculation means is adapted to form a first difference between average values obtained during the window positioned inside said time of operation with said first AV-delay value and obtained during the time window positioned inside said time of operation with said second AV-delay value, as well as a second difference between average values obtained during the time window positioned inside said time of operation with said second AV-delay value and the time window positioned inside said time of operation after the return of said AV-delay back to said first AV-delay value for using said first and second differences in determining which AV-delay results in a higher cardiac output. In this way the possibility of extracting reliable information from the measurement signals is still more improved. According to still another advantageous embodiment of the pacemaker according to the invention in which said altering means is adapted to repeatedly alter the AV-delay a plurality of times between said predetermined first and second AV-delay values, the calculation means is adapted to form a mean value of a resulting plurality of said first differences and a mean value of a plurality of said sec- ond differences for use said mean values in determining which AV-delay value results in a higher cardiac output. The possibility of the extracting information from the measurement signals is then further improved. According to another advantageous embodiment of the pacemaker according to the invention said altering means is adapted, after determination of which one of said first and second AV-delay values is indicating a higher cardiac output, to alter the AV-delay between this better AV-delay value of said first and second AV-delay values indicating a higher cardiac output and a third AV-delay value and said determining means is adapted to then determine which one of said better AV-delay value and said third AV-delay value results in an indication of a higher cardiac output, said altering means being adapted to repeat this procedure till an AV-delay value is determined which results in an indication of a highest cardiac output. Thus the pacemaker according to the invention will automatically find out the optimum AV-delay value and will then toggle around this optimum value. If conditions should change such that another AV-delay value is needed to obtain a maximum cardiac output, the pacemaker will automatically find this new optimum AV-delay value. According to yet another advantageous embodiment of the pacemaker according to the invention said altering means in adapted to alter said AV-delay values after times of operation according to a pseudo-stochastic sequence. Since several biological variations and external disturbances have cyclic characters, which can interfere with the measurements, it is an advantage not to use a cyclic variation of the AV-delays but pseudo-stochastic sequences of delay values. According to another advantageous embodiment of the pacemaker according to the invention said time windows are positioned immediately before and immediately after an alteration of the AV-delay value. In this way changes in the measured parameter just related to the change of the AV-delay is determined and errors originating from variations in oxygen consumption's of the patient and sensor drift are minimised. According to still other advantageous embodiments of the pacemaker according to the invention said sensor measuring a parameter related to cardiac output is one of the following kind of sensors, a pO2-sensor, a SO2-sensor, a mean blood pressure sensor, a coronary artery flow sensor or a sinus rate sensor, and said blood pressure sensor is preferably adapted to measure the blood pressure in the vena cava or the right atrium. Artery blood pressure, mean blood pressure, systolic and diastolic pressure all correlate to cardiac output. As appears from figure 1 curve f the central venous pressure (CVP) responds very quickly and very distinctly to changes in the AV-delay. There is no delay in the CVP-response due to e.g. a blood circulation time as in the SO2-response, and the determination of best AV-delay value can in principle be performed even on a beat-to-beat basis. By applying a pseudo-stochastic sequence the desired result can be obtained by direct measurements on the CVP-response. However, by applying the technique according to the present invention on the signal from a CVP sensor the reliability of the obtained result is increased. Also the mean carotid flow responds quickly and distinctly to changes of the AV-delay in an analogous way, cf. curve e in figure 1. Brief description of the drawings To explain the invention in greater detail embodiments of the invention will now be described with reference to the drawings, on which Figure 1 shows experimental data obtained from animal studies, Figure 2 shows the average pO2 at AV-delay change points, Figure 3 illustrates the result obtained by analysis of the data in figure 2 by the pacemaker according to the invention, Figure 4 illustrates the differential technique implemented in the pacemaker according to the invention to obtain an optimum AV-delay, Figure 5 illustrates different types of sampling measured parameter values, Figure 6 shows a pseudo-stochastic AV-delay sequence, Figure 7 shows the AV-delay sequence when an optimum AV-delay is reached, Figure 8 is a diagram illustrating the spread and medium value of pO2 differences obtained from the data shown in figure 2 and presented in ta- ble 1 , Figures 9-13 are corresponding diagrams for the parameters oxygen saturation (SO2), central venous pressure (CVP), mean blood pressure (MBP), carotid artery flow (CAF), and sinus rate (SR) respectively, and Figure 14 is a block diagram of a closed loop regulation system of the pace- maker according to the invention. Description of preferred embodiments Figure 1 illustrates experimental data obtained from studies on animal as explained above. Figure 2 shows the AV-delay as a function of time according to curve a in figure 1 in an enlarged scale. In this example the upper AV-delay value is 130 msec and the lower value 80 msec. The AV-delay was altered according to a 32 bit pseudo-stochastic sequence. In this diagram dots are shown representing the average value of the measured pO2 during a period of 30 sec immediately before and immediately after each change in the AV-delay. The marked values are average values during 30 sec immediately preceding the position of the dot. The difference between each couple of average values from either side of the 15 transitions between the two AV-delay values shown in figures 1 and 2 are given in table 1. In table 1 the column "Step" indicates the number of the transition between the AV-delay values, counted from the left in figure 2. "Bits" indicates the bit number in the sequence, the column "AV STEP" indicates the direction of the transition, "neg" indicates a transition from 130 msec to 80 msec and "pos" a transition in the opposite direction. Column pO2-a indicates the average value during 30 msec immediately before the transition and pO2-b the average value during 30 msec immediately after the transition. The column pO2-diff indicates the difference between these two average values. Figure 3 shows the average value of pO2-diff for negative transitions, to the left in figure 3, and for positive transitions, to the right in the figure. From figure 3 it appears that a negative AV-transition - from 130 to 80 msec - increased the pO2- difference with 0.003 kPa, whereas a positive AV-step from 80 to 130 msec decreased the pO2-difference with 0.020 kPa. This significant difference between the two pO2-differences indicates that the shorter AV-delay of 80msec is more effective than the longer delay. In figure 8 the minimum and maximum values of the used pO2 differences are shown as well as the 25%-75% spread of these values and for the median values. These results are obtained by an analysis of variance of the measured data, cf. below. The animal studies described above show that it is possible to statistically distinguish an optimum and a sub-optimum of AV-timing. It is possible to identify hemodynamic improvements of cardiac output by measuring changes in O2 after a step change of the AV-delay. The oxygen contents can be measured electro- chemically, by a pO2-sensor, or optically by a SO2 sensor. Thus in the example described above the AV-delay, or the timing of the pulse generator of the pacemaker, is altered between two settings, e.g. a level A and a level B, one of which is the "better" one. By forming the difference between the average oxygen content, Δp (AB) during a time window of predetermined length immediately before a change of the AV-delay and during a time window of the same length immediately after the change from level A to level B, and com- paring this result with the corresponding difference, Δp (BA), when the AV-delay is changed in the opposite direction from level B to level A, it is possible to find the best setting, A or B. The length of the time window is suitably in the range of 15- 120 sec and the sampling interval within the range of 2-10 sec. The described procedure can be repeated and the results averaged for obtain a better resolution as described above. If Δp(AB) < Δp(BA) setting A of the AV-delay gives a higher O2 content indicating a better ventricular performance. If, on the other hand, Δp(AB) > Δp(BA) setting B of the AV-delay give a better cardiac performance. In figure 4 n is defined as the first oxygen measurement p(n) after a step change of the AV-delay from level A to level B. The sample # m is defined as the first oxygen measurement p(m) after a change of AV-delay from level B to level A. The number of averaged O2 samples is denoted by i, in figure 4, i =4. Figure 4 illustrates the differential technique according to the invention for selecting the best AV-delay value as explained above. After # n + i - 1 measurements of 02 it is possible to calculate the 02 response of a change of the AV-delay from level A to level B according to the equation. After # m + i -1 02 measurements it is possible to calculate the 02 response of a change of the AV-delay from level B to level A according to equation By repeating this procedure several times u the risk of fault decisions is Ap(BA) = - Ϋ ι p(m -x) - ' ∑p(m + x-ϊ) V *=ι x=\ practically eliminated. The corresponding mean values Ψ(A,B) are given by the following equations Ψ(AB) = - 1 -∑r Ap(AB)(x) x v= =l Thus if Ψ(AB) < Ψ(BA) the AV-delay value B does not improve the heart performance compared to the situation with an AV-delay value equal to level A. Different types of differentiation of the 02 signal can be used. In the example above and in situations "A" and "B" in figure 5 the time windows, in which the measurements are performed, i.e. the measurements samples are taken, do not overlap. In the type of differentiation illustrated at "C'and "D" in figure 5 the same measurement samples are sometimes used twice, since adjacent time win- dows, in which the measurements are carried out, overlap. The time windows in question are marked tw. Curve A illustrates a situation with an intermediate time interval between each couple of time windows in which measurements are performed, curve B illustrates a situation in which consecutive measurement time windows directly follow each other, curve C illustrates a situation with partially overlapping measurement time windows and curve D illustrates a situation in which the time windows are totally overlapping. It is an advantage not to use a cyclic variation of the AV-delay, since many biological variations and external disturbances are cyclic which consequently can interfere with the measurements. It may therefore be an advantage to change the AV-delay according to a pseudo-stochastic sequence as illustrated in figure 6. When an AV-delay value has been selected as the "better" one, this "better" value is used in a new comparison procedure in which it is compared with another AV-delay. In each step of this selection procedure the AV-delay value is favoured which results in the highest 02 value, and when the optimum AV-delay value is reached, the AV-delays will toggle around this optimum value, as illus- trated in figure 7. In the shown example an AV-delay equal to B is supposed to give a better 02 value than an AV-delay equal to A. Further, an AV-time equal to B is also supposed to give a better 02 value than an AV-time equal to C. From the description above it appears that, if the situation of the patient changes such that the optimum AV-delay is changed, the pacemaker according to the invention will automatically found out a new optimum value and the pacemaker will operate with this new AV-delay. Figures 9-13 are diagrams corresponding to figure 8 showing the limits for minimum and maximum values, the 25%-75% spread and the median values of the parameters obtained at animal studies described in connection with figure 1. Thus figure 9 shows these values for the SO2 difference, figure 10 the results for the central venous pressure difference, Delta CVP, figure 11 the mean blood pressure difference, Delta MBP, figure 12 the carotid artery flow difference, Delta CAF, and figure 13 the sinus rate difference, Delta SR. The analysis of all these parameters clearly shows that an AV-delay value of 80 msec is better than an AV-delay value of 130 msec. The differential technique described above is a simple way of eliminating errors originating from variations in oxygen consumption of the patient and sensor drift. It is also advantages to use this technique because the variations of the oxygen content due to AV-delay changes are much smaller that changes in the oxy- gen content due to metabolic variations and also other factors. Figure 14 shows a block diagram of the principal layout of the pacemaker according to the invention. The pacemaker comprises a sensor 2, preferably a pO2-sensor, for measuring a parameter related to cardiac output of the patient (=e.g. oxygen pressure). The measurement signals are processed in a suitable signal processing unit 4 and the average value during predetermined time windows immediately before and after a change in the AV-delay is calculated in the calculating means 6. In this calculating means 6 the difference between average values obtained in the respective time window on each side of an AV-delay transi- tion are calculated, and finally a mean value is determined for this difference for "negative" transitions and "positive" transitions in the AV-delay, respectively, as described above, for determining which one of the AV-delay values results in a higher cardiac output. This result is supplied to a controlling means 8 including an altering means 10. The timing of the pulse generator 12 is then controlled by the altering means 10 to change the AV-delay between this "better" AV-delay value and a new AV-delay value. In the example above a change of the AV-delay between 130 msec and 80 msec is described. In practise the difference between the two AV- delay values can suitably be 20 msec The length of the time window in which the measurements are performed can also be varied and the sampling frequency can also be varied from the controlling means 8. An IEGM detector 14 is also connected to the controlling means 8, a.o. to synchronise the measurements to the cardiac cycle of the patient. The optimum AV-delay at rest is longer than at exercise. Different activity levels therefore have to be distinguished. Considerable variations in activity level can, however, give rise to problems. The easiest way to avoid such problem is to inhibit the AV-selection function of the pacemaker when an activity sensor indicates a work of the patient exceeding a predetermined threshold level. An activity sensor 16 is therefore connected to the controlling means 8. This activity sensor can be the O2 sensor used and/or e.g. a movement sensor. If an increased activity persists over a longer time it is possible with the pacemaker according to the invention to search a new optimum AV-delay at this defined level of workload. In such a state it is probably advantageous to have a shorter decision time for de- ciding the optimum AV-delay than at rest condition. The sensor used in the pacemaker according to the invention is preferably an electrochemically pO2-sensor of the kind described in WO 98/14772. The invention is, however, not limited to the use of such a sensor. A pO2-sensor can be implanted together with an implanted pacemaker, e.g. for measuring the oxygen concentration in the right atrium. However, variations of the oxygen content in e.g. the ventricle or arteria pulmonaris can be continuously measured in a corresponding way. Further, with a pO2-sensor the measuring pulses can be made so short that synchronisation of the measurement to the cardiac cycle is possible, and the pO2-sensor has proved to give reliable measurement results over time. Above the invention has been explained primarily in connection with the optimisation of the AV-delay in dual chamber pacemakers. However, as mentioned before the PV-interval between the occurrence of an intrinsic P-wave and the application of a cardiac stimulation pulse can be different from the AV-interval between consecutive cardiac stimulation pulses to the atrium and the ventricle respectively. Therefore these intervals ought to be optimised separately if a patient utilises both intervals. Further, in pacemakers designed for biatrial and biventricu- lar stimulation it is not always an optimum to stimulate left and right ventricle simultaneously. The time interval between left and right stimulation should therefore preferably be optimised. A proper delay will result in haemodynamic advantages, reflected in an increased cardiac output. The described technique can also be used in such pacemakers for multisite stimulation for simultaneously optimising several time intervals or delays, like these mentioned time intervals. In this way patients having e.g. a bundle block or a prolonged interatrial conduction time can be aided too.

Claims: CLAIMS 1. A pacemaker comprising a pulse generating means (12) for delivering stimulation pulses to a patient's heart and a controlling means (8) for controlling the delivery of stimulation pulses from said pulse generating means, said controlling means comprising an altering means (10) for altering the AV-delay from a predetermined first AV-delay value to a predetermined second AV-delay, and back to said first AV-delay value, a sensor (2) being provided to measure a parameter related to cardiac output of the patient, characterized in that said sensor (2) is adapted to measure said parameter in a time window inside a time of operation with said first AV-delay value, in a time window inside a time of operation with said second AV-delay value, and in a time window inside a time of operation after the return back to said first AV-delay value, and in that a determining means comprises a calculation means (6) for calculating an average value of said measured pa- rameter during each of said time windows, said determining means using said average values in determining which one the AV-delay values results in a higher cardiac output. 2. The pacemaker according to claim 1 , characterized in that said calcula- tion means (6) is adapted to form a first difference between average values obtained during the time window positioned inside said time operation with said first AV-delay value and obtained during the time window positioned inside said time of operation with said second AV-delay value as well as a second difference between average values obtained during the time window positioned inside said time of op- eration with said second AV-delay value and the time window positioned inside said time of operation after the return of said AV-delay back to said first AV-delay value for using said first and second differences in determining which AV-delay results in a higher cardiac output. 3. The pacemaker according to claim 2, characterized in that said sensor (2) is adapted to measure in one single time window during said time of operation with said second AV-delay value 4. The pacemaker to claim 2, characterized in that said sensor (2) is adapted to measure parameter values in different time windows during said time of operation with said second AV-delay value for use in determining said first and second difference respectively. 5. The pacemaker according to any of the preceding claims, said altering means (10) being adapted to repeatedly alter the AV-delay a plurality of times between said predetermined first and second AV-delay values, characterized in that said calculation means (6) is adapted to form a mean value of a resulting plurality of said first differences and a mean value of a plurality of said second differences for use said mean values in determining which AV-delay value results in a higher cardiac output. 6. The pacemaker according to any of the preceding claims, characterized in that said altering means (10) is adapted, after determination of which one of said first and second AV-delay values is indicating a higher cardiac output, to alter the AV-delay between this better AV-delay value of said first and second AV-delay values indicating a higher cardiac output and a third AV-delay value, and in that said determining means is adapted to then determine which one of said better AV- delay value and said third AV-delay value results in an indication of a higher cardiac output, said altering means (10) being adapted to repeat this procedure till an AV-delay value is determined which results in an indication of a highest cardiac output. 7. The pacemaker according to any of the preceding claims, characterized in that said altering means (10) is adapted to alter the AV-delay a plurality of times between a plurality of AV-delay values after predetermined times of operation with the respective AV-delay values and in that said sensor (2) is adapted to measure said parameter in time windows of lengths which are shorter than associated times of operation, and in that said determining means is provided to determine from said detected changes which one of said AV-delay values results in an indication of a highest cardiac output. 8. The pacemaker according to any of the preceding claims, characterized in that said times of operation are equal. 9. The pacemaker according to any of the claims 1-7, characterized in that said times of operations are different. 10. The pacemaker according to any of the preceding claims, characterized in that said altering means (10) is adapted to alter said AV-delay values after times of operation according to a pseudo-stochastic sequence. 11. The pacemaker according to any of the preceding claims, characterized in that the lengths of said times of operation are of the order of minutes. 12. The pacemaker according to any of the preceding claims, characterized in that said time-windows are positioned immediately before and immediately after an alteration of the AV-delay value. 13. The pacemaker according to any of the preceding claims, characterized in that the length of said time-windows are of the order 0,5-1 min. 14. The pacemaker according to any of the preceding claims, characterized in that said sensor (2) is controlled to sample parameter values with a sampling interval of the order 2-10 sec. 15. The pacemaker according to any of the preceding claims, characterized in that a synchronisation means(14) is provided to synchronise the sensor sampling to the cardiac cycle. 16. The pacemaker according to any of the preceding claims, characterized in that said sensor (2) measuring a parameter related to cardiac output is one of the following kind of sensors, a pO2-sensor, a SO2-sensor, a mean blood pressure sensor, a coronary artery flow sensor or a sinus rate sensor. 17. The pacemaker according to claim 16, characterized in that said blood pressure sensor (2) is adapted to measure the blood pressure in the vena cava or the right atrium.

Inventors: HOLMSTROEM NILS, LIDMAN JOHAN, NOREN KJELL, HOLMSTROEM, NILS, LIDMAN, JOHAN, NOREN, KJELL
Applicants: HOLMSTROEM NILS, LIDMAN JOHAN, NOREN KJELL, ST JUDE MEDICAL, HOLMSTROEM, NILS, LIDMAN, JOHAN, NOREN, KJELL, ST. JUDE MEDICAL AB
Application year: 2001
Main classification: A61N1
IPC codes: A61N1