Abstract:
A dual chamber pacemaker is provided, preferably either DDDR or DDIR, having logic hardware and/or software for normally carrying out the DDIR or DDDR mode of operation, and further having means for carrying out a safe atrial pace method of operation in circumstances where normal atrial pacing could otherwise be competitive or result in loss of atrial capture. The pacemaker has means for detecting an atrial sense during PVARP, timing out a delay from the time of the early atrial sense, delivering a safe atrial pulse at the end of the delay, and controlling generation of a ventricular pace pulse in synchronous relation to the safe atrial pulse and with at least a minimum AV interval.

Description:
CROSS REFERENCE TO CO-PENDING APPLICATION 
     Reference is made to U.S. patent application Ser. No. 07/830,089, by Den Dulk, filed as of the date of the present application. 
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     This invention relates to cardiac pacemakers and, more particularly, to a dual chamber pacemaker and method of pacing which optimizes pacemaker response to an early sensed atrial beat. 
     2. Description of the Prior Art 
     Various types of pacemakers are disclosed in the prior art, and are presently in widespread use. The pacing literature has documented the different types of pacemakers and their characteristics extensively. An excellent summary of the evolution and characteristics of pacemaker types, and specifically different types of dual chamber pacemakers, is set forth in U.S. Pat. No. 4,951,667, Markowitz et al., which is incorporated herein by reference. 
     Another and more recent advance in the field of cardiac pacing systems is that of the rate responsive pacemaker which increases cardiac output in response to exercise or other body demands. Such pacemakers may control pacing rate based upon sensing any one or a combination of different body parameters such as body activity, blood pH, respiratory rate, QT interval or historical atrial activity. See, for example, U.S. Pat. No. 4,428,378, Anderson et al., disclosing a pacemaker which varies pacing rate in response to sensed patient activity; and U.S. Pat. No. 4,228,308, Rickards, which discloses controlling pacing rate in response to Q-T interval. Additionally, rate responsive control has been integrated into dual chamber pacing systems, e.g., DDDR and DDIR systems. See &#34;Rate Responsive Dual Chamber Pacing&#34; in PACE, vol. 9, pp. 987-991;U.S. Pat. No. 4,467,807, Bornzin; and the above-noted U.S. Pat. No. 4,951,667. 
     A problem that has been recognized as arising in dual chamber pacemakers is that of &#34;competitive atrial pacing&#34; where, following an early natural atrial depolarization, the pacemaker may either fail to achieve atrial capture with a subsequent atrial pace pulse, or the atrial pace pulse may induce an atrial arrhythmia. Dual chamber pacing at rapid rates implies pacing near and possibly within the atrial cardiac refractory period of spontaneous P-waves, PACs and retrograde P waves. If atrial pacing occurs within the natural refractory period of the atrium, i.e., the refractory period of the heart, not that of the pacemaker, the pace stimulus will not capture the atrium. In such a situation, the actual interval between atrial and ventricular depolarizations will be prolonged beyond the physician-programmed AV interval. Further, if atrial stimuli are delivered such that they fall not in the natural refractory period of the atrium, but immediately afterwards, there exists the potential to initiate atrial fibrillation, atrial flutter, or other re-entrant tachycardias. This likelihood is especially prevalent in patients with a prior history of atrial arrhythmias. One prior art response to the detection of a PAC is to switch the mode of the dual chamber pacemaker into a ventricular asynchronous mode of operation, i.e., sacrifice synchronous operation and simply deliver ventricular pace pulses at a fixed rate until natural atrial signals are sensed having timing which enables switching back to synchronous operation. See, for example, the patent to Funke et al., U.S. Pat. No. 5,027,815, also incorporated herein by reference, where the response to an early atrial sense is to simply inhibit delivery of an atrial pulse and proceed to deliver the ventricular pulse at the scheduled time. In this type of dual chamber system, ventricular rate regularity is maintained, but at the expense of synchronous pacing operation. 
     The consequence of either switching to asynchronous operation, or pacing the atrium at a time which causes loss of atrial capture with a resultant long AV interval, has the adverse effect of hemodynamic loss of the atrial kick on ventricular filling, and decrease in subsequent cardiac output. Also, a long interval between atrial and ventricular depolarizations allows the normal AV conduction system to repolarize and conduct retrogradely to the atrium. In this manner, the patient may suffer from the contraction of the atria on closed AV valves (i.e., the pacemaker syndrome) and even worse, the patient may be subject to initiation of pacemaker-mediated tachycardia (PMT). Maintaining short or reasonable AV intervals is critical to prevention of PMT. 
     A response to these concerns is found in the patent to Markowitz et al., U.S. Pat. No. 4,951,667, incorporated herein by reference. The pacemaker of this patent responds to an atrial sense (AS) that is deemed early by delaying the timing of the atrial pulse (AP) which is to be delivered, to correspond to a lower pacing rate. The scheduled VA interval is normally set by a sensor, i.e., it is a rate responsive interval. When and if a natural atrial signal is sensed within a relative atrial refractory period, and also within a safety period just preceding the time out of the scheduled VA escape interval, then the VA interval is shifted to a longer interval corresponding to a lower rate. Thus, instead of delivering an atrial pulse at the normal scheduled time, it is delayed following such an early atrial sense, and the ventricular pace pulse (VP) is synchronized to the delayed atrial pace pulse. However, while this arrangement increases the probability of safe atrial pacing, there is no mechanism for ensuring that the atrial pacing pulse will be delivered at least a safe interval following the early atrial depolarization. Further, the atrial pace pulse is not correlated to the early atrial sense, such that the ventricular pace rate can vary widely, from a relatively high rate to a low rate. 
     There thus remains a need for a pacemaker, and method of pacing which maintains safe synchronized dual chamber pacing wherever possible. It is undesirable from both hemodynamic and electrophysiologic rationales to allow atrial pacing during times at which the pacemaker may either fail to capture or may induce an arrhythmia. It is the intention of the safe atrial pacing feature of this invention to reduce the occurrence of such behavior, and to the full extent possible eliminate it, i.e., avoid competitive atrial pacing while maintaining synchronous pacing. 
     SUMMARY OF THE INVENTION 
     It is an object of this invention to provide a method of dual chamber pacing, and a pacemaker for such pacing, which responds to sensed early atrial signals in a way such as to avoid atrial competition, while at the same time optimizing dual chamber synchronous operation and minimizing ventricular rate variation. 
     In accordance with this object, there is provided a dual chamber pacemaker having means for identifying sensed early atrial signals with respect to which scheduled atrial pulses would be potentially competitive. The pacemaker has means for timing a delay from the time of the early atrial sense and for controlling delivery of an atrial pulse at the end of the delay rather than at the end of the prior scheduled atrial escape interval. The pacemaker controls the generation of a ventricular pace stimulus in synchronous relation to the delayed atrial pace stimulus, and minimizes the AV delay in a way such as to maintain effective synchrony while minimizing variation in ventricular rate. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     FIG. 1 is an illustrative block diagram of the components of the dual chamber pacemaker system as utilized by this invention, showing the relationship of the control unit to the primary signal sensing and stimulus generating elements. 
     FIG. 2(a) is a series o timing diagrams illustrating atrial and ventricular events and pacemaker time periods, for an illustrative situation where an early atrial sense results in a safe atrial pace and a ventricular pace which is delivered following an AV delay of AV min . 
     FIG. 2(b) is a series of timing diagrams illustrating atrial and ventricular events and pacemaker time periods, for an illustrative situation where an early atrial sense results in a safe atrial pace and a ventricular pace which is delivered following a compressed AV delay which is less than the scheduled PAV but greater than AV min . 
     FIG. 2(c) is a series of timing diagrams illustrating atrial and ventricular events and pacemaker time periods, for an illustrative situation where an early atrial sense does not alter the scheduled delivery of atrial and ventricular paces. 
     FIG. 3(a) is a flow chart showing the basic logic steps taken by hardware and/or software incorporated into a DDD or DDDR pacemaker of this system and adapted to carry out the logical operations to provide improved anti-competitive atrial pacing. 
     FIG. 3(b) is a flow chart showing the basic logic steps taken by hardware and/or software incorporated into a DDI or DDIR pacemaker of this system and adapted to carry out the logical operations to provide improved anti-competitive atrial pacing. 
    
    
     DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     The following symbols are used in the specification to define events, intervals, and times: 
     
         ______________________________________AS          atrial senseASR         atrial sense during PVARPAP          atrial paceSAP         safe atrial paceVP          ventricular paceEI          escape intervalVA.sub.ei   atrial escape interval, illustrated as       the interval from V event to scheduled       delivery of an APVV.sub.ei   ventricular escape interval, illustrated       as the interval from V event to       scheduled delivery of a VP assuming an       AP occurs.AIW         interval timed out after an early atrial       sense, and representing period of       vulnerability or inexcitability of the       atriumt.sub.w     time when AIW endsAV.sub.min  the minimum AV interval during safe       atrial pacing operation to which the AV       interval may be compressedt.sub.VA    time when VA.sub.ei endst.sub.VV    time when VV.sub.ei endst.sub.AS    time of early atrial senseDDD?        DDD or DDDR modeDDI?        DDI or DDIR modePVARP       post-ventricular atrial refractory       periodPVAB        post-ventricular atrial blankingPAV         paced AV interval, i.e., AV interval to       follow atrial pacingSAV         sensed atrial interval, i.e., AV       interval to follow sensed atrial beat______________________________________ 
    
     In the following discussion, the pacemaker is illustrated as being ventricular-time-based, i.e., timing is referenced to the ventricular event. It is to be noted that atrial, or A-A timing is equally suitable for this invention. Thus, e.g., the atrial escape interval may be the V-A time, or the A-A time; the ventricular escape interval may be calculated as V-A interval plus PAV interval, etc. V-A timing is used consistently for purposes of illustrating the timing of the invention. 
     Referring now to FIG. 1, there is shown a basic block diagram of the primary hardware components of a DDR pacer 30, it being noted that the invention is also applicable to other types, e.g., DDI, DDIR and DDD. In DDI and DDD type pacers, the safe atrial pacing feature will primarily be of benefit in those cases in which variable V-A intervals are provided, e.g., in pacers which employ flywheel pacing, rate smoothing, or other similar features, or when the rate is programmed to a high value (i.e., &gt;1006 pm). 
     An atrial pace pulse generator 31 is shown, which is connected to the patient&#39;s atrium through lead 32, for delivery of pacing pulses. An A sense amplifier 35 is illustrated, also connected to atrial lead 32, to receive and sense signals from the patient&#39;s atrium. A ventricular pace pulse generator 33 is illustrated which is connected to the patient&#39;s ventricle through lead 34, to deliver pacing pulses, and V sense amplifier 36 is also connected to lead 34, to receive and sense signals from the patient&#39;s ventricle. Generators 31 and 33, and sense amplifies 35 and 36, are interconnected with microprocessor 40, and/or other desired control hardware 41, for control of timing of pulse delivery, blanking, refractory intervals, and the like, in a well known matter. Microprocessor 40 suitably has software which is parameter-driven to control the operation of the hardware units. Such software control is well known in the art, and has been incorporated into both external and implantable commercial pacemakers. As affects the scope of this invention, the degree to which software supplants hardware, or vice-versa, is a matter of design choice. Thus, for the timing functions that are carried out in the pacing system of this invention, it is to be understood that the microprocessor may have built-in timing circuits, or suitably may control external hardware timer circuits. Software control of pacing functions is well known in the art, such that the following detailed discussions of the timing and software specifications enable one of ordinary skill in this art area to design a system for carrying out the required functions within the scope of the invention. 
     A sensor S is illustrated as providing an input to the microprocessor 40. Sensor S is understood to be representative of any type of sensor, or combination of sensors, as known in the pacer art for developing one or more signals from which a desired sensor pacing rate can be developed. Although the sensor S is illustrated as being outside of the pacemaker 30, it can be positioned within or without the pacemaker housing. Likewise, a body parameter representative of desired pacing rate may be derived from one or both of the pacing leads, e.g., the QT pacemaker of the above-noted U.S. Pat. No. 4,228,803. A DDDR pacemaker also has hardware and/or software for transforming the sensed signal or signals into a desired sensor rate control signal, for controlling pacing rate, in a known fashion. 
     FIG. 2(a) illustrates the timing of this invention, by which the pacemaker responds to an early atrial sense (ASR) so as to avoid competitive atrial pacing, but yet maintains consistent AV synchronous operation. The top diagram of FIG. 2(a) represents an EKG, illustrating both atrial and ventricular events and pacemaker spikes; the bottom diagram represents a marker channel, and the middle three diagrams represent pacemaker time periods, as labelled. A first pair of atrial and ventricular pace pulses is shown, separated by the normal AV interval (PAV). Beginning with the ventricular pace pulse, a post ventricular atrial refractory period (PVARP) is timed. As used in this specification, the term PVARP may comprise PVAB, during which the atrial sense amplifier is blanked. PVARP refers to an atrial sense period following a ventricular event during which a sensed atrial signal is not used to initiate an AV interval (SAV). By contrast, any atrial sense after the end of PVARP, and up to the end of the scheduled VA interval (the VA interval is illustrated as VA ei ) is used to initiate an SAV interval, the time out of which can trigger a synchronized ventricular pulse. Thus, PVARP may be any portion of the post-ventricular period up to the time when the occurrence of an AS initiates timing of an AV delay for ventricular tracking of the atrium. 
     Still referring to FIG. 2(a), and remembering that the invention is illustrated by V-V timing, the control circuitry of this invention normally times a scheduled VA interval (VA ei ), referred to as the atrial escape interval, and ending at t VA . The end of VA ei  is followed by a scheduled PAV, which ends at tvv (VA ei  and PAV make up the ventricular escape interval). Also, although not illustrated, if an AS appears after PVARP, the pacer times a normal AV interval (SAV) and delivers at the end of SAV a synchronized ventricular pulse in the absence of an intervening VS. Note that these intervals may vary, e.g., in a rate responsive mode or as illustrated in the Funke et al. U.S. Pat. No. 5,027,815. However, if an atrial sense is recognized within the effective PVARP, as illustrated, then a time interval AIW is timed out commencing with the early sense (ASR). When this happens, delivery of an AP at the end of VA ei  is inhibited, and a safe atrial pulse is generated and delivered at the end of AIW (t w ). An AV interval which is shorter than PAV and greater than or equal to AV min  is initiated, resulting in delivery of a ventricular stimulus at the conclusion thereof. In a typical embodiment, AIW may be 300 ms, and AV min  is 80 ms. These figures are, of course, illustrative, and other values may be selected for use in this invention. 
     As illustrated in FIG. 2(a), where the end of AIW (t w ) occurs after the calculated end of VA ei  (t VA ), the shortened AV interval results in the ventricular pace being delivered close to the scheduled t VV , i.e., the change in Ventricular pacing rate is small. Note, however, that there is a limit to how much the AV interval can be shortened and still maintain effective synchrony, and for this reason a condition is imposed that the AV delay following a SAP must be at least as great as AV min , which can be programmed by the physician. Note, however, that the AV delay following an SAP can be as long as the scheduled PAV. FIG. 2(b) illustrates the same situation as FIG. 2(a), except that VA ei  has been extended from about 450 ms to 550 ms (as seen by comparing VA ei  to the 200 ms reference). This results in the calculated t VV  (VA ei  +PAV) being later than the end of AIW+AV min , in which case the later time is chosen to schedule delivery of ventricular pace in order to optimize AV synchrony and maintain regularity of the ventricular rhythm. Thus, as seen also in connection with FIGS. 3(a) and 3(b), the logic is to choose the later of VA ei  +PAV, or AIW+AV min . 
     FIG. 2(c) illustrates the situation where VA ei  is even larger (about 625 ms), such as where the sensor calls for a lower pacing rate. Here, t w  is calculated to occur before the end of VA ei  (t VA ) In such a situation, the normally scheduled escape intervals can be maintained, so that there is no SAP delivered and the AP is delivered at scheduled t VA . Thus, with this timing, the early atrial sense does not alter the standard DDDR or DDIR operation. 
     The following logical rules apply to safe atrial pacing in the DDI? and DDD? modes: 
     Upon an AS during PVARP, start the AIW interval. 
     Upon completion of the atrial escape interval (VA ei ), start the PAV interval; 
     if VA ei  is completed during the ventricular refractory interval, cancel the AIW interval, and pace the atrium; 
     if VA ei  is completed, not during the ventricular refractory period, not during the AIW interval, and the inhibit condition is false (no AS has occurred to inhibit delivery of an AP), pace the atrium. 
     Upon a further atrial sense not during PVARP, cancel the AIW interval, and 
     if in DDI? mode: if during the atrial escape interval, declare the atrial inhibit condition; if not during the escape interval, and not during the PAV interval, pace the ventricle. 
     if in DDD? mode, start the SAV interval. 
     Upon an atrial pace, start the AV min  interval. 
     Upon completion of the AIW interval, if the escape interval (VA ei ) has completed, pace the atrium. 
     Upon completion of the AV min , but not during the PAV interval, pace the ventricle. 
     Upon completion of the PAV interval, not during the AV min  interval, and not during the AIW interval, pace the ventricle. 
     Upon a ventricular pace, or a ventricular sense, 
     start the escape interval, 
     reset the inhibit condition, 
     cancel the AV min  interval, 
     cancel the PAV interval, and 
     cancel the SAV interval. 
     It is to be noted that these logic rules are intended to operate in conjunction with established methods for dual chamber pacing. Conditions such as inhibition of ventricular pacing have not been included in these rules. Likewise, conditions for carrying out ventricular safety pacing (VSP) have not been included. VSP is used as a safety measure against cross-talk inhibition. In VSP operation, if the ventricular sense amplifier senses a signal within a predetermined time interval following an atrial pace, then a VP is delivered at the end of such predetermined interval. Although not illustrated in this specification, VSP may be included in a pacemaker according to this invention. 
     Referring now to FIG. 3(a), there is shown a flow diagram for carrying out the functions necessary for safe atrial pacing in the DDD? mode of a dual chamber pacemaker. As indicated at block 50, a ventricular event such as VS starts the timing of PVAB and PVARP. PVAB causes blanking of the atrial sense amplifier, and may be accomplished by any desired combination of hardware and software. At the end of PVAB, at block 52 it is determined whether an atrial sense occurs (AS) in PVARP. If no, meaning the PVARP is timed out without any atrial sense, the logic branches to block 53, where standard DDD? operation is continued. However, when an AS is sensed in PVARP, the logic branches to block 55, where the AIW timer is initiated. Following initiation of the AIW period, the pacemaker calculates whether AIW or EI (e.g., VA ei ) is going to time out sooner. If AIW is calculated to time out sooner, the logic reverts to block 52, to continue to determine whether another AS will be detected within PVARP. Note that, as discussed above in connection with FIGS. 2(a)-(c), if AIW is calculated to time out sooner, there is no reason to deviate from waiting for the end of the escape interval; if no additional AS is sensed, the pacemaker proceeds to normal DDD? operation. 
     If, at 55, it is determined that the end of the AIW window is to occur after the escape interval, the pacemaker waits until the end of AIW at 57 and if no AS occurred within AIW, and an SAP is delivered directly, as indicated at block 58. When an AS occurs during AIW, the pacemaker branches to block 59, to determine whether this AS has occurred in PVARP. If no, meaning that it was an AS after the end of PVARP, the pacemaker branches to standard DDD? operation, as indicated by the branch leading to block 53. If the answer at 59 is yes, meaning that a second ASR has occurred in PVARP, then the pacemaker returns to 55 to start a new AIW. This ensures that when an SAP is delivered, it is delayed by at least AIW following the last ASR. Optionally, blocks 57 and 59 may be omitted and the device may proceed directly to block 58, triggering delivery of an SAP. 
     Referring back to the delivery of an SAP at block 58, the pacemaker proceeds to block 62 to determine when a VP can be delivered. The pacemaker picks which comes later, the calculated AIW+AV min , or EI+PAV. If the former, then at block 64 the pacemaker determines the end of AIW+AV min , and initiates delivery of a VP as shown at block 68. If EI +PAV is calculated to occur later than AIW+AV min , then at block 66 the pacemaker determines the end of EI+PAV, and initiates VP as indicated at block 68. 
     FIG. 3(b) is a modification of safe atrial pacing for the DDI? mode. In comparison to DDD? mode as indicated in FIG. 3(a), the difference is in the response following the detection of an AS in the AIW interval, but not in PVARP, as indicated at the &#34;NO&#34; output of block 59. At block 70, it is determined whether such AS occurred within EI. If yes, the pacemaker returns to standard DDI operation at block 53. If at block 70 the response is no, meaning that EI (e.g., VA ei ) has ended, the pacemaker goes to 72 where it is determined whether the AS has occurred in PAV. If yes, operation branches to 66, resulting in delivery of a VP at the end of EI+PAV. If no, a VP is delivered directly, or, alternatively, after a minimum A-V delay. 
     The system and method of this invention are seen to provide a response to sensed early atrial depolarizations in a manner that ensures avoidance of competitive pacing, and maintains atrial-ventricular synchrony when it paces the ventricle. This invention utilizes the rate responsive information available in a DDIR or DDDR pacer, by delivering the SAP directly upon completion of the AIW rather than waiting for the end of a low rate escape interval. By continuously searching for early atrial senses, the pacemaker is enabled to respond at times of greater risk, i.e., during periods of high rate response, while maintaining the benefits of rate responsiveness. Further, by compressing the following AV interval, a high degree of ventricular rate regularity is maintained along with continuous synchronous operation. 
     Although specific software embodiments have been presented, it is to be understood that the safe atrial pacing method of this invention can be carried out with somewhat different logical sequences, and in combination with other pacemaker functions.