Source: https://patents.google.com/patent/US20030130702
Timestamp: 2018-04-20 14:38:03
Document Index: 551113029

Matched Legal Cases: ['art 101', 'art 101', 'art 101', 'art 101', 'art 101', 'art 101', 'art.\n3', 'art.\n4', 'art.\n5', 'art.\n6', 'art.\n7', 'art.\n8', 'art.\n55', 'art.\n63', 'art.\n64', 'art.\n65', 'art.\n66', 'art.\n67', 'art.\n68', 'art.\n76']

US20030130702A1 - Timing cycles for synchronized multisite cardiac pacing - Google Patents
US20030130702A1
US20030130702A1 US10270035 US27003502A US2003130702A1 US 20030130702 A1 US20030130702 A1 US 20030130702A1 US 10270035 US10270035 US 10270035 US 27003502 A US27003502 A US 27003502A US 2003130702 A1 US2003130702 A1 US 2003130702A1
US7260432B2 (en )
[0014]FIGS. 1A and 1B are partial views of embodiments of an implantable medical device with an endocardial lead system extending into the heart and the cardiac venous system with electrodes positioned at multiple locations in or adjacent to various heart chambers;
[0015]FIG. 2 is a system block diagram of an implantable medical device configured for multichamber cardiac sensing and pacing in accordance with an embodiment of the invention;
[0016]FIG. 3 is a timing diagram illustrating intact AV conduction and adequate ventricular rates;
[0017]FIG. 4 is a timing diagram illustrating a pacing mode involving pacing both the left ventricle and the right ventricle after a sensed atrial contraction in accordance with an embodiment of the invention;
[0018]FIG. 5 is a timing diagram illustrating representative pacing timing cycles in accordance with embodiments of the invention;
[0019]FIG. 6 is a timing diagram illustrating RV based timing in accordance with embodiments of the invention;
[0021]FIG. 8 illustrates various combinations of right ventricular and left ventricular paced and sensed events that may occur following an atrial pace in accordance with an embodiment of the invention;
[0022]FIG. 9 is a table specifying synchronized multisite pacing modes with a letter code in accordance with an embodiment of the invention;
[0023]FIGS. 10A and 10B illustrate enforcement of a maximum tracking rate in accordance with an embodiment of the invention;
[0024]FIG. 11 is a timing diagram illustrating inhibition of right and left ventricular paces by sensed events in the right and left ventricles in accordance with an embodiment of the invention;
[0025]FIG. 12 is a timing diagram illustrating competitive pacing during a vulnerable period;
[0026]FIGS. 13 and 14 are timing diagrams illustrating competitive pacing in the situation of univentricular sensing combined with biventricular pacing;
[0029]FIG. 21 is a timing diagram illustrating sensed and paced RV-LV intervals in accordance with an embodiment of the invention;
[0030]FIG. 22 is a timing diagram illustrating biventricular sensing with pacing upon sensing an intrinsic event in accordance with an embodiment of the invention;
[0032]FIG. 25 is a timing diagram illustrating biventricular sensing and left ventricular pacing with triggering and left ventricle based timing in accordance with an embodiment of the invention;
[0033]FIG. 26 illustrates a ventricular protection period in accordance with an embodiment of the invention;
[0036]FIG. 35 illustrates pairing intervals in accordance with an embodiment of the invention;
[0038]FIG. 38 is a timing diagram illustrating cross chamber refractory periods in accordance with an embodiment of the invention;
[0040]FIG. 47 is a timing diagram illustrating negative AV hysteresis in accordance with an embodiment of the invention;
[0041]FIG. 48 is a timing diagram illustrating dynamic RV-LV interval in accordance with an embodiment of the invention; and
[0042]FIG. 49 is timing diagram illustrating asynchronous pacing.
[0059]FIG. 1B shows one embodiment of a medical device system that may be used for synchronized multisite sensing or pacing within a heart chamber. The medical device system includes a CFM device 100 electrically and physically coupled to an intracardiac lead system 102. The intracardiac lead system 102 is implanted in a human body with portions of the intracardiac lead system 102 inserted into a heart 101. The intracardiac lead system 102 is used to detect and analyze electric cardiac signals produced by the heart 101 and to provide electrical energy to the heart 101 under certain predetermined conditions to treat cardiac arrhythmias.
In this configuration, the intracardiac lead system 102 is shown positioned within the heart 101, with the first and the second right ventricular lead systems 104, 106 extending through the right atrium 120 and into the right ventricle 118. In particular, the RV-tip electrode 112 and RV-coil electrode 114 are positioned at appropriate locations to sense and pace a first site within the right ventricle 118. The SVC-coil 116 is positioned at an appropriate location within the right atrium chamber 120 of the heart 101 or a major vein leading to the right atrium chamber 120 of the heart 101. The RVP-coil 114 and SVC-coil 116 depicted in FIG. 1B are defibrillation electrodes. An RV-tip electrode 132, and an RV-ring electrode 134 are positioned at appropriate locations to sense and pace a second site within the right ventricle 118.
The right ventricular lead system includes conductors 102 and 104 for transmitting sense and pacing signals between terminals 202 and 204 of the CFM device and the RV-tip and RV-coil electrodes, respectively. The right ventricular lead system further includes conductor 101 for transmitting signals between the SVC coil and terminal 201 of the CFM device 200. The right atrial lead system includes conductor 106 for transmitting signals between the RA-tip electrode and terminal 206 and conductor 108 for transmitting signals between the RA-ring electrode and terminal 208.
The left atrial/ventricular lead system includes conductors 110,112 for transmitting sense and pacing signals between terminals 210, 212 of the CFM device 200 and LV-tip and LV-ring electrodes respectively. The left atrial/ventricular lead system also includes conductor 118 for transmitting sense signals between terminal 218 of the CFM device 200 and the CV electrode. A can electrode 209 coupled to a housing 130 of the CFM device 200 is also provided.
In atrioventricular timing, the maximum tracking rate is enforced by delaying the ventricular pace to the MTR when the AV interval expires during the MTR interval. When biventricular pacing includes a positive or negative RV-LV interval, pacing at the maximum tracking rate is adjusted according to the timing mode. For example, as illustrated in FIG. 10A, with RV-based timing and positive RV-LV interval, the right ventricular pace RVP1, RVP2 occurs at the end of the MTR followed after the RV-LV interval by the left ventricular pace LVP1, LVP2. With a negative RV-LV interval, the right ventricular pace RVP1, RVP2 still occurs at the end of the MTR interval, but is preceded by the left ventricular pace LVP1, LVP2 at the beginning of the RV-LV interval, as illustrated in FIG. 10B.
In biventricular pacing, prolonged RV-LV intervals present a risk of competitive pacing. Whenever a ventricular depolarization is not sensed, there is a risk of pacing that ventricle when it is no longer refractory, potentially stimulating-a ventricular arrhythmia. The likelihood of competitive pacing may be increased by combinations of several factors, including prolonged right to left conduction delays typical of patients for whom biventricular pacing is currently indicated, long RV-LV pacing intervals that have opposite signs from intrinsic RV-LV intervals, fast pacing rates, and sensed ventricular cross-chamber refractory periods. For example, as illustrated in FIG. 12, if the intrinsic RV-LV conduction interval is 150 ms, pacing at an interval of 500 ms with a negative RV-LV delay of 50 ms may increase the risk of competitive pacing. In this example, the left ventricular paced event LVP2 may occur when the left ventricle is no longer refractory. In FIG. 12, as with other examples provided herein, RV based timing is used, although timing intervals based on LV based timing, first-in timing or any other timing for bi-chamber pacing may be used.
[0107]FIG. 22 illustrates an example of biventricular sensing with pacing upon sensing an intrinsic event. When an intrinsic left ventricular event LVS1, LVS2 occurs in the AV or RV-LV interval before a left ventricular pace, the left ventricular pace is inhibited (LVP1), (LVP2). The right ventricular pace RVP1 is unaffected and initiates the VA interval VAI1. However, if left ventricle to right ventricle conduction occurs quickly enough, resulting in a conducted right ventricular sense RVS2 before the right ventricular pace is scheduled, the right ventricular pace may be inhibited (RVP2). In this situation, the sensed right ventricular event RVS2 initiates the VA interval VAI2.
[0114]FIG. 25 illustrates an example of biventricular sensing and left ventricular pacing with triggering and left ventricle based timing. A right ventricular sensed event RVS2 in the AV interval AVI2 triggers a left ventricular pace LVP2 initiating the VA interval VAI2. In addition, a sensed right ventricular event RVS3 in the VA interval VAI2 triggers an immediate left ventricular pace LVP3 and resets the VA interval VAI3.
[0129]FIG. 27C illustrates the use of a protection period when the second site is sensed and paced. In this particular example, left ventricular based timing is used with a negative RV-LV interval. As before, a sensed left ventricular event LVS1 initiates a VA interval VAI. After the VA interval expires, the atrium is paced and the AV interval begins. If a right ventricular event is sensed RVS2, a right ventricular protection period RVPP begins. Because the scheduled right ventricular pace falls within the right ventricular protection period RVPP, the scheduled right ventricular pace is inhibited (RVP2) preventing pacing the right ventricle during the vulnerable period.
[0133]FIG. 28B illustrates this pacing approach when left ventricular sensing is used with right ventricular pacing. The left ventricular sense LVS1 initiates the pacing escape interval PEI. The right ventricle is paced RVP2 after the expiration of the pacing escape interval and initiates the next pacing escape interval.
[0176]FIG. 34C illustrates the effect of an intervening second cardiac event on a pairing state in accordance with one embodiment involving sensing at five sites. A first pairing state PS1 is initiated by a first unpaired event E1. Cardiac events E2, and E3, are detected during the first pairing state PS1. An intervening second cardiac event E2′ is detected at the second site during the first pairing state PS1 before cardiac events E4 and E5 are detected. Detection of the intervening second cardiac event E2′ causes the first pairing state PS1 to be terminated. A second pairing state PS2 may be commenced using the second cardiac event E2′ as the first unpaired event initiating the second pairing state PS2.
[0184]FIG. 35 illustrates PVC detection using a maximum pairing interval. Following an atrial event AP1, a left ventricular sense LVS1 following a right ventricular sense RVS1 that initiates the VA interval VAI1 is not detected as a premature ventricular contraction so long as the left and the right ventricular events are paired in the pairing state PS1. In this example, the left ventricular event occurs within a maximum pairing interval PI1 after the occurrence of the right ventricular event RVS1.
[0193]FIG. 37 illustrates an example of prolonged sensing refractoriness wherein same chamber and cross chamber refractory periods merge. A right ventricular pace is followed by a left ventricular pace producing prolonged refractoriness in all chambers.
[0210]FIG. 44 illustrates shortening the PVARP to restore biventricular pacing. An intrinsic atrial event AS3 occurs within PVARP2. This situation could lead to loss of biventricular pacing because the intrinsic atrial contraction would not be followed by corresponding ventricular paces. However, according to one approach, when a P-wave is sensed within a post ventricular refractory period PVARP2, the next post ventricular refractory period PVARP3 is shortened to reestablish biventricular pacing.
Other methods of cardiac rhythm management for synchronized pacing of the heart are described in U.S. patent application Ser. No. 09/748736 entitled “System and Method for Timing Synchronized Pacing,” U.S. patent application Ser. No. 09/748754 entitled “System and Method for Cardiac Rhythm Management with Synchronized Pacing Protection Period,” and U.S. patent application Ser. No. 09/748733 entitled “System and Method for Managing Refractory Periods in a Cardiac Rhythm Management Device with Biventricular Sensing,” all commonly owned and filed on Jun. 27, 2002 which are hereby incorporated by reference herein in their respective entireties.
detecting cardiac events associated with a plurality of cardiac sites in a single heart chamber or in bilateral heart chambers; and
identifying a group of the detected cardiac events associated with a depolarization wavefront, the depolarization wavefront representing a myocardial activation initiated at a particular cardiac origin and conducted to the plurality of cardiac sites.
2. The method of claim 1, wherein the cardiac sites are located in a left ventricle and a right ventricle of a heart.
3. The method of claim 1, wherein the cardiac sites are located in a left atrium and a right atrium of a heart.
4. The method of claim 1, wherein the cardiac sites are located in a right ventricle of a heart.
5. The method of claim 1, wherein the cardiac sites are located in a left ventricle of a heart.
6. The method of claim 1, wherein the cardiac sites are located in a left atrium of a heart.
7. The method of claim 1, wherein the cardiac sites are located in a right atrium of a heart.
8. The method of claim 1, wherein the depolarization wavefront originates in a ventricle.
9. The method of claim 1, wherein the depolarization wavefront originates in an atrium.
10. The method of claim 1, wherein each group of the detected cardiac events associated with the depolarization wavefront comprises a single cardiac event for each cardiac site.
11. The method of claim 1, wherein identifying the group comprises establishing a pairing state during which a single cardiac event is detected for each cardiac site.
12. The method of claim 11, wherein detecting the cardiac events comprises implantably detecting the cardiac events.
13. The method of claim 11, wherein identifying the group of the detected cardiac events comprises implantably identifying the group of the detected cardiac events associated with the depolarization wavefront.
14. The method of claim 11, wherein establishing the pairing state comprises:
initiating the pairing state in response to detecting a particular cardiac event; and
terminating the pairing state in response to a terminating event.
15. The method of claim 14, wherein initiating the pairing state comprises detecting a first occurring cardiac event that is not a member of a previous group.
16. The method of claim 15, wherein the first occurring cardiac event is an intrinsic cardiac event.
17. The method of claim 15, wherein the first occurring cardiac event is a paced cardiac event.
18. The method of claim 11, wherein establishing the pairing state comprises:
terminating a first pairing state if a second cardiac event at a particular site is detected; and
initiating a second pairing state using the second cardiac event as a first occurring cardiac event in a particular group identified during the second pairing state.
19. The method of claim 11, wherein establishing the pairing state comprises:
terminating a first pairing state if a second paced cardiac event at a particular site is detected; and
initiating a second pairing state using the second paced cardiac event as a first occurring cardiac event in a particular group identified during the second pairing state.
20. The method of claim 14, wherein terminating the pairing state comprises terminating the pairing state if a single cardiac event has been detected for each cardiac site.
21. The method of claim 14, wherein terminating the pairing state comprises terminating the pairing state if a second sensed cardiac event from a particular cardiac site is detected.
22. The method of claim 14, wherein terminating the pairing state comprises terminating the pairing state if a second paced cardiac event at a particular site is detected.
23. The method of claim 14, wherein terminating the pairing state comprises terminating the pairing state if the group has not been identified within a pairing interval.
24. The method of claim 23, wherein the pairing interval is a selected time interval.
25. The method of claim 1, further comprising delivering therapy to a heart based on at least one cardiac event of the group.
26. The method of claim 25, wherein delivering therapy comprises implantably delivering therapy to the heart based on the at least one cardiac event of the group.
27. The method of claim 1, further comprising initiating a pacing timing cycle based on at least one cardiac event of the group.
28. The method of claim 27, wherein initiating the pacing timing cycle comprises initiating the pacing timing cycle based on a particular cardiac event of the group.
29. The method of claim 27, wherein initiating the pacing timing cycle comprises initiating the pacing timing cycle based on a first occurring cardiac event of the group.
30. The method of claim 27, wherein initiating the pacing timing cycle comprises initiating the pacing timing cycle based on a particular sequence of the detected cardiac events.
31. The method of claim 1, further comprising initiating a pacing escape interval based on at least one cardiac event of the group.
32. The method of claim 1, wherein the cardiac sites are located in at least one of a left atrium and a right atrium of a heart and further comprising:
initiating an atrioventricular escape interval based on at least one cardiac event of the group; and
pacing at least one ventricle after the atrioventricular interval has expired.
33. The method of claim 1, wherein the cardiac sites are located in at least one of a left ventricle and a right ventricle of a heart and further comprising:
initiating a ventriculoatrial escape interval based on at least one cardiac event of the group; and
pacing at least one atrium after the ventriculoatrial escape interval has expired.
34. The method of claim 33, further comprising classifying a second group of intrinsic cardiac events initiating in the ventriculoatrial escape interval as a premature ventricular contraction.
detecting right ventricular cardiac events associated with a right ventricular cardiac site;
detecting left ventricular cardiac events associated with a left ventricular cardiac site; and
identifying a pair of the detected cardiac events associated with a depolarization wavefront, the depolarization wavefront representing a myocardial activation initiated at a cardiac origin and conducted to the cardiac sites.
36. The method of claim 35, wherein detecting the cardiac events comprises implantably detecting the cardiac events.
37. The method of claim 35, wherein identifying the pair of the detected cardiac events comprises implantably identifying the pair of the detected cardiac events associated with the depolarization wavefront.
38. The method of claim 35, wherein the depolarization wavefront originates in a ventricle.
39. The method of claim 35, wherein the depolarization wavefront originates in an atrium.
40. The method of claim 35, wherein each pair of the detected cardiac events associated with the depolarization wavefront comprises a single cardiac event for each cardiac site.
41. The method of claim 35, wherein identifying the pair comprises establishing a pairing state during which a single cardiac event is detected for each cardiac site.
42. The method of claim 41, wherein establishing the pairing state comprises:
initiating the pairing state in response to a particular cardiac event; and
43. The method of claim 42, wherein initiating the pairing state comprises detecting a first occurring cardiac event that is not a member of a previous group.
44. The method of claim 43, wherein the first occurring cardiac event is an intrinsic cardiac event.
45. The method of claim 43, wherein the first occurring cardiac event is a paced cardiac event.
46. The method of claim 41, wherein establishing a pairing state comprises:
initiating a second pairing state using the second cardiac event as a first occurring cardiac event in a particular pair identified during the second pairing state.
47. The method of claim 41, wherein establishing a pairing state comprises:
initiating a second pairing state using the second paced cardiac event as a first occurring cardiac event in a particular pair identified during the second pairing state.
48. The method of claim 42, wherein terminating the pairing state comprises terminating the pairing state if a single cardiac event has been detected for each cardiac site.
49. The method of claim 42, wherein terminating the pairing state comprises terminating the pairing state if a second sensed cardiac event from a particular cardiac site is detected.
50. The method of claim 42, wherein terminating the pairing state comprises terminating the pairing state if a second paced cardiac event at a particular site is detected.
51. The method of claim 42, wherein terminating the pairing state comprises terminating the pairing state if the pair has not been identified within a pairing interval.
52. The method of claim 51, wherein the pairing interval is a selected time interval.
53. The method of claim 35, further comprising delivering therapy to a heart based on at least one cardiac event of the pair.
54. The method of claim 53, wherein delivering therapy comprises implantably delivering therapy to the heart.
55. The method of claim 35, further comprising initiating a pacing timing cycle based on at least one cardiac event of the pair.
56. The method of claim 55, wherein initiating the pacing timing cycle comprises initiating the pacing timing cycle based on a particular cardiac event of the pair.
57. The method of claim 56, wherein the particular cardiac event is a first occurring cardiac event of the group.
58. The method of claim 35, further comprising initiating a pacing escape interval based on at least one cardiac event of the pair.
initiating a ventriculoatrial escape interval based on at least one cardiac event of the pair; and
pacing an atrium after the ventriculoatrial escape interval has expired.
60. The method of claim 59, further comprising classifying a second pair of intrinsic cardiac events initiating in the ventriculoatrial escape interval as a premature ventricular contraction.
a lead system, the lead system comprising electrodes for detecting cardiac events at a plurality of cardiac sites in a single heart chamber or bilateral heart chambers;
sensing circuitry, the sensing circuitry coupled to the lead system and configured to sense cardiac signals transmitted via the lead electrodes; and
a control system configured to detect cardiac events associated with the plurality of cardiac sites and identify a group of the detected cardiac events associated with a depolarization wavefront.
62. The medical device of claim 61, wherein the cardiac sites are located in a left ventricle and a right ventricle of a heart.
63. The medical device of claim 61, wherein the cardiac sites are located in a left atrium and a right atrium of a heart.
64. The medical device of claim 61, wherein the cardiac sites are located in a right ventricle of a heart.
65. The medical device of claim 61, wherein the cardiac sites are located in a left ventricle of a heart.
66. The medical device of claim 61, wherein the cardiac sites are located in a left atrium of a heart.
67. The medical device of claim 61, wherein the cardiac sites are located in a right atrium of a heart.
68. The medical device of claim 61, wherein the sensing system and the control system are arranged in an implantable medical device.
69. The medical device of claim 61, wherein each group of the detected cardiac events associated with a depolarization wavefront comprises a single cardiac event for each cardiac site.
70. The medical device of claim 61, wherein the control system is further configured to initiate a pairing state upon detection of a first occurring cardiac event that is not a member of a previous group.
71. The medical device of claim 70, wherein the control system is further configured to terminate the pairing state based upon detection of a single cardiac event associated with each cardiac site.
72. The medical device of claim 70, wherein the control system is further configured to terminate the pairing state if a second cardiac event from a particular cardiac site is detected.
73. The medical device of claim 70, wherein the control system is further configured to terminate the pairing state if a second paced cardiac at a particular site is detected.
74. The medical device of claim 70, wherein the control system is further configured to terminate the pairing state if the group has not been identified within a selected time interval.
75. The medical device of claim 61, further comprising a pulse generator coupled to the control system and configured to deliver therapy to a heart.
76. The medical device of claim 75, wherein the control system is configured to initiate a pacing escape cycle based on at least one cardiac event of the group.
77. The medical device of claim 75, wherein the lead system further comprises:
an atrial lead system comprising an atrial electrode and extending into an atrium of the heart; and
wherein the control system is further configured to detect cardiac events associated with an atrium of the heart and initiate a ventriculoatrial escape interval based on at least one cardiac event of the group.
78. The medical device of claim 77, wherein the control system is configured to classify a second group of intrinsic cardiac events initiating in the ventriculoatrial escape interval as a premature ventricular contraction.
means for detecting cardiac events associated with a plurality of cardiac sites in a single heart chamber or in bilateral heart chambers; and
means for identifying a group of the detected cardiac events associated with a depolarization wavefront.
means for initiating a ventriculoatrial escape interval based on at least one cardiac event of the group; and
means for pacing at least one atrium after the ventriculoatrial interval has expired.
81. The system of claim 80, further comprising means for classifying a second group of intrinsic cardiac events initiating in the ventriculoatrial escape interval as a premature ventricular contraction.
means for detecting right ventricular cardiac events associated with a right ventricular cardiac site;
means for detecting left ventricular cardiac events associated with a left ventricular cardiac site; and
means for identifying a pair of the detected cardiac events associated with a depolarization wavefront, the depolarization wavefront representing a myocardial activation initiated at a cardiac origin and conducted to the cardiac sites.
means for initiating a ventriculoatrial escape interval based on at least one cardiac event of the pair; and
means for pacing an atrium after the ventriculoatrial escape interval has expired.
84. The system of claim 83, further comprising means for classifying a second pair of intrinsic cardiac events initiating in the ventriculoatrial escape interval as a premature ventricular contraction.
US20030130702A1 true true US20030130702A1 (en) 2003-07-10
US7260432B2 US7260432B2 (en) 2007-08-21
JP2014502536A (en) * 2010-12-20 2014-02-03 カーディアック ペースメイカーズ， インコーポレイテッド Refractory and blanking intervals for multi-site ventricular pacing
JP2014502537A (en) * 2010-12-20 2014-02-03 カーディアック ペースメイカーズ， インコーポレイテッド Left ventricular limited and right ventricular safety pacing