Venticle is paced but no QRS follows! Only stimulation spike is recorded with no QRS following 1.

Capture failure if QRS rate is slow, pacing threshold is too low. Heart is stimulated on demand but QRS is not triggered. Pacing threshold = amplitude (volts) x pulse duration 2. Undersencing if QRS rate is not slow, sensitivity (detection level, sencing level, sencing thresold) is too high. Heart is stimulated competitively at an inappropriate timing during refractory period. 3. Isoelectric fusion beat QRS complex happens to be so small as to resemble a stimulus only. Look at different lead. 4. In DDD, atrium sensed QRS (far-field sensing), and gave a V stimuli after AVI or URI (upper rate interval), when ventricule is in still refractory period.

No V pace! Pacemaker does not stimulate ventricle no matter what! V stimulation appears inhibited by something. In DDD mode, if there is only A stilulation and no V stimulation, and there is patients own QRS or ventricular asystole. Self inhibition = Cross talk Ventricle is sensing Atrial activity. Venticules oversensing. Solution: Reduce A output pulse. Reduce ventricular sensitivity. Set PAVB (ventricular blanking). PAVB can prevent crosstalk. Set VSP. PAVB (Postatrial ventricular blanking period) = short interval after A atrial pace stimulus during which ventricle cannot sense the activity. Postatrial ventricular blanking. PAVB does not occur after spontaneous P (atrial activity). VSP (Vensricular safety pacing) = If ventricle sensed some activity right after A atrial (or you may say, if cross talk happens), the pacemaker will give V stimuli faster than AVI without waiting until it comes on T. The pacemaker will drop a spike after VSP peroid after the sensing.

Pacemaker drops a spike on QRS or T wave.! The pacemaker can overlook a true QRS during PAVB period and will provide V stimulus sometimes on T wave.

VSP (Vensricular safety pacing) = If ventricle sensed own QRS right after A atrial, the pacemaker will give V stimuli on top of QRS without waiting AVI and therefore it would come on T. The pacemaker will drop a spike after VSP peroid after A atrial.

AVI appears Shorter than you set. Cross talk is occurring on VSP setting.

Appears VOO. Pacemaker stimulates ventricle regardless of atrial activity. Atrium is senseing some noise.Far-field sensing Atriaum senses ventricular activity. Solution: Reduce atrial sensing. Set PVARP. PVARP - Prevent far field sensing. Also prevent sensing retrograde P. DDD pacemaker cannot initiate a new AVI during PVARP. Caution: This can cause atrial undersensing, however.

Endless loop tachycardia. Far-field sensing Atriaum senses ventricular activity. Retrograde P (outside the PVARP) is sensed by pacemaker. Retrograde P is sensed by atrium and starts AVI. RR interval is usually equal to URI but can be longer as URI + AVI. Cannot be shorter than URI. Appears AVNRT

Atrium does not capture! Retrograde P is making atrium refractory, but ventricle is successfully paced after AVI. RNRVAS (retrograde P is inside the PVARP) CL = LRI Appears no sinus activity. Appears capture failure of atrium.

Because of Retrograde P, Atrium is in refractory period, when pacemaker provides A stimuli. P wave does not follow A pace stimuli, but ventricle is paced after AVI. The ventricle activity produce retrograde P again.

Sudden reduction of HR to half. -- Spontaneous P: pacing V stimuli = 2:1 Tachycardia indused 2:1 block. Ventricular paced interval (VPI) = 2x spontaneous atrial P interval. This is caused because URI is shorter than TARP. Tx : Set longer URI to ensure a Wencheback URI. Wenckeback UR response makes the patient maintain the URI (fastest HR).

Automatic interval = Basic lower rate interval (LRI) = pVRP + Escape interval = sVRP +

LRI = determines the lowest ventricular rate. (longest interval) URI = fastest ventricular rate. DDD mode does not have atrial rate. DDD mode does reset the rate by atrial activity and ventricular activity. If it sensed an atrial activity, it will provides V slimulation after AVI. AVI = AV interval.

Hysteresis = Escape interval longer than LRI Pacemaker does not see its own stimulous and resultant QRS-T = (almost the same as Blanking period) = VRP (pacemaker ventricular refractory period)

Higher definiton VRP = short interval after stumulus or spontaneous QRS. Pacemaker will not sense ventricular activity during this period, and wait to start counting LRI during this period.

PVARP = short interval after stumulus or spontaneous QRS. Pacemaker will not sense atrial activity during this period. Prevent far field sensing. Also prevent sensing retrograde P. DDD pacemaker cannot initiate a new AVI during PVARP. Caution: This can cause atrial undersensing, however.

superior QRS vector RV apical pacing normal vector RVOT pacing lead is moving toward pulmonary valve! RAD ECG lead is too high or, unintended LV pacing pacing wire cross the PFO or coronary sinus!

T wave maybe inverted after long period of pacing = memory effect

Retrograde P causes the following problems. Endless loop tachycardia (retrograde P is outside the PVARP) CL= URI (or <URI +AVI) Appears AVNRT Retrograde P is sensed by atrium and starts AVI. RR interval is usually equal to URI but can be longer as URI + AVI. Cannot be shorter than URI.

RNRVAS (retrograde P is inside the PVARP) CL = LRI Appears no sinus activity. Appears capture failure of atrium. Because of Retrograde P, Atrium is in refractory period, when pacemaker provides A stimuli. P wave does not follow A pace stimuli, but ventricle is paced after AVI. The ventricle activity produce retrograde P again.

AV dissociation

 due to VVI No p wave or there is a retrograde p VVI Fusion beat VVI