CONCEPTS

OF ICD TECHNOLOGY

2017
CONCEPTS OF
ICD TECHNOLOGY
SENSING &
DETECTION

MAY 2017
DISCLOSURES

This presentation is provided for general educational purposes only and should not be
considered the exclusive source for this type of information. This training does not replace or
supersede approved labeling. The content will be shared with physicians and allied health
professionals who seek a deeper understanding of the operation and use of Medtronic
products and therapies with the intent of enhancing their knowledge of features and
operations described in the clinician manuals.

The device data presented in this module is fictional and is designed only for educational
purposes. At all times, it is the professional responsibility of the practitioner to exercise
independent clinical judgment in a particular situation. Changes in a patient’s disease and/or
medications may alter the efficacy of a device’s programmed parameters or related features
and results may vary. The device functionality and programming described in this
presentation are based on Medtronic products and can be referenced in the published device
manuals.

Important Reminder: This information is intended only for users in markets where Medtronic
products and therapies are approved or available for. Content on specific Medtronic products
and therapies is not intended for users in markets that do not have authorization for use.
The device functionality and programming described in this module can be found in some
Medtronic ICD and CRT-D devices. Please go to manuals.medtronic.com or consult with your
local Medtronic representative regarding device models available in your geography.
OBJECTIVES

 Identify the components of an Implantable

Cardiac Defibrillator (ICD) system
 Explain the basic concepts of sensing and
detection in an ICD
 Describe the detection zones and parameters
used to identify a tachyarrhythmia
THE ICD SYSTEM
SUDDEN CARDIAC ARREST
IMPLANTABLE CARDIAC DEFIBRILLATORS
 Implantable cardiac defibrillators
(ICDs) treat abnormal heart rhythms
(ventricular arrhythmias) such as
ventricular tachycardia and
ventricular fibrillation.

 These life-threatening rhythms can

cause sudden cardiac arrest (SCA),
which results in death if not treated.

 98% of people survive a lethal

arrhythmia when treated with
defibrillation.1 Only 5% of people
survive SCA without defibrillation.2

1Glikson M, Friedman PA. The implantable cardioverter defibrillator. Lancet. April 7, 2001;357(9262):1107-1117.
2 EpsteinAE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities [corrections
appear at J Am Coll Cardiol. April 21, 2009; 53(16):1473. J Am Coll Cardiol. January 6, 2009;53(1):147]. J Am Coll Cardiol. May 27, 2008;51(21):e1-
62.
THE ICD SYSTEM

IMPLANTED ICD

VENTRICULAR ATRIAL LEAD

LEAD
• Bradycardia
• Bradycardia sensing/pacing
sensing/pacing • Antitachycardia pacing
• Antitachycardia pacing (ATP)
(ATP) • Atrial Arrhythmia
• Cardioversion prevention therapies
• Defibrillation
DEVICE COMPONENTS OVERVIEW

HEADER
BATTERY

CIRCUITRY

CAPACITOR
HOW HIGH VOLTAGE IS GENERATED
LEAD ELECTRICAL DESIGN
PACING AND SENSING CONFIGURATIONS

TRUE BIPOLAR
CONFIGURATION

Pacing and sensing circuit:

• Cathode – Right ventricular tip
• Anode – Right ventricular ring
LEAD ELECTRICAL DESIGN
PACING AND SENSING CONFIGURATIONS

INTEGRATED BIPOLAR
CONFIGURATION

Pacing and sensing circuit:

• Cathode – Right ventricular Tip
• Anode – Right ventricular coil
LEAD ELECTRICAL DESIGN
SHOCKING CIRCUIT

Dual-Coil Configuration Single-Coil Configuration

Shocking circuit: Shocking circuit:
• Right Ventricular Coil (RVC) • Right Ventricular Coil (RVC)
• Supraventricular Coil (SVC) • Can
• Can
MAJOR FUNCTIONS OF AN ICD

 Sense appropriate cardiac signals

 Detect dangerous rhythms

reliably

 Provide pacing and defibrillation

therapy

 Store diagnostics
SENSING
ICD SENSING

Appropriate sensing is crucial to the successful operation of an ICD

SENSING CARDIAC DEPOLARIZATION
ELECTROGRAM (EGM)
 THE SENSING CIRCUIT

Amplifier Bandpass
Rectifier Threshold
Filter

Sensitivity setting

Ellenbogen KA, Wilkoff BL, Kay GN, Lau CP, Auricchio A. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy.
Philadelphia, PA: Elsevier Health Sciences; 2016.
A SENSING CHALLENGE
COMPLEX AND CHANGING MORPHOLOGIES

Normal Sinus
Rhythm

Ventricular
Tachycardia
VT

Ventricular
Fibrillation
VF
AUTO-ADJUSTING SENSITIVITY

 Adjusts over the course of the cardiac cycle

 Allows for sensing of fine VF waves while avoiding sensing of T-waves,
cross-chamber events, and pacing artifacts
 Programmed sensitivity represents minimum sensing threshold

PROGRAMMED SENSITIVITY AUTO-ADJUSTING SENSITIVITY

PROGRAMMABLE RV SENSING POLARITY

Flexibility to choose a different vector to resolve sensing issue with

programmable RV sensing

RV TIP TO RV RING
True Bipolar

RV TIP TO RV COIL
Integrated Bipolar
CLASSIFYING SENSED BEATS

 Two consecutive sensed events

create an interval. This interval is
measured in milliseconds
 A sensed event is classified
according to the preceding
interval
Interval
 This classification generates a (milliseconds)
marker channel symbol and
increments a counter if the
V
interval falls within an enabled
detection zone.
S
MARKER CHANNELS™
ATRIAL SENSED BEAT

VENTRICULAR
SENSED BEAT

VENTRICULAR
PACED BEAT
DETECTION ZONES

Programmed VF Programmed VT
Detection Interval Detection Interval
(VFDI) (VTDI)
 MARKER CHANNELS*

TS = Sensed Beat in
VT Detection Zone

TD = VT Detected
or Redetected

FS = Sensed Beat in
VF Detection Zone

FD= VF Detected or
Redetected

*in Medtronic devices

DETECTION
PROGRAMMING DETECTION ZONES

 Three detection zones and a monitor zone available

 VF zone
 Fast VT zone
 VT zone
 VT Monitor zone
 Able to program specific therapies for different arrhythmias.
PROGRAMMING
VENTRICULAR DETECTION
DETECTING ARRHYTHMIAS

Ventricular Tachycardia
 Regular intervals
 Monomorphic
 Less susceptible to
undersensing than VF

Ventricular Fibrillation
 Irregular intervals
 Polymorphic
 More susceptible to
undersensing than VT
CONSECUTIVE COUNTER
VT ZONE

 Counts consecutive intervals that fall within the programmed VT detection zone
 Consecutive method makes VT detection very specific
 Applies to the VT or Fast VT via VT zone

*NID – Number of intervals to detect

 PROBABILISTIC COUNTER
VF ZONE

 Uses a ratio of VF intervals to consecutive intervals for detection

 Probabilistic method makes VF detection very sensitive
 Longer programmed NIDs (30 /40) may be programmed to allow for non
sustained arrhythmias to self terminate
 Applies to the VF or Fast VT via VF zone

ECG

VF
Intervals
1 2 3 4 5 6 7 8 9 1011 12 1314 15 16 1718

1 2 3 4 5 6 7 8 910111213 14 15 16 17 18 19 20 21 22 23

If the NID is set to 18/24, detection is met here.

REDETECTION

Initial detection

Re-detection
Unsuccessful
shock
COMBINED COUNT

What does this rhythm appear to be?

 Rhythm fluctuates between
programmed VF and VT zone
What does the device classify the rhythm
as?
 VFNID is 24/32
 VTNID is 16
COMBINED COUNT NID
EXAMPLE

Combined Count is used when a rhythm fluctuates between the VT and VF zone.
COMBINED COUNT NID
OPERATION

VF
COUNTER
=6

COMBINE
D COUNT
NID

LOOK
BACK 8
BEATS
7/6 x VF beats to detect = 7/6 x 24 = 28
FAST VT ZONE

 The Fast VT via VT zone can be used to allow for different therapies for
patients with 2 VTs of different rates.

 Fast VT via VF zone can be used to detect and treat VT episodes that fall in
the VF zone.
CASE EXAMPLE
CASE EXAMPLE

Initial detection & ATP Shock

FAST VT DETECTED IN THE VF ZONE
FAST VT DETECTED IN THE VF ZONE

FOR INFORMATION ON ATP

BEFORE/DURING CHARGING CLICK
HERE
SUSPENDING DETECTION
MAGNET OPERATION

For Medtronic ICDs

 Temporary suspension of VT/VF detection via magnet
application.*
 Magnet application does not affect the pacemaker function of
the device.*

*ICDs of different manufacturers respond to magnets differently

Use a magnet when:

 Electromagnetic Interference (EMI) is present
(surgery, TENS, etc.)
 Therapy is temporarily not desired
KNOWLEDGE
CHECKS
KNOWLEDGE CHECK
QUESTION 1

This device feature allows for sensing of fine VF waves while preventing
sensing of T-waves, cross chamber events, and pacing artifacts.

A. Marker Channels
B. Programmable RV Sensing
C. Auto-adjusting sensitivity
D. None of the above
KNOWLEDGE CHECK
QUESTION 2

Is there appropriate
sensing observed in
this strip?

A. Yes
B. No
KNOWLEDGE CHECK
QUESTION 3

What are the possible names for this sensing configuration?

A. True Bipolar
B. Integrated Bipolar
C. RV tip to RV coil
D. RV tip to RV ring
KNOWLEDGE CHECK
QUESTION 4

Review the programmed settings in this example.

What would the device classify a rhythm that averages 172 beats per
minute (348 ms cycle length) ?

A. FVT
B. VF
C. VT
D. VT Monitor
KNOWLEDGE CHECK
QUESTION 5

Given the detection windows shown below, which of the following zones
have been programmed:

A. VT Monitor (OFF), VT (370ms), FVT (320ms), VF (320ms)

B. VT Monitor (OFF), VT (370ms), FVT (320ms), VF (320ms)
C. VT Monitor (OFF), VT (370ms), FVT OFF), VF (320ms)
D. VT Monitor (400ms), VT (370ms), FVT (OFF), VF (320ms)
KNOWLEDGE CHECK
QUESTION 6

How did the device classify this stored episode?

A. VF
B. Monitored VT
C. VT
D. Fast VT
KNOWLEDGE CHECK
QUESTION 7

What type of counter was used to detect this episode?

A. Probabilistic Counter
B. Consecutive Counter
C. Combined Counter
KNOWLEDGE CHECK
QUESTION 8

Is there any undersensing observed in this strip leading up to detection?

A. Yes
B. No
SUMMARY
CONCLUSION

 Accurate sensing of R-waves is important to the

appropriate operation of an ICD.

 Medtronic ICDs use auto-adjusting sensitivity to

sense large amplitude R-waves during normal
sinus rhythm and small amplitude fibrillation
signals during VF.

 Accurate detection of ventricular arrhythmias is

crucial to the appropriate operation of an ICD.

 Medtronic ICDs use rate and number of

intervals to detect to detect arrhythmias.

 Detection zones can be programmed based on

the patient's ICD indication and adjusted as a
patient’s condition changes.
CONCEPTS OF ICD
TECHNOLOGY
THERAPY

2017
DISCLOSURES

This presentation is provided for general educational purposes only and should not be
considered the exclusive source for this type of information. This training does not replace or
supersede approved labeling. The content will be shared with physicians and allied health
professionals who seek a deeper understanding of the operation and use of Medtronic
products and therapies with the intent of enhancing their knowledge of features and
operations described in the clinician manuals.

The device data presented in this module is fictional and is designed only for educational
purposes. At all times, it is the professional responsibility of the practitioner to exercise
independent clinical judgment in a particular situation. Changes in a patient’s disease and/or
medications may alter the efficacy of a device’s programmed parameters or related features
and results may vary. The device functionality and programming described in this
presentation are based on Medtronic products and can be referenced in the published device
manuals.

Important Reminder: This information is intended only for users in markets where Medtronic
products and therapies are approved or available for. Content on specific Medtronic products
and therapies is not intended for users in markets that do not have authorization for use.
The device functionality and programming described in this module can be found in some
Medtronic ICD and CRT-D devices. Please go to manuals.medtronic.com or consult with your
local Medtronic representative regarding device models available in your geography.
OBJECTIVES

 Recall the different types of therapies that

can be delivered by an implantable
cardioverter defibrillator (ICD).

 Describe how antitachycardia pacing (ATP)

therapy can terminate reentrant
arrhythmias and how it can be
programmed.

 Identify the differences between a

cardioversion and a defibrillation shock.

 Recognize how the ATP Before/During

Charging feature operates
ICD THERAPIES
MENU
Select each button to learn more

BRADYARRHYTHMIA PACING

ANTITACHYCARDIA PACING (ATP)

CARDIOVERSION

DEFIBRILLATION

ATP BEFORE/DURING CHARGING

CONFIRMATION
BRADYARRHYTHMIA
PACING
 BRADYCARDIA
LOW POWER THERAPY

 Low power bradycardia pacing in ICDs works the same way as in a pacemaker.
 The device paces when the heart rate drops below the programmed lower rate or
AV conduction is lost. Pacing is also crucial after a shock is delivered in the
event that normal sinus rhythm takes time to restore.
 ICD patients generally do not have a pacing indication and therefore the percent
of pacing should be minimized.1

MAIN
MENU
¹Sweeney MO, Hellkamp AS, Ellenbogen KA, et al. Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal
baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation. 2003:107(23):2932-2937.
ANTITACHYCARDIA
PACING
(ATP)
ANTITACHYCARDIA PACING (ATP)
LOW POWER

 Fast pacing pulses delivered to the heart through the lead to interrupt the
reentrant circuit of an arrhythmia
 Provides pain free therapy
 Different types available (i.e. Burst, Ramp)
HOW ATP THERAPY WORKS
INTRODUCTION

 ATP therapy is a train of rapid pacing

pulses, of sufficient voltage to
depolarize the heart, capable of
terminating a reentrant arrhythmia.

 Ventricular tachycardia is a reentrant

arrhythmia which continues to
depolarize and repolarize.

 The excitable gap is the area of

repolarized tissue which has not yet
begun to depolarize again, and is
capable of stimulation.

Unidirectional block
 Overdrive pacing of the tissue in this Reentry circuit/loop
gap can stop the tachycardia. Excitable gap
HOW ATP THERAPY WORKS
A MORE DETAILED LOOK
ANTITACHYCARDIA PACING
RATE

Programmed as a percentage of the detected tachycardia rate

T T T T T T T T T
S S S S D P P P P

V-V Minimum ATP Interval: 200 ms

 ANTITACHYCARDIA PACING
PROGRAMMABLE PARAMETERS

 Sequences – the number of times ATP will be applied upon redetection

 Pulses – the number of pulses per sequence
 Rate of pulses delivered – adaptive percentage (%)

Pulses (S1)

Initial
detection redetection redetection

1st Sequence 2nd Sequence 3rd Sequence

 ANTITACHYCARDIA PACING
BURST
Rate of the first pacing interval = 350 ms x 0.88 = 308ms
(truncated to 300 ms)

VT or FVT 300 300 300 300

detection

350 ms R-R average 1st sequence

redetection 280 280 280 280 redetection 270 270 270 270

330 ms 330 ms
2nd sequence 3rd sequence
R-R average R-R average

Rate of the 2nd pacing interval = 330 ms x 0.88 = Rate of the 3rd pacing interval = 330 ms x 0.88 =
* Decrement between sequences 290 ms – 10 ms decrement = 280 ms 290 ms – 20 ms decrement = 270 ms
 ANTITACHYCARDIA PACING
RAMP
Rate of the first pacing interval = 350 ms x 0.91 = 320
ms

VT or FVT detection 320 310 300 290

350 ms R-R average 1st sequence

4 pulses

320 310 300 290 280 redetection 300 290 280 270 260250
redetection

2nd sequence 3rd sequence

6 pulses
350 ms 5 pulses 330 ms
R-R average R-R average
* Decrement between pulses
Rate of the 3rd pacing interval =
* Adds a pulse per sequence
330 ms x 0.91 = 300 ms
ATP
PROGRAMMING

FOR INFORMATION ON
PROGRAMMING ATP CLICK
HERE
WHEN SHOULD ATP BE PROGRAMMED?

 ATP is recommended for VTs, including fast VTs. 2

 In the PainFREE Rx and Rx II trials which evaluated efficacy of ATP
versus shock: ATP successfully terminated 3 out of 4 fast VTs painlessly.
2,3
3

2 Wathen MS, Sweeney MO, DeGroot PJ, et al. Shock Reduction using antitachycardia pacing for spontaneous rapid ventricular tachycardia in patients with coronary
artery disease. Circulation. 2001;104:796-801.
3 Wathen MS, DeGroot PJ, Sweeney MO, et al. Prospective randomized multicenter trial of empirical antitachycardia pacing versus shocks for spontaneous rapid

ventricular tachycardia in patients with implantable cardioverter-defibrillators. Pacing Fast Ventricular Tachycardiac Reduces Shock Therapies (PainFREE Rx II) trial
results. Circulation. 2004;110:2591-2596.
 MARKERS CHANNELS

Therapy Marker Channels:*

 TP = Antitachycardia Pacing Initiated
(ATP)
 CE = Charge End
 CD = Charge Delivered

Decision Channels:*
 Provides additional ICD detection
information
 Stored on EGM Strip, or printed real-
time (not displayed on screen)

MAIN
*in Medtronic ICDs MENU
KNOWLEDGE CHECK
QUESTION 1 OF 8

Antitachycardia Pacing (ATP) therapy works by which of the following

concepts: select all that apply

A. Pacing pulses delivered at a rate faster than a reentrant arrhythmia

can depolarize the excitable gap.
B. Depolarization of the excitable gap does not impact the reentrant
arrhythmia.
C. Pacing pulses must be delivered at a rate equal to the arrhythmia
cycle length.
D. The timing and number of pacing pulses needed to successfully
terminate a reentrant tachyarrhythmia can vary.
KNOWLEDGE CHECK
QUESTION 2 OF 8

The rate of the ATP pulses is dependent upon the cycle length of the
detected arrhythmia.

A. True
B. False
KNOWLEDGE CHECK
QUESTION 3 OF 8

What type of ATP is being delivered in this strip?

A. Burst
B. Ramp
KNOWLEDGE CHECK
QUESTION 4 OF 8

What type of ATP is being delivered in this strip?

A. Burst
B. Ramp

MAIN
MENU
CARDIOVERSION
CV
CARDIOVERSION (CV) – HIGH POWER

 Delivered for VT and Fast VT episodes

 A cardioversion (CV) is always synchronized and delivered on a R-wave.

T
S
CARDIOVERSION
PROGRAMMING

MAIN
MENU
DEFIBRILLATION
SHOCK
DEFIBRILLATION SHOCK

• Used in the treatment of ventricular fibrillation which is unorganized and

often the result of many reentrant circuits.
• The ICD attempts to synchronize the shock to an R-wave first, but will
deliver the shock regardless of whether the synchronization is
successful.
DEFIBRILLATION SHOCK
PROGRAMMING
SHOCKING CIRCUIT

High voltage coils are required to complete the shocking vector.

Single Coil Dual Coil

SHOCKING VECTORS
PROGRAMMABLE

Shock energy should encompass as much of the heart’s muscle mass as

possible, to provide the best chance for defibrillation.

X A X A

B B B
NOMINAL ACTIVE CAN OFF SVC OFF
B > AX B>X B>A
SHOCKING VECTORS
PROGRAMMING
KNOWLEDGE CHECK
QUESTION 5 OF 8

What is the difference between a cardioversion and a defibrillation shock?

A. Nothing they are the same.

B. A Defibrillation shock is higher energy.
C. Only a Cardioversion shock is synchronized to a R-wave.
D. None of the above
KNOWLEDGE CHECK
QUESTION 6 OF 8
Match the following programmable parameters with their definitions
Pathway
 Specifies the electrodes used
for defibrillation and/or
cardioversion

Active Can/ SVC Coil

 Determines the rate of pacing
intervals for the ATP burst

R-S1 Interval = %RR  Specifies the direction of

current flow during the initial
segment of a defibrillation or
cardioversion biphasic
waveform
MAIN
MENU
ATP BEFORE /
DURING
CHARGING
ATP BEFORE CHARGING™ & ATP DURING CHARGING™
OVERVIEW

ATP During Charging™

Confirmation/Synchronization
Capacitor Charging

ATP Before Charging™

FOR INFORMATION ON
ATP BEFORE/DURING
CHARGING CLICK
HERE
CONFIRMING THERAPY DELIVERY
ATP DURING CHARGING
Patient’s rhythm is monitored while the ICD is charging.
During this confirmation phase, the ICD will compare the current arrhythmia cycle
length to the calculated confirmation interval. This calculated confirmation interval
is based on the rate of the detected arrhythmia.
ATP BEFORE DURING CHARGING
PROGRAMMING
CHARGESAVER™ AND SWITCHBACK™
DETAILED OPERATION
Switches between ATP During Charging and ATP Before Charging based
on ATP success.

ChargeSaver™ SwitchBack™
Switches to ATP BC Switches to ATP DC
after one* ATP DC after two ATP BC
success failures

*Programmable number of ATP During Charging success.

FOR INFORMATION ON
CHARGESAVER/
SWITCHBACK CLICK
HERE
KNOWLEDGE CHECKPOINT
QUESTION 7 OF 8

What type of episode was detected and what therapy was delivered?

A. VF, Defibrillation
B. VT, Cardioversion
C. FVT, ATP
D. VF, ATP
KNOWLEDGE CHECK
QUESTION 8 OF 8

Is ATP During
Charging™
successful at
terminating the
arrhythmia in this
rhythm strip?

A. Yes
B. No

MAIN
MENU
CONFIRMATION
 CONFIRMING THERAPY DELIVERY
CONCEPT
Before the ICD delivers the first defibrillation shock for a VF episode, it
monitors the cardiac rhythm to confirm VF remains present.

VF detected VF spontaneously terminates Device aborts therapy and stops

Charging starts Normal Sinus Rhythm charging
Begin to confirm tachyarrhythmia Resumes
CONFIRMING THERAPY DELIVERY
CONFIRMATION+

Calculate Determine if Otherwise, Confirmation

Confirmation rhythm is rhythm is Interval* =
Interval polymorphic or monomorphic detected
monomorphic
arrhythmia
based on last 6 R
to R intervals
cycle length +
60ms

If difference Confirmation
>50ms, Interval =
rhythm is VF Detection
polymorphic Interval + 60ms
*Confirmation Interval must
be at least equal to VFDI

• Confirmation uses the intervals following the delivery of ATP During Charging
to apply the confirmation process.
• VF Rx1 can abort more than once per episode
 CONFIRMING THERAPY DELIVERY
CONFIRMING VT OR FVT AFTER DETECTION

VT detected & Charging starts VT spontaneously terminates Device aborts therapy and stops
and normal sinus rhythm charging
Begin to confirm tachyarrhythmia resumes
SUMMARY
SUMMARY

 There are four types of therapies available in an

ICD:
 Bradycardia pacing
 Antitachycardia pacing (ATP)
 Cardioversion
 Defibrillation

 ATP interrupts the reentrant activation pattern of

VT with pacing stimuli.

 Cardioversion requires synchronization to a

sensed R-wave, while Defibrillation does not.

 The ATP Before/During Charging™ feature

provides the ability to deliver ATP therapy in the
VF zone without delaying time to shock.
REFERENCES

1Sweeney MO, Hellkamp AS, Ellenbogen KA, et al. Adverse effect of ventricular pacing on
heart failure and atrial fibrillation among patients with normal baseline QRS duration in a
clinical trial of pacemaker therapy for sinus node dsyfunction. Circulation.
2003:107(23):2932-2937.
2 Wathen MS, Sweeney MO, DeGroot PJ, et al. Shock Reduction using antitachycardia
pacing for spontaneous rapid ventricular tachycardia in patients with coronary artery disease.
Circulation. 2001;104:796-801.
3 Wathen MS, DeGroot PJ, Sweeney MO, et al. Prospective randomized multicenter trial of
empirical antitachycardia pacing versus shocks for spontaneous rapid ventricular tachycardia
in patients with implantable cardioverter-defibrillators. Pacing Fast Ventricular Tachycardia
Reduces Shock Therapies (PainFREE Rx II) trial results. Circulation. 2004;110:2591-2596.
4Medtronic Evera MRI™ system reference guide. www.medtronic.com/manuals
CONCEPTS OF ICD
TECHNOLOGY
SVT
DISCRIMINATION
ALGORITHMS

JULY 2017
DISCLOSURES

This presentation is provided for general educational purposes only and should not
be considered the exclusive source for this type of information. This training does
not replace or supersede approved labeling. The content will be shared with
physicians and allied health professionals who seek a deeper understanding of the
operation and use of Medtronic products and therapies with the intent of enhancing
their knowledge of features and operations described in the clinician manuals.
Patient information (names, serial numbers, date, etc.) has been changed or
removed to protect the privacy of the patients used in this presentation.

At all times, it is the professional responsibility of the practitioner to exercise

independent clinical judgment in a particular situation. Changes in a patient’s
disease and/or medications may alter the efficacy of a device’s programmed
parameters or related features and results may vary. The device functionality and
programming described in this presentation are based on Medtronic products and
can be referenced in the published device manuals.

Important Reminder: This information is intended only for users in markets where
Medtronic products and therapies are approved or available for. Content on
specific Medtronic products and therapies is not intended for users in markets that
do not have authorization for use.
OBJECTIVES

 Describe how an Implantable Cardiac

Defibrillator (ICD) identifies
supraventricular tachycardias (SVTs)
 Identify different types of single and dual
chamber discriminators available in
Medtronic ICDs and how they can
distinguish between ventricular arrhythmias
and different types of SVTs
 Compare how each discrimination
algorithm uses collected information to
identify an SVT
 Recognize on stored episode strips when
SVT discrimination has withheld therapy
SVT DISCRIMINATION
SVT DISCRIMINATION
WHY

Prevent inappropriate therapy for supraventricular tachyarrhythmias (SVTs).

IDENTIFYING AN SVT

Consider the following questions:

 What is the atrial rate?
 What is the ventricular rate?
 Are there more R-waves than P-waves?
 What is the relationship between P- and R-
waves?
 Are the P-waves driving the fast rate?
 Does the rhythm’s morphology look similar
to the morphology of sinus rhythm?
When is therapy withheld and when
is it delivered?
 Safety first, if a VT or VF is
suspected, the ICD will deliver
therapy.
 The rhythm is continuously
monitored for changes.
SVT DISCRIMINATION
EVALUATE THE FOLLOWING CHARACTERISTICS

Onset of the
arrhythmia

Relationship between
P- and R-waves

Waveform Stability of the

morphology arrhythmia
 MENU

Wavelet Onset

PR Logic™ Stability

Select each algorithm to learn more about how they work

* Wavelet was introduced in dual and triple chamber Protecta ICD models in 2011
WAVELET
 RHYTHM MORPHOLOGY

1
EGM: Atip
ECG to Aring

EGM: Can
to RV Coil

2
ECG
EGM: Atip
to Aring

EGM: Can
to RV Coil
WAVELET FEATURE
OPERATION

 Compares how well the current EGM morphologies compare to the NSR
(template) and assigns a “match” or “no match”
 If ICD decides there are enough “matches”, therapy is withheld and the rhythm is
monitored

Can/RV coil 0.5/mm

Template
Collection
WAVELET OPERATION
EVALUATING MATCH SCORES
WAVELET
EXAMPLE

 Wavelet determines that 8 of

the last 8 complexes match the
sinus rhythm template
 WV indicates Wavelet is
satisfied and withholds
detection
WAVELET FEATURE
PROGRAMMING
WAVELET FEATURE
CONSIDERATIONS

Signal too
Signal too
large
small
(clipped)

FIX FIX
PR LOGIC
PR LOGIC
IDENTIFIES AND CLASSIFIES THE FOLLOWING RHYTHMS:
PR LOGIC
HOW IT WORKS
 PR LOGIC
ALGORITHM

Rate and Median Are there Is the rhythm a

Ventricular Rate dissociated Initial VT VF
Duration (NID) conducted
is faster than A and V detection
Met SVT?
SVT limit tachyarrhyth-
mias?

NO NO NO

YE
YE
YE

S
S
S

Initial VT/VF Initial VT/VF Initial VT/VF

detection detection detection withheld
PR LOGIC
PROGRAMMING
PR LOGIC  More atrial than ventricular sensed events
 Irregular ventricular cycle length
AF/AFL  No evidence of Far-Field R-waves
ATRIAL FLUTTER
  1:1 atrial to ventricular events
PR LOGIC  Rhythm gradually accelerates
SINUS TACH
  1:1 atrial to ventricular events
PR LOGIC  Nearly simultaneous depolarization
OTHER 1:1 SVT
PR LOGIC
DOUBLE TACH
FAR FIELD R-WAVES (FFRW)
WHEN PR LOGIC + WAVELET ARE PROGRAMMED ON

PR Logic A rate > Wavelet

Withholds V rate Applied
Detection
NO YES
NO
YE
S

Withhold VT/VF Initial VT/VF

detection detection
PR LOGIC + WAVELET
 PR Logic NOT withholding
 Arate > Vrate
 Wavelet evaluates rhythm and classifies as
SVT
ONSET
  What is the rhythm?
ONSET  How should the device respond?
PLOT

Gradual
entrance to
arrhythmic
zone

Abrupt
entrance into
the
arrhythmic
zone
ONSET
EGM
  Applies only in VT zone
ONSET  Nominally programmed Off
PROGRAMMING  Requires an onset percentage
to be programmed
ONSET
CONSIDERATIONS  Atrial Paced, Ventricular Sensed
 VT with dissociated A and V

VT
Apace-Vsense

*Onset prevents the VT counter from incrementing, and therefore detection. As a result,
discriminators such as PR Logic and Wavelet that are applied once the NID is met are never
applied.
STABILITY
STABILITY  What is the rhythm?
INTERVAL PLOT & EGM  What is the device’s
response?
  During atrial fibrillation, atrial events can be
STABILITY irregularly conducted to the ventricle
PROGRAMMING  VT counter reset when V. cycle length varies by
more than programmed stability interval
STABILITY Stability inappropriately withholding VT detection
CONSIDERATIONS
CLINICAL EVIDENCE
HISTORICAL CLINICAL EVIDENCE

Virtual ICD3 (2011)

GEM DR1 (2001)
PR Logic has 100% sensitivity
and 88.4% PPV for detection
of sustained VT/VF in dual
chamber ICDs.
WAVE2 (2006)
Wavelet substantially reduced
inappropriate therapy (78.2%)
while maintaining sensitivity
(99.2%) for the detection of
sustained VT/VF in single
chamber ICDs.
SmartShock™ Technology
has 99.2% sensitivity for
detection of sustained VT/VF
and reduced the number of
inappropriate shocks in dual
chamber ICD patient's
by2.4% at 1 year and 8.4% at
5 years.

SmartShock™ Technology is defined as: Wavelet, PR

Logic*, SVT Discriminators in the VF zone, Confirmation+,
T-Wave Discrimination, RV Lead Integrity Alert, RV Lead
Noise Discrimination and Alert, and a nominal NID of 18/24
*PR Logic does not apply to VF devices

For more information on

SmartShock Technology
click here
 98% OF PATIENTS ARE FREE FROM INAPPROPRIATE
AT ONE YEAR WITH SMARTSHOCK™ 2.0 TECHNOLOGY4
SHOCK

SmartShock™ 2.0 Technology is defined as: Wavelet, PR Logic*, SVT Discriminators in the VF zone, Confirmation+, T-Wave Discrimination, RV
Lead Integrity Alert, RV Lead Noise Discrimination and Alert, and a nominal NID of 30 out of 40.
*PR Logic does not apply to VR devices
KNOWLEDGE
CHECKS
KNOWLEDGE CHECKPOINT
QUESTION 1 OF 6
Match the description to each SVT discriminator
Uses differences in morphologies
between rhythms of ventricular origin
Stability and those of supraventricular origin.

Analyzes activation patterns and

timing in both chambers using pattern
Onset and rate analysis to withhold
inappropriate ventricular detection
during episodes of rapidly conducted
PR Logic
SVT.
Evaluates the acceleration of the
ventricular rate to prevent detection of
Wavelet sinus tachycardia as VT.

Prevents detection of atrial fibrillation

episodes as VT if the ventricular rate
is unstable.
KNOWLEDGE CHECKPOINT
QUESTION 2 OF 6

Select the rhythm that is best represented in the following interval plot.

A. Sinus tachycardia
B. VT
C. AVNRT
D. Atrial Fibrillation
KNOWLEDGE CHECK
QUESTION 3 OF 6

Which discrimination algorithm could help to discriminate this rhythm from

VT? Select all that apply

A. Wavelet
B. Stability
C. Onset
D. PR Logic
KNOWLEDGE CHECKPOINT
QUESTION 4 OF 6

True or False: A rhythm with the displayed QRS snapshots will cause
therapy to be withheld. (Match threshold = 70%)

A. True
B. False
KNOWLEDGE CHECK
QUESTION 5 OF 6
Review the following
episode plot diagram and
EGM. What algorithm is
withholding detection of
VT?

A. Onset
B. Stability
C. Wavelet
D. PR Logic
KNOWLEDGE CHECK
QUESTION 6 OF 6
Is this appropriate detection
of VT?

A. Yes
B. No
SUMMARY
SUMMARY
 ICDs use SVT discrimination algorithms to differentiate
supraventricular tachyarrhythmias from ventricular
arrhythmias.

 Medtronic ICDs use the following SVT discrimination

algorithms:
 PR Logic
 Wavelet
 Onset
 Stability

 These algorithms use the following aspects to identify

supraventricular arrhythmias:
 Pattern and rate analysis
 Differences in QRS morphology
 Acceleration of the ventricular rate
 Regularity of the ventricular rate
REFERENCES

1 WilkoffBL, Kühlkamp, Volosin K, et al. Critical Analysis of Dual-Chamber Implantable

Cardioverter-Defibrillator Arrhythmia Detection Results and Technical Considerations.
Circulation. January 2001;103:381-386.
2 KleinGJ, Gillberg JM, Tang A, et al, for the Worldwide Wave Investigators. Improving SVT
Discrimination in Single-Chamber ICDs : A New Electrogram Morphology-Based Algorithm. J
Cardiovasc Electrophysiol. December 2006;17(12):1310-1319
3 Volosin
KJ, Exner DV, Wathen MS, Sherfesee L, Scinicariello AP, Gillberg JM. Combining
shock reduction strategies to enhance ICD therapy: a role for computer modeling. J
Cardiovasc Electrophysiol. 2011 Mar;22(3):280-9.
4 Auricchio A, Schloss EJ, Kurita T, et al, on behalf of the PainFree SST Investigators. Low
inappropriate shock rates in patients with single- and dual/triple-chamber ICDs using a novel
suite of detection algorithms: PainFree SST trial primary results. Heart Rhythm 2015;12:926-
936.
INDICATIONS, SAFETY, AND WARNINGS

If you are located in the United States, please refer to the brief statement(s) below to
review applicable indications, safety and warning information. See the device manual for
detailed information regarding the implant procedure, indications, contraindications,
warnings, precautions, and potential complications/adverse events. For further information,
please call Medtronic at 1.763.514.4000 and/or consult the Medtronic website
at www.medtronic.com.

If you are located outside the United States, see the device manual for detailed
information regarding the implant procedure, indications, contraindications, warnings,
precautions, and potential adverse events. For further information, contact your local
Medtronic representative and/or consult the Medtronic website at www.medtronic.com.

Consult instructions for use at this website. Manuals can be viewed using a current version of
any major Internet browser. For best results, use Adobe Acrobat Reader® with the browser.
BRIEF STATEMENT (USA): ICDS
Indications
Implantable cardioverter defibrillators (ICDs) are indicated for ventricular antitachycardia pacing and ventricular defibrillation
for automated treatment of life-threatening ventricular arrhythmias. Some ICDs are also indicated for use in patients with
atrial tachyarrhythmias, or those patients who are at significant risk for developing atrial tachyarrhythmias.
Notes on some features in ICDs: The RV Lead Integrity Alert (LIA) feature is intended primarily for patients who have a
Medtronic ICD or CRT-D device and a Sprint Fidelis lead (Models 6949, 6948, 6931, and 6930), based on performance data.
The RV LIA feature may not perform as well with a St. Jude Riata/Durata lead or a Boston Scientific Endotak lead as it does
when used with a Medtronic Sprint Fidelis lead. This is because different lead designs may have different failure signatures
and conditions that may or may not be detected early by the RV LIA feature. The clinical value of the OptiVol fluid monitoring
diagnostic feature has not been assessed in those patients who do not have fluid retention related symptoms due to heart
failure. Additional notes for DR ICDs: The use of the device has not been demonstrated to decrease the morbidity related to
atrial tachyarrhythmias. The effectiveness of high-frequency burst pacing (atrial 50 Hz Burst therapy) in terminating device
classified atrial tachycardia (AT) was found to be 17%, and in terminating device classified atrial fibrillation (AF) was found to
be 16.8%, in the VT/AT patient population studied. The effectiveness of high-frequency burst pacing (atrial 50 Hz Burst
therapy) in terminating device classified atrial tachycardia (AT) was found to be 11.7%, and in terminating device classified
atrial fibrillation (AF) was found to be 18.2% in the AF-only patient population studied.

Contraindications
ICDs are contraindicated in patients experiencing tachyarrhythmias with transient or reversible causes including, but not
limited to, the following: acute myocardial infarction, drug intoxication, drowning, electric shock, electrolyte imbalance,
hypoxia, or sepsis; patients who have a unipolar pacemaker implanted, patients with incessant ventricular tachycardia (VT)
or ventricular fibrillation (VF), and patients whose primary disorder is chronic atrial tachyarrhythmia with no concomitant VT
or VF.
BRIEF STATEMENT (USA): ICDS
Warnings/Precautions
Changes in a patient's disease and/or medications may alter the efficacy of the device's programmed parameters. Patients
should avoid sources of magnetic and electromagnetic radiation to avoid possible underdetection, inappropriate sensing
and/or therapy delivery, tissue damage, induction of an arrhythmia, device electrical reset or device damage. Do not place
transthoracic defibrillation paddles directly over the device.
Potential complications
Potential complications include, but are not limited to, rejection phenomena, erosion through the skin, muscle or nerve
stimulation, oversensing, failure to detect and/or terminate arrhythmia episodes, and surgical complications such as
hematoma, infection, inflammation, and thrombosis. An additional complication for ICDs is the acceleration of ventricular
tachycardia.
See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings,
precautions, and potential complications/adverse events. For further information, please call Medtronic at 1-800-328-2518
and/or consult Medtronic's website at www.medtronic.com.
Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.
BRIEF STATEMENTS (USA): CRT DEFIBRILLATORS (ICDS)
Indications
Cardiac Resynchronization Therapy (CRT) ICDs are indicated for ventricular antitachycardia pacing and ventricular
defibrillation for automated treatment of life-threatening ventricular arrhythmias and for providing cardiac resynchronization
therapy in heart failure patients on stable, optimal heart failure medical therapy if indicated, and meet any of the following
classifications: New York Heart Association (NYHA) Functional Class III or IV and who have a left ventricular ejection
fraction < 35% and a prolonged QRS duration. Left bundle branch block (LBBB) with a QRS duration > 130 ms, left
ventricular ejection fraction < 30%, and NYHA Functional Class II. NYHA Functional Class I, II, or III and who have left
ventricular ejection fraction ≤ 50% and atrioventricular block (AV block) that are expected to require a high percentage of
ventricular pacing that cannot be managed with algorithms to minimize right ventricular pacing. Optimization of heart failure
medical therapy that is limited due to AV block or the urgent need for pacing should be done post implant. Some CRT ICDs
are also indicated for use in patients with atrial tachyarrhythmias, or those patients who are at significant risk for developing
atrial tachyarrhythmias. The RV Lead Integrity Alert (LIA) feature is intended primarily for patients who have a Medtronic
ICD or CRT-D device and a Sprint Fidelis lead (Models 6949, 6948, 6931, and 6930, based on performance data. The RV
LIA feature may not perform as well with a St. Jude Riata/Durata lead or a Boston Scientific Endotak lead as it does when
used with a Medtronic Sprint Fidelis lead. This is because different lead designs may have different failure signatures and
conditions that may or may not be detected early by the RV LIA feature.

Contraindications
CRT ICDs are contraindicated in patients experiencing tachyarrhythmias with transient or reversible causes including, but
not limited to, the following: acute myocardial infarction, drug intoxication, drowning, electric shock, electrolyte imbalance,
hypoxia, or sepsis; patients who have a unipolar pacemaker implanted, patients with incessant ventricular tachycardia (VT)
or ventricular fibrillation (VF), and patients whose primary disorder is chronic atrial tachyarrhythmia with no concomitant VT
or VF.
BRIEF STATEMENTS (USA): CRT DEFIBRILLATORS (ICDS)
Warnings/Precautions
Changes in a patient’s disease and/or medications may alter the efficacy of the device’s programmed parameters. Patients
should avoid sources of magnetic and electromagnetic radiation to avoid possible underdetection, inappropriate sensing
and/or therapy delivery, tissue damage, induction of an arrhythmia, device electrical reset or device damage. Do not place
transthoracic defibrillation paddles directly over the device.
Additionally, for CRT ICDs and CRT IPGs, certain programming and device operations may not provide cardiac
resynchronization. Also for CRT IPGs, Elective Replacement Indicator (ERI) results in the device switching to VVI pacing at
65 ppm. In this mode, patients may experience loss of cardiac resynchronization therapy and / or loss of AV synchrony. For
this reason, the device should be replaced prior to ERI being set. Use of the device should not change the application of
established anticoagulation protocols.

Potential Complications
Potential complications include, but are not limited to, rejection phenomena, erosion through the skin, muscle or nerve
stimulation, oversensing, failure to detect and/or terminate arrhythmia episodes, and surgical complications such as
hematoma, infection, inflammation, and thrombosis. An additional complication for CRT ICDs is the acceleration of
ventricular tachycardia.

See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings,
precautions, and potential complications/adverse events. For further information, please call Medtronic at 1-800-328-2518
and/or consult Medtronic’s website at www.medtronic.com.

Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.
BRIEF STATEMENT (USA): MEDTRONIC CARELINK 2090
PROGRAMMER

The Medtronic CareLink programmer system is comprised of prescription devices indicated for use in the interrogation and
programming of implantable medical devices. Prior to use, refer to the Programmer Reference Guide as well as the
appropriate programmer software and implantable device technical manuals for more information related to specific
implantable device models. Programming should be attempted only by appropriately trained personnel after careful study
of the technical manual for the implantable device and after careful determination of appropriate parameter values based
on the patient's condition and pacing system used. The Medtronic CareLink programmer must be used only for
programming implantable devices manufactured by Medtronic or Vitatron.

See the device manuals for detailed information regarding the instructions for use, indications, contraindications, warnings,
precautions, and potential adverse events. For further information, please call Medtronic at 1-800-328-2518 and/or
consult Medtronic’s website at www.medtronic.com.

Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.

NOVEMBER 16, 2015

BRIEF STATEMENT (USA): MEDTRONIC MYCARELINK™
PATIENT AND CARELINK™ MONITORS AND MEDTRONIC
CARELINK™ NETWORK
Intended Use
The MyCareLink Patient Monitor, CareLink Monitor, and CareLink Network are indicated for use in the transfer of patient
data from some Medtronic implantable cardiac devices based on physician instructions and as described in the product
manual. These products are not a substitute for appropriate medical attention in the event of an emergency and should only
be used as directed by a physician. CareLink Network availability may be unavailable at times due to maintenance or
updates, or due to coverage being unavailable in your area.

Contraindications
There are no known contraindications.

Warnings and Precautions

The MyCareLink Patient Monitor and CareLink Monitors must only be used for interrogating compatible Medtronic
implantable devices. While using the MyCareLink Patient Monitor and CareLink Monitors do not use a cellular phone while
the antenna is positioned over the implanted device.
The MyCareLink Patient Monitor, and CareLink Monitors are intended for use within the prescribing country.
See the device manuals for detailed information regarding the instructions for use, indications, contraindications, warnings,
precautions, and potential complications/adverse events. For further information, please call Medtronic at 1 (800) 929-4043
and/or consult Medtronic’s website at www.medtronic.com.

Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician.
Updated Nov 16 2015
Medtronic
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USA

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Worldwide: +1.763.514.4000

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2017

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