Electrocadiography of Devices:
Concepts and Unknown ECGs
Kenneth A. Ellenbogen, MD
Kimmerling Professor
VCU School of Medicine, Richmond, VA
March 2025
Disclosures
Relevant Financial Relationships
None Relevant
Suggested Reading for Cardiology Fellows
• Chapters in General Cardiology Textbook; Braunwald, etc.
• Cardiac Pacing and ICDs. Edited by Kenneth A. Ellenbogen
and Karoly Kaszala, Seventh Edition, 2020
Think like a pacemaker!
• You have to learn the language and vocabulary first:
Pacemaker code
• Have to understand basics of electricity and Ohm’s Law
• Understand indications for CIEDs; who and when
• Understand programmed parameters
• EKGs and rhythm strips are fundamental
• Marker channel: “what the pacemaker thinks it is doing”
• CXR a secondary data source
What is an EGM?--- Unipolar, far field
What is an EGM?---Bipolar, near field
What is an EGM?
Basics - Electricity
Ohm’s Law
V=IxR
V=IxR
Constant System determined. If
(device insulation failure, it will
programmed) decrease and if
conductor fracture
increase towards infinity
Pacing Nomenclature
Pacemaker Timing cycles
Single-chamber (atrial or ventricular) pacemaker
Cardiac events / timing cycles Description
(Abbreviation)
Atrial sensed event (P / AS) Sensed a native Atrial depolarization (P wave)
Atrial paced event (A / AP) Delivered Atrial Pacing output
Ventricular sensed event (R / VS) Sensed native Ventricular depolarization (QRS complex)
Ventricular paced event (V / VP) Delivered Ventricular Pacing output
Atrial blanking period (AB) Atrial sensing amplifier is “blind” and will not detect or respond to atrial sensed event
Ventricular blanking period (VB) Ventricular sensing amplifier is “blind” and will not detect and respond to any ventricular
sensed event
Atrial refractory period (ARP) An atrial sensed event will be noted but ignored, without affecting pacemaker timing
cycle
Ventricular refractory period (VRP) A ventricular sensed event will be noted but ignored, without affecting pacemaker timing
cycle
Lower rate limit (LRL) Minimum pacing rate
Upper rate limit (URL) Maximum Pacing rate
Maximum sensor rate (MSR) Maximum pacing rate by rate-responsive sensor
Pacing modes
Pacing Mode Indication / Advantages Disadvantages
Asynchronous Pacemaker dependent patients exposed to Pacing regardless of intrinsic events.
AOO, VOO, DOO, DOOOV (CRT) noise (e.g. electrocautery during surgery). Potential risk for arrhythmia induction.
Avoids oversensing and asystole.
LRL LRL
V P R V P R V
V
DDD, DDDR, Preserves AV synchrony (less pacemaker syndrome) Requires at least a two-chamber lead system and has
DDDRV (CRT) Low incidence of atrial arrhythmias & improved a lesser battery longevity
hemodynamics
LRL
VAI VAI VAI
PAV SAV SAV
V A V P V P R
Pacing Modes
Four potential scenarios of DDD
AV sequential pacing Atrial pacing only
A V A V
A V A V P S P S
P P P P
P-synchronous pacing Complete inhibition
A V A V
A V A V
S S S S
S P S P
Blanking / Refractory periods
• Blanking and refractory periods are essential to the appropriate
pacemaker function.
• The presence or absence of these periods depends on the pacemaker
system as well as the pacing sensing mode.
• These are basic timing periods that avoid oversensing of inappropriate
signals (evoked potentials and repolarization).
• Avoid inhibition of pacing
• Reset of timing cycles
• Some of these blanking and refractory periods are not programmable.
Blanking / Refractory periods
Blanking period
Sense amplifier is “blind” and usually may not detect cardiac event (not counted)
Physiologically, represents the absolute refractory period during the action potential.
The main purpose is to avoid crosstalk and oversensing mostly related to evoked potentials.
Refractory period
Sense amplifier is “ON” and it allows detecting rapid signals or cardiac events.
Sensed events during this period are ignored and will not reset timing cycles, however,
events are included in the counters.
Pacemaker Timing cycles
Blanking / Refractory periods
VS does not occur since it
falls within PAVB period.
Pacemaker Timing cycles
Blanking / Refractory periods
Lack of tracking
How would you fix this?
1) Increase atrial
sensitivity
2) Shortening PVARP
3) Atrial lead revision
Pacemaker Timing cycles
Pacemaker Timing cycles
Blanking / Refractory periods
Lack of tracking
The following ECG was obtained on a CRT-D patient at time of ICU Admission:
The following day, a device interrogation revealed the following electrograms:
Mode: DDDR
AT/AF Mode Switch: On at 350 ms (171 bpm)
Atrial rate is around
133 bpm, or ~ 451
Note the presence of “Pacemaker Wenkebach”
ms
The device will not allow the ventricular
rate to exceed the Upper Tracking Rate Atrial rate stays constant but, due to the lengthening AV delays,
(UTR). Therefore, the distance from the atrial events periodically fall into PVARP and are ignored for
“AS” to the “BV” pace lengthens until an pacemaker timing purposes. They are labeled as “AR,” or “Atrial
atrial event eventually falls into refractory. Refractory” events.
Reducing the ventricular pacing rate reveals the patient is in complete heart block.
Atrial rate is around Mode Switch (MS) rate was lowered:
133 bpm, or ~ 451
ms
Reducing the Mode Switch (MS) rate from 171 bpm (350 ms)
to 133 bpm (450 ms) permitted the device to automatically
switch from the tracking mode of DDDR to the non-tracking
mode of DDIR. This resulted in a subsequent reduction in
ventricular pacing rate to match the sensor-indicated rate for
this patient. Note that 133 bpm (450 ms) is the lowest possible
Mode Switch rate in this device.
Basic Tenets
• 12 lead EKG is invaluable!
• Combined with device interrogation (how device is
programmed) and marker channel (what device “thinks” it
is seeing)
• Understanding of device specific algorithms; can be
confusing and complex
• Basic building blocks: understand pacemaker and
defibrillator timing cycles
s/p TAVI and new LBBB so place temporary
Yesterday’s Case
• The patient shows up with no complaints
• You are in the middle of clinic and the nurse hands you this
EKG
• The patient is in long standing persistent AF, not pacing
much
• Is this pacemaker working?
• What would you do next?
Reading EKGs—here is an old one 6 months earlier
What is the pacing mode?
The following ECG was obtained from a patient with a dual-chamber pacemaker:
Note the chaotic appearance of “pacing spikes” throughout this tracing:
Blue arrows indicate atrial pacing spikes Atrial Pacing rate ~ 960 ms (63
bpm)
Orange arrows indicate unexpected ECG machine
artifacts
Rhythm Strip on presentation
Oversensing:
1.EMI
2. Noise, lead fracture, loose set screw
3. Myopotential oversensing
