Dual Chamber
Timing Cycles
TIMERS
A-A interval indicates
the minimum rate the
device will pace under
normal circumstances
(Lower Rate Interval -
LRI).
• AV Delay determines how much time between an atrial event
and a ventricular event
• Ex. 200 ms
• Atrial Escape Interval time from the ventricular spike
to the next atrial spike.
• Ex. 800ms
AV INTERVALS / AV DELAY
Initiated by a paced or non-refractory sensed atrial event
Separately programmable AV intervals – Sensed AV / Paced AV
SAV is programmed shorter than PAV to allow for the interatrial
conduction between intrinsic and paced atrial events.
SAV uses normal conduction between RA and LA – allows for LV
filling
SAV resets LRI
PAV uses muscle tissue to conduct the signal which takes longer to
contract
PAV begins when LRI has expired
Lower Rate Interval
PAV SAV
200 ms 170 ms
*PAV 30 ms
AP AS longer than
DDD 60 VP VP the SAV
Atrial Escape Interval (V-A Interval)
The AV interval allows the appropriate amount of time to optimize ventricular
filling and mimic the activation sequence of the normal heart.
Knowing the LRI and the PAV interval (AV after a paced atrial event), the V-A
interval can be found V-A interval = LRI - PAV
The V-A interval is the longest period that may elapse after a ventricular
event before the atrium must be paced in the absence of atrial activity.
Lower Rate Interval DDD 60 (1000 ms)
200 ms 800 ms PAV 200 ms; V-A 800 ms
AV Interval VA Interval
AP AP
VP VP
Must use PAV not SAV – SAV would use intrinsic beat which
does not reflect the longest programmed rate.
FOUR FACES OF DDD
Dual chamber pacing versus single chamber pacing
provides AV synchrony which is more physiologic.
1. Atrial Pace, Ventricular Pace (AP/VP) AV sequential Pacing
Pacing in both the atrium and the ventricle
AP re-starts the LRI and triggers an AV delay timer (PAV)
The PAV expires without being inhibited by a VS, resulting in a VP
LRI expires without being inhibited by an intrinsic atrial beat.
Most likely a patient with SND and AV block, bradycardia causes LRI to
expire.
AV V-A AV V-A
AP AP
VP VP
Rate = 60 bpm / 1000 ms
A-A = 1000 ms
2. Atrial Pace, Ventricular Sense (AP/VS)
The atrium is being paced, but AV conduction is intact, so the ventricular
output is inhibited by a sensed ventricular event.
AP restarts the LRI and triggers an AV delay timer (PAV)
Before the PAV can expire, it is inhibited by a VS (R-wave)
Patient’s intrinsic AV conduction occurs faster than the PAV interval, but
the patient’s sinus rate (A-A interval) is still longer than the LRI
programmed into the pacemaker. (Bradycardia, SND)
AV V-A AV V-A
AP AP
VS VS
Rate = 60 ppm / 1000 ms
A-A = 1000 ms
3. Atrial Sense, Ventricular Pace (AS/ VP) “tracking”
Intrinsic P-waves followed by ventricular pacing.
The atrial rate is driving the ventricular rate – also called ‘ tracking’.
Ventricular spike is triggered by the intrinsic P-wave
An AS (P-wave) inhibits the LRI and triggers an AV delay timer (SAV)
LRI does not expire!
SAV expires without being inhibited by an VS, resulting in a VP.
This patient now has adequate sinus node function with AV block!
AV V-A AV V-A
AS AS
VP VP
Rate (sinus driven) = 70 bpm / 857 ms
A-A = 857 ms
4. Atrial Sense, Ventricular Sense (AS/VS) – Fully Inhibited
An AS (P-wave) inhibits the LRI and triggers an AV delay timer (SAV)
Before the SAV can expire, it is inhibited by a VS (R-wave)
The patient has adequate sinus node function and intact AV conduction
but may experience little to no increase in sinus rate with activity and/or AV
block that occurs at increased rates.
AV V-A AV V-A
AS AS
VS VS
Rate (sinus driven) = 70 bpm / 857 ms
Spontaneous conduction at 150 ms
A-A = 857 ms
DDI does not trigger an SAV – used for atrial tachycardias
DDD CAN CANGE BEHAVIOUR BASED ON PATIENTS
NEEDS.
DUAL CHAMBER TIMING
Refractory and Blanking Periods
PVAB
PVARP
Those affecting the atrial
ARP
channel are indicated above
the ECG baseline.
VRP
Those affecting the
ventricular channel are
indicated below the ECG
baseline.
Red: Blanking
Orange: Refractory period
DUAL CHAMBER TIMING
Atrial Refractory and Blanking
Periods Post Ventricular Atrial
Blanking
• Prevents far-field R-wave
sensing of the
ventricular pacing
output, and the R-wave,
on the atrial channel.
PVAB
Atrial Blanking • The PVAB prevents
ARP PVARP oversensing.
• Prevents the
pacemaker from
being “self-
inhibited” by VRP
the atrial pacing
output.
• PAV only
Post Ventricular Atrial Refractory
Period
Atrial Refractory Period • Prevents the AV interval from restarting due
• Ignores sensed events on the atrial to sensed retrograde P-waves or PACs.
channel during the AV delay, so (prevents tracking)
they do not restart the AV interval. • If the retrograde P-waves are sensed, the
patient could go into Pacemaker Mediated
Tachycardia (PMT).
• atrial
The atrial blanking that is shown, occurs only if there is an Any pacing
atrial beat falling into PVARP is noted as
output. Had a P-wave occurred (an atrial sense), the AV delay would haveused from a timing diagram
AR, but not
ISSUE: PACEMAKER MEDIATED TACHYCARDIA
A Pacemaker Mediated
Tachycardia (PMT) may occur
when retrograde P-waves (due
to a loss of AV synchrony) are
sensed and tracked in atrial
tracking mode AS-VP.
AS
PVARP helps to prevent
sensing retrograde P waves
(retrograde conduction is the
ability to conduct an electrical
VP impulse backward)
ISSUE: FAR-FIELD SENSING
An intrinsic event is sensed in the opposite chamber it
originates from.
Surface
ECG
Atrial
EGM
Ventricular
EGM
INAPPROPRIATE MODE SWITCHING
Far field R waves can cause the
device to think the patient is in AF
and may inappropriately mode
switch.
This can cause inaccuracy of the
device diagnostics.
Mode Switch -
If pacemaker patient has an atrial
arrhythmia, the device will “track”
the atrium (AS-VP), by pacing the
ventricles at a high rate - possibly
causing patient symptoms.
This feature automatically
reprograms the pacemaker to a non-
tracking rate response mode
(DDIR) whenever an atrial
arrhythmia is detected.
Covered in Unit 3
DUAL CHAMBER TIMING
Ventricular Refractory and Blanking
Periods
PVAB
ARP PVARP
Post Atrial VRP
Ventricular
Blanking
Ventricular Refractory Period
• Prevent sensing
• Prevents oversensing of T-
in the ventricle
waves
after an atrial
paced beat
• This may Ventricular Blanking
prevent
crosstalk. • Prevents “self-inhibition”
from the ventricular pacing
• PAV only output
20
ISSUE: CROSSTALK
A paced signal that is detected on the opposite lead.
Surface
ECG
Atrial
EGM
Ventricular
EGM
DUAL CHAMBER TIMING
Atrial Pace (AP) - Ventricular Pace (VP) example
A-A interval A-A interval
DDD 60
V-A interval V-A interval
PAV PAV
PVAB PVAB
ARP PVARP ARP PVARP
VRP VRP
The pacemaker applies these periods every timing cycle.
UPPER RATE
BEHAVIORS
UPPER SENSOR RATE
Sensor rate drives the atrial rate up
In rate responsive, dual chamber modes, the Upper
Activity (Sensor) Rate provides the limit for sensor-driven
atrial pacing
Upper Activity Rate limit for rate responsive is from start of
PAV to the start of the next PAV.
Lower Rate Limit 1000 ms
Upper Activity Rate Limit 500 ms
PAV PAV
DDDR 60 / 120 A-A = 500 ms
UPPER TRACKING RATE
IN AS-VP THE PACEMAKER WILL “TRACK” THE ATRIUM
Tracking = Pacing the
ventricle after an atrial
intrinsic event
AS
No intrinsic
communication
between atria and
ventricles!
VP
Maintains AV Synchrony
Want to limit how fast we
pace!
TARP
Total Atrial Refractory Period (TARP) =
SAV+PVARP.
• No atrial beats can be tracked within this
interval.
AS or VS or
AP VP
Atrial AB AV PVAB PVARP
Channel
TARP
AS or VS or
AP VP
Ventricular PAVB VB
Channel VSP VRP
UPPER TRACKING RATE (UTR) – SENSING!
The maximum rate the ventricle can be paced in response to AS.
Prevents ventricle from speeding up if atria speeds up.
The sequence of an AS, starting an SAV , timing out the SAV , and VP – is called
"tracking.”
If the atrial rate begins to increase and continues to increase, is it desirable to let
the ventricle "track" to extremely high rates?
No - limit the rate at which the ventricle can pace in the presence of
high atrial rates.
Lower Rate Interval {
Upper Tracking Rate Limit
SAV VA SAV VA
UTR starts at the end
of an SAV and
finishes at the end of
the next SAV. AS AS
VP VP
DDDR 60 / 100 (upper tracking rate) (The Upper Rate is often set at 85%
Sinus rate: 100 bpm of the maximum heart rate.)
1:1 UPPER RATE TIMING INTERVALS
TRACKING AS - VP
AS
AS
VP
1:1
Atrial AB AV PVAB PVARP Pacemaker will track 1:1 if the
Channel intrinsic atrial rate is:
TARP • Above the LRI
AS VP • Below the UTR
1:1 - for each atrial event there will be
Ventricular PAVB VB a ventricular event at the end of the
Channel VSP VRP programmed AV interval.
Lower Rate
Interval
AV VA interval
LRi
Upper Rate UTR
Interval
UPPER RATE BEHAVIOR: RESPONSE TO HIGH
ATRIAL RATES
To a pacemaker, an increase in atrial rate means that V-
A intervals are getting shorter (the next atrial sense is
getting closer to the previous ventricular event).
Pacemaker Wenckebach
Caused by the atrial rate exceeding the UTR.
Produces gradual change in tracking rate ratio.
Prolongs the SAV until upper rate limit expires.
Has the characteristics of Wenckebach—
The AV(PR) interval gradually extending, until an atrial
event falls into the PVARP and cannot restart an AV
interval.
In effect, a ventricular beat is “dropped.”
2:1 Block
Occurs when P-waves are faster than TARP.
Caused by the atrial rate exceeding the TARP.
TARP = SAV + PVARP
WENCKEBACH UPPER RATE TIMING
Wenckebach occurs because the pacemaker cannot track faster than the UTR.
If the P-wave rate is above the
UTR and below TARP, the
pacemaker will be in
Wenckebach.
AS
AS VP
Wenckebach
Atrial AB AV PVAB PVARP
Channel
TARP
AS VP
Ventricular PAVB VB
Channel VSP VRP
Lower Rate
Interval
AV VA interval
LRi
Upper Rate
Interval
UTR
4:3 WENCKEBACH UPPER RATE TIMING
AV AV+ AV++ AV AV+
AS AS AS AR AS AS
PVARP PVARP PVARP PVARP PVARP
UTR UTR UTR UTR
1. The patient’s atrial rate is above the UTR and below the TARP rate.
2. The VP is limited to the UTR limit which causes a lengthening of the
AV delay .
3. The fourth atrial beat falls into PVARP (AR) and is not tracked.
– This produces a 4:3 Wenckebach and the cycle repeats until the atrial rate falls
below the UTR.
When the sinus rate is greater than the upper tracking rate and less than the
TARP rate, then the Wenckebach behavior is normal for a pacemaker.
WENCKEBACH EXAMPLE
Pacemaker patient on an exercise test
4:3 Wenckebach operation
Each AS (P-wave) is followed by an increasing SAV, and then
the VP
Eventually an atrial beat is not tracked, and a ventricular
beat is dropped
The P-wave fell into the PVARP of the previous ventricular
event
32
UPPER RATE BEHAVIOR
When the intrinsic atrial rate approaches (and exceeds) the UTR,
pacemaker operations will change from 1:1 tracking operations, to
blocking operations, which are designed to prevent tracking atrial
arrhythmias, which are too fast, and will likely cause patients to become
symptomatic.
These are normal upper rate behaviours. But are they ideal?
• If the UTR interval is longer than the TARP, the pacemaker will
exhibit Wenckebach behavior for some period before it goes into a 2:1
block pattern as the atrial rate increases.
• If the UTR interval is shorter than the TARP, the pacemaker will
exhibit 2:1 block behavior first and will never be able to achieve the
2:1 Block
UTR as the atrial rate increases.
Caused by the atrial rate exceeding the Total Atrial Refractory Period
(TARP)
Every other P-wave will fall
into refractory and will not
be sensed. The ventricular
paced rate will typically be
half the atrial rate.
Is achieving 2:1 block immediately at the UTR a desirable
situation?
2:1 Block = 60,000 / (SAV+PVARP)
2:1 BLOCK UPPER RATE TIMING
AR AS
AS VP
2:1
If the P-wave is inside of TARP,
Atrial AB AV PVAB PVARP then the VP cannot track or
Channel follow the AS .
TARP
AS VP
The pacemaker then exhibits a
2:1 or higher block.
Ventricular PAVB VB
Channel VSP VRP Patient exhibits symptoms
when this occurs
Lower Rate reprogramming is needed.
AV VA Interval
Interval
LRi
Upper Rate
Interval UTR
UPPER RATE BEHAVIOR
TARP is an interval, so it must be converted to bpm in order to compare it to an
atrial rate.
Given an SAV of 200 ms, and a PVARP of 300 ms, what is TARP?
• TARP = 500 ms
Given the same parameters, what pacemaker rhythm will result from an atrial
rate of 130 bpm?
• 2:1 block
Explanation:
• TARP of 500 ms converts to 120 bpm (60,000 / 500 ms = 120 bpm)
• The atrial rate (130 bpm) is faster than TARP, resulting in 2:1 block
ARP PVARP ARP PVARP ARP
TARP TARP TARP
A A A A A
S R S R S
SAV SAV SAV
V V V
P 2:1 Block P P
Occurs when P-waves are faster than TARP
TARP = SAV + PVARP
ACHIEVING A HIGHER UTR WITHOUT 2:1
BLOCK
In both cases, the effect is to increase the 1:1 tracking window and to
allow for Wenckebach at the UTR. *Rate Adaptive AV
• Decrease SAV • Decrease PVARP
This may result in Short PVARP
ARP PVARP ARP PVARP may allow
more VP, which may
have consequences retrograde
TARP for the patient.
TARP conduction
A A A A to be
S R S R sensed
SAV SAV
ARP PVARP Increased ARP PVARP Increased
Tracking TARP Tracking
TARP
A A A A
S S S
S
SAV SAV SAV SAV
CASE STUDIES
PATIENT CASE STUDY #1
A 79 year old Patient has a DDD pacemaker. He came into the office
complaining of dizziness and pre-syncope when he walked briskly to his
car.
In the office you check his thresholds, sensing, and impedance. They are
all are normal, as well as his blood pressure.
Programmed Parameters:
PAV = 230 ms
SAV = 200 ms
PVARP = 400 ms
UTR = 120 bpm
Treadmill Test
Since the patient was briskly walking to their car when they became
faint, we want to explore what happens to their pacemaker with a
treadmill test.
KNOWLEDGE CHECKPOINT
What do you observe?
a. Loss of atrial sensing
b. PMT
c. 2:1 Block Behavior
d. Wenckebach Behavior
KNOWLEDGE CHECKPOINT
When this patient needed a heart rate
What do you observe? greater than 100 bpm the pacemaker
a. Loss of atrial sensing was not able to follow the atrium.
b. PMT
This caused the patient’s heart rate to
c. 2:1 Block Behavior
drop suddenly which explains the
d. Wenckebach Behavior patient’s dizziness.
RESULTS OF THE TREADMILL TEST
PVAR PVARP PVAR PVAR
P P P
Tracking 2:1 Block
When the atrial rate exceeds 100 bpm (intrinsic not paced!) then suddenly
the ventricular rate drops to a rate of 50 bpm. Now every other atrial beat
falls within PVARP as shown on the ECG causing 2:1 Block.
DUAL CHAMBER 2:1 BLOCK UPPER RATE TIMING
Programmed Parameters:
PAV = 230 ms
SAV = 200 ms
PVARP = 400 ms
UTR = 120 bpm
AR AS
AS or AP VS or VP
2:1 TARP (SAV+PVARP)
200 ms 400 ms
200 ms + 400 ms = TARP 600 ms
Atrial AB AV PVAB PVARP TARP Rate = 100 bpm
Channel
TARP = 600 ms UTR = 120 bpm or (500ms)
AS or AP VS or VP As the atrial rate increases,
the P-waves fall into TARP before ever
reaching the UTR.
Ventricular PAVB VB
Channel VSP VRP Every other P-wave falls into PVARP
causing a 2:1 Block behavior.
Lower Rate
AV VA Interval
Interval
LRi
Upper Rate UTR = 500 ms
Interval
Programmed Parameters:
REPROGRAMMING CONSIDERATIONS PAV = 230 ms
SAV = 200 ms
PVARP = 400 ms
UTR = 500ms or 120 bpm
1 ) What upper rate do we want for this patient?
TARP Rate = 600 ms or 100 bpm
.85 x (220 -79) = 120 bpm
Program UTR = 120 bpm (The Upper Rate is often set at 85% of the
maximum heart rate.)
2) What other parameters need to be
programmed?
We want 2:1 Block point = 120 bpm + 30 bpm =
150 bpm
We want a TARP rate of 150 bpm (60000/150 bpm =
400ms)
TARP = SAV + PVARP = 400 ms
If SAV = 200 ms then reprogram PVARP = 200 ms
New programming will ensure the following:
• 1:1 tracking up to 120 bpm
• Wenckebach between 120bpm – 150 bpm
DUAL CHAMBER WENCKEBACH UPPER RATE
TIMING TARP = 400 ms or a rate of 150 bpm
(60,000/400=150 bpm).
AS
AS or AP VS or VP
200 ms 200 ms
2:1 Wenckebach 1:
AB 1
Atrial AV PVAB PVARP
Channel
TARP = 400 ms
New programming will ensure the
AS or AP VS or VP following:
• 1:1 tracking up to 120 bpm
Ventricular PAVB VB • Wenckebach between 120bpm
Channel VSP VRP – 150 bpm
• 2:1 Block above 150 bpm
Lower Rate
AV VA Interval
Interval
LRi
Upper Rate UTR = 500 ms
Interval
RESULTS OF NEW TREADMILL TEST
Patient can now track to UTR = 120 bpm!
• Upper Rate Behaviours are normal pacemaker
function. The Pacemaker is responded to
programming.
• Programming needs to be adjusted to modify
these behaviours!
KNOWLEDGE CHECK
1. Given the following pacemaker parameters, what
behaviour will result from an atrial rate of 140 bpm?
UTR = 120 bpm
SAV = 150 ms
PVARP = 250 ms
46
KNOWLEDGE CHECK
2. Given the same pacemaker parameters, what atrial rate
would result in 2:1 block?
47
PRACTICE
AS or AP VS or VP
Atrial
Channel
AS or AP VS or VP
Ventricular
Channel
Lower Rate
Interval
Upper Rate Interval
Define the following terms
Chapter 10 Readings
AV delay:
Use updated terminology from lecture slides
V-A interval: Page 76 – 79 -
• ( alert period terms not used)
UTR: • Skip – Rate Responsive AV Delay
PVARP: Page 80 – 88
• MTR – Upper Tracking Rate
• Multiblocks – 2:1 block
PVAB: • DDI or DDIR will be discussed in Unit 3
• DVI mode - skip
• VDD mode - skip
PAVB:
TARP:
