Absolutely, I would absolutely also underline this. Please interact, you can stand up. It's not a problem if you're no longer anonymous. So if you don't use an app, but are here, not virtual, but in real life, I would even like that very much. Now, as you all know, pacing is, you know, very easy. And that is the general attitude that we had, I think, for 20 years maybe. So the people with the least brain do pacing. And that's a very, very, very important, well, problem, I would say. Because a lot of things that are basically, if you have some kind of experience, if you have a little bit of fantasy, are easy. If you just do a zero, whatever, routine, you will not make a good job. And I have a couple of cases. I hope that that stress what I mean. So this was all our real cases. And that is one of the cases I find most impressive. A 78-year-old female patient came to our hospital in the neurology department because she had a symptomatic epilepsy since a couple of years. And the problem was that her seizures didn't get better with any drug. I think she had been in hospital at least 10 times for a new drug treatment and titration, and nothing worked. Her history is that she had a stroke seven years ago, and that's why this kind of epilepsy is called symptomatic epilepsy. She had been, since that time, in a wheelchair because she had problems with walking and was insecure. Before that, she had had a pacemaker for complete heart block a long time ago. And she was sent to pacemaker control from the neurology department, and it's also quite funny. Neurologists are interested in atrial fibrillation as a cause of stroke. And so they wanted to know if there were stored episodes of atrial fibrillation. I like that because some neurologists have much better understanding how important stored episodes are than some cardiologists, by the way. So I find the idea to have a checkup of the pacemaker on this patient very good. Now, the point was that all threshold impedances sensing was okay, the battery was okay, and there were no stored AF episodes. There was a little bit of atrial pacing and 100% ventricular pacing, which is not completely surprising in a patient with complete heart block. I have a comment. Yep, you have a comment. My question would be, maybe your comment is exactly the right one. Yeah. I don't want, you know, I want a little bit of suspense, you know? Is that all? Is there anything else that we should do? Is that the whole thing? And we can send the patient up to the ward again, saying, okay, no atrial fibrillation in the memory. Is there anything you would also do? And if there's nobody coming up to the microphone or shouting, then that would be a yes for me. Who's silence agrees? So nothing, no idea what you could do? Nora is getting nervous, me too. Yes, please. Why is she a great response? That's a good point. In fact, rate response of the pacemaker was a DDDR. Rate response, I think, was not activated. Make sure there's enrolled in remote monitoring. Remote, with what? So why not take her on remote monitoring? What's the idea behind it? Future monitoring for other episodes that may occur. Okay, yep. So in case the pacemaker doesn't catch up, maybe she has ventricular tachycardia, or VF, and that would explain why she loses consciousness, which is interpreted as a seizure, and it's not captured by the stored electrogram. So that's an idea, but, yeah? Folks, stand up to ask your question if you're not gonna go to the mic. The atrial sensing in some of the AF could be very minor and the problem would be done in terms of, and the rate detection is also very slow. So the point that was made here, if a pacemaker doesn't store any AF episode, it might be that either there's AF undersensing, so she has atrial fibrillation, but it's not detected, or it might be that the rate for AF detection is set too high, 220 upwards, and in fact, because of undersensing, whatever, it's only one. But let me go to something even much, much more old-fashioned, maybe. Who has the most old-fashioned idea what to do with a pacemaker patient? Yes, please. From the EPG. That is very good, very, it's nice, old-fashioned, and I like that, but that will not, it just shows you AV synchronous ventricular pacing. No, I mean, even much worse in technical terms. If you're really old-fashioned, have, you know, you could talk to the patient. That is something that the very old generation did in their times. And so when you talk to her. Yeah, so she sees us, she has at least once per week, sometimes much more frequent. So that, nothing about the ventricoda. If you go on with that, so she sees us a lot, even almost, I always ask, is it at rest or during exercise, you know, because, so she says, well, it's always during exercise, and I say, what type of exercise do you do? Well, it's always when I'm, you know, moving my wheelchair with my arms. Okay, so. Have her move her wheelchair while she's being moved? There are two things. Number one, please, pacemaker control is only complete if you talk to the patient. And this was, you know, a 30 second, so how often do you lose consciousness? In what situation do you lose consciousness? After these 30 seconds, four, six, or seven expensive in-hospital stays are immediately abolished, because when she says, yes, I always have it when I move my wheelchair with my arms strongly, because sometimes, you know, the wheels are not so good, I have to use a lot of force, you know, so do at least an, I didn't have the wheelchair there, and I didn't want to put her back, but we did an over-sensing test. Please, in any patient with a pacemaker, the pacemaker control is only complete if you checked everything, if you looked at the memory, and if you also, you know, pressed and pulled the arm a little bit, because that is here a picture. In fact, you can see this is not the lady I'm talking about. So, very, very simple, because if we did this, this was the telemetry ECG. You see leads two, you see the markers, and you see the ventricular electrogram down here. I can see it. I am trying to get also a laser pointer here, so. And what you see is very easy, and even she said, oh, yeah, now it starts. You know, this is just simple ventricular over-sensing, and in this case, she had a unipolar ventricular lead that some people still like to implant because it's safer than bipolar, which is, of course, nonsense, but anyway, some are still doing it. So, the only thing that was there, she had a unipolar lead, and with a ventricular sensitivity of 2.8 millivolts, normally, that was fine, but if she was using the ipsilateral arm, she could inhibit her own pacemaker, you know, until she fainted, and when she fainted, then she came back, of course, because she was no longer moving her arm in the wheelchair. Can I just make a tiny process suggestion, and that is the only thing I would have done differently is I would have actually put the patient on some kind of external ECG monitor, because a record of it to prove to the community can be very helpful, because this looks like technical recordings to non-EP-related people. No, this is just my potential test that I do. No, I understand, I understand, but in that situation, I mean, that's a pretty compelling story. I would have actually got the ECG machine there, hooked her up to an ECG, pressed rhythm strip, and then done the test. Yeah, the problem is that in neurology, she was almost all the time on ECG because they are always looking for atrial fibrillation. However, she was in bed, not in a wheelchair. So yes, telemetry is one option. Whenever you are not sure what's going on, then use, in addition to the memory of a pacemaker, you may use any type of holter event recording system because what the pacemaker doesn't understand and doesn't detect, it will not store. So it is, yes, on top of memory. Yeah, I was just being practical. I would actually get the ECG cart to the pacemaker clinic, hook her up to the 12-lead ECG, and then do the test, because that will then create another component of the electronic health record that has the pause in it. So I know I'm being fussy, but our electronic health record totally sucks, so the more redundant you can make it, the more likely it is that that diagnostic information will be available to others. So my point is that whenever you have a patient with a syncope, despite a pacemaker, do provocation testing, which is, first of all, myo-potential, pull and push, and secondly, if you have any doubt that the lead might have an issue, then just take your fingers, take the pacemaker housing, and push it left, right, up, down, and have maybe what I do also, have the patient rotate the ipsilateral arm behind the back because then you pull maybe the fragments of the leads apart from each other because one of the problems is it may be that the lead is fractured, but the two parts of the lead have contact, and then it may be that you have a normal lead impedance and you think everything is normal while it isn't. So in this case, it was very easy. We just reprogrammed, in fact, the sensitivity, and everything was fine, and let me just tell you, the worst that I had was a similar case of a lady, exactly the same, and I said, okay, we couldn't get rid of the myo-potential over-sensing even with changing the sensitivity, so I told her, okay, we have to put in a new ventricular lead. Can you please show me your pacemaker passport? And she did so, and I saw she had a Medtronic 4024 lead, Medtronic Capture 4024. Does it have any special meaning to you? So one thing, Medtronic leads that have an even number at the end are bipolar, so she had been implanted with a bipolar lead, but from obviously the beginning, it was always programmed to unipolar sensing, and again, a patient that had an odyssey of lots of hospital stays for nothing. So my point that I want to make, please don't forget provocation over-sensing testing. Only then your pacemaker control is complete in case of syncope. A question for you. In some of these difficult patients, historically, what is your percent, if not zero, of not simultaneous to pacemaker implant, but in these kinds of cases, implanting a loop recorder? This comes up in my hospital. Yeah, it's rather rare. We have it very rare, I would say. I can't remember any single person in the last five years, but we have it the other way around. We frequently implant a loop recorder in patients with syncope of unknown origin. Then we see there is a pause of, let's say, 3.2 seconds. Then we implant a pacemaker, and then I always say, please, let's keep the loop recorder inside, because in case the patient faints again, and the pacemaker says everything was fine, it is always nice to have that information. So we have some patients running around, so usually only if they don't faint six months after pacemaker implant, I take out a loop recorder, which frequently has been there only for two or three months, anyway. Do you do this check every clinic visit? Or just with this stool? Honestly, we don't do it in every single checkup visit. We do it in all patients who have syncope, dizziness, or similar, which we cannot explain. So last week, I actually had a patient who had a 17-second pause with a loop recorder. So that was pretty compelling enough to put a pacemaker in, and they were from a remote place where they did not like to travel. And so we talked about it and wanted to take the loop recorder out. They didn't wanna come back for another procedure. Is there a cutoff or a context in which you choose to remove it as opposed to leave it in? Only if it's upon patient request. Otherwise, I always convince them, or I would even say persuade them, please keep it in, because we had a couple of these cases that patient received a pacemaker, and after the pacemaker had three or four faints. So in the end, it looks very much like the reason for fainting was not the pause of 3.2 seconds, but maybe something else. And the worst that I could imagine would be a VT that is not detected even by the pacemaker, which can happen if it's pacing for a block or whatever. Great, so thank you very much. I apologize. All people who raised their hands because being a fellow or allied professional will start to get severe headache now. And I make sure that I'm out of the room before you get too angry. So because this is a typical problem, and I would love to have your opinion about it. Patient with a sinus node disease, clear pacemaker indication, receives a pacemaker. After the pacemaker, she says that, well, it's fine. But every now and then, I have these very, very crazy, you know, bumping in my chest, which is extremely unpleasant. We checked the pacemaker, everything was fine. And we did what Andrew suggested, also old-fashioned. We took the patient with the pacemaker on a good old 24-hour holter. And that is what you see on the holter. It is a continuous recording. Here you see the overview very much down. And in the upper panel, you see how it starts. Age-replacing P-wave, QRS complex. And then you may appreciate that something happens, and suddenly the whole ECG looks completely different. And I would be happy if somebody immediately would tell me the six-digit abbreviation for this. And the seizure along your trapezius may have a different start because of the non-physiological contact. So she says, it's loss of atrial capture. Beautiful, how did you see that? How do you know? And you're on the right track. After here, these atrial paces, you see clearly a P-wave. And then here, after these atrial paces, you clearly see no P-wave at all, right? That is a marvelous, very, very important and good observation. Now, but the P-wave is approximately 2.8 millivolts in size, in sensing. And the threshold was 0.5 volt at 0.4 milliseconds. And the device is programmed to something like two volts. How can it be that it's pacing here effectively, and here it is loss of capture? I think there was a record-breaking P-wave after the ECG that might not have. Excellent, let me repeat this because if you take this home for your daily practice, I would be very, very happy. What you see, it starts with a PVC. And PVCs may be associated with retrograde P-waves. And if there should be a retrograde P-wave here, that explains why the next atrial pace cannot be effective no matter how high you put the output because it is pacing in the atrial, myocardial, refractory period. So that is one of the things. And just let me emphasize this, how this looks from the inside. This is an episode of atrial high-rate episodes from a Medtronic device. So the device thinks this is maybe something like atrial fibrillation. And let me blow it up. You can see exactly what you described here. There's atrial pacing with a rather long AV delay to help intrinsic conduction. So atrial pacing and then ventricular sensing. You even see the far-field signal here in the atrial electrogram. After that, you see another ventricular far-field with ventricular sensing marker annotation. So this is again a PVC, exactly like we've seen in a Holter. And then you see here is most likely the next sinus P-wave that appears here just after the ventricular sensing. So this is in the atrial refractory period. And refractory means it doesn't change pacemaker timing. So if the pacemaker thinks this is a good point in time to put in the next atrial pace, it will put it in there no matter what has been detected before. And you can see here that the interval between atrial refractory sensing and atrial pacing is just 200 milliseconds. And that is within the myocardial refractory period. So this atrial pace cannot be effective. However, the pacemaker doesn't understand that, waits for response to this atrial pace, which doesn't come, and then puts in the ventricular pace. In fact, as you see, with a programmed long AV delay of, in this case, 330 milliseconds. And then the whole thing continues. Ventricular pacing in an AV node that had for a long time nothing to do. So the AV node can conduct retrogradely. So VVI pacing, basically, with retrograde conduction, atrial ineffective pacing, next ventricular pace with retrograde conduction, and so forth. And this is, in fact, that is something I would be happy, if you remember this, it is repetitive non-reentrant V-asynchrony, a little bit long-term, RNR-VAS. But I tell you this particularly because this is something that is in almost all education boards that I've been involved, not known. Even if that is a study that deals with pacemaker detection of atrial fibrillation, you know what this has always been mistaken for? If you just look at the electrogram here, down there, all the education committee members said, no ventricular far-field over-sensing, you know? You have to reduce atrial sensitivity, which is ridiculous. You see here the scale. This is one millivolt. So this is most likely like six, seven millivolt. No far-field can be so big. And it's a very sharp signal. So this is a P-wave, and the problem is not far-field over-sensing or similar. Let me just, for this case, sum this up with two more electrograms. This is the St. Jude, similar episode in St. Jude devices. You see always that it's refractory atrial sensing. And again, in the SR trial, this has been always mistaken for far-field over-sensing because it looks like this, far-field over-sensing, atrial pacing, far-field over-sensing. And let me point out, in St. Jude, you can usually see the evoked response. So on the left side, after A, atrial pacing, you see in the atrial electrogram just a tiny artifact because it is ineffective. On the right side, here suddenly, the VA interval became longer, and now atrial pacing is effective again. And now you see, after the atrial spike, in the atrial electrogram, a positive mountain, or let's say at least a small hump. So if you compare this one ineffective to this one, you know, okay, this is ineffective pacing, this is effective pacing. Let me, can I make a point? I think it's wise to distinguish types of capture. This has been called, and I think it's a great term, functional non-capture. And it's functional non-capture because capture is disallowed because of atrial refractoriness. It is not true non-capture. That's not a problem. So functional and true are very different. The other point I wanna make about this is that your counters are going to be misleading. Your counters are not going to register the undersensed atrial signal. They will falsely tell you there's a greater percent of atrial stimulus delivery, and that would be wrong because the stimulus being delivered in atrial refractoriness, it's being delivered, so it's counted, but it doesn't count for the patient. And by the same token, the atrial pace conducted will result in this situation to ventricular stimulus output over counting and that would be wrong as well So watch your counters when you do See something like this and talk about asking the patient ask about pulsations in the neck because these are cannon waves and If you examine your patients, which we all should be doing We will see cannon waves and that can make the diagnosis These patients can be very symptomatic because they're hype is pacemaker syndrome Exactly. They are hypotensive They have no chronotropy really and they're very uncomfortable that their CVP can be 15-20 that's the same thing as their wedge it can double so they'll present to you more often than not with this type of rhythm and And in addition to the halter and for all of us and I do it routinely not everybody does if you run all 12 leads All 12 simultaneously as a rhythm strip You will see QRS native and paste P wave native and base in every lead Which is very very helpful because on your regular 12 leads you may not know what's the stimulus output was not registered You may not even see the Designation of the vertical line or the inverted triangle, but all 12 leads is a rhythm strip. You'll see something somewhere And two technical comments on this would you like to be informed about this issue from by your pacemaker Who says yes, I would like to know this who say I don't care at all who would who would like to know about this Okay, some okay almost everybody so in Sanju devices ever devices It's important you need to set your atrial tachyarrhythmia detection to a TAF Because only then the atrial pacing is also included in calculating the atrial rate Nominally sent to devices ever devices are set to AMS automatic mode switch detection in automatic mode switch Atrial pacing is not included. So if you keep it on nominal, you will never be informed about it You will never know and see how this crazy patient is there again with this funny bumping feeling in the neck and are you know? Everything is fine. I checked it last time send a home and give her a little bit of diacepam or whatever. So Be sure that you have to actively change send two devices to store not AMS, but a TAF But then don't be mistaken that whenever you have a TAF episodes that this is atrial fibrillation that requires aura Anticollation it is rather this problem. Yeah now the problem or just one more One more word. This is how it looks in Boston scientific devices and it is very very I think now if you don't have having headache up to now, you will get it now because here you see an atrial tachyarrhythmia episode with the Annotations atrial sense ventricular pace and Atrial sense in brackets meaning in the refractory period at this point in time when you see this bar The device detects atrial tachyarrhythmia and switches from DDD to DDI Now what happens now looks a little bit funny because by chance just in this point in time the atrial tachyarrhythmia stops And what you have now is by chance a ventricular pacing here with the next P wave which is obviously this very big signal in the refractory period and Only if you associate this with the markers you see a funny there's atrial pacing in fallback mode So that is exactly the same what I've just shown you repetitive non reentrant VA synchrony in a Boston scientific device and I'm 100% sure that Most of the people who look at this will either say oh funny I don't know what it is or will mistake this for far-field over sensing and I say this again What can you do? First of all, how can you solve this problem? And I tell you it is not by changing atrial sensitivity So first of all, the problem is that you have atrial pacing too early after a refractory atrial sense signal so what you want to do is either pull the ventricular pacing a little bit forward shorten the AV delay or push the next pace a little bit backward and So causes we had is a you have this and that's why we had it a lot in assert in assert We had a protocol that all intrinsic conduction should have priority. So all the AV delays were programmed to 350 milliseconds And so the longer your AV delay the more likely retrograde conduction can occur So that is one and the other thing is also an assert We had the atrial overdrive pacing on but you can also have atrial rate response on So in the case that I showed you the problem was also that pacing was not at 60 But rather at 95 beats per minute and the faster you pace to atrium the nearer it gets to the preceding ventricle So what could you do as a solution? Reduce either the atrium or the pacing rate So deactivate or limit the rate adaptive algorithm or put any other kind of algorithm like overdrive off Number one and if only if that doesn't work, I would shorten the paste or that the AV delay I would normally not do this because in the first And second example, you saw that a little bit long AV delay help intrinsic conduction. So solution of our an RV s Switch sensor off or limit it switch overdrive pacing off if that doesn't do the job shorten the paste AV programming Oh Thank you, that's a very good point in metronic There's something funny that is called NC AP or n cap Which I would say in the younger generation of device expert. Nobody knows what this means So it's not not yes It is the minimum interval between a refractory sense and the next pace and that should be put to 300 milliseconds And that also thank you very much That is also an important solution of that problem if a true pacing cannot be earlier than 300 milliseconds after a true refractory sensing You won't have this problem Yeah Yeah So that's but that's something I would want not going to cut out So that's very good comment about endless loop tachycardia that has of course a similar Mechanism one of the points that I wanted to make would it be a solution to reprogram this device from DDD to DDI? Does it solve a problem No is right because you know, actually You have DDI pacing here DDI pacing means no tracking so important point To switch from DDD to DDI doesn't help. So again Change of atrial sensitivity does not help because this is not far-field over sensing even if you Even if 95% of pacemaker experts think it is It does not help to prolong the PV AB the blanking period then you don't have a true refractory sensing No, you don't have that but you have no sensing at all anymore It doesn't have to shorten the P warp because then you don't have this anymore But then instead you have endless loop tachycardia which is at least as bad and it doesn't have to reprogram to DDI are and So let's let's quickly make in honor of search barreled in his book this is a very nicely explained causes of R&R VAS and programming solution of R&R VAS so That is something I would love to draw your attention to because again in my experience Not only beginners, but also extreme experts have no idea about the problem and the solution Okay, can I ask if you if you shorten the P varp? And you go into PMT which may or may not happen But if it does all the people will the PMT algorithms not corrected after the census for a period of time Hopefully yes But but that would then make turn the patient into at least 12 beats Tachycardia stopping it and if you're unlucky then it starts again and again So I think that there's a fair solution that and it's a typical problem Because if you over paste the patient if you paste the atrium too fast a intrinsic AV delay Frequently gets longer and longer So and that then causes you have a long intrinsic conduction then you have retrograde conduction and so forth So I think the cleanest solution is just to switch off the sensor or something similar But you're right and the stoop tachycardia would be Maybe something that the pacemaker can detect and can solve and stop but I wouldn't I wouldn't really try that Because the trade-off in a way is if you're meddling with AV intervals We are really have a culture of trying to force intrinsic conduction and it is mostly good for patients. Absolutely I did and this is this is unusual. So You know, I don't think to take a message to take a message for troubleshooting it is to shorten it But not that we should be pacing with shorter AV delays Take home message is reduce the sensor and only if that doesn't work Then I would as a second step maybe in non Medtronic devices because what the lady said is absolutely correct in Medtronic is in solve the problem by switching on and cap and to put it to 300 Yeah I Would say yes and no you're right But I think the number one issue is too fast a true pacing and I solve this problem usually By limiting the sense maximum sensor rate to 110 particularly in all patients who have coronary artery disease which is the majority of our patients because there is a quite quite a couple of literature that if you have heart rates above 120 or 120 and above you have more angina and you've more frequently have cardiovascular events. So Sensor is nice. But all the studies show if if you have an aggressive Center sensor activation that usually harms the patient more than helping him. So I'm happy this for me a win-win situation I detected an inappropriate sensor behavior and I terminated this problem While cool Yeah, that's a very important point Yeah So also what he said one of the problems is patients with anti-grade complete heart block may have retrograde conduction It's only 20% of patients. It's more and so you can have I had a couple I had one patient who had endless loop tachycardia at a heart rate of 180 if you put the maximum track rate to 180 you had to end this loop of 180 Despite the fact that integrally nothing came over. So just as a take-home message complete heart block doesn't Make you safe against retrograde conduction So if you give me another two minutes, I would love is okay Just because this is this is the theme of this Congress his bundle pacing. I love it But this creates ECGs that are really really funny and difficult to understand. So first of all, you are all doing thresholds, okay? What is the ventricular threshold here? It's a his bundle pacemaker How many different thresholds do you see If you just say what's the ventricular threshold 2.5 to 1.7 5 1 5 or 0 5 Cool So I think unfortunately You have to look very close. This is a blow-up What you see is here at 2.5 volt pacing you first see to a little bit more white curious complexes with a delta wave And then starting from 2 volt you see no longer a delta wave after the ventricular spike but a Q wave, okay So the two first His bundle capture plus myocardial capture around his bundle. So this is called non-selective his bundle pacing Then you see starting from 2 volt, which is nice. The myocardium doesn't capture anymore, but the history captures That's why you have a Q wave. It means that's why I love this tracing That means your screw is exactly in his bundle around the his bundle is some Whatever tissue but no myocardium and you only with 2.5 volt and upwards you catch the myocardium However, now this is the 2.5 2.0 and you have a change in curious morphology Now here down at one point zero zero five zero zero seven five zero five The left two are zero seven five and you see a true pacing ventricular pacing Q wave and curious complex and then the zero to zero point five volts the last two Only at that time you see there's still ventricular pacing, but the stimulus curious interval gets longer and I love that very much because in his bundle pacing you are forced to look at your CG and Very much like old-fashioned people here at the podium. That is a case where you need to have a 12 ECG Ouch So so so help me out here the native QRS that conducted for the last two beats looks pretty darn skinny. Why are we pacing? This is intrinsic intrinsic conduction. It looks exactly the same like his bundle pacing Of course in this case, you can you can program the device to avoid ventricular pacing like like a I yeah So in this case, yes. Yes And This is the metronic 3830 in the ventricle and the normal bipolar lead in the atrium and one thing I would love if I have The chance now to talk to you Please if you perform his bundle pacing put it always to unipolar pacing because otherwise nobody knows what's going on and you cannot So I have a lot of tracing when nobody can say is it pacing or is it not pacing? No idea because I don't see the spike here. At least you see the spike. You still have to look carefully. What's the stimulus? secure as interval But without the spike you're lost completely and you have at least two different thresholds You have the parahesion and his bundle threshold And so this was one of the cases where one of my consultants did it completely wrong said Oh Carsten. Sorry Your threshold went up to 2.5 volts said no, it is beautiful. And this is a similar case. We said Oh Carsten. Sorry And I was checking here the threshold and I cannot understand it You see here. There's a stressor test in VVI mode because otherwise too difficult You see here stimulus QS complex a Little bit apart from each other then you see stimulus and a much broader wider QS complex. Do you see that? and Then you see finally at 0.5 volt or 0.75 stimulus QS stimulus QS wide QS Then you see ventricular pacing and a very narrow QS complex That must be his bundle beautiful, but a little bit longer stimulus to QS And then finally you see stimulus and no QS at all And now I get do you have any explanation for it and that's just to frighten you So first you have here selective his bundle pacing at 1.5 1.25 So starting from 1 volt downwards you have non-selective his bundle pacing So the his bundle and the surrounding and the QS gets wider Okay, so far so good. That's I would say easy, but then you have ventricular pacing you have a clear QS complex live it further apart, but very very very narrow What is this you're capturing the right bundle? No that the lead is pretty proximal I heard it Excellent Wow so I thought this was more much more difficult So yes, of course in his bundle pacing frequently if not usually we put the lead in the atrium It is in his bundle insertion in the atrium But this is funny enough at 0.5 volt you still have atrial capture which you didn't see before because it was Overruled by other things so but now you have atrial capture, and then you have loss of atrial capture So just to make one point very very very clear please Always use 12 lead EKG because in a single lead you cannot really see what I've just you know alluded to you and With that I had terrible over time Oh One very last so my poor consultant my poor consultant had even worse He said okay threshold is difficult And I think it's very high and there's your our wave went down from two point two point four millivolt Which is not so good, but typical for his bundle pacing down to zero point six millivolt And I think we have to unfortunately we have to revise it and put in a normal ventricular leads So the point here right is that that automated measurements Make a measurement in a limited period of time after the stimulus and their design I'm sorry you were gonna say, but perfect so so that so that Depending on which company and exactly how it's done. It's in the range of 50 to 100 milliseconds, and I don't know the You know the details of this, but let's say for example At one point Medtronic devices measured say 60 milliseconds with you know pick the maximum point in the 60 milliseconds after your pacing stimulus if your HV interval is Why not if the time between your pacing stimulus and The peak of your our wave is longer than that and the peak of your local our wave Might of the local ventricular signal might be even if the beginning of it is within the first 50 or 60 Milliseconds the peak is later that you'll get a falsely low measure Excellent well, and I think that is wonderful thing and it gives me a lot of credibility if you say this So that is exactly the problem and this was the threshold and if already at the threshold testing a true threshold testing you see an Atrial spike and an atrial signal in the EGM to you see the his bundle itself, and you see a QS But this is the sense QS you have here the scale. This is one millivolt So this must be something like at least 2.5 or 3 millivolt right so 0.6 can never be true and the problem is exactly like Chuck was was explained to us Was was explaining you see it nicer here here that my poor colleague said okay sensing is very bad So I rather put the device to a I pacing and deactivate the ventricular lead because it doesn't work And this is what happened then you have a true pacing and ventricular sensing twice And this is exactly like Chuck was saying the ventricular sensing the first signal is sensed And this yes, this is in the range below one millivolt But it's the atrial far-field signal and the second signal Which is much bigger is not taken into account by the automatic algorithm So just repeat automatic sensing testing with an atrial sensitivity of let's say 1.5 millivolt volt and the end then you have paradoxically the less sensitive you make the test the bigger will be your our way Because then this far-field are traitor over sensing doesn't appear anymore and suddenly we have a beautiful in fact Yes, it was 2.4 millivolt like before Yes, please In this case you can see it because you have three signals you have the atrial far-field signal Which is in the range of zero point something and then here you see there's a very very tiny signal in between atrium and ventricle That is a typical size of the his if it's nice if you have a nicest that is a typical size it I would say It's in a range of 0.1 0.2 millivolt Sometimes it's a little bit bigger and it can be also his bundle over sending that also happens But that is much more rare and in fact, I don't care what is over sensed But please get rid of it because in the letter it said please Revise the lead because it doesn't function anymore for sensing and not so good for pacing Yeah, thank you so much

pacing

pacemakers

patient interaction

individualized approaches

symptomatic epilepsy

complete heart block

ECG monitoring

comprehensive assessments