Method and apparatus for treating irregular ventricular contractions such as during atrial arrhythmia

• US 20040215259A1
• Filed: 05/24/2004
• Published: 10/28/2004
• Est. Priority Date: 05/21/1999
• Status: Active Grant

• Current Assignee: Cardiac Pacemakers Incorporated (Boston Scientific Corporation)
• Original Assignee: Cardiac Pacemakers Incorporated (Boston Scientific Corporation)
• Inventors: Stahmann, Jeffrey E., Hartley, Jesse W., Stahl, Wyatt, Krig, David B.
• Granted Patent: US 7,460,908 B2
• Time in Patent Office: Days
• US Class Current: 607/9
• CPC Class Codes: A61N 1/3621 for treating or preventing abnormally high heart rate
• CPC Class Codes: A61N 1/3627 for treating a mechanical deficiency of the heart, e.g. congestive heart failure or cardiomyopathy
• CPC Class Codes: A61N 1/3682 with a variable atrioventricular delay
• CPC Class Codes: A61N 1/395 for treating atrial fibrillation
• CPC Class Codes: A61N 1/39622 Pacing therapy
• CPC Class Codes: A61N 1/3987 characterised by the timing or triggering of the shock

Abstract

A cardiac rhythm management system is capable of treating irregular ventricular heart contractions, such as during atrial tachyarrhythmias such as atrial fibrillation. A first indicated pacing interval is computed based at least partially on a most recent V-V interval duration between ventricular beats and a previous value of the first indicated pacing interval. Pacing therapy is provided based on either the first indicated pacing interval or also based on a second indicated pacing interval, such as a sensor-indicated pacing interval. A weighted averager such as an infinite impulse response (IIR) filter adjusts the first indicated pacing interval for sensed beats and differently adjusts the first indicated pacing interval for paced beats. The system regularizes ventricular rhythms by pacing the ventricle, but inhibits pacing when the ventricular rhythms are stable.

Claims

1. A method of delivering biventricular coordination therapy, comprising:

initiating an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event paced or sensed using one or more atrial electrodes;

decreasing the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, if an intrinsic ventricular depolarization is sensed before expiration of the atrioventricular pacing delay for the first cardiac cycle; and

delivering the biventricular coordination therapy during the second cardiac cycle, using one or more right ventricular electrodes and one or more left ventricular electrodes separate from the one or more right ventricular electrodes, using the decreased atrioventricular pacing delay.

2. The method of claim 1, wherein initiating the atrioventricular pacing delay relative to the atrial event comprises initiating the atrioventricular pacing delay relative to an intrinsic atrial depolarization sensed using the one or more atrial electrodes.

3. The method of claim 1, wherein initiating the atrioventricular pacing delay relative to the atrial event comprises initiating the atrioventricular pacing delay relative to delivery of an atrial pacing pulse using the one or more atrial electrodes.

4. The method of claim 1, wherein delivering the biventricular coordination therapy comprises, using the decreased atrioventricular pacing delay, pacing the left ventricle using the one or more left ventricular electrodes, and pacing the right ventricle using the one or more right ventricular electrodes.

5. The method of claim 4, wherein pacing the left ventricle and pacing the right ventricle comprises pacing at least a first one of the left and the right ventricle after the decreased atrioventricular pacing delay.

6. The method of claim 4, further comprising sensing for the intrinsic ventricular depolarization using the one or more right ventricular electrodes.

7. The method of claim 6, wherein pacing the right ventricle and sensing for the intrinsic ventricular depolarization using the one or more right ventricular electrodes comprises pacing and sensing using a common electrode of the one or more right ventricular electrodes.

8. The method of claim 6, wherein pacing the right ventricle and sensing for the intrinsic ventricular depolarization using the one or more right ventricular electrodes comprises pacing and sensing using different electrodes of the one or more right ventricular electrodes.

9. The method of claim 4, further comprising sensing for the intrinsic ventricular depolarization using the one or more left ventricular electrodes.

10. The method of claim 9, wherein pacing the left ventricle and sensing for the intrinsic ventricular depolarization using the one or more left ventricular electrodes comprises pacing and sensing using a common electrode of the one or more left ventricular electrodes.

11. The method of claim 9, wherein pacing the left ventricle and sensing for the intrinsic ventricular depolarization using the one or more left ventricular electrodes comprises pacing and sensing using a different electrode of the one or more left ventricular electrodes.

12. The method of claim 1, wherein delivering the biventricular coordination therapy comprises:

sensing, during the second cardiac cycle, for an intrinsic depolarization of the right ventricle using the one or more right ventricular electrodes; and

pacing the left ventricle, during the second cardiac cycle, using the one or more left ventricular electrodes using an interventricular pacing delay.

13. The method of claim 1, wherein delivering the biventricular coordination therapy comprises:

sensing, during the second cardiac cycle, for an intrinsic depolarization of the left ventricle using the one or more left ventricular electrodes; and

pacing the right ventricle, during the second cardiac cycle, using the one or more right ventricular electrodes using an interventricular pacing delay.

14. The method of claim 1, wherein delivering the biventricular coordination therapy comprises:

sensing, during the second cardiac cycle, for an intrinsic depolarization of one of the right ventricle or left ventricle using the respective one or more right or left ventricular electrodes; and

pacing both the left ventricle and right ventricle, during the second cardiac cycle, using the one or more left ventricular electrodes and the one or more right ventricular electrodes upon sensing the intrinsic depolarization.

15. The method of claim 1, wherein delivering the biventricular coordination therapy comprises delivering a first pacing pulse to the right ventricle using the one or more right ventricular electrodes and a second pacing pulse to the left ventricle using the one or more left ventricular electrodes, the first and the second pacing pulses delivered substantially simultaneously.

16. The method of claim 1, wherein the intrinsic ventricular depolarization sensed during the atrioventricular delay for the first cardiac cycle comprises a right ventricular intrinsic depolarization sensed using the one or more right ventricular electrodes.

17. The method of claim 1, wherein the intrinsic ventricular depolarization sensed during the atrioventricular delay for the first cardiac cycle comprises an left ventricular intrinsic depolarization sensed using the one or more left ventricular electrodes.

18. The method of claim 1, further comprising:

increasing the atrioventricular pacing delay for a third cardiac cycle, after the second cardiac cycle, if an intrinsic ventricular depolarization is not sensed during an atrioventricular pacing delay for a cardiac cycle immediately preceding the third cardiac cycle; and

delivering a biventricular coordination therapy during the third cardiac cycle using the increased atrioveritricular pacing delay.

19. The method of claim 18, wherein increasing the atrioventricular pacing delay for the third cardiac cycle if the intrinsic depolarization is not sensed during the atrioventricular pacing delay for the cardiac cycle immediately preceding the third cardiac cycle comprises increasing the atrioventricular pacing delay for the third cardiac cycle if a pace is delivered to the right ventricle or the left ventricle using the atrioventricular pacing delay for the cardiac cycle immediately preceding the third cardiac cycle.

20. The method of claim 1, wherein decreasing the atrioventricular pacing delay for the second cardiac cycle comprises decreasing the atrioventricular pacing delay based on an intrinsic atrioventricular interval.

21. The method of claim 1, further comprising limiting the atrioventricular pacing delay during a tachyarrhythmia episode.

22. The method of claim 1, further comprising limiting the atrioventricular pacing delay during an atrial tachyarrhythmia episode.

23. The method of claim 1, further comprising sensing hemodynamic need of a patient and decreasing the atrioventricular delay for the second cardiac cycle based on the sensed hemodynamic need of the patient.

24. The method of claim 1, further comprising sensing for the intrinsic ventricular depolarization using at least one of 1) the one or more right ventricular electrodes or 2) the one or more left ventricular electrodes.

25. The method of claim 1, wherein the second cardiac cycle immediately follows the first cardiac cycle.

26. The method of claim 1, wherein delivering the biventricular coordination therapy includes at least one of pacing a right ventricle and sensing for a right ventricular intrinsic depolarization and at least one of pacing a left ventricle and sensing for a left ventricular depolarization.

27. The method of claim 1, wherein the decreasing the atrioventricular pacing delay comprises decreasing the atrioventricular pacing delay within a predetermined limit.

28. The method of claim 27, wherein the predetermined limit comprises a minimum atrioventricular pacing delay.

29. A method of delivering biventricular coordination therapy, comprising:

initiating an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event paced or sensed using one or more atrial electrodes;

modifying the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, if an intrinsic ventricular depolarization is sensed before expiration of the atrioventricular pacing delay for the first cardiac cycle; and

delivering the biventricular coordination therapy during the second cardiac cycle using one or more right ventricular electrodes and one or more left ventricular electrodes separate from the one or more right ventricular electrodes using the decreased atrioventricular pacing delay.

30. A method of delivering biventricular coordination therapy, comprising:

sensing an atrium using one or more atrial electrodes;

sensing and pacing a right ventricle using one or more right ventricular electrodes;

pacing a left ventricle using one or more left ventricular electrodes;

initiating an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event that is paced or sensed using the one or more atrial electrodes;

sensing an intrinsic ventricular depolarization using the one or more right ventricular electrodes before expiration of the atrioventricular pacing delay;

decreasing the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, after sensing the intrinsic ventricular depolarization using the one or more right ventricular electrodes; and

in the second cardiac cycle, pacing the right ventricle using the one or more right ventricular electrodes and pacing the left ventricle using the one or more left ventricular electrodes using the decreased atrioventricular pacing delay.

31. The method of claim 30, further comprising, in a third cardiac cycle, occurring after the second cardiac cycle, increasing the atrioventricular pacing delay based on the delivery of a ventricular pace.

32. The method of claim 31, wherein the third cardiac cycle immediately follows the second cardiac cycle.

33. A biventricular coordination therapy device, comprising:

one or more atrial electrodes for electrically coupling to an atrium;

one or more right ventricular electrodes for electrically coupling to a right ventricle;

one or more left ventricular electrodes for electrically coupling to a left ventricle; and

a pulse generator coupled to the one or more atrial electrodes, the one or more right ventricular electrodes, and the one or more left ventricular electrodes, the pulse generator configured to initiate an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event paced or sensed using the one or more atrial electrodes, decrease the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, if an intrinsic ventricular depolarization is sensed during the atrioventricular pacing delay for the first cardiac cycle, and deliver the biventricular coordination therapy during the second cardiac cycle using the one or more right ventricular electrodes and the one or more left ventricular electrodes using the decreased atrioventricular pacing delay.

34. The device of claim 33, wherein the pulse generator is configured to initiate the atrioventricular pacing delay relative to an intrinsic atrial depolarization.

35. The device of claim 33, wherein the pulse generator is configured to initiate the atrioventricular pacing delay relative to an atrial pacing pulse.

36. The device of claim 33, wherein the pulse generator is configured to, using the decreased atrioventricular pacing delay, deliver a right ventricular pacing pulse to the right ventricle using the one or more right ventricular electrodes and deliver a left ventricular pacing pulse to the left ventricle using the one or more left ventricular electrodes.

37. The device of claim 36, wherein the pulse generator is configured to deliver at least a first one of the right ventricular pacing pulse and the left ventricular pacing pulse after the decreased atrioventricular delay.

38. The device of claim 36, wherein the pulse generator is configured to sense for the intrinsic ventricular depolarization using the one or more right ventricular electrodes.

39. The device of claim 38, wherein the pulse generator is configured to use a common electrode of the one or more right ventricular electrodes to sense for the intrinsic ventricular depolarization and deliver the right ventricular pacing pulse to the right ventricle.

40. The device of claim 38, wherein the pulse generator is configured to use one electrode of the one or more right ventricular electrodes to sense for the intrinsic ventricular depolarization and another of the one or more right ventricular electrodes to deliver the right ventricular pacing pulse to the right ventricle.

41. The device of claim 36, wherein the pulse generator is configured to sense for the intrinsic ventricular depolarization using the one or more left ventricular electrodes.

42. The device of claim 41, wherein the pulse generator is configured to use a common electrode of the one or more left ventricular electrodes to sense for the intrinsic ventricular depolarization and deliver the left ventricular pacing pulse to the left ventricle.

43. The device of claim 41, wherein the pulse generator is configured to use one electrode of the one or more left ventricular electrodes to sense for the intrinsic ventricular depolarization and another of the one or more left ventricular electrodes to deliver the left ventricular pacing pulse to the left ventricle.

44. The device of claim 33, wherein the pulse generator is configured to sense, during the second cardiac cycle, for an intrinsic depolarization of the right ventricle using the one or more right ventricular electrodes and to deliver, during the second cardiac cycle, a pacing pulse to the left ventricle using the one or more left ventricular electrodes using an interventricular pacing delay.

45. The device of claim 33, wherein the pulse generator is configured to sense, during the second cardiac cycle, for an intrinsic depolarization of the left ventricle using the one or more left ventricular electrodes and to deliver, during the second cardiac cycle, a pacing pulse to the right ventricle using the one or more right ventricular electrodes using an interventricular pacing delay.

46. The device of claim 33, wherein the pulse generator is configured to sense, during the second cardiac cycle, for an intrinsic depolarization of one of the right ventricle and the left ventricle and, upon sensing the intrinsic depolarization, pace the left ventricle using the one or more left ventricular electrodes during the second cardiac cycle and pace the right ventricle using the one or more right ventricular electrodes during the second cardiac cycle.

47. The device of claim 33, wherein the pulse generator is configured to deliver a first pacing pulse to the right ventricle using the one or more right ventricular electrodes and deliver a second pacing pulse to the left ventricle using the one or more left ventricular electrodes, the first and the second pacing pulses delivered substantially simultaneously.

48. The device of claim 33, wherein the pulse generator is configured use the one or more right ventricular electrodes to sense a right ventricular intrinsic depolarization during the atrioventricular delay for the first cardiac cycle.

49. The device of claim 33, wherein the pulse generator is configured use the one or more right left electrodes to sense a left ventricular intrinsic depolarization during the atrioventricular delay for the first cardiac cycle.

50. The device of claim 33, wherein the pulse generator is configured to increase the atrioventricular pacing delay for a third cardiac cycle, occurring after the second cardiac cycle, if an intrinsic ventricular depolarization is not sensed during an atrioventricular pacing delay for a cardiac cycle immediately preceding the third cardiac cycle and deliver biventricular coordination therapy during the third cardiac cycle using the increased atrioventricular delay.

51. The device of claim 50, wherein the pulse generator is configured to increase the atrioventricular pacing delay for the third cardiac cycle if a pace is delivered to the right ventricle or the left ventricle using the atrioventricular pacing delay for the cardiac cycle immediately preceding the third cardiac cycle.

52. The device of claim 33, wherein the pulse generator is configured to decrease the atrioventricular pacing delay for the second cardiac cycle based on an intrinsic atrioventricular interval.

53. The device of claim 33, wherein the pulse generator is configured to limit the atrioventricular pacing delay during a tachyarrhythmia episode.

54. The device of claim 33, wherein the pulse generator is configured to limit the atrioventricular pacing delay during an atrial tachyarrhythmia episode.

55. The device of claim 33, further comprising a sensing system configured to sense hemodynamic need of a patient, wherein the pulse generator is configured to adjust the atrioventricular pacing delay based on the sensed hemodynamic need of the patient.

56. The device of claim 55, wherein the sensing system comprises an activity sensor.

57. The device of claim 55, wherein the sensing system comprises a respiration sensor.

58. The device of claim 33, wherein the pulse generator is configured to sense for the intrinsic ventricular depolarization using at least one of 1) the one or more right ventricular electrodes or 2) the one or more left ventricular electrodes.

59. The device of claim 33, wherein the second cardiac cycle immediately follows the first cardiac cycle.

60. The device of claim 33, wherein the biventricular coordination therapy comprises at least one of pacing a right ventricle and sensing for a right ventricular intrinsic depolarization and at least one of pacing a left ventricle and sensing for a left ventricular depolarization.

61. The device of claim 33, wherein the pulse generator is configured to decrease the atrioventricular pacing delay within a predetermined limit.

62. The device of claim 61, wherein the predetermined limit comprises a minimum atrioventricular pacing delay.

63. A biventricular coordination therapy device, comprising:

one or more atrial electrodes configured to implement at least one of sensing and pacing an atrium;

one or more right ventricular electrodes configured to implement at least one of sensing and pacing a right ventricle;

one or more left ventricular electrodes configured to implement at least one of sensing and pacing a left ventricle; and

a pulse generator coupled to the one or more atrial electrodes, the one or more right ventricular electrodes, and the one or more left ventricular electrodes, the pulse generator configured to initiate an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event paced or sensed using the one or more atrial electrodes, modify the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, if an intrinsic ventricular depolarization is sensed before expiration of the atrioventricular pacing delay for the first cardiac cycle, and deliver a biventricular coordination therapy during the second cardiac cycle using the one or more right ventricular electrodes and the one or more left ventricular electrodes separate from the one or more right ventricular electrodes using the modified atrioventricular pacing delay.

64. A biventricular coordination therapy device, comprising:

one or more atrial electrodes configured to sense an atrium;

one or more right ventricular electrodes configured to sense and pace a right ventricle;

one or more left ventricular electrodes configured to pace a left ventricle; and

a pulse generator coupled to the one or more atrial electrodes, the one or more right ventricular electrodes, and the one or more left ventricular electrodes, the pulse generator configured to initiate an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event paced or sensed using the one or more atrial electrodes, decrease the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, after sensing an intrinsic ventricular depolarization before expiration of the atrioventricular pacing delay for the first cardiac cycle, and, during the second cardiac cycle, pace the right ventricle using the one or more right ventricular electrodes and pace the left ventricle using the one or more left ventricular electrodes using the decreased atrioventricular pacing delay.

65. The device of claim 64, wherein the pulse generator is configured to increase the atrioventricular pacing delay for a third cardiac cycle, occurring after the second cardiac cycle, based on the delivery of a ventricular pace during the second cardiac cycle.

66. The device of claim 65, wherein the third cardiac cycle immediately follows the second cardiac cycle.

67. A system for delivering biventricular coordination therapy to a patient, comprising:

means for initiating an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event paced or sensed using one or more atrial electrodes;

means for decreasing the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, if an intrinsic ventricular depolarization is sensed before expiration of the atrioventricular pacing delay for the first cardiac cycle; and

means for delivering the biventricular coordination therapy during the second cardiac cycle, using one or more right ventricular electrodes and one or more left ventricular electrodes separate from the one or more right ventricular electrodes, using the decreased atrioventricular pacing delay.

68. The system of claim 67, further comprising:

means for sensing, during the second cardiac cycle, for an intrinsic depolarization of the right ventricle using the one or more right ventricular electrodes; and

means for pacing the left ventricle, during the second cardiac cycle, using the one or more left ventricular electrodes using an interventricular pacing delay.

69. The system of claim 67, further comprising:

means for sensing, during the second cardiac cycle, for an intrinsic depolarization of the left ventricle using the one or more left ventricular electrodes; and

means for pacing the right ventricle, during the second cardiac cycle, using the one or more right ventricular electrodes using an interventricular pacing delay.

70. The system of claim 67, further comprising:

means for sensing, during the second cardiac cycle, for an intrinsic depolarization of one of the right ventricle or left ventricle using the respective one or more right or left ventricular electrodes; and

means for pacing both the left ventricle and right ventricle, during the second cardiac cycle, using the one or more left ventricular electrodes and the one or more right ventricular electrodes upon sensing the intrinsic depolarization.

71. The system of claim 67, further comprising:

means for increasing the atrioventricular pacing delay for a third cardiac cycle, after the second cardiac cycle, if an intrinsic ventricular depolarization is not sensed during an atrioventricular pacing delay for a cardiac cycle immediately preceding the third cardiac cycle; and

means for delivering a biventricular coordination therapy during the third cardiac cycle using the increased atrioventricular pacing delay.

72. The system of claim 67, further comprising means for decreasing the atrioventricular pacing delay within a predetermined limit.

73. The system of claim 67, further comprising means for sensing hemodynamic need of the patient and decreasing the atrioventricular delay for the second cardiac cycle based on the sensed hemodynamic need of the patient.

74. A system for delivering biventricular coordination therapy, comprising:

means for initiating an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event paced or sensed using one or more atrial electrodes;

means for modifying the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, if an intrinsic ventricular depolarization is sensed before expiration of the atrioventricular pacing delay for the first cardiac cycle; and

means for delivering the biventricular coordination therapy during the second cardiac cycle using one or more right ventricular electrodes and one or more left ventricular electrodes separate from the one or more right ventricular electrodes using the decreased atrioventricular pacing delay.

75. A system for delivering biventricular coordination therapy, comprising:

means for sensing an atrium using one or more atrial electrodes;

means for sensing and pacing a right ventricle using one or more right ventricular electrodes;

means for pacing a left ventricle using one or more left ventricular electrodes;

means for initiating an atrioventricular pacing delay for a first cardiac cycle relative to an atrial event that is paced or sensed using the one or more atrial electrodes;

means for sensing an intrinsic ventricular depolarization using the one or more right ventricular electrodes before expiration of the atrioventricular pacing delay;

means for decreasing the atrioventricular pacing delay for a second cardiac cycle, occurring after the first cardiac cycle, after sensing the intrinsic ventricular depolarization using the one or more right ventricular electrodes; and

in the second cardiac cycle, means for pacing the right ventricle using the one or more right ventricular electrodes and pacing the left ventricle using the one or more left ventricular electrodes using the decreased atrioventricular pacing delay.

76. The method of claim 75, further comprising means for increasing, in a third cardiac cycle, occurring after the second cardiac cycle, the atrioventricular pacing delay based on the delivery of a ventricular pace.

77. A method for operating a cardiac pacemaker, comprising:

sensing a ventricle so as to detect a ventricular sense upon depolarization occurring in the ventricle;

pacing a ventricle upon expiration of an atrio-ventricular escape interval initiated by an atrial event and stopped by a ventricular sense;

measuring an intrinsic atrio-ventricular interval as the time between an atrial event and a ventricular sense when no ventricular pace is delivered;

decreasing the atrio-ventricular escape interval upon detection of a ventricular sense in a manner dependent upon the measured intrinsic atrio-ventricular interval; and

,

if no subsequent ventricular sense is detected, increasing the atrio-ventricular escape interval.

78. The method of claim 77, further comprising delivering paces to both the right and left ventricles upon expiration of the atrio-ventricular escape interval.

79. The method of claim 77, wherein the atrial event initiating the atrio-ventricular escape interval is an atrial pace.

80. The method of claim 77, wherein the atrial event initiating the atrio-ventricular escape interval is an atrial sense.

81. The method of claim 77, wherein the atrio-ventricular escape interval is decreased by computing a weighted average of the measured intrinsic atrio-ventricular interval multiplied by a scaling factor and the atrio-ventricular escape interval.

82. The method of claim 81, wherein the atrio-ventricular escape interval is decreased in accordance with the measured intrinsic atrio-ventricular interval after each ventricular sense.

83. The method of claim 82, wherein the atrio-ventricular escape interval is increased after each ventricular pace by multiplying the atrio-ventricular escape interval by a specified filter coefficient.