Atrial tracking confirmation in an intracardiac ventricular pacemaker

• US 10,744,329 B2
• Filed: 07/05/2018
• Issued: 08/18/2020
• Est. Priority Date: 07/07/2017
• Status: Active Grant

• Current Assignee: Medtronic Incorporated (Medtronic Plc)
• Original Assignee: Medtronic Incorporated (Medtronic Plc)
• Inventors: Sheldon, Todd J., Demmer, Wade M., Herr, Greggory R.
• Primary Examiner(s): Hulbert, Amanda K
• Assistant Examiner(s): Edwards, Philip C
• Application Number:
  US16/027,717
• Publication Number:
  US 20190009095A1
• Time in Patent Office: 775 Days
• Field of Search: 607 18
• CPC Class Codes: A61B 5/1102 Ballistocardiography
• CPC Class Codes: A61B 5/352 Detecting R peaks, e.g. for synchronising diagnostic apparatus; Estimating R-R interval
• CPC Class Codes: A61B 5/4836 Diagnosis combined with treatment in closed-loop systems or methods A61B5/0036 takes precedence
• CPC Class Codes: A61B 5/686 Permanently implanted devices, e.g. pacemakers, other stimulators, biochips A61B5/6861 takes precedence
• CPC Class Codes: A61B 5/7282 Event detection, e.g. detecting unique waveforms indicative of a medical condition A61B5/4094, A61B5/4818, A61B5/349, A61B5/0823 take precedence
• CPC Class Codes: A61N 1/0573 chacterised by means penetrating the heart tissue, e.g. helix needle or hook
• CPC Class Codes: A61N 1/36121 Production of neurotransmitters; Modulation of genes expression
• CPC Class Codes: A61N 1/36578 controlled by mechanical motion of the heart wall, e.g. measured by an accelerometer or microphone
• CPC Class Codes: A61N 1/3682 with a variable atrioventricular delay
• CPC Class Codes: A61N 1/37205 Microstimulators, e.g. implantable through a cannula
• CPC Class Codes: A61N 1/37217 characterised by the communication link, e.g. acoustic or tactile
• CPC Class Codes: A61N 1/3756 Casings with electrodes thereon, e.g. leadless stimulators

Abstract

A pacemaker having a motion sensor delivers atrial-synchronized ventricular pacing by detecting events from a signal produced by the motion sensor and delivering ventricular pacing pulses at a rate that tracks the rate of the detected events. The pacemaker is configured to confirm atrial tracking of the ventricular pacing pulses by determining if detected events from the motion sensor signal are atrial events. The pacemaker is configured to adjust a control parameter used for detecting events from the motion sensor signal if atrial tracking is not confirmed.

Claims

1. An intracardiac pacemaker, comprising:

a pulse generator configured to deliver pacing pulses to a ventricle of a patient'"'"'s heart via electrodes coupled to the pacemaker;

a motion sensor configured to generate a signal that indicates an atrial event attendant to atrial motion and at least one ventricular event attendant to ventricular motion during each cardiac cycle; and

a control circuit coupled to the motion sensor and the pulse generator and configured to;

detect a first event from the motion sensor signal;

set an atrioventricular (AV) interval in response to detecting the first event;

controlling the pulse generator to deliver a first ventricular pacing pulse in response to the AV interval expiring;

withhold delivering a second ventricular pacing pulse for one cardiac cycle;

detect a second event from the motion sensor signal following the first event;

confirm that the first event is the atrial event in response to the second event occurring at least a threshold time interval since the first ventricular pacing pulse; and

deliver a therapy based on confirming that the first event is the atrial event.

2. The intracardiac pacemaker of claim 1, wherein the control circuit is configured to confirm the first event is an atrial event in response to the second event occurring at twice a ventricular rate interval from the first event.

3. The intracardiac pacemaker of claim 1, wherein the control circuit is configured to withhold delivering the second ventricular pacing pulse by extending a refractory period set in response to delivering the first ventricular pacing pulse.

4. The intracardiac pacemaker of claim 3, wherein the control circuit is further configured to:

determine a time interval from a ventricular event to a previously detected atrial event of the motion sensor signal;

extend the refractory period by setting the refractory period to be longer than the time interval.

5. The intracardiac pacemaker of claim 1, wherein the control circuit is further configured to:

determine a ventricular event interval ending on the first ventricular pacing pulse and beginning on a most recent preceding ventricular event;

update a ventricular rate interval using the ventricular event interval; and

withhold delivering the second ventricular pacing pulse by adjusting a ventricular pacing interval from a first value to a second value, the second value being at least twice the ventricular rate interval.

6. The intracardiac pacemaker of claim 1, wherein the control circuit is further configured to:

adjust the ventricular pacing interval from the second value back to the first value in response to confirming that the first event is the atrial event.

7. The intracardiac pacemaker of claim 1, wherein the control circuit is further configured to:

establish a first value of a refractory period;

in response to confirming that the first event is an atrial event, adjust the refractory period to the first value;

identify a ventricular event following the detected second event; and

start the refractory period set to the first value in response to identifying the ventricular event.

8. The intracardiac pacemaker of claim 7, wherein the control circuit is further configured to:

establish the first value of the refractory period by determining a median ventricular event interval and setting the first value based on the median ventricular event interval;

update the median ventricular event interval in response to the first ventricular pacing pulse; and

update the first value of the refractory period based on the updated median ventricular event interval.

9. The intracardiac pacemaker of claim 1, wherein the control circuit is further configured to:

set an event detection threshold amplitude;

detect each of the first event and the second event in response to respective first and second crossings of the event detection threshold amplitude by the motion sensor signal.

10. The intracardiac pacemaker of claim 1, wherein the control circuit is further configured to:

set a time window ending after an expected time of the ventricular event of the motion sensor signal;

set an event detection threshold amplitude to a first value during the time window;

set the event detection threshold amplitude to a second value less than the first value after the time window; and

detect the first event from the motion sensor signal in response to the motion sensor signal crossing the event detection threshold amplitude.

11. The intracardiac pacemaker of claim 1, wherein the control circuit is further configured to:

determine a ventricular rate; and

withhold delivering the second ventricular pacing pulse in response to the ventricular rate being greater than an atrial tracking confirmation threshold rate.

12. The intracardiac pacemaker of claim 11, wherein the control circuit is further configured to:

start a timer in response to confirming that the first event is the atrial event;

update the ventricular rate in response to a plurality of ventricular events subsequent to confirming that the first event is the atrial event; and

in response to the updated ventricular rate being greater than the atrial tracking confirmation threshold rate, withhold a third ventricular pacing pulse in response to the timer expiring to confirm that a third event detected from the motion sensor signal is an atrial event.

13. The intracardiac pacemaker of claim 1, wherein the control circuit is further configured to:

determine that the detected first event is not the atrial event in response to the second event occurring earlier than the threshold time interval since the first ventricular pacing pulse; and

limit a maximum atrial-tracking ventricular pacing rate of the pacing pulses delivered by the pulse generator in response to determining that the first event is not the atrial event.

14. The intracardiac pacemaker of claim 13, wherein the control circuit is configured to:

withhold delivering the second ventricular pacing pulse by adjusting a refractory period applied to the motion sensor signal from a first value to a second value greater than the first value and starting the adjusted refractory period in response to delivering the first ventricular pacing pulse; and

limit the maximum atrial-tracking ventricular pacing rate by maintaining the adjusted refractory period at the second value for a plurality of cardiac cycles.

15. The intracardiac pacemaker of claim 14, wherein the control circuit is configured to:

deliver a ventricular pacing pulse at the AV interval after each event detected from the motion sensor signal outside the refractory period set to the second value;

adjust the refractory period from the second value to a third value less than the second value after the plurality of cardiac cycles; and

reconfirm atrial tracking of the delivered ventricular pacing pulses after adjusting the refractory period from the second value to the third value.

16. The intracardiac pacemaker of claim 13, wherein the control circuit is configured to:

increase an oversensing counter value in response to determining that the first event is not the atrial event;

compare the oversensing counter value to a threshold; and

in response to the oversensing counter value reaching the threshold, limit the maximum atrial-tracking ventricular pacing rate of pacing pulses delivered by the pulse generator by setting a minimum limit to a refractory period applied to the motion sensor signal, wherein motion sensor signal events occurring during the refractory period are not used to set an AV interval.

17. The intracardiac pacemaker of claim 1, wherein the control circuit is configured to:

determine that the first event is not the atrial event in response to the second event occurring earlier than the threshold time interval since the first ventricular pacing pulse; and

responsive to determining that the first event is not the atrial event, adjusting a control parameter used by the control circuit for detecting events from the motion sensor signal.

18. The intracardiac pacemaker of claim 17, wherein the control circuit is configured to adjust the control parameter by adjusting at least one of:

a refractory period applied to the motion sensor signal, an atrial event detection threshold, a ventricular event detection threshold, and a ventricular event time window.

19. The intracardiac pacemaker of claim 1, wherein the control circuit is configured to:

identify a plurality of ventricular events;

determine a ventricular event interval from the identified ventricular events;

determine that the detected first event is not the atrial event in response to the second event occurring earlier than the threshold time interval since the first ventricular pacing pulse; and

adjust a ventricular pacing interval from a first time interval to the ventricular event interval in response to determining that the detected first event is not the atrial event.

20. The intracardiac pacemaker of claim 19, wherein the control circuit is configured to:

gradually increase the ventricular pacing interval from the ventricular event interval to the first time interval.

21. A method performed by an intracardiac ventricular pacemaker, the method comprising:

detecting by a control circuit of the pacemaker a first event from a motion sensor signal produced by a motion sensor, the motion sensor signal comprising an atrial event attendant to each atrial contraction and at least one ventricular event attendant to ventricular motion during each ventricular cardiac cycle;

setting an atrioventricular (AV) interval in response to detecting the first event;

controlling a pulse generator to deliver a first ventricular pacing pulse in response to the AV interval expiring;

withholding delivering a second ventricular pacing pulse for one cardiac cycle;

detecting a second event from the motion sensor signal following the first event;

confirming that the first event is the atrial event in response to the second event occurring at least a threshold time interval since the first ventricular pacing pulse, and

confirming atrial tracking of pacing pulses delivered by the pacemaker in response to confirming that the first event is the atrial event.

22. The method of claim 21, further comprising confirming that the first event is the atrial event in response to the second event occurring at twice a ventricular rate interval from the first event.

23. The method of claim 21, further comprising withholding delivering the second ventricular pacing pulse by extending a refractory period set in response to delivering the first ventricular pacing pulse.

24. The method of claim 23, further comprising:

determining a time interval from a ventricular event to a previously detected atrial event of the motion sensor signal;

extending the refractory period by setting the refractory period to be longer than the time interval.

25. The method of claim 21, further comprising:

determining a ventricular event interval ending on the first ventricular pacing pulse and beginning on a most recent preceding ventricular event;

updating a ventricular rate interval using the ventricular event interval; and

withholding delivering the second ventricular pacing pulse by adjusting a ventricular pacing interval from a first value to a second value, the second value being at least twice the ventricular rate interval.

26. The method of claim 25, further comprising:

adjusting the ventricular pacing interval from the second value back to the first value in response to confirming that the first event is the atrial event.

27. The method of claim 21, further comprising:

establishing a first value of a refractory period;

in response to confirming that the first event is an atrial event, adjusting the refractory period to the first value;

identifying a ventricular event following the detected second event; and

starting the refractory period set to the first value in response to identifying the ventricular event.

28. The method of claim 21, further comprising:

establishing the first value of a refractory period by determining a median ventricular event interval and setting the first value based on the median ventricular event interval;

updating the median ventricular event interval in response to the first ventricular pacing pulse; and

updating the first value of the refractory period based on the updated median ventricular event interval.

29. The method of claim 21, further comprising:

setting an event detection threshold amplitude;

detecting each of the first event and the third event in response to respective first and second crossings of the event detection threshold amplitude by the motion sensor signal.

30. The method of claim 21, further comprising:

setting a time window ending after an expected time of the ventricular event of the motion sensor signal; and

setting an event detection threshold amplitude to a first value during the time window;

setting the event detection threshold amplitude to a second value less than the first value after the time window; and

detecting the first event from the motion sensor signal in response to the motion sensor signal crossing the event detection threshold amplitude.

31. The method of claim 21, further comprising:

determining a ventricular rate; and

withholding delivering the second ventricular pacing pulse in response to the ventricular rate being greater than an atrial tracking confirmation threshold rate.

32. The method of claim 31, further comprising:

starting a timer in response to confirming that the first event is the atrial event;

updating the ventricular rate subsequent to confirming that the first event is the atrial event; and

in response to the updated ventricular rate being greater than the atrial tracking confirmation threshold rate, withhold a third ventricular pacing pulse in response to the timer expiring to confirm that a third event detected from the motion sensor signal is an atrial event.

33. The method of claim 21, further comprising:

determining that the detected first event is not the atrial event in response to the second event occurring earlier than the threshold time interval since the first ventricular pacing pulse; and

limiting a maximum atrial-tracking ventricular pacing rate of pacing pulses delivered by the pulse generator in response to determining that the first event is not the atrial event.

34. The method of claim 33, further comprising:

withholding delivering the second ventricular pacing pulse by adjusting a refractory period applied to the motion sensor signal from a first value to a second value greater than the first value and starting the adjusted refractory period in response to delivering the first ventricular pacing pulse; and

limiting the maximum atrial-tracking ventricular pacing rate by maintaining the adjusted refractory period at the second value for a plurality of cardiac cycles.

35. The method of claim 34, further comprising:

delivering a ventricular pacing pulse at the AV interval after each event detected from the motion sensor signal outside the refractory period set to the second value;

adjusting the refractory period from the second value to a third value less than the second value after the plurality of cardiac cycles; and

reconfirming atrial tracking of the delivered ventricular pacing pulses after adjusting the refractory period from the second value to the third value.

36. The method of claim 33, further comprising:

increasing an oversensing counter value in response to determining that the first event is not the atrial event;

comparing the oversensing counter value to a threshold; and

in response to the oversensing counter value reaching the threshold, limiting a maximum atrial-tracking ventricular pacing rate of pacing pulses delivered by the pulse generator by setting a minimum limit to a refractory period applied to the motion sensor signal, wherein motion sensor signal events occurring during the refractory period are not used to set an AV interval.

37. The method of claim 21, further comprising:

determining that the first event is not the atrial event in response to the second event occurring earlier than the threshold time interval since the first ventricular pacing pulse; and

responsive to determining that the first event is not the atrial event, adjusting a control parameter used by the control circuit in detecting events from the motion sensor signal.

38. The method of claim 37, further comprising adjusting the control parameter by adjusting at least one of:

a refractory period applied to the motion sensor signal, an atrial event detection threshold, a ventricular event detection threshold, and a ventricular event time window.

39. The method of claim 21, further comprising:

identifying a plurality of ventricular events;

determining a ventricular event interval from the identified ventricular events;

determining that the first event is not the atrial event in response to the second event occurring earlier than a threshold time interval since the first ventricular pacing pulse; and

adjusting a ventricular pacing interval from a first time interval to the ventricular event interval in response to determining that the detected first event is not the atrial event.

40. The method of claim 39, further comprising:

gradually increasing the ventricular pacing interval from the ventricular event interval to the first time interval.

41. A non-transitory computer-readable medium storing a set of instructions which when executed by a control circuit of an intracardiac ventricular pacemaker having a motion sensor, cause the pacemaker to confirm atrial tracking of pacing pulses delivered by the pacemaker by:

detecting a first event from the motion sensor signal;

setting an atrioventricular (AV) interval in response to detecting the first event;

delivering a first ventricular pacing pulse in response to the AV interval expiring;

withholding delivering a second ventricular pacing for one cardiac cycle;

detecting a third event from the motion sensor signal following the first event;

confirming that the first event is the atrial event in response to the second event occurring at least a threshold time interval since the first ventricular pacing pulse; and

confirming atrial tracking of pacing pulses delivered by the pacemaker in response to confirming that the first event is the atrial event.

42. A pacemaker comprising:

a pulse generator configured to deliver pacing pulses to a ventricle of a patient'"'"'s heart via electrodes coupled to the pacemaker;

a motion sensor configured to produce a signal comprising an atrial event attendant to atrial motion and at least one ventricular event attendant to ventricular motion during each cardiac cycle; and

a control circuit coupled to the motion sensor and the pulse generator and configured to;

detect a plurality of events from the motion sensor signal;

during an atrial-synchronized ventricular pacing mode, control the pulse generator to deliver the pacing pulses at a rate that is tracked to the detected plurality of events;

confirm whether the detected plurality of events from the motion sensor signal are atrial events;

return to the atrial-synchronized ventricular pacing mode in response to confirming that the detected plurality of events are the atrial events; and

adjust a control parameter used to detect events from the motion sensor signal in response to not confirming that the detected plurality of events are the atrial events.

43. The pacemaker of claim 42, wherein the control circuit is configured to confirm whether the detected plurality of events are atrial events by:

detecting a first event from the motion sensor signal;

setting an atrioventricular (AV) interval in response to detecting the first event;

controlling the pulse generator to deliver a first ventricular pacing pulse in response to the AV interval expiring;

withholding delivering a second ventricular pacing pulse following the first ventricular pacing pulse;

detecting a second event from the motion sensor signal following the first event;

confirming that the detected plurality of events are the atrial events each attendant to an atrial contraction in response to the second event occurring at least a threshold time interval since the first ventricular pacing pulse; and

not confirming that the detected plurality of events are the atrial events in response to the second event occurring less than the threshold time interval since the first ventricular pacing pulse.