In Vitro Evaluation of a Sensor Sensitive to Acceleration Forces Included in a New Rate Modulated Pacemaker

The characteristics of the sensor and rate adaptive algorithm included in a new dual chamber rate responsive pacemaker (Relay 294–03, Intermedics, Inc.) were studied by submitting the device to calibrated to-and-fro movements of specific frequencies and peak accelerations by means of a mechanical arm connected to a speed adapter. Atrial pacing rate was continuously recorded on a Holter monitor. The influences of the frequency, the magnitude, and the axis of the acceleration forces as well as the reproducibility of the rate response were evaluated. Results: (1) the sensor was sensitive to frequencies ranging from 0.5 to 7 Hz with a peak sensitivity at 3 Hz; (2) the pacing rate was not affected during movements at frequencies > 6 Hz, commonly presented as nonactivity related signals fear, bus transportation, drilling); (3) the pacing rate increased as a function of the acceleration magnitude up to 0.5 G (0.3 G for 3 Hz), then remained constant. This level of acceleration usually corresponds to high degrees of activity; (4) rate response was maximum when acceleration was directed in the anteroposterior direction; (5) reproducibility of the rate response was excellent (R²: 0.999; slope of the regression line: 0.999). Conclusion: Relay 294-03 is a low frequency signal sensing rate modulated pacemaker using an accelerometer sensitive to motion, mainly in the anteroposterior direction.     

Improved Accelerometer-Based Rate Adaptive Pacing by Means of Second-Generation Signal Processing

Accelerometer-based rate adaptive pacing has gained widespread clinical use. Limitations exist for the distinction between walking upstairs and downstairs. It was the aim of this study to evaluate a new signal processing algorithm for more physiological rate adaptation. A custom-made pacemaker incorporating an accelerometer was randomly fixed to the left or right chest of 16 pacemaker patients (7 females, age: 64 ± 11 years), 18 elderly study participants (6 females, age: 62 ± 11 years), and 15 students (7 females age: 23 ± 2 years). Study participants walked on level ground, upstairs and downstairs at five different step rates (72, 84, 96, 108, and 120 steps/min) controlled by an acoustic quartz metronome. The accelerometer signals, recorded on a portable data recorder, were analyzed with respect to frequency content, peak average of the mean acceleration, and morphology characteristics of the acceleration signal above and belowzero baseline. By calculating the quotient of the signal's duration above and below zero baseline, a reliable discrimination between walking upstairs and downstairs was possible. A correction of the Leaky integrator signal by the new quotient yielded a more adequate rate adaptation to walking up and downstairs to represent at the patient's daily life activities. A more physiological rate adaptation can be achieved when using not only the accelerometer signal's amplitude, but applying additionally the morphology criterium of the acceleration signal's content in the positive and negative direction.     

A Comparative Analysis of Signal Processing Methods for Motion-Based Rate Responsive Pacing

Pacemakers that augment heart rate (HR) by sensing body motion have been the most frequently prescribed rate responsive pacemakers. Many comparisons between motion-based rate responsive pacemaker models have been published. However, conclusions regarding specific signal processing methods used for rate response (e.g., filters and algorithms) can be affected by device-specific features. To objectively compare commonly used motion sensing filters and algorithms, acceleration and ECG signals were recorded from 16 normal subjects performing exercise and daily living activities. Acceleration signals were filtered (1–4 or 15-Hz band-pass), then processed using threshold crossing (TC) or integration (IN) algorithms creating four filter/algorithm combinations. Data were converted to an acceleration indicated rate and compared to intrinsic HR using root mean square difference (RMSd) and signed RMSd. Overall, the filters and algorithms performed similarly for most activities. The only differences between filters were for walking at an increasing grade (1–4 Hz superior to 15-Hz) and for rocking in a chair (15-Hz superior to 1–4 Hz). The only differences between algorithms were for bicycling (TC superior to IN), walking at an increasing grade (IN superior to TC), and holding a drill (IN superior to TC). Performance of the four filter/algorithm combinations was also similar over most activities. The 1–4/IN (filter [Hz]/algorithm) combination performed best for walking at a grade, while the 15/TC combination was best for bicycling. However, the 15/TC combination tended to be most sensitive to higher frequency artifact, such as automobile driving, downstairs walking, and hand drilling. Chair rocking artifact was highest for 1–4/IN. The RMSd for bicycling and upstairs walking were large for all combinations, reflecting the nonphysiological nature of the sensor. The 1–4/TC combination demonstrated the least intersubject variability, was the only filter/algorithm combination insensitive to changes in footwear, and gave similar RMSd over a large range of amplitude thresholds for most activities. In conclusion, based on overall error performance, the preferred filter/algorithm combination depended upon the type of activity.     

Selective Vibration Sensing: A New Concept for Activity-Sensing Rate-Responsive Pacing

A clinically available model of an activity-sensing, rate-responsive pacemaker (Activitrax, Medtronic) utilizes body vibration during exercise as an indicator of the need for a rate increase. Although having the advantage of rapid onset of rate response, this system lacks specificity and the rate response does not closely correlate with the level of exertion. In addition, this pacemaker is susceptible to the effects of extraneous vibration. In this study involving 20 normal subjects fitted with an external Activitrax pacemaker, the rate responses to a variety of exercises were studied and were compared with the corresponding sinus rates. The vibration generated at the level of the pacemaker was also measured by accelerometers in three axes. Only a fair correlation (r = 0.51) was achieved between the pacemaker rate and the sinus rate. The total root mean square value of acceleration in either the anteroposterior or the vertical axes was found to have a better correlation (r = 0.8). As the main accelerations during physical activities were in the lower frequency range (0.1-4 Hz), a low-pass filter was used to reduce the influence of extraneous vibration. Selective sensing of the acceleration level may be usefully implemented in an algorithm for activity pacing.     

Activity-Based Pacing: Comparison of a Device Using an Accelerometer Versus a Piezoelectric Crystal

The EXCEL VR, an accelerometer-based pacemaker (AC), and the Legend, a pacemaker utilizing a piezoelectric crystal (PZ), were compared under ergometric conditions and during stair climbing to assess the appropriateness of their rate responses. The pacemakers, programmed to the manufacturers' nominal settings in order to compare different technologically based sensors under identical conditions, were strapped over subjects' left mid-pectoral region. Placement of the devices was randomized to control for positional effects. Ten healthy subjects (55-72 years) completed a graded exercise treadmill test to 80% of maximum predicted heart rate (HR). An additional group of ten subjects (50-66 years) completed exercise protocols involving bicycle ergometry and stair climbing. Throughout all tests, pacemaker pulse rates and subjects' intrinsic HR were monitored continuously. For the treadmill exercise, the average correlations between the AC and PZ pacemakers' pulse rate and HR for the group as a whole were r = 0.92 and r = 0.82, respectively. Individual subject comparisons were also made between each pacemaker rate and intrinsic HR. The mean difference from intrinsic rate was 11 ppm for the AC pacemaker and 24 ppm for the PZ pacemaker. In addition, the PZ pacemaker's maximal pulse rate was significantly lower (105 +/- 9.6 ppm) than the other two rates (AC 137 +/- 6 ppm; intrinsic HR 129 +/- 2 beats/min). Throughout the bicycle ergometry testing, the intrinsic HR was higher than the AC and PZ pacing rates. However, the AC's rate was significantly higher than the PZ's rate. When subjects ascended stairs, the intrinsic HR and AC rate were closely correlated, but the PZ rate was significantly lower.(ABSTRACT TRUNCATED AT 250 WORDS)     

Electromagnetic interference in implantable pacemakers.

The inhibited pacemaker (VVI or AAI) has become the most popular in recent years because of its ability to combine a physiological advantage with economical current consumption in cases with spontaneous activity. One of its disadvantages is its sensitivity to external electromagnetic interference. Though today's pacemakers possess effective protection against most interference signals there may be instances in which patients are subjected to uncomfortable or even life-threatening situations. This is the case of "amplitude modulated" or "pulsed" fields with modulation frequencies in the physiological range. Fields of that sort have been found in the vicinity of a welder, an electric steel plant, and in medical practice where therapeutic currents were applied. Even touch-actuated switches may influence a demand pacemaker. However, these situations may be overcome by a device within the pacemaker for simple time analysis which can be carried out with few components. If electromagnetic fields of diathermy equipment are applied, today's pacemakers may react with intolerably high or low rates. They should, therefore, be avoided.     

Characteristics and Clinical Effects of Myopotential Signals in a Unipolar DDD Pacemaker Population

Myopotential signals were recorded from atrial and ventricular leads during isometric exercise in 25 patients who had chronically implanted dual chamber pacemakers using the electrogram telemetry capability of the pacemakers. Average electrogram amplitude on the atrial channel was 0.92 mV (range 0.3 to 1.9) and on the ventricular channel was 0.98 mV (range 0.3 to 2.2); the difference was not significant. There was a strong correlation (R = 0.82) between the amplitude of myopotentials on the atrial and ventricular leads for individual patients. Myopotential sensing caused ventricular output inhibition in two patients (8%) and ventricular tracking in sixteen patients (64%). Pacemaker reprogramming abolished ventricular myopotential inhibition in all patients and stopped ventricular myopotential tracking in seven patients. We conclude that myopotentials can be analyzed and their effects ameliorated by a multiprogrammable pacemaker with electrogram telemetry capability.     

Scoring Method for Assessing Rate Adaptive Pacemakers: Application to Two Different Activity Sensors

To optimize programming of rate adaptive pacemakers (RAPs), we explored a new mathematical method to assess the performance of RAPs during daily-life tests, using customized Windows-based software. By stepwise discriminant analysis and linear regression, this method allows calculation of the acceleration and deceleration capacity of pacemakers and their general behavior during effort and recovery phases. Twenty-three patients (10 females and 13 males; 68 ± 8 years) with chronic atrial fibrillation and a slow ventricular response were evaluated. They randomly received an accelerom-eter-controlled VVIR Dash Intermedics pacemaker (10 patients) or a vibration piezoelectric-controlled WIR Sensolog III Siemens pacemaker (13 patients). All patients underwent the same test protocol: 6 minutes walking, 1.5 minutes climbing stairs, 1.5 minutes descending stairs, and 0.5 minutes sit-ups. By definition, the pacemaker responsiveness slope was programmed so that the heart rate response of paced patients during the walking test corresponded best to that of healthy controls. The slope was left unchanged for the other tests. We considered four scores: an acceleration score (EA score), an effort rate score (ER score), a deceleration score (RD score), and a recovery rate score (RR score). Scores ranged from 10 (hypochronotropic behavior of the pacemaker) to +10 (hyperchronotropic behavior), based on daily-life tests of 15 healthy controls (7 females and 8 males, 65 ± 9 years). A score of 0 represented exact concordance with healthy controls. During stair descent, the Sensolog III produced excessive acceleration (EA score =+2.9 ± 1.1) compared to: (1) stair climbing (EA score =?4.0 ± 1.9; P = 0.01, with the same pacemaker); and (2) the Dash (+1.8 ± 1.9; P = 0.04) and healthy controls (P = 0.02). The sit-up tests revealed a hypochronotropic response of both pacemakers compared to healthy controls, with a larger difference for the Sensolog III (EA score =?2.0 ± 5.8; P = 0.04; RD score =?6.8 ± 3.8; P = 0.02). We conclude that activity-driven pacemakers can accommodate brief activities, except for isovolumetric exercise such as sit-ups. During daily activities, accelerometer-driven pacemakers seem to provide a heart rate response closer to that of healthy controls. Our new mathematical analysis is a simple and reproducible method for evaluating and quantifying the efficacy of any sensor-driven pacemaker.     

Biomechanical examination of the 'plateau phenomenon' in ActiGraph vertical activity counts

This paper determines if the leveling off ('plateau/inverted-U' phenomenon) of vertical ActiGraph activity counts during running at higher speeds is attributable to the monitor's signal filtering and acceleration detection characteristics. Ten endurance-trained male participants (mean (SD) age = 28.2 (4.7) years) walked at 3, 5 and 7 km h(-1), and ran at 8, 10, 12, 14, 16, 18 and 20 km h(-1)?on a force treadmill while wearing an ActiGraph GT3X monitor at the waist. Triaxial accelerations of the body's center of mass (CoM) and frequency content of these accelerations were computed from the force treadmill data. GT3X vertical activity counts demonstrated the expected 'plateau/inverted-U' phenomenon. In contrast, vertical CoM accelerations increased with increasing speed (1.32 ± 0.26 g at 10 km h(-1)?and 1.68 ± 0.24 g at 20 km h(-1)). The dominant frequency in the CoM acceleration signals increased with running speed (14.8 ± 3.2 Hz at 10 km h(-1)?and 24.8 ± 3.2 Hz at 20 km h(-1)) and lay beyond the ActiGraph band-pass filter (0.25 to 2.5 Hz) limits. In conclusion, CoM acceleration magnitudes during walking and running lie within the ActiGraph monitor's dynamic acceleration detecting capability. Acceleration signals of higher frequencies that are eliminated by the ActiGraph band-pass filter may be necessary to distinguish among exercise intensity at higher running speeds.     

Inappropriate Rate Change in Minute Ventilation Rate Responsive Pacemakers Due to Interference by Cardiac Monitors

Observations of inappropriate rate increase in five patients with minute ventilation rate responsive implanted pacemakers (Telectronics Meta) are reported. Pacing rate increases were observed immediately upon connection of the resting patients to two brands of widely used cardiac monitors, and one commonly used echocardiograph. In some circumstances, the rate increase remained until monitor disconnection; in others the rate increase was transient, lasting about 20 seconds. A hardware thoracic resistance variation simulator was constructed and connected to one of the pacemakers to test sensitivity to rate modifying interference from external sources. This demonstrated that the sensitivity to interference is dependent upon the frequency of the interfering signal and is highest in the range 10–60 kHz. that peak currents as low as 10 μA can cause maximum rate increase, and that the signals injected into patients by several cardiac monitors, for purposes of lead-off detection or respiratory monitoring, fall into the frequency range at which the pacemaker is most susceptible to interference.     

Determining Optimal Atrial Sensitivity Settings for Single Lead VDD Pacing: The Importance of the P Wave Histogram

In order to provide atrioventricular synchrony, VDD pacing systems require reliable atrial sensing. Variations in atrial signals with exercise and daily activities may lead to undersensing, with loss of physiological pacing. The aim of this study was to determine, for a single lead VDD pacing system, the maximal variation in atrial signals in order to facilitate optimal programming of atrial sensitivity. Fifteen patients underwent implantation of a Vitatron Saphir VDD pacemaker with a Vitatron Brilliant electrode. At a mean (± SD) follow-up of 67.3 ± 38.8 days, resting P wave amplitude was compared with the P wave amplitude histogram obtained from the pacemaker, which recorded atrial signals over the preceding 30 days. Resting P wave amplitude was also compared with P wave amplitudes during variations in posture, respiration, and during exercise. P wave amplitude showed great variation with changes in posture and respiration, but there was no consistent increase or reduction. During exercise, the mean P wave amplitude fell hy 36.6%± 31.3% compared with the resting value (P < 0.05). During daily activities, 22.6% of P wave amplitudes recorded on the P wave histogram were < 0.5 mV. The smallest P wave amplitudes were detected by the P wave histogram in 11 (79%) of 14 patients. These data suggest that atrial sensitivity may need to be programmed higher than that indicated by single readings or exercise. The P wave amplitude histogram is the most reliable indicator of the smallest atrial signal and should be used to opthnize atrial sensitivity settings.     

Noise Mode Response at Peak Exercise in a DDD Pacemaker

The noise sampling period has been recognized as a cause of apparent sensing malfunction in demand pacemakers. Physiologic signals as well as external electromagnetic interference can cause certain demand pacemakers to remain refractory and escape asynchronously at a specified rate. In this case, noise mode reversion pacing at the programmed lower rate limit of a Cordis 415A DDD pacemaker was observed during exercise when P-waves fell within the noise sampling period.     

Muscle Noise and Interference Behavior in Pacemakers: A Comparative Study

Inhibition of VVI pacemakers by muscle noise, though known since 1972, has attracted increased interest in recent years. More sensitive dual chamber atrial synchronized pacemakers have proved to be more susceptible to interference and will further enhance the effort at improving pacemaker resistance to interference of ail kinds. To study the reaction of 16 pacemakers of 10 different manufacturers with respect to muscle noise, we stored a noisy episode on a 16-second endless loop tape. Each pacemaker was subjected to an identical muscle noise signal, with amplitude varied to reach the response threshold. The results are: (J) The range of muscle noise thresholds consists of more than one decade, varying from 0.4 mV to 4.6 mV. (2) Only 4 of 16 pacemakers remained unaffected if a noise signal of 3 mV maximum is assumed. (3) In 11 out of 16 pacemakers, the threshold amplitude for muscle noise is lower than that for intracardiac electrographic signals which can be explained by a sensitizing mechanism caused by noise. (4) Five pacemakers were so sensitive that even a sensitivity setting of 4 mV would not reject muscle noise. (5) Filtering muscle noise, 50-Hz signals, and intracardiac electrograms with a 12 dB filter of variable upper cut-off frequency revealed that heart signals are always attenuated more than interference signals.     

比较青年男子走与跑的能量消耗

背景：能量代谢是健身、减重、行军、假肢评定、医疗诊断等比较关注的热点之一。康复师与健身教练根据具体情况以及不同目的选择不同的运动方式、运动量与运动强度,有关同等运动速度不同走跑步态模式的能量消耗差异研究较少。目的：探讨相同运动速度两种步态模式下走跑步态特征以及能耗差异,为大众健身以及运动处方的制定提供理论支持。方法：受试者为男性健康大学生志愿者20名,使用H/P/COSMOS Gaitway跑台控制走跑运动的速度,测量走跑的步频和步长,使用气体成分分析仪VO2000间接测试人体的能量代谢。在人体第一骶椎放置两维加速度传感器采集前后方向以及垂直方向的加速度原始信号。结果与结论：相同速度跑模式的步频明显高于走模式下的步频。随着速度的递增,行走主要依靠步频的增加,而跑动时主要依靠步长加大来维持速度。同等速度下跑的能耗明显高于行走的能耗。相同速度下跑明显大于走的人体质心垂直方向加速度均方根值。建议根据不同目的选择不同的步态模式,如需要减重健身时可选择跑模式,而在长距离行军时为了节省能量可以选择快走模式。     

The Six-Minute Walk—An Adequate Exercise Test for Pacemaker Patients?

LANGENFELD, H., ET AL.: The Six-Minute Walk—An Adequate Exercise Test for Pacemaker Patients? In many pacemaker patients bicycle and treadmill ergometry are not practicable. As an alternative, we performed a 6-minute walk on a 20-m corridor in 97 pacemaker patients, who were asked to walk as far as possible determining their speed by themselves. Results were compared with those of bicycle ergometry in 42 of these patients and with treadmill exercise of a group of 92 other pacemaker patients. In the 6-minute walk, performance and maximal heart rate were slightly lower (49 ± 18 W; 96 ± 23 beats/min) than in bicycle (57 ± 16 W; 110 ± 26 beats/min) and treadmill ergometry (50 ± 37 W; 102 ± 35 beats/min). A good correlation was found between walking and bicycling (r = 0.74) and in subgroups of patients with different pacemaker indications. All patients preferred the walk to bicycle ergometry considering it to be more related to daily physical activity. In conclusion, a 6-minute walk is a simple and physiological exercise test for nearly all pacemaker patients with good correlation to other types of exercise. It seems to be preferable to other tests because of its better acceptance and practicability.     

A Comparative Evaluation of a Minute Ventilation Sensing and Activity Sensing Adaptive-Rate Pacemakers During Daily Activities

Most studies evaluating the rate response of adaptive-rate pacemakers have been based on treadmill or bicycle exercise. These studies disregard the fact that few pacemaker recipients voluntarily undertake such activities. The rate responses of nine patients (mean age 62 years, range 33-79 years) with implanted minute ventilation sensing (Meta) pacemakers were studied. The indications for pacing were complete heart block (seven patients), sick sinus syndrome (one patient), and five nodal disease (one patient). Significant improvement in maximum distance covered during a 12-minute walking test was observed in the rate adaptive compared to the VVI pacing mode (989 +/- 104 vs 921 +/- 90 m, P less than 0.02). The rate responses of this pacemaker during daily activities were recorded with telemetry during a variety of structured daily activities. The rate responses were also compared to those of an externally attached Activitrax pacemaker in each patient and to a group of ten age and sex matched volunteers. For less strenuous activities such as walking, descending stairs, washing, and bed making, both pacemakers achieved adequate rate responses compared to normal subjects. For more strenuous activities, the Activitrax pacemaker failed to achieve an adequate rate response. For example, the pacing rate achieved on ascending stairs was lower than that achieved on descending stairs (92 +/- 3 vs 102 +/- 3 bpm, P less than 0.02). The direction of rate responses was more appropriate for the Meta pacemaker. Similar to the normal subjects, the maximum rate was reached before the end of an activity with the Activitrax pacemaker.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reliability of Minute Ventilation as a Parameter for Rate Responsive Pacing

A minute ventilation sensing rate responsive pacemaker was implanted in 11 patients with bradycardias. Their mean age was 59 +/- 4 years (mean +/- SEM). The pacemaker measures minute ventilation by sensing intravascular impedance using a standard bipolar electrode. The rate responsive programming was simple: apart from ascribing an upper and lower rate, the only programmable parameter was the slope of rate response. This could be derived approximately by assessing the suggested slope value during an exercise test in the 'adaptive VVI' mode. Compared with exercise in the VVI mode, symptom limited treadmill tests in the rate responsive mode showed a 33% improvement of exercise capacity and a 44% improvement of cardiac output as determined noninvasively by continuous wave Doppler measurements of the ascending aortic blood flow. The pacing rate was appropriately increased during a variety of daily activities such as walking at different speeds and gradients, and ascending and descending stairs. Voluntary interference of the respiratory pattern such as during coughing and hyperventilation increased the pacing rate from a resting rate of 70 bpm to 111 +/- 10 and 86 +/- 4 bpm respectively. Continuous talking during exercise attenuated the expected rate response. The pacemaker can sense activity induced by arm swinging. In conclusion, the Meta pacemaker improved cardiac output and exercise capacity in patients with bradycardias. Its rate response was related to workload. Although voluntary interference affected the pacing rate, excessive rate acceleration was not encountered.     

Clinical Experience with Sensolog 703: A New Activity Sensing Rate Responsive Pacemaker

Sensolog 703 is a new activity sensing rate responsive pacemaker which detects body vibration during physical exercise and uses the vibration as an indicator of the physiological need for a rate increase. This pacemaker was implanted in 11 patients with complete heart block and atrial arrhythmias. Their mean age was 58 (range 39-72) years. With appropriate rate response, exercise capacity, as assessed by the duration of graded treadmill exercise using the Bruce protocol, was significantly improved over the VVI pacing mode (mean +/- SEM, 462 +/- 52 s in the rate responsive mode and 368 +/- 34 s in the VVI mode, P less than 0.02). Cardiac output at peak exercise, as assessed by continuous wave Doppler sampling of aortic root blood flow, was also significantly increased compared to the resting value in both piecing modes. However, the increase was more marked when exercise was performed in the rate response mode (93 +/- 22% increase over resting cardiac output in the rate responsive mode and 57 +/- 13% increase in the VVI mode, P less than 0.05). The rate responses of this pacemaker were compared with those of a Medtronic Activitrax pacemaker. Although both pacemakers responded to an increase in walking speed, neither responded appropriately to walking up different gradients, In both cases, ascending and descending four flights of stairs resulted in similar pacing rates. There was no response to physiological activities with minimal body movements such as isometric exercise and the Valsalva maneuver. Technical problems were encountered in two implanted Sensolog pacemakers: one had spontaneous rate acceleration at rest immediately following implantation and one showed intermittent rate acceleration while the patient was at rest. Both units were programmed to the VVI mode. In conclusion, satisfactory rate response, improvement in exercise duration and increase in cardiac output were achieved with the Sensolog 703 pacemaker. However, as body vibration is not closely related to physiological needs, it has similar limitations in rate response as the Activitrax pacemaker.     

Do European GSM Mobile Cellular Phones Pose a Potential Risk to Pacemaker Patients?

BARBARO, V., et al .: Do European GSM Mobile Cellular Phones Pose a Potential Risk to Pacemaker Patients? A series of in vivo trials were carried out in order to verify whether the electromagnetic field radiated by GSM (Groupe Systemes Mobiles) mobile cellular phones might affect implanted pacemakers. Two European GSM phones of 2-watt power were tested and trials conducted on 101 pacemaker implanted outpatients attending day hospital for routine check-up, who volunteered for trials. Forty-three pacemaker models from 11 manufacturers were tested in all. When the sensing threshold of the pacemakers was set at a minimum and the antenna of the phone was in direct contact with the patient's chest, interference was detected for 26 implanted pacemakers. Specifically, pulse inhibition in 10 of 101 cases, ventricular triggering in 9 of 46 DDD-VDD pacemakers, and asynchronous pacing in 4 of 52 devices. Pulse inhibition was also observed combined with asynchronous pacing in 1 of 52 cases and with ventricular triggering in 2 of 46 cases. Minimum effect duration was ca. 3 seconds but in 6 cases effects continued as long as the interfering GSM signal was on. No permanent malfunctioning or changes in the programmed parameters were detected. Whenever interference was detected, trials were repeated to determine the maximum sensing threshold at which interference persisted (with the antenna in contact with the skin over the pacemaker). Then maximum distance between antenna and pacemaker at which interference occurred was determined at pacemaker maximum and minimum sensing threshold. Under our experimental conditions electromagnetic interference effects were detected at a maximum distance of 10 cm with the pacemaker programmed at its minimum sensing threshold. When the phone antenna was in direct contact with patient's skin over the implant, electromagnetic interference effects occurred at maximum ventricular and atrial sensing thresholds of 4 mV and 2.5 mV, respectively.     

Myopotential Interference in Unipolar Rate Responsive Pacemakers

The effects of myopotential interference on unipolar rate responsive pacemakers were assessed in 22 patients. Six types of pacemakers (from four manufacturers) were studied: five TX2 (QT sensing), seven Biorate (five RDP3 and two MB-1, respiratory rate sensing), seven Activitrax (activity sensing), two Medtronic 2503 (dP/dt sensing), and one Sensolog P703 (activity sensing). Provocative tests using arm exercises were performed in both VVI and rate responsive modes. At nominal sensitivity settings (1.8-2.5 mV), 55% of these patients were myopotential positive for at least 1 provocative test. Pressing the palms together was found to be the most sensitive provocative test. Rate response was achieved with treadmill exercise (all patients), hyperventilation (RDP3 and MB-1) and tapping (Activitrax) or wobbling the pacemaker in its pocket (Sensolog). During continued rate acceleration, myopotential interference was induced by arm exercises. The duration of inhibition was shorter when the provocative tests were performed during rate response compared to that occurred at rest. Short periods of myopotential interference resulted in temporary inhibition of pacing but rate response continued immediately on removal of the interference. In one patient with a RDP3 pacemaker, a prolonged episode of myopotential interference during treadmill exercise resulted in reversion of the pacemaker to the interference mode. Appropriate adjustment of the sensitivity setting effectively controlled the symptoms in most patients. However, one patient with a QT sensing pacemaker and symptomatic myopotential interference required programming to the VVT pacing mode. Two out of five patients with RDP3 required pacemaker replacement because of uncontrolled myopotential interference.(ABSTRACT TRUNCATED AT 250 WORDS)