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Cardiac rhythm technologies

EffectivCRT™ diagnostic

EffectivCRT™ diagnostic uses a unipolar electrogram to evaluate morphology to verify effective pacing.

Indications, Safety, and WarningsThe Claria™ MRI CRT-D SureScan™ Model DTMA1D4/DTMA1D1 and Claria™ MRI Quad CRT-D SureScan™ Model DTMA1QQ/DTMA1Q1, hereafter referred to collectively as the Claria™ MRI CRT-D device, is MR Conditional and, as such is designed to allow patients to be safely scanned by an MRI machine when used according to the specified MRI conditions for use. When programmed to "on", the MRI SureScan™ feature allows the patient to be safely scanned while the device continues to provide appropriate pacing.Indications for useThe Claria™ MRI CRT-D system is indicated for ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias, for use in patients with atrial tachyarrhythmias, or those patients who are at significant risk for developing atrial tachyarrhythmias and for providing cardiac resynchronization therapy in heart failure patients on stable, optimal heart failure medical therapy if indicated, and meet any of the following classifications: New York Heart Association (NYHA) Functional Class III or IV and who have a left ventricular ejection fraction ≤ 35% and a prolonged QRS duration. Left bundle branch block (LBBB) with a QRS duration ≥ 130 ms, left ventricular ejection fraction ≤ 30%, and NYHA Functional Class II. NYHA Functional Class I, II, or III and who have left ventricular ejection fraction ≤ 50% and atrioventricular block (AV block) that are expected to require a high percentage of ventricular pacing that cannot be managed with algorithms to minimize right ventricular pacing. Optimization of heart failure medical therapy that is limited due to AV block or the urgent need for pacing should be done post-implant.A complete SureScan™ CRT-D system is required for use in the MR environment.  A complete SureScan™ CRT-D system includes the following components:

The Claria™ MRI CRT-D device

A SureScan™ right atrial pacing lead or a Model 6725 pin plug for the right atrial port

A SureScan™ left ventricular pacing lead

A SureScan™ defibrillation lead

When a single coil SureScan™ defibrillation lead is used, a Medtronic DF-1 pin plug must be secured in the SVC port to make a complete SureScan™ DF-1 defibrillation system.  Any other combination may result in a hazard to the patient during an MRI scan.Lead integrity alertThe RV lead integrity alert feature is intended primarily for patients who have a Medtronic ICD or CRT-D device and a Sprint Fidelis lead (Models 6949, 6948, 6931, and 6930), based on performance data. The RV LIA feature may not perform as well with a St. Jude Medical Riata™*/Durata™* lead or a Boston Scientific Endotak^TM* lead as it does when used with a Medtronic Sprint Fidelis lead. This is because different lead designs may have different failure signatures and conditions that may or may not be detected early by the RV LIA feature.ContraindicationsThe Claria™ MRI CRT-D system is contraindicated for patients experiencing tachyarrhythmias with transient or reversible causes including, but not limited to, the following: acute myocardial infarction, drug intoxication, drowning, electric shock, electrolyte imbalance, hypoxia, or sepsis. The device is contraindicated for patients who have a unipolar pacemaker implanted. The device is contraindicated for patients with incessant ventricular tachycardia (VT) or ventricular fibrillation (VF). The device is contraindicated for patients whose primary disorder is chronic atrial tachyarrhythmia with no VT or VF.Warnings and precautionsChanges in patient’s disease and/or medications may alter the efficacy of the device’s programmed parameters. Patients should avoid sources of magnetic and electromagnetic radiation to avoid possible underdetection, inappropriate sensing and/or therapy delivery, tissue damage, induction of an arrhythmia, device electrical reset, or device damage. Do not place transthoracic defibrillation paddles directly over the device.  Certain programming and device operations may not provide cardiac resynchronization.Patients and their implanted systems must be screened to meet the following requirements for MRI: no implanted lead extenders, lead adaptors, or abandoned leads; no broken leads or leads with intermittent electrical contact as confirmed by lead impedance history; a SureScan™ CRT-D system implanted in the left or right pectoral region; no diaphragmatic stimulation at a pacing output of 5.0 V and at a pulse width of 1.0 ms in patients whose device will be programmed to an asynchronous pacing mode when MRI SureScan™ is programmed to "on."Additionally for pacemaker-dependent patients, it is not recommended to perform an MRI scan if the right ventricular (RV) lead pacing capture threshold is greater than 2.0 V at 0.4 ms.  A higher pacing capture threshold may indicate an issue with the implanted lead.Patients may be scanned using a horizontal field, cylindrical bore, clinical 1.5T or 3T MRI system for hydrogen proton imaging, maximum spatial gradient ≤ 20 T/m, and maximum gradient slew rate performance per axis ≤ 200 T/m/s.  1.5T scanners must be operated in "normal" operating mode (whole body averaged specific absorption rate (SAR) ≤ 2.0 W/kg, head SAR ≤ 3.2 W/kg).  3T scanners must be operated in "first level controlled" operating mode or "normal" operating mode.   B1+RMS must be ≤ 2.8 μT when the isocenter (center of the bore) is inferior to the C7 vertebra.  Scans can be performed without B1+RMS restriction when the isocenter is at or superior to the C7 vertebra. Continuous patient monitoring is required while MRI SureScan™ is programmed to "on."  While MRI SureScan™ is programmed to "on," arrhythmia detection and therapies are suspended, leaving the patient at risk of death from untreated spontaneous tachyarrhythmia. In addition, if the device is programmed to an asynchronous pacing mode, arrhythmia risk may be increased.Potential complicationsPotential complications include, but are not limited to, rejection phenomena, erosion through the skin, muscle, or nerve stimulation, oversensing, failure to detect and/or terminate tachyarrhythmia episodes, acceleration of ventricular tachycardia, and surgical complications such as hematoma, infection, inflammation, and thrombosis. Other potential complications related to the lead may include lead dislodgement, lead conductor fracture, insulation failure, threshold elevation, or exit block.Potential MRI complications for the SureScan™ system include, but are not limited to, lead electrode heating and tissue damage resulting in loss of sensing or capture or both, or induced currents on leads resulting in continuous capture, VT/VF, and/or hemodynamic collapse; spontaneous tachyarrhythmia occurring during the scan that is not detected and treated because tachyarrhythmia detection is suspended while MRI SureScan™ is programmed to "on"; potential for VT/VF induction when the patient is programmed to an asynchronous pacing mode during MRI SureScan™; device heating resulting in tissue damage in the implant pocket or patient discomfort or both; or damage to the functionality or mechanical integrity of the device resulting in the inability of the device to communicate with the programmer.See the MRI SureScan™ technical manual before performing an MRI scan and the MRI SureScan™ device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. Caution:  Federal law (United States) restricts this device to sale by or on the order of a physician.TM* Third-party brands are trademarks of their respective owners.MAJ_83907

Overview

A high percentage of BiV pacing is associated with improved cardiac resynchronization therapy (CRT) response.¹ However, the presence of a pacing stimulus does not imply full capture.^2,3 Traditional pacing counters only report the presence of a pacing stimulus, potentially leading to over-reporting of effective pacing.^2,3

You can now verify effective pacing with the EffectivCRT™ diagnostic.

The EffectivCRT™ diagnostic uses a unipolar electrogram to evaluate morphology, looking for a negative deflection which implies when a paced beat is effective.⁴

This EGM strip shows six consecutive paced beats.
Traditional pacing counters would report this as 100% V pacing.
With the EffectivCRT™ diagnostic, it would report 100% V pacing, but 50% is effective pacing.
- The first three beats are ineffective (positive deflection implies tissue is paced and not captured).
- The last three beats are effective (negative deflection implies tissue is paced and captured).

In 18% of patients, device-reported % V pacing overestimated effective CRT by 3%. Three out of 57 patients had virtually no effective pacing, whereas the % V pacing was > 90%, as demonstrated in the graph below.⁵

Before the EffectivCRT™ diagnostic:
Only see the quantity of pacing⁵

With the EffectivCRT™ diagnostic:
Also see the quality of pacing⁵

You can use the data provided by the EffectivCRT™ diagnostic to identify ineffective pacing and will find it in these places:

Cardiac Compass™ trends
Quick Look™ II screen
Rate histogram report
EffectivCRT™ episodes

Related links

Related products

Cobalt XT™ MRI SureScan™ CRT-D

Cobalt™ XT CRT-Ds are used in heart failure (HF) management.

Hayes DL, Boehmer JP, Day JD, et al. Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival. Heart Rhythm. 2011;8:1469–1475. doi: 10.1016/j.hrthm.2011.04.015.
Daubert JC, Saxon L, Adamson PB, et al. EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Heart Rhythm. 2012;9:1524–1576. doi.org/10.1016/j.hrthm.2012.07.025.
Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34:2281–2329. doi: 10.1093/eurheartj/eht150.
Ghosh S, Stadler RW, Mittal S. Automated detection of effective left-ventricular pacing: going beyond percentage pacing counters. Europace. 2015;17:1555–1562. doi: 10.1093/europace/euv062.
Hernandez. Presented at CardioStim 2016 (Abstract 99-06).

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