Unipolar Configuration Research Articles

Contributions of High Resolution Electrograms Memorized by DDDR Pacemakers in the Interpretation of Arrhythmic Events

The accuracy of information retrievable from the memories of DDDR pacing systems has been limited by the absence of actual electrograms confirming the proper sensing of spontaneous cardiac activity versus that of extraneous signals. This study examined the diagnostic power of a new arrhythmia interpretation scheme, which includes the recording and storage of high resolution endocavitary atrial and ventricular electrograms (HREGM). HREGM stored in the memories of new generation pacemakers (PM) in response to nonsustained ventricular tachycardia (NSVT), sustained VT, and atrial arrhythmias were analyzed in a follow-up registry of 520 patients at 1 month, and 3 to 6 months after implantation of a PM for standard indications. For each sequence of stored HREGM, the accuracy of the PM response was examined, classified as accurate (true positive), versus inaccurate (false positive), versus undetermined, and the relative contribution of the HREGM in verifying the PM diagnosis was measured. During a follow-up of 4.9 +/- 2 months, 256 (49%) of the 520 patients had an event recorded, which was confirmed to be arrhythmic on the basis of HREGM. Overall, approximately 34% of atrialtachy response (ATR) episodes were confirmed to be appropriate. Similar percentages of episodes were prompted by oversensing of signals unrelated to cardiac arrhythmias, while nearly 12% of the episodes could not be clarified because of such brief duration as to preclude recording of their onset. Approximately one-third of NSVT, and one-half of VT detections were false positive. Ventricular oversensing, most often due to myopotential interference in presence of unipolar sensing, and atrial undersensing were both identified as sources of false-positive detections of ventricular events. The proportion of true-positive detections was significantly higher in the bipolar (83%) than unipolar configuration. Among 520 PM recipients, miscellaneous episodes of atrial arrhythmias were confirmed by HREGM in 37% of patients within 3 to 6 months of follow-up. Atrial fibrillation was confirmed in only 6% of patients, of whom over 50% already had histories of atrial fibrillation. The prevalence of unsuspected atrial arrhythmia in this unselected population was lower than previously reported.

Alternans in QRS amplitude during ventricular tachycardia.

Although the value of T wave alternans as an index of electrical instability has been extensively investigated, little is known about QRS alternans during VT. Intracardiac electrograms of 111 episodes of spontaneous monomorphic regular VT retrieved from implantable defibrillators in 25 patients were retrospectively selected. Three beat series, representing the total amplitudes and amplitudes from baseline to summit and from baseline to lower point of 16 or 32 successive QRS complexes before deliverance of electrical therapy were generated for each episode. Spectral analysis was then performed using the fast Fourier transform. VT was considered as alternans if the magnitude of the spectral power at the 0.5-cycle/beat frequency was greater than the mean +/- 3 SD of the noise in at least one of the three spectral curves. QRS alternans was present in 23 (20%) of 111 episodes and in 9 (36%) of 25 patients. Alternans was not related to the VT cycle length, QRS duration, QRS amplitude, signal amplification, nor to clinical variables. Alternans was more frequently detected in unipolar configuration and when a higher number of complexes was included in analysis. Failure of antitachycardia pacing was more frequent in case of alternans VT (50% vs 75% success in nonalternans VT, P = 0.05). Spontaneous termination before deliverance of therapy occurred in 16 non-alternans VT but never in alternans episodes (P = 0.02). Alternans in QRS amplitude is a relatively common finding during VT and could be associated with failure of antitachycardia pacing and lack of spontaneous termination. Lower efficacy of electrical therapies in case of QRS alternans must be confirmed in a way to improve the effectiveness of antitachycardia pacing.

Use of a Transurethral Microwave Thermotherapeutic Device With Permanent Pacemakers and Implantable Defibrillators

To determine whether a device (Urologix Targis system) used for transurethral microwave treatment interferes with sensing, pacing, and arrhythmia detection by permanent pacemakers and implantable cardioverter-defibrillators (ICDs). We tested 13 pacemakers in both bipolar and unipolar sensing configurations and 8 ICDs in vitro. Pacemakers and ICDs were programmed to their most sensitive settings. Energy outputs of the microwave device were typical of those used clinically. The probe of the microwave device was anchored 1.2 cm from the pacemaker or ICD being tested. No sensing, pacing, or arrhythmic interactions were noted with any ICD or any pacemaker programmed to the bipolar configuration. One pacemaker (Guidant Vigor 1230) showed intermittent tracking when programmed to the unipolar configuration. Most patients with permanent pacemakers or ICDs can safely undergo transurethral microwave therapy using the device tested. Pacemakers and ICDs should be programmed to the bipolar configuration (if available) during therapy. The pacemaker or ICD should be interrogated before and after therapy to determine whether programming changes occurred as a result of treatment. However, our findings suggest that this is unlikely.

Optimal position of atrial epicardial leads for temporary pacing in infants after cardiac surgery

Background. The atrial epicardial wall of pediatric patients was topographically assessed to identify the optimal position for temporary atrial pacing.Methods. Unipolar electrodes were fixed at the cephalic wall between the right and left atrial appendages, the interatrial groove, and the right atrial appendage of fifteen pediatric patients who underwent definitive surgical repair. The performance of the three electrodes in terms of pacing patterns and six combinations of bipolar pacing were evaluated in terms of the pacing threshold, P-wave amplitude, slew rate, and lead impedance.Results. Unipolar pacing of the right atrial appendage showed a significantly higher threshold than the other groups. A bipolar configuration of the cephalic atrial wall and interatrial groove had a significantly higher P-wave amplitude than groups without the electrode at the cephalic atrial wall, and a significantly higher slew rate than a unipolar configuration of the atrial appendage.Conclusions. Bipolar pacing with the negative electrode at the cephalic atrial wall and the indifferent electrode at the interatrial groove is the most efficient method for pediatric patients.

Unipolarity Without Hegemony

The current power configuration of the world system is unipolarity without hegemony. Nonhegemonic unipolarity is understudied, and deserves study. A few previous instances can be found in the history of the Central world system: they are usually brief, associated with intense warfare, hegemonism, counteralliance, exhaustion, and collapse into multipolarity. In other world systems, however, nonhegemonic unipolarity has been more frequent, more durable, and with more diverse exits. Plausible exit scenarios from the current unipolar nonhegemonic phase exist for U.S. hegemony, for bipolarity and tripolarity (via rise of the European Union and/or China), and for multipolarity (via U.S. introversion), but all entail rather lengthy evolutionary processes. Unipolarity without hegemony is not inherently unstable, and could endure for decades. A unipolar configuration probably has equilibrium rules for its maintenance. Nonhegemonic unipolarity affects the characteristic structure of “deadly quarrels” in the world system, and allows some approaches to the policy issue of “deadly quarrels” not readily available in less centralized system structures. Unipolarity without hegemony deserves further comparative and theoretical attention.

An Algorithm for Automatic Measurement of Stimulation Thresholds: Clinical Performance and Preliminary Results

We have developed an algorithmic method for automatic determination of stimulation thresholds in both cardiac chambers in patients with intact atrioventricular (AV) conduction. The algorithm utilizes ventricular sensing, may be used with any type of pacing leads, and may be downloaded via telemetry links into already implanted dual-chamber Thera pacemakers. Thresholds are determined with 0.5 V amplitude and 0.06 ms pulse-width resolution in unipolar, bipolar, or both lead configurations, with a programmable sampling interval from 2 minutes to 48 hours. Measured values are stored in the pacemaker memory for later retrieval and do not influence permanent output settings. The algorithm was intended to gather information on continuous behavior of stimulation thresholds, which is important in the formation of strategies for programming pacemaker outputs. Clinical performance of the algorithm was evaluated in eight patients who received bipolar tined steroid-eluting leads and were observed for a mean of 5.1 months. Patient safety was not compromised by the algorithm, except for the possibility of pacing during the physiologic refractory period. Methods for discrimination of incorrect data points were developed and incorrect values were discarded. Fine resolution threshold measurements collected during this study indicated that: (1) there were great differences in magnitude of threshold peaking in different patients; (2) the initial intensive threshold peaking was usually followed by another less intensive but longer-lasting wave of threshold peaking; (3) the pattern of tissue reaction in the atrium appeared different from that in the ventricle; and (4) threshold peaking in the bipolar lead configuration was greater than in the unipolar configuration. The algorithm proved to be useful in studying ambulatory thresholds.

Lead System Optimization for Transvenous Defibrillation

Lead systems that include an active pectoral shell reduce defibrillation thresholds and permit transvenous defibrillation in nearly all patients. A further improvement in defibrillation efficacy is desirable to allow for smaller pulse generators with a reduced maximum output. Accordingly, the purpose of this study was to compare defibrillation thresholds with multiple transvenous lead systems including those with an active pectoral shell to determine which system would optimize defibrillation energy requirements. This prospective study was performed on 21 consecutive patients. Each subject was evaluated with 3 lead configurations with the order of testing randomized. The configurations were a dual coil transvenous lead (lead), the distal right ventricular coil and pectoral pulse generator shell (unipolar), and all 3 components (triad). The right ventricular coil was the cathode for the first phase of the biphasic defibrillation waveform. Delivered energy at defibrillation threshold was 11.2 ± 3.4 J for the lead configuration, 10.1 ± 5.2 J for the unipolar configuration, and 7.8 ± 3.6 J for the triad configuration (p <0.01). Leading edge voltage (p <0.01) and shock impedance (p <0.001) were also decreased for the triad configuration compared with the lead or unipolar configurations, whereas peak current was minimized with the unipolar configuration (p <0.01). We conclude that the combination of a dual coil, transvenous lead and an active pectoral shell reduces defibrillation energy requirements compared with either the lead alone or unipolar configuration. Moreover, the defibrillation thresholds were ≤15 J in all patients using the triad lead system.

Toward optimizing a preshaped catheter and system parameters to achieve single lead DDD pacing.

P wave electrogram amplitudes and atrial stimulation thresholds were determined in eight Hanford miniature swine using a preshaped catheter with an "S" curve in the SVC, and a major lobe in the atrium to enhance electrode contact with the atrial wall. The catheter was designed for pacing and sensing in the DDD mode. P wave amplitudes were also ascertained with two commercially available VDD leads and compared to the data from the experimental catheters. The preshaped catheter used two 6-mm2 platinum iridium atrial electrodes with a 7-mm separation. Both atrial electrodes are on the same side of the catheter, facing outward on the major atrial lobe formed in the catheter. The P wave amplitudes were tested only in the differential bipolar configuration. For the eight preshaped catheters, the mean was 6.6 +/- 3.8 mV while for the conventional leads it was 2.9 +/- 1.6 mV. The mean atrial stimulation thresholds ranged from 1.1 +/- 0.2 V to 2.3 +/- 1.2 V, with still lower thresholds of 0.9-1.3 V when using the parallel unipolar atrial electrode configuration, in which both parts of the bipolar atrial electrode are configured as a unipolar electrode. The data suggest that bipolar simulation may be effective if sequential reverse polarity pulses are used to achieve cathodal stimulation from each electrode of the bipolar pair, on a beat-to-beat basis.

Effects of internal defibrillation on an implanted pacing system with programmable polarity.

Management of multiple cardiac arrhythmias in some patients with both an implantable cardioverter defibrillator (ICD) and a pacemaker has demonstrated several advantages. In such circumstances, it is imperative that pacemaker function and its programmed parameters be preserved following a defibrillation shock. This article describes the effects encountered by a specific programmable polarity pacemaker (RelayR 294-03) when subjected to electrical defibrillation in a canine model. Three pacemakers were repeatedly tested in three separate dog experiments. Each pacemaker, with its leads implanted in the right atrium and the right ventricle, was subjected to a minimum total number of 24 high energy biphasic and monophasic shocks (600-700 V) delivered by a coexisting ICD system using three different defibrillating lead configurations. None of the pacemaker systems showed any failure in function; all pacemakers continued to function within preshock specification and conversion to unipolar pacing and/or backup mode was not observed in any of the tests. Intracardiac electrical potentials measured directly off the ICD and the pacemaker leads, during a defibrillation shock (mean 566.6 V; 23.7 J), showed that potentials measured in a bipolar configuration (tip-ring: mean 21.0 V in atrium, 12.0 V in ventricle) were significantly less than potentials measured in a unipolar configuration (tip-can: mean 387.9 V in atrium, 394.0 V in ventricle; ring-can: mean 405.6 V in atrium, 395.4 V in ventricle). Our compatibility tests demonstrate that use of this programmable-polarity pacemaker in concert with an ICD system appears to be safe. Testing similar to the present study should be conducted prior to complete clinical acceptance of combined ICD and pacemaker implantation.

?The friend of my enemy is my enemy?: Modeling triadic internation relationships

The evolution of internation relationships is studied by means of a mathematical model based on a popular rule of triadic interaction: “the friend of my friend is my friend, the friend of my enemy is my enemy, the enemy of my enemy is my friend, the enemy of my friend is my enemy”. The rule is shown to lead to the formation and preservation of unipolar and bipolar configurations of nations, with the strengths of relationships, both friendly and conflictual, intensifying through time. These results confirm speculations originally made in static, graph theoretic studies of the balancing of relationships within individuals, small groups and systems of nations.

Action potential propagation through embryonic dorsal root ganglion cells in culture. I. Influence of the cell morphology on propagation properties.

1. In this and the companion paper the reliability of action potential (AP) propagation through dorsal root ganglion (DRG) cells was investigated. Experimental data were collected from DRG cells of embryonic rat slice cultures of the spinal cord. A field stimulation electrode was used to elicit an AP in the axon. The propagated AP or, in case of conduction block, its electronic residue (ER), was measured intracellularly in the soma of the DRG cell. 2. The morphological and electrophysiological data combined with published data from voltage-clamp studies were taken to implement a compartmental computer model, which allows a precise description of the propagating AP and the channel kinetics at any point along the axon. 3. The safety factor for conduction was found to be low. Thus failures of AP invasion of the DRG cell soma could occur at sites of impedance mismatch when a hyperpolarizing current was applied, a second stimulus felt into the relative refractory period of the first, or when the axon was repetitively stimulated. 4. The ERs of the failed APs had discrete amplitude levels, suggesting that the failures were always caused at the same site along the axon. These sites of low safety factor were found to be the branch point in the unipolar DRG cell and the entrance of the stem piece into the soma in both cell types, the bipolar as well as the unipolar. 5. A systematic comparison of bipolar and unipolar DRG cells showed that the AP conduction through the latter is more reliable. For large cell bodies, the unipolar configuration is needed for save conduction. 6. Conduction through unipolar DRG cells is faster than through bipolar cells because the electrical load of the soma is masked by the high-resistive stem piece. The length of this stem piece is correlated inversely to the delay caused at the branch point, as the electrical load of the soma is more efficiently masked by a long stem piece.

The effect of temperature-guided radiofrequency ablation of ventricular myocardium.

The safety and feasibility of temperature-guided radiofrequency (RF) ablation of ventricular myocardium were assessed in an open-chest animal model. RF ablation was performed in the ventricles of 19 pigs using ablation catheters with a tip electrode of 2 or 4 mm length. The energy was delivered in a bipolar (2 mm tip electrode only) or unipolar configuration. Set temperature ranged from 60 to 90 degrees C. Pulse duration was 30 s. Histological examination showed coagulation necrosis with a haemorrhagic zone. However, lesions with a deep cleavage were found after five unipolar (2 mm tip electrode) energy applications. No such lesions were found after unipolar energy applications with a 4 mm tip electrode. During or shortly after ablation, premature ventricular beats and non-sustained VT were frequently observed and in some instances ventricular fibrillation. In the bipolar mode we found a positive correlation between lesion area/volume and peak temperature with a correlation coefficient of 0.48 and 0.56, respectively (P < 0.05). However no correlation was found between lesion size and applied energy. In the unipolar configuration there was no correlation between lesion size and these parameters. Median depth and area were: bipolar: 4.0 mm/23.5 mm2, unipolar (2 mm tip electrode): 3.5 mm/12.2 mm2, unipolar (4 mm tip electrode): 4.0 mm/15.7 mm2. We conclude that in a beating heart it is difficult to predict lesion size from temperature or energy.

Radiofrequency catheter ablation of left lateral accessory pathways via the coronary sinus.

The purpose of this study was to describe a new technique for catheter ablation of left lateral accessory pathways (APs) by radiofrequency energy applied at the epicardium through the coronary sinus wall using a unipolar configuration. In an overall group of 212 patients with left lateral APs, multiple endocardial ablation attempts of the AP were unsuccessful in eight patients. The mean +/- SD cumulative duration of previous attempts was 12 +/- 9 hours, using DC shocks and/or radiofrequency energy applied both at the atrial and/or ventricular AP insertions. Epicardial AP insertion was determined by bipolar and unipolar unfiltered distal electrograms by scanning the coronary sinus with a steerable 6F or 7F catheter with a 4-mm distal electrode. The local atrial to ventricular electrogram amplitude ratio was 0.3-1.6. At the ablation site, the catheter tip was slightly deflected toward the annulus to increase both the ventricular component of electrograms and contact with the epicardium. In four patients, epicardial electrogram timings were earlier than endocardial ones. The AP was ablated in seven of the eight patients with 20-30 W applied for 10-60 seconds. No complications occurred except a marked nonspecific pain during radiofrequency energy application; however, the catheter remained adherent to the coronary sinus wall, and its withdrawal was performed during a new radiofrequency application to decrease the risk of coronary sinus rupture. After ablation, echocardiograms, coronary artery angiograms, and levophase coronary sinus angiograms showed no abnormality in all patients except two who had a probable mural thrombus in the coronary sinus. AP conduction remained abolished for 1-10 months of follow-up in seven patients. Radiofrequency catheter ablation of left lateral APs can be achieved effectively and relatively safely via the mid or distal coronary sinus when endocardial approaches are unsuccessful.

The measurement of the paced depolarization integral using the braided endocardial lead.

Previous studies have shown that the paced depolarization integral (PDI) data recorded in unipolar configuration could potentially improve the specificity of tachyarrhythmia classification in an implantable cardioverter defibrillator (ICD). However, the defibrillation protection would be compromised if the ICD case were used as an indifferent electrode. Since transvenous defibrillation leads are being investigated to be used with ICDs, this study determined if reliable PDI data could be obtained using the braided endocardial defibrillation lead (BEDL). The results demonstrated that comparable PDI values and PDI changes with epinephrine induced sinus tachycardia were obtained with all three tested sensing configurations: conventional unipolar, tip electrode to right ventricular defibrillation electrode, and tip electrode to superior vena cava defibrillation electrode. Therefore, the BEDL can be used to measure PDI data, which possibly may improve tachyarrhythmia classification in an ICD, without compromising its defibrillation protection.

VDD pacing with a previously implanted single lead system.

Three patients who had undergone implantation of a rate modulated, atrial sensitive RS4 pacemaker, with a single orthogonal lead underwent replacement of a depleted unit with a DDD pulse generator, reusing the original lead with an adapter that allowed conversion of the bipolar atrial electrode into unipolar configuration. The mean atrial electrogram amplitude was 1.8 mV and no significant atrial sensing defects were found during Holter monitoring. As the RS4 pulse generator is no longer available, continued VDD pacing is possible by replacing it with a DDD pulse generator using the previously implanted single lead system.

Comparison of catheter ablation using radiofrequency versus direct current energy: Biophysical, electrophysioiogic and pathologic observations

The effects of catheter ablation with radiofrequency versus direct current energy were compared in 18 dogs assigned to two groups (of 9 dogs each). Each dog underwent a single ablation at two sites in the left ventricle at energy levels of 100, 200 or 300 J delivered in unipolar configuration to six dogs each. A transient decrease in left ventricular systolic pressure (from 121.3 ± 24.5 to 94.2 ± 18.7 mm Hg, p < 0.01) and wall motion abnormality were noted in dogs with direct current shock. The left ventricular ejection fraction decreased (from 50 ± 2% to 34 ± 3%, p < 0.001) shortly after direct current ablation but improved 4 weeks later to 43 ± 3%. There were no significant changes in left ventricular pressure, wall motion or ejection fraction in dogs in the radiofrequency ablation group.Sustained ventricular tachycardia (≥30 s) was seen immediately after direct current shock in all dogs, and one dog died of intractable ventricular fibrillation. A 24-h ambulatory electrocardiographic (ECG) monitor obtained immediately after the procedure showed multiple runs of ventricular tachycardia in all dogs exposed to direct current ablation but in only three dogs that underwent radiofrequency ablation. No differences were found in peak creatine kinase, complete blood count with smear and B-beta 15–42 fibrinopeptide levels. Pathologically, direct current-induced lesions were larger (mean length × width × depth 10.9 × 7.5 × 5.2 vs. 4.8 × 4.6 × 4.3 mm) and were poorly circumscribed with inhomogeneous margins of necrosis.Thus, compared with direct current ablation, radiofrequency current ablation created little ventricular dysfunction and fewer ventricular arrhythmias and induced more discrete and homogeneous necrosis with a smaller lesion size.

Catheter Ablation of Canine Ventricular Myocardium Utilizing Radiofrequency Current

To determine if catheter‐delivered radiofrequency current (RFC) could safely destroy ventricular myocardium, 6P quadripolar catheters were inserted into the right ventricular and left ventricular endocardium of 11 heparinized, closed‐chest dogs. RFC (continuous wave, 625 kHz) was delivered via a commercially available eiectrosurgical unit for 10–20 sec between the catheter tip and a surface electrode (unipolar configuration). Voltage delivered was 42 ± 8 volts with a current of 0.23 ± 0.07 amperes and an impedance of 182 ± 32 ohms. An average power of 9.8 ± 4.4 watts resulted in a delivered energy of 112 ± 60 joules. The catheters were repositioned in the right and left ventricular apices and RFC was delivered between the two tip electrodes for 10–20 sec (bipolar configuration). Voltage delivered was 44 ± 7 watts with a current of 0.20 ± 0.07 amperes and an impedance of 241 ± 49ohms. An averageof 8.5 ± 4.3 watts of power resulted on delivered energy of 106 ± 29 joules.At necropsy, lesions were identified in 5/11 right and 9/11 left ventricular free‐wall sites and 7/11 right and 11/11 left ventricular apical sites. Lesion size ranged from 4–8 mm in depth and 3–9 mm in diameter and the size did not correlate with energy delivered. The endocardial surface was grossly intact in all. No hemodynamic compromise, electrode pitting, or changes in postshock catheter resistance were noted. However, one dog had spontaneous ventricular fibrillation after a transseptal pulse. Although no large thrombi were noted, a thin layer of endocardial thrombus formation was usually present. We conclude that catheter‐delivered RFC can selectively damage myocardial tissue with minimal complications.

Radiofrequency Catheter Ablation of the Left and Right Ventricles: Anatomic and Electrophysiologic Observations

Certain untoward effects associated with the use of direct-current electrical catheter ablation of the ventricular endomyocardium have been noted. We assessed the efficacy and safety of closed-chest catheter ablation of the left and right ventricles using radiofrequency (RF) energy (750 kHz) in six dogs. Mean RF energies between 93 and 123 joules (J) were randomly delivered to three left ventricular (LV) sites via two distal adjacent electrodes (bipolar configuration) using 6-7F USCI tripolar or quadripolar catheters with an interelectrode distance of 5-10 mm. Another 90-143 J were given to two right ventricular (RV) sites in single or multiple divided applications between a distal electrode and an external patch electrode (unipolar configuration). Ventricular arrhythmias were not observed during application of RF energy. Programmed ventricular stimulation before and after the procedure did not induce ventricular tachycardia (VT) or fibrillation except in one dog who had inducible VT prior to ablation. There were no significant changes in LV and RV effective refractory periods after the procedures. Occasional premature ventricular beats and rare episodes of non-sustained VT (3-12 beats) were observed in ambulatory electrocardiographic recordings (13-24 hrs) done immediately after ablation. Dogs were sacrificed after 4-5 days. Pathology showed well-demarcated round or ovoid lesions of varying sizes. Mural thrombus was found in one dog. Microscopic findings consisted of circumscribed areas of coagulation necrosis with a peripheral zone of cellular infiltration. Transmural necrosis without perforation was occasionally seen in the thin RV wall when higher energies were delivered. In conclusion, discrete areas of desiccation injury in the ventricles can be achieved by transcatheter bipolar or unipolar ablation using RF energy. The complications associated with this method appear to be minimal. Further experiments are needed to evaluate its potential for catheter ablation of ventricular tachycardia.

Morphologic Differences of the Endocardial Electrogram in Beats of Sinus and Ventricular Origin*

The lack of accurate arrhythmia detection and identification is one of the major obstacles to improvement in the efficacy of antitachycardia devices. We evaluated a method for detection of beats of ventricular origin compared to sinus rhythm based on the morphology of the endocardial electrogram. In order to compare mechanically induced ventricular beats to normal sinus beats, endocardial electrograms from a standard pacing electrode were recorded from eight open-chested dogs. Time and frequency domain features analyzed included peak-to-peak amplitude (AMP), maximal slew rate (dV/dT), and frequency content (-3 dB downpoint). Quantitative morphologic comparison of the waveforms was performed using standard correlation and by the absolute area of difference between the waveform and a sinus beat template. The AMP and dV/dT for a group of ventricular beats did not differ significantly from beats of sinus origin. In the unipolar configuration -3 dB for ventricular beats was significantly different from sinus beats (p = .01), but overlap occurred in three of eight cases. Conversely, using either method of assessment of morphological differences, all ventricular beats could be identified without overlapping the values for normal beats. We concluded that morphologic analysis of the endocardial electrogram by such methods may be a highly accurate means of distinguishing between beats of sinus and ventricular origins. This technique may also be applicable to the problem of automatic rhythm identification by implanted devices.

Comparison of Myopotential Interference in Unipolar‐Bipolar Programmable DDD Pacemakers

Myopotential interference (MPI) can inhibit or trigger single and dual chamber unipolar pacemakers while bipolar pacemakers are resistant. Twenty units of two different models of dual chamber pacemaker, each capable of being programmed to single chamber or dual chamber and unipolar or bipolar function were tested to provoke myopotential interference. No patient had evidence of myopotential interference at any sensitivity setting in the bipolar configuration either in atrium or in ventricle. All patients (20/20) interfered with pacemaker function at the highest atrial or ventricular sensitivity settings in the unipolar configuration. T wave sensing occurred at the 0.25 mV sensitivity setting in four patients in pacemaker model 925, in both bipolar and unipolar configurations. Twenty-five percent of patients had myopotential interference at the unipolar atrial sensing threshold and did not allow a setting which would reject myopotential interference while providing satisfactory atrial sensing. Twenty percent (2/10) had myopotential caused ventricular inhibition at the least sensitive ventricular channel setting in model 240G so that myopotential interference could not be avoided in that unit no matter how large the electrogram.