技术领域Technical Field
本公开涉及一种用于设置心室后心房消隐期的医疗装置和方法。The present disclosure relates to a medical device and method for setting a post-ventricular atrial blanking period.
背景技术Background technique
可植入心脏起搏器通常放置在皮下袋中，并且耦接到携带定位在心脏中的起搏和感测电极的一条或多条经静脉医疗电引线。皮下植入的心脏起搏器可以是耦接到一条经静脉医疗引线以将电极定位在一个心脏腔室(心房或心室)中的单腔室起搏器或耦接到两条心脏内引线以将电极定位在心房腔室和心室腔室两者中的双腔室起搏器。多腔室起搏器也是可用的，该多腔室起搏器可以耦接到三条引线，以例如将用于起搏和感测的电极定位在一个心房腔室以及左心室和右心室两者中。An implantable cardiac pacemaker is typically placed in a subcutaneous pocket and coupled to one or more transvenous medical electrical leads that carry pacing and sensing electrodes positioned in the heart. A subcutaneously implanted cardiac pacemaker may be a single-chamber pacemaker coupled to one transvenous medical lead to position electrodes in one heart chamber (atrium or ventricle) or a dual-chamber pacemaker coupled to two intracardiac leads to position electrodes in both the atrial chamber and the ventricular chamber. Multi-chamber pacemakers are also available that may be coupled to three leads to, for example, position electrodes for pacing and sensing in one atrial chamber and both the left and right ventricles.
最近已经引入了可植入患者心脏的心室腔室内以递送心室起搏脉冲的心脏内起搏器。这种起搏器可以感测伴随固有心室去极化的R波信号，并且在不存在感测到的R波的情况下递送心室起搏脉冲。虽然通过心脏内心室起搏器进行单腔室心室感测和起搏可以充分地解决一些患者病状，但是一些患者可能受益于用于提供心房同步的心室起搏以便维持规则的心脏节律的心房和心室(双腔室)感测。Intracardiac pacemakers that can be implanted within the ventricular chamber of a patient's heart to deliver ventricular pacing pulses have recently been introduced. Such pacemakers can sense the R-wave signal accompanying intrinsic ventricular depolarization and deliver ventricular pacing pulses in the absence of a sensed R-wave. While single-chamber ventricular sensing and pacing by an intracardiac ventricular pacemaker can adequately address some patient conditions, some patients may benefit from atrial and ventricular (dual-chamber) sensing for providing atrial synchronized ventricular pacing to maintain a regular heart rhythm.
发明内容Summary of the invention
本公开的技术整体涉及在诸如能够进行心房同步心室起搏的心室起搏器的心脏装置中设置心室后心房消隐(PVAB)期。该装置可以感测对应于心房收缩的心房事件信号，用于触发与心房事件同步递送心室起搏脉冲。在一些示例中，该医疗装置可以具有被配置为感测心脏运动信号的运动传感器。该医疗装置可以被配置为从该运动信号中感测心房事件信号。根据本文公开的技术操作的医疗装置在心室事件之后设置应用于该运动信号的PVAB期，在该PVAB期期间，不从运动信号中感测心房事件信号。该医疗装置可以被配置为调整PVAB期的持续时间。在一些示例中，该医疗装置可以响应于心率变化和/或感测到的心房事件信号的频率或定时的变化而调整PVAB期的持续时间。在一些示例中，该医疗装置可以被配置为基于对运动信号的振幅的分析来调整心室事件之后的PVAB期的持续时间，从而促进对PVAB期之外的心房事件信号的可靠感测，并促进通过可以由医疗装置生成的心室起搏脉冲对心房事件的正确跟踪。The technology disclosed herein as a whole relates to setting a post-ventricular atrial blanking (PVAB) period in a cardiac device such as a ventricular pacemaker capable of atrial synchronous ventricular pacing. The device can sense an atrial event signal corresponding to atrial contraction, which is used to trigger the delivery of a ventricular pacing pulses in synchronization with the atrial event. In some examples, the medical device may have a motion sensor configured to sense a cardiac motion signal. The medical device may be configured to sense an atrial event signal from the motion signal. A medical device operating according to the technology disclosed herein sets a PVAB period applied to the motion signal after a ventricular event, during which an atrial event signal is not sensed from the motion signal. The medical device may be configured to adjust the duration of the PVAB period. In some examples, the medical device may adjust the duration of the PVAB period in response to changes in heart rate and/or changes in the frequency or timing of the sensed atrial event signal. In some examples, the medical device can be configured to adjust the duration of the PVAB period following a ventricular event based on analysis of the amplitude of the motion signal, thereby facilitating reliable sensing of atrial event signals outside of the PVAB period and facilitating correct tracking of atrial events via ventricular pacing pulses that can be generated by the medical device.
在一个示例中，本公开提供了一种医疗装置，该医疗装置包括被配置为感测运动信号的运动传感器和与该运动信号通信的控制电路。该控制电路可以被配置为标识第一组心脏事件、基于该第一组心脏事件确定第一心脏事件间期以及确定该第一心脏事件间期是小于阈值间期还是大于该阈值间期。该控制电路可以被配置为选择在该第一心脏事件间期小于该阈值间期的情况下的第一消隐期持续时间或在该第一心脏事件间期大于该阈值间期的情况下的第二消隐期持续时间。该第二消隐期持续时间大于该第一消隐期持续时间。该控制电路还可以被配置为标识在该第一组心脏事件之后发生的第二组心脏事件以及开始在该第二组心脏事件期间应用于该运动信号的PVAB期。在该第二组心脏事件期间，响应于每个心室事件，可以对运动信号应用PVAB期。将在该第二组心脏事件期间对该运动信号应用的PVAB期设置为该第一消隐期持续时间或该第二消隐期持续时间中的所选择的消隐期持续时间。In one example, the present disclosure provides a medical device, the medical device comprising a motion sensor configured to sense a motion signal and a control circuit that communicates with the motion signal. The control circuit can be configured to identify a first group of cardiac events, determine a first cardiac event interval based on the first group of cardiac events, and determine whether the first cardiac event interval is less than a threshold interval or greater than the threshold interval. The control circuit can be configured to select a first blanking period duration when the first cardiac event interval is less than the threshold interval or a second blanking period duration when the first cardiac event interval is greater than the threshold interval. The second blanking period duration is greater than the first blanking period duration. The control circuit can also be configured to identify a second group of cardiac events that occur after the first group of cardiac events and to start a PVAB period applied to the motion signal during the second group of cardiac events. During the second group of cardiac events, in response to each ventricular event, the PVAB period can be applied to the motion signal. The PVAB period applied to the motion signal during the second group of cardiac events is set to the selected blanking period duration of the first blanking period duration or the second blanking period duration.
在另一示例中，本公开提供了一种可以由医疗装置执行的方法。该方法可以包括：感测运动信号；标识第一组心脏事件；基于该第一组心脏事件确定第一心脏事件间期以及确定该第一心脏事件间期是小于阈值间期还是大于该阈值间期。该方法还可以包括选择以下项中的一者：在该第一心脏事件间期小于该阈值间期的情况下的第一消隐期持续时间或在该第一心脏事件间期大于该阈值间期的情况下的第二消隐期持续时间。该第二消隐期持续时间可以大于该第一消隐期持续时间。该方法还可以包括：标识在该第一组心脏事件之后发生的第二组心脏事件以及在该第二组心脏事件期间对该运动信号应用PVAB期。在该第二组心脏事件期间，响应于每个心室事件，可以对运动信号应用PVAB期。将在该第二组心脏事件期间对该运动信号应用的PVAB期设置为该第一消隐期持续时间或该第二消隐期持续时间中的所选择的消隐期持续时间。In another example, the present disclosure provides a method that can be performed by a medical device. The method may include: sensing a motion signal; identifying a first group of cardiac events; determining a first cardiac event interval based on the first group of cardiac events and determining whether the first cardiac event interval is less than a threshold interval or greater than the threshold interval. The method may also include selecting one of the following items: a first blanking period duration when the first cardiac event interval is less than the threshold interval or a second blanking period duration when the first cardiac event interval is greater than the threshold interval. The second blanking period duration may be greater than the first blanking period duration. The method may also include: identifying a second group of cardiac events that occur after the first group of cardiac events and applying a PVAB period to the motion signal during the second group of cardiac events. During the second group of cardiac events, in response to each ventricular event, a PVAB period may be applied to the motion signal. The PVAB period applied to the motion signal during the second group of cardiac events is set to the selected blanking period duration of the first blanking period duration or the second blanking period duration.
在另一示例中，本公开提供了一种存储指令集的非暂态计算机可读存储介质，该指令集在由医疗装置的控制电路执行时使该医疗装置：感测运动信号、标识第一组心脏事件、基于该第一组心脏事件确定第一心脏事件间期以及确定该第一心脏事件间期是小于阈值间期还是大于该阈值间期。这些指令可进一步使该医疗装置选择以下项中的一者：在该第一心脏事件间期小于该阈值间期的情况下的第一消隐期持续时间或在该第一心脏事件间期大于该阈值间期的情况下的第二消隐期持续时间。该第二消隐期持续时间可以大于该第一消隐期持续时间。这些指令可进一步使该医疗装置标识在该第一组心脏事件之后发生的第二组心脏事件以及在该第二组心脏事件期间对该运动信号应用PVAB期。在该第二组心脏事件期间，响应于每个心室事件，可以对运动信号应用PVAB期。将在该第二组心脏事件期间对该运动信号应用的PVAB期设置为该第一消隐期持续时间或该第二消隐期持续时间中的所选择的消隐期持续时间。In another example, the present disclosure provides a non-transitory computer-readable storage medium storing an instruction set, which, when executed by a control circuit of a medical device, causes the medical device to: sense a motion signal, identify a first group of cardiac events, determine a first cardiac event interval based on the first group of cardiac events, and determine whether the first cardiac event interval is less than a threshold interval or greater than the threshold interval. These instructions may further cause the medical device to select one of the following items: a first blanking period duration when the first cardiac event interval is less than the threshold interval or a second blanking period duration when the first cardiac event interval is greater than the threshold interval. The second blanking period duration may be greater than the first blanking period duration. These instructions may further cause the medical device to identify a second group of cardiac events occurring after the first group of cardiac events and to apply a PVAB period to the motion signal during the second group of cardiac events. During the second group of cardiac events, in response to each ventricular event, a PVAB period may be applied to the motion signal. The PVAB period applied to the motion signal during the second group of cardiac events is set to the selected blanking period duration of the first blanking period duration or the second blanking period duration.
本文还公开了以下条款的主题：This article also discloses the subject matter of the following articles:
1.一种医疗装置，该医疗装置包括：运动传感器，该运动传感器被配置为感测运动信号；脉冲发生器，该脉冲发生器被配置为生成心室起搏脉冲；和控制电路，该控制电路与该运动传感器和该脉冲发生器通信，该控制电路被配置为：标识第一多个心脏事件；1. A medical device, the medical device comprising: a motion sensor configured to sense a motion signal; a pulse generator configured to generate a ventricular pacing pulse; and a control circuit in communication with the motion sensor and the pulse generator, the control circuit configured to: identify a first plurality of cardiac events;
基于该第一多个心脏事件确定第一心脏事件间期；确定该第一心脏事件间期是小于阈值间期还是大于该阈值间期；选择以下项中的一者：在该第一心脏事件间期小于该阈值间期的情况下的第一消隐期持续时间或在该第一心脏事件间期大于该阈值间期的情况下的第二消隐期持续时间，该第二消隐期持续时间大于该第一消隐期持续时间；标识该第一多个心脏事件之后的第二多个心脏事件；以及在该第二多个心脏事件期间对该运动信号应用心室后心房消隐期，该心室后心房消隐期被设置为该第一消隐期持续时间或该第二消隐期持续时间中的所选择的消隐期持续时间。Determine a first cardiac event interval based on the first plurality of cardiac events; determine whether the first cardiac event interval is less than a threshold interval or greater than the threshold interval; select one of the following: a first blanking period duration when the first cardiac event interval is less than the threshold interval or a second blanking period duration when the first cardiac event interval is greater than the threshold interval, the second blanking period duration being greater than the first blanking period duration; identify a second plurality of cardiac events following the first plurality of cardiac events; and apply a post-ventricular atrial blanking period to the motion signal during the second plurality of cardiac events, the post-ventricular atrial blanking period being set to the selected blanking period duration of the first blanking period duration or the second blanking period duration.
2.根据条款1所述的医疗装置，其中该控制电路被进一步配置为：2. The medical device according to clause 1, wherein the control circuit is further configured to:
根据该第二多个心脏事件确定第二心脏事件间期；将该第二心脏事件间期与该阈值间期进行比较；基于该第二心脏事件间期与该阈值间期的比较，选择以下项中的一者：响应于该第二心脏事件间期小于该阈值间期的该第一消隐期持续时间或响应于该第二心脏事件间期大于该阈值间期的该第二消隐期持续时间；标识该第二多个心脏事件之后的第三多个心脏事件；以及在该第三多个心脏事件期间对该运动信号应用该心室后心房消隐期，其中该心室后心房消隐期被设置为该第一消隐期持续时间或该第二消隐期持续时间中的基于该第二心脏事件间期与该阈值间期的该比较而选择的消隐期持续时间。Determine a second cardiac event interval based on the second plurality of cardiac events; compare the second cardiac event interval with the threshold interval; based on the comparison of the second cardiac event interval with the threshold interval, select one of the following: the first blanking period duration in response to the second cardiac event interval being less than the threshold interval or the second blanking period duration in response to the second cardiac event interval being greater than the threshold interval; identify a third plurality of cardiac events following the second plurality of cardiac events; and apply the post-ventricular atrial blanking period to the motion signal during the third plurality of cardiac events, wherein the post-ventricular atrial blanking period is set to the blanking period duration of the first blanking period duration or the second blanking period duration selected based on the comparison of the second cardiac event interval with the threshold interval.
3.根据条款1至2中任一项所述的医疗装置，其中该控制电路被进一步配置为通过标识由该脉冲发生器生成的至少一个心室起搏脉冲来标识该第一多个心脏事件。3. The medical device of any one of clauses 1 to 2, wherein the control circuit is further configured to identify the first plurality of cardiac events by identifying at least one ventricular pacing pulse generated by the pulse generator.
4.根据条款1至3中任一项所述的医疗装置，该医疗装置还包括感测电路，该感测电路被配置为接收心脏电信号并且从该心脏电信号中感测心室事件，其中该控制电路被配置为通过标识由该感测电路感测的至少一个心室事件来标识该第一多个心脏事件。4. A medical device according to any one of clauses 1 to 3, further comprising a sensing circuit configured to receive cardiac electrical signals and sense ventricular events from the cardiac electrical signals, wherein the control circuit is configured to identify the first plurality of cardiac events by identifying at least one ventricular event sensed by the sensing circuit.
5.根据条款1至4中任一项所述的医疗装置，其中该控制电路被进一步配置为在该心室后心房消隐期之外从该运动信号中感测心房事件信号；以及响应于感测到该心房事件信号而生成输出；该医疗装置还包括与该控制电路通信的存储器，该存储器被配置为存储由该控制电路响应于感测到该心房事件信号而生成的该输出。5. A medical device according to any one of clauses 1 to 4, wherein the control circuit is further configured to sense an atrial event signal from the motion signal outside the post-ventricular atrial blanking period; and generate an output in response to sensing the atrial event signal; the medical device also includes a memory in communication with the control circuit, the memory being configured to store the output generated by the control circuit in response to sensing the atrial event signal.
6.根据条款1至5中任一项所述的医疗装置，其中该控制电路被进一步配置为在该心室后心房消隐期期间设置节电时间段；以及在该节电时间间期期间禁用该运动传感器的至少一部分。6. A medical device according to any one of clauses 1 to 5, wherein the control circuit is further configured to set a power saving time period during the post-ventricular atrial blanking period; and disable at least a portion of the motion sensor during the power saving time interval.
7.根据条款6所述的医疗装置，其中该控制电路被进一步配置为将该节电时间段设置为比该心室后心房消隐期早(例如，提前)预定时间间期到期，该心室后心房消隐期被设置为该第一消隐期持续时间或该第二消隐期持续时间中的所选择的消隐期持续时间。7. A medical device according to claim 6, wherein the control circuit is further configured to set the power-saving time period to expire earlier (e.g., in advance) than a predetermined time interval of the post-ventricular atrial blanking period, and the post-ventricular atrial blanking period is set to a selected blanking period duration of the first blanking period duration or the second blanking period duration.
8.根据条款1至7中任一项所述的医疗装置，其中该控制电路被进一步配置为通过响应于该第一心脏事件间期小于该阈值间期而选择最小消隐期持续时间来选择该第一消隐期持续时间。8. A medical device according to any one of clauses 1 to 7, wherein the control circuit is further configured to select the first blanking period duration by selecting a minimum blanking period duration in response to the first cardiac event interval being less than the threshold interval.
9.根据条款1至8中任一项所述的医疗装置，其中该控制电路被进一步配置为通过响应于该第一心脏事件间期大于该阈值间期而选择最大消隐期持续时间来选择第二消隐期。9. A medical device according to any one of clauses 1 to 8, wherein the control circuit is further configured to select the second blanking period by selecting a maximum blanking period duration in response to the first cardiac event interval being greater than the threshold interval.
10.根据条款1至9中任一项所述的医疗装置，其中该控制电路被进一步配置为确定该第一心脏事件间期何时小于该阈值间期；响应于该第一心脏事件间期小于该阈值间期，确定该运动信号在至少一个心室后心房消隐期期间的振幅；确定该振幅大于阈值振幅；响应于该振幅大于该阈值振幅，拒绝响应于该第一心脏事件间期小于该阈值间期而选择该第一消隐期持续时间；以及当该第一心脏事件间期小于该阈值间期时，响应于确定该运动信号的该振幅大于该阈值振幅而选择该第二消隐期。10. A medical device according to any one of clauses 1 to 9, wherein the control circuit is further configured to determine when the first cardiac event interval is less than the threshold interval; in response to the first cardiac event interval being less than the threshold interval, determine the amplitude of the motion signal during at least one post-ventricular atrial blanking period; determine that the amplitude is greater than a threshold amplitude; in response to the amplitude being greater than the threshold amplitude, refuse to select the first blanking period duration in response to the first cardiac event interval being less than the threshold interval; and when the first cardiac event interval is less than the threshold interval, select the second blanking period in response to determining that the amplitude of the motion signal is greater than the threshold amplitude.
11.根据条款1至10中任一项所述的医疗装置，其中该控制电路被进一步配置为确定该运动信号的振幅；以及基于该运动信号的该振幅设置该第一消隐期持续时间。11. The medical device of any one of clauses 1 to 10, wherein the control circuit is further configured to determine an amplitude of the motion signal; and to set the first blanking period duration based on the amplitude of the motion signal.
12.根据条款1至11中任一项所述的医疗装置，其中该控制电路被进一步配置为确定该运动信号的峰值振幅或振幅阈值跨越中的一者的时间；以及基于所确定的时间设置该第一消隐期持续时间。12. A medical device according to any one of clauses 1 to 11, wherein the control circuit is further configured to determine the time when one of the peak amplitude or amplitude threshold crossing of the motion signal occurs; and to set the first blanking period duration based on the determined time.
13.根据条款1至12中任一项所述的医疗装置，其中该控制电路被进一步配置为等待预定时间间期或预定数量的心脏事件间期中的一者；标识第二多个心脏事件；根据该第二多个心脏事件确定第二心脏事件间期；以及在等待该预定时间间期或该预定数量的心脏事件间期中的一者之后基于该第二心脏事件间期来调整该心室后心房消隐期。13. A medical device according to any one of clauses 1 to 12, wherein the control circuit is further configured to wait for a predetermined time interval or one of a predetermined number of cardiac event intervals; identify a second plurality of cardiac events; determine a second cardiac event interval based on the second plurality of cardiac events; and adjust the post-ventricular atrial blanking period based on the second cardiac event interval after waiting for the predetermined time interval or one of the predetermined number of cardiac event intervals.
14.根据条款1至13中任一项所述的医疗装置，其中该控制电路被进一步配置为基于该心室后心房消隐期的当前持续时间从第一较长阈值间期和第二较短阈值间期中的一者中选择该阈值间期。14. A medical device according to any one of clauses 1 to 13, wherein the control circuit is further configured to select the threshold interval from one of a first longer threshold interval and a second shorter threshold interval based on a current duration of the post-ventricular atrial blanking period.
15.根据条款1至14中任一项所述的医疗装置，其中该控制电路被进一步配置为在该心室后心房消隐期到期后从该运动信号中感测心房事件信号；并且该脉冲发生器被配置为响应于该控制电路感测到该心房事件信号而生成心室起搏脉冲。15. A medical device according to any one of clauses 1 to 14, wherein the control circuit is further configured to sense an atrial event signal from the motion signal after expiration of the post-ventricular atrial blanking period; and the pulse generator is configured to generate a ventricular pacing pulse in response to the control circuit sensing the atrial event signal.
16.一种方法，该方法包括：感测运动信号；标识第一多个心脏事件；基于该第一多个心脏事件确定第一心脏事件间期；确定该第一心脏事件间期是小于阈值间期还是大于该阈值间期；选择以下项中的一者：在该第一心脏事件间期小于该阈值间期的情况下的第一消隐期持续时间或在该第一心脏事件间期大于该阈值间期的情况下的第二消隐期持续时间，该第二消隐期持续时间大于该第一消隐期持续时间；标识该第一多个心脏事件之后的第二多个心脏事件；以及在该第二多个心脏事件期间对该运动信号应用心室后心房消隐期，该心室后心房消隐期被设置为该第一消隐期持续时间或该第二消隐期持续时间中的所选择的消隐期持续时间。16. A method, the method comprising: sensing a motion signal; identifying a first plurality of cardiac events; determining a first cardiac event interval based on the first plurality of cardiac events; determining whether the first cardiac event interval is less than a threshold interval or greater than the threshold interval; selecting one of the following items: a first blanking period duration when the first cardiac event interval is less than the threshold interval or a second blanking period duration when the first cardiac event interval is greater than the threshold interval, the second blanking period duration being greater than the first blanking period duration; identifying a second plurality of cardiac events following the first plurality of cardiac events; and applying a post-ventricular atrial blanking period to the motion signal during the second plurality of cardiac events, the post-ventricular atrial blanking period being set to a selected blanking period duration of the first blanking period duration or the second blanking period duration.
17.根据条款16所述的方法，该方法还包括：根据该第二多个心脏事件确定第二心脏事件间期；将该第二心脏事件间期与该阈值间期进行比较；基于该第二心脏事件间期与该阈值间期的比较，选择以下项中的一者：响应于该第二心脏事件间期小于该阈值间期的该第一消隐期持续时间或响应于该第二心脏事件间期大于该阈值间期的该第二消隐期持续时间；标识该第二多个心脏事件之后的第三多个心脏事件；以及在该第三多个心脏事件期间对该运动信号应用该心室后心房消隐期，其中该心室后心房消隐期被设置为该第一消隐期持续时间或该第二消隐期持续时间中的基于该第二心脏事件间期与该阈值间期的该比较而选择的所选择的消隐期持续时间。17. The method according to clause 16 further includes: determining a second cardiac event interval based on the second plurality of cardiac events; comparing the second cardiac event interval with the threshold interval; based on the comparison of the second cardiac event interval with the threshold interval, selecting one of the following items: the first blanking period duration in response to the second cardiac event interval being less than the threshold interval or the second blanking period duration in response to the second cardiac event interval being greater than the threshold interval; identifying a third plurality of cardiac events after the second plurality of cardiac events; and applying the post-ventricular atrial blanking period to the motion signal during the third plurality of cardiac events, wherein the post-ventricular atrial blanking period is set to the selected blanking period duration of the first blanking period duration or the second blanking period duration selected based on the comparison of the second cardiac event interval with the threshold interval.
18.根据条款16至17中任一项所述的方法，该方法还包括：生成心室起搏脉冲；以及通过标识至少一个心室起搏脉冲来标识该第一多个心脏事件。18. The method of any of clauses 16 to 17, further comprising: generating a ventricular pacing pulse; and identifying the first plurality of cardiac events by identifying at least one ventricular pacing pulse.
19.根据条款16至18中任一项所述的方法，该方法还包括：接收心脏电信号；从该心脏电信号中感测心室事件；以及通过标识由该感测电路感测的至少一个心室事件来标识该第一多个心脏事件。19. A method according to any one of clauses 16 to 18, further comprising: receiving a cardiac electrical signal; sensing a ventricular event from the cardiac electrical signal; and identifying the first plurality of cardiac events by identifying at least one ventricular event sensed by the sensing circuit.
20.根据条款16至19中任一项所述的方法，该方法还包括：在该心室后心房消隐期之外从该运动信号中感测心房事件信号；响应于感测到该心房事件信号而生成输出；以及在存储器中存储响应于感测到该心房事件信号而生成的该输出。20. A method according to any one of clauses 16 to 19, further comprising: sensing an atrial event signal from the motion signal outside the post-ventricular atrial blanking period; generating an output in response to sensing the atrial event signal; and storing the output generated in response to sensing the atrial event signal in a memory.
21.根据条款16至20中任一项所述的方法，该方法还包括在该心室后心房消隐期期间设置节电时间段；以及在节电时间间期期间禁用该运动传感器的至少一部分。21. The method of any one of clauses 16 to 20, further comprising setting a power saving time period during the post-ventricular atrial blanking period; and disabling at least a portion of the motion sensor during the power saving time interval.
22.根据条款21所述的方法，该方法还包括：将该节电时间段设置为比该心室后心房消隐期提前预定时间间期到期。22. The method according to clause 21, further comprising: setting the power saving time period to expire a predetermined time interval earlier than the post-ventricular atrial blanking period.
23.根据条款16至22中任一项所述的方法，其中选择该第一消隐期持续时间包括：响应于该第一心脏事件间期小于该阈值间期而选择最小消隐期持续时间。23. The method of any of clauses 16 to 22, wherein selecting the first blanking period duration comprises selecting a minimum blanking period duration in response to the first cardiac event interval being less than the threshold interval.
24.根据条款16至23中任一项所述的方法，其中选择该第二消隐期持续时间包括：响应于该第一心脏事件间期大于该阈值间期而选择最大消隐期持续时间。24. A method according to any one of clauses 16 to 23, wherein selecting the second blanking period duration comprises selecting a maximum blanking period duration in response to the first cardiac event interval being greater than the threshold interval.
25.根据条款16至24中任一项所述的方法，该方法还包括：确定该第一心脏事件间期何时小于该阈值间期；响应于该第一心脏事件间期小于该阈值间期，确定该运动信号在至少一个心室后心房消隐期期间的振幅；确定该振幅大于阈值振幅；响应于该振幅大于该阈值振幅，拒绝响应于该第一心脏事件间期小于该阈值间期而选择该第一消隐期持续时间；以及当该第一心脏事件间期小于该阈值间期时，响应于确定该运动信号的该振幅大于该阈值振幅而选择该第二消隐期。25. A method according to any one of clauses 16 to 24, the method further comprising: determining when the first cardiac event interval is less than the threshold interval; in response to the first cardiac event interval being less than the threshold interval, determining the amplitude of the motion signal during at least one post-ventricular atrial blanking period; determining that the amplitude is greater than a threshold amplitude; in response to the amplitude being greater than the threshold amplitude, refusing to select the first blanking period duration in response to the first cardiac event interval being less than the threshold interval; and when the first cardiac event interval is less than the threshold interval, selecting the second blanking period in response to determining that the amplitude of the motion signal is greater than the threshold amplitude.
26.根据条款16至25中任一项所述的方法，该方法还包括：确定该运动信号的振幅以及基于该运动信号的该振幅设置该第一消隐期持续时间。26. A method according to any of clauses 16 to 25, further comprising: determining an amplitude of the motion signal and setting the first blanking period duration based on the amplitude of the motion signal.
27.根据条款16至26中任一项所述的方法，该方法还包括：确定该运动信号的峰值振幅或振幅阈值跨越中的一者的时间；以及基于所确定的时间设置该第一消隐期持续时间。27. A method according to any one of clauses 16 to 26, further comprising: determining a time of one of a peak amplitude or an amplitude threshold crossing of the motion signal; and setting the first blanking period duration based on the determined time.
28.根据条款16至27中任一项所述的方法，该方法还包括：等待预定时间间期或预定数量的心脏事件间期中的一者；标识第二多个心脏事件；根据该第二多个心脏事件确定第二心脏事件间期；以及28. The method of any one of clauses 16 to 27, further comprising: waiting for one of a predetermined time interval or a predetermined number of cardiac event intervals; identifying a second plurality of cardiac events; determining a second cardiac event interval based on the second plurality of cardiac events; and
在等待该预定时间间期或该预定数量的心脏事件间期中的一者之后基于该第二心脏事件间期来调整该心室后心房消隐期。The post-ventricular atrial blanking interval is adjusted based on the second cardiac event interval after waiting one of the predetermined time interval or the predetermined number of cardiac event intervals.
29.根据条款16至28中任一项所述的方法，该方法还包括：基于该心室后心房消隐期的当前持续时间从第一阈值间期和比该第一阈值间期短的第二阈值间期中的一者中选择该阈值间期。29. The method according to any one of clauses 16 to 28, further comprising: selecting the threshold interval from one of a first threshold interval and a second threshold interval shorter than the first threshold interval based on a current duration of the post-ventricular atrial blanking period.
30.根据条款16至29中任一项所述的方法，该方法还包括：为在该心室后心房消隐期到期后从该运动信号中感测心房事件信号；以及30. The method of any of clauses 16 to 29, further comprising: sensing an atrial event signal from the motion signal after expiration of the post-ventricular atrial blanking period; and
响应于该控制电路感测到该心房事件信号而生成心室起搏脉冲。A ventricular pacing pulse is generated in response to the control circuit sensing the atrial event signal.
31.一种存储指令集的非暂态计算机可读介质，该指令集在由医疗装置的控制电路执行时使该医疗装置：感测运动信号；标识第一多个心脏事件；基于该第一多个心脏事件确定第一心脏事件间期；31. A non-transitory computer readable medium storing a set of instructions that, when executed by control circuitry of a medical device, causes the medical device to: sense a motion signal; identify a first plurality of cardiac events; determine a first cardiac event interval based on the first plurality of cardiac events;
确定该第一心脏事件间期是小于阈值间期还是大于该阈值间期；选择以下项中的一者：在该第一心脏事件间期小于该阈值间期的情况下的第一消隐期持续时间或在该第一心脏事件间期大于该阈值间期的情况下的第二消隐期持续时间，该第二消隐期持续时间大于该第一消隐期持续时间；标识该第一多个心脏事件之后的第二多个心脏事件；以及在该第二多个心脏事件期间对该运动信号应用心室后心房消隐期，该心室后心房消隐期被设置为该第一消隐期持续时间或该第二消隐期持续时间中的所选择的消隐期持续时间。Determine whether the first cardiac event interval is less than a threshold interval or greater than the threshold interval; select one of the following: a first blanking period duration when the first cardiac event interval is less than the threshold interval or a second blanking period duration when the first cardiac event interval is greater than the threshold interval, the second blanking period duration being greater than the first blanking period duration; identify a second plurality of cardiac events following the first plurality of cardiac events; and apply a post-ventricular atrial blanking period to the motion signal during the second plurality of cardiac events, the post-ventricular atrial blanking period being set to the selected blanking period duration of the first blanking period duration or the second blanking period duration.
32.根据条款31所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：根据该第二多个心脏事件确定第二心脏事件间期；将该第二心脏事件间期与该阈值间期进行比较；基于该第二心脏事件间期与该阈值间期的比较，选择以下项中的一者：响应于该第二心脏事件间期小于该阈值间期的该第一消隐期持续时间或响应于该第二心脏事件间期大于该阈值间期的该第二消隐期持续时间；标识该第二多个心脏事件之后的第三多个心脏事件；以及在该第三多个心脏事件期间对该运动信号应用该心室后心房消隐期，其中该心室后心房消隐期被设置为该第一消隐期持续时间或该第二消隐期持续时间中的基于该第二心脏事件间期与该阈值间期的该比较而选择的所选择的消隐期持续时间。32. A non-transitory computer-readable medium according to clause 31, the non-transitory computer-readable medium also including instructions that cause the medical device to: determine a second cardiac event interval based on the second plurality of cardiac events; compare the second cardiac event interval with the threshold interval; based on the comparison of the second cardiac event interval with the threshold interval, select one of the following: the first blanking period duration in response to the second cardiac event interval being less than the threshold interval or the second blanking period duration in response to the second cardiac event interval being greater than the threshold interval; identify a third plurality of cardiac events following the second plurality of cardiac events; and apply the post-ventricular atrial blanking period to the motion signal during the third plurality of cardiac events, wherein the post-ventricular atrial blanking period is set to the selected blanking period duration of the first blanking period duration or the second blanking period duration selected based on the comparison of the second cardiac event interval with the threshold interval.
33.根据条款31至32中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：生成心室起搏脉冲；以及通过标识至少一个心室起搏脉冲来标识该第一多个心脏事件。33. The non-transitory computer-readable medium of any one of clauses 31 to 32, further comprising instructions that cause the medical device to: generate a ventricular pacing pulse; and identify the first plurality of cardiac events by identifying at least one ventricular pacing pulse.
34.根据条款31至33中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：接收心脏电信号；从该心脏电信号中感测心室事件；以及通过标识由该感测电路感测的至少一个心室事件来标识该第一多个心脏事件。34. A non-transitory computer-readable medium according to any one of clauses 31 to 33, the non-transitory computer-readable medium also including instructions that cause the medical device to: receive cardiac electrical signals; sense ventricular events from the cardiac electrical signals; and identify the first plurality of cardiac events by identifying at least one ventricular event sensed by the sensing circuit.
35.根据条款31至34中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：在该心室后心房消隐期之外从该运动信号中感测心房事件信号；响应于感测到该心房事件信号而生成输出；以及在该医疗装置的存储器中存储响应于感测到该心房事件信号而生成的该输出。35. A non-transitory computer-readable medium according to any one of clauses 31 to 34, further comprising instructions that cause the medical device to: sense an atrial event signal from the motion signal outside the post-ventricular atrial blanking period; generate an output in response to sensing the atrial event signal; and store the output generated in response to sensing the atrial event signal in a memory of the medical device.
36.根据条款30至35中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：在该心室后心房消隐期期间设置节电时间段；以及在该节电时间间期期间禁用该运动传感器的至少一部分。36. A non-transitory computer-readable medium according to any one of clauses 30 to 35, the non-transitory computer-readable medium also including instructions that cause the medical device to: set a power-saving time period during the post-ventricular atrial blanking period; and disable at least a portion of the motion sensor during the power-saving time interval.
37.根据条款36所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置将该节电时间段设置为比该心室后心房消隐期提前预定时间间期到期。37. The non-transitory computer-readable medium of clause 36, further comprising instructions that cause the medical device to set the power saving period to expire a predetermined time interval earlier than the post-ventricular atrial blanking period.
38.根据条款30至37中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置通过响应于该第一心脏事件间期小于该阈值间期而选择最小消隐期持续时间来选择该第一消隐期持续时间。38. A non-transitory computer-readable medium according to any one of clauses 30 to 37, further comprising instructions that cause the medical device to select the first blanking period duration by selecting a minimum blanking period duration in response to the first cardiac event interval being less than the threshold interval.
39.根据条款30至38中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置通过响应于该第一心脏事件间期大于该阈值间期而选择最大消隐期持续时间来选择第二消隐期持续时间。39. A non-transitory computer-readable medium according to any one of clauses 30 to 38, further comprising instructions that cause the medical device to select a second blanking period duration by selecting a maximum blanking period duration in response to the first cardiac event interval being greater than the threshold interval.
40.根据条款30至39中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：确定该第一心脏事件间期何时小于该阈值间期；响应于该第一心脏事件间期小于该阈值间期，确定该运动信号在至少一个心室后心房消隐期期间的振幅；确定该振幅大于阈值振幅；响应于该振幅大于该阈值振幅，拒绝响应于该第一心脏事件间期小于该阈值间期而选择该第一消隐期持续时间；以及当该第一心脏事件间期小于该阈值间期时，响应于确定该运动信号的该振幅大于该阈值振幅而选择该第二消隐期。40. A non-transitory computer-readable medium according to any one of clauses 30 to 39, the non-transitory computer-readable medium also including instructions that cause the medical device to: determine when the first cardiac event interval is less than the threshold interval; in response to the first cardiac event interval being less than the threshold interval, determine the amplitude of the motion signal during at least one post-ventricular atrial blanking period; determine that the amplitude is greater than a threshold amplitude; in response to the amplitude being greater than the threshold amplitude, refuse to select the first blanking period duration in response to the first cardiac event interval being less than the threshold interval; and when the first cardiac event interval is less than the threshold interval, select the second blanking period in response to determining that the amplitude of the motion signal is greater than the threshold amplitude.
41.根据条款30至40中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：确定该运动信号的振幅；以及基于该运动信号的该振幅设置该第一消隐期持续时间。41. The non-transitory computer-readable medium of any one of clauses 30 to 40, further comprising instructions that cause the medical device to: determine an amplitude of the motion signal; and set the first blanking period duration based on the amplitude of the motion signal.
42.根据条款30至41中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：确定该运动信号的峰值振幅或振幅阈值跨越中的一者的时间；以及基于所确定的时间设置该第一消隐期持续时间。42. A non-transitory computer-readable medium according to any one of clauses 30 to 41, further comprising instructions that cause the medical device to: determine the time of one of the peak amplitude or amplitude threshold crossing of the motion signal; and set the first blanking period duration based on the determined time.
43.根据条款31至42中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：等待预定时间间期或预定数量的心脏事件间期中的一者；标识第二多个心脏事件；根据该第二多个心脏事件确定第二心脏事件间期；以及在等待该预定时间间期或该预定数量的心脏事件间期中的一者之后基于该第二心脏事件间期来调整该心室后心房消隐期。43. A non-transitory computer-readable medium according to any one of clauses 31 to 42, further comprising instructions that cause the medical device to: wait for a predetermined time interval or one of a predetermined number of cardiac event intervals; identify a second plurality of cardiac events; determine a second cardiac event interval based on the second plurality of cardiac events; and adjust the post-ventricular atrial blanking period based on the second cardiac event interval after waiting for the predetermined time interval or one of the predetermined number of cardiac event intervals.
44.根据条款30至43中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置基于该心室后心房消隐期的当前持续时间从第一阈值间期和比该第一阈值间期短的第二阈值间期中的一者中选择该阈值间期。44. A non-transitory computer-readable medium according to any one of clauses 30 to 43, further comprising instructions that cause the medical device to select the threshold interval from one of a first threshold interval and a second threshold interval that is shorter than the first threshold interval based on a current duration of the post-ventricular atrial blanking period.
45.根据条款30至44中任一项所述的非暂态计算机可读介质，该非暂态计算机可读介质还包括指令，这些指令使该医疗装置：在该心室后心房消隐期到期后从该运动信号中感测心房事件信号；以及45. The non-transitory computer-readable medium of any of clauses 30 to 44, further comprising instructions that cause the medical device to: sense an atrial event signal from the motion signal after expiration of the post-ventricular atrial blanking period; and
响应于该控制电路感测到该心房事件信号而生成心室起搏脉冲。A ventricular pacing pulse is generated in response to the control circuit sensing the atrial event signal.
46.一种医疗装置，该医疗装置包括：运动传感器，该运动传感器被配置为感测运动信号；脉冲发生器，该脉冲发生器被配置为生成心室起搏脉冲；和控制电路，该控制电路耦接到该运动传感器以接收该运动信号并且被配置为：标识多个心室事件；在该多个心室事件中的每个心室事件之后设置心室后心房消隐期；确定由该运动传感器在这些心室后心房消隐期中的至少一个心室后心房消隐期期间感测的该运动信号的振幅；以及基于所确定的该运动信号的振幅来调整该心室后心房消隐期。46. A medical device, comprising: a motion sensor configured to sense a motion signal; a pulse generator configured to generate a ventricular pacing pulse; and a control circuit coupled to the motion sensor to receive the motion signal and configured to: identify multiple ventricular events; set a ventricular post-atrial blanking period after each of the multiple ventricular events; determine the amplitude of the motion signal sensed by the motion sensor during at least one of the ventricular post-atrial blanking periods; and adjust the ventricular post-atrial blanking period based on the determined amplitude of the motion signal.
47.根据条款46所述的医疗装置，其中该控制电路被进一步配置为通过标识由该脉冲发生器生成的至少一个心室起搏脉冲来标识该多个心室事件。47. The medical device of clause 46, wherein the control circuit is further configured to identify the plurality of ventricular events by identifying at least one ventricular pacing pulse generated by the pulse generator.
48.根据条款46至47中任一项所述的医疗装置，该医疗装置还包括感测电路，该感测电路被配置为接收心脏电信号并且从该心脏电信号中感测心室事件，其中该控制电路被配置为通过标识由该感测电路感测的至少一个心室事件来标识该多个心室事件。48. A medical device according to any one of clauses 46 to 47, further comprising a sensing circuit configured to receive cardiac electrical signals and sense ventricular events from the cardiac electrical signals, wherein the control circuit is configured to identify the multiple ventricular events by identifying at least one ventricular event sensed by the sensing circuit.
49.根据条款46至48中任一项所述的医疗装置，其中该控制电路被进一步配置为：通过确定根据在该至少一个心室后心房消隐期的至少一部分期间感测的该运动信号的峰值振幅来确定该振幅；确定该峰值振幅是否小于振幅阈值；以及通过响应于该峰值振幅小于该振幅阈值而缩短该心室后心房消隐期来调整该心室后心房消隐期。49. A medical device according to any one of clauses 46 to 48, wherein the control circuit is further configured to: determine the amplitude by determining a peak amplitude of the motion signal sensed during at least a portion of the at least one ventricular post-atrial blanking period; determine whether the peak amplitude is less than an amplitude threshold; and adjust the ventricular post-atrial blanking period by shortening the ventricular post-atrial blanking period in response to the peak amplitude being less than the amplitude threshold.
50.根据条款46至49中任一项所述的医疗装置，其中该控制电路被进一步配置为：通过确定根据在该至少一个心室后心房消隐期的至少一部分期间感测的该运动信号的峰值振幅来确定该振幅；确定该峰值振幅是否大于振幅阈值；以及通过响应于该峰值振幅大于该振幅阈值而增加该心室后心房消隐期来调整该心室后心房消隐期。50. A medical device according to any one of clauses 46 to 49, wherein the control circuit is further configured to: determine the amplitude by determining a peak amplitude of the motion signal sensed during at least a portion of the at least one ventricular post-atrial blanking period; determine whether the peak amplitude is greater than an amplitude threshold; and adjust the ventricular post-atrial blanking period by increasing the ventricular post-atrial blanking period in response to the peak amplitude being greater than the amplitude threshold.
51.根据条款56至50中任一项所述的医疗装置，其中该控制电路被进一步配置为通过调整可应用于未来心动周期的心室后心房消隐期的持续时间来调整该心室后心房消隐期。51. A medical device according to any one of clauses 56 to 50, wherein the control circuit is further configured to adjust the post-ventricular atrial blanking period by adjusting the duration of the post-ventricular atrial blanking period applicable to future cardiac cycles.
52.根据条款46至51中任一项所述的医疗装置，其中该控制电路被进一步配置为：通过在该至少一个心室后心房消隐期期间检测到该运动信号的最晚振幅阈值跨越来确定该振幅；确定该振幅阈值跨越比从该心室后心房消隐期到期后的阈值时间间期提前；以及通过响应于该振幅阈值跨越比从该心室后心房消隐期到期后的该阈值时间间期提前而缩短该心室后心房消隐期来调整该心室后心房消隐期。52. A medical device according to any one of clauses 46 to 51, wherein the control circuit is further configured to: determine the amplitude by detecting a latest amplitude threshold crossing of the motion signal during the at least one ventricular post-atrial blanking period; determine that the amplitude threshold crossing is earlier than a threshold time interval from the expiration of the ventricular post-atrial blanking period; and adjust the ventricular post-atrial blanking period by shortening the ventricular post-atrial blanking period in response to the amplitude threshold crossing being earlier than the threshold time interval from the expiration of the ventricular post-atrial blanking period.
53.根据条款52所述的医疗装置，其中该控制电路被配置为基于用于调整该心室后心房消隐期的减量间期来设置该阈值时间间期。53. The medical device of clause 52, wherein the control circuit is configured to set the threshold time interval based on a decrement interval for adjusting the post-ventricular atrial blanking period.
54.根据条款46至53中任一项所述的医疗装置，其中该控制电路被进一步配置为：检测心率的变化；以及响应于检测到该心率的该变化而确定该运动信号的该振幅。54. The medical device of any one of clauses 46 to 53, wherein the control circuit is further configured to: detect a change in heart rate; and determine the amplitude of the motion signal in response to detecting the change in heart rate.
55.根据条款46至54中任一项所述的医疗装置，其中该控制电路被进一步配置为：在该至少一个心室后心房消隐期期间设置振幅分析窗口；通过确定在该振幅分析窗口期间感测的该运动信号的峰值振幅来确定该振幅；确定该峰值振幅小于振幅阈值；以及通过响应于该峰值振幅小于该振幅阈值而缩短该心室后心房消隐期来调整该心室后心房消隐期。55. A medical device according to any one of clauses 46 to 54, wherein the control circuit is further configured to: set an amplitude analysis window during the at least one ventricular post-atrial blanking period; determine the amplitude by determining the peak amplitude of the motion signal sensed during the amplitude analysis window; determine that the peak amplitude is less than an amplitude threshold; and adjust the ventricular post-atrial blanking period by shortening the ventricular post-atrial blanking period in response to the peak amplitude being less than the amplitude threshold.
56.根据条款46至55中任一项所述的医疗装置，其中该控制电路被进一步配置为：检测心率的减小；响应于检测到该心率的该减小而增加该心室后心房消隐期；检测该心率的增加；以及基于确定的振幅和该心率的该增加，通过减少该心室后心房消隐期来调整该心室后心房消隐期，或者保持该心室后心房消隐期不变。56. A medical device according to any one of clauses 46 to 55, wherein the control circuit is further configured to: detect a decrease in heart rate; increase the ventricular post-atrial blanking period in response to detecting the decrease in heart rate; detect an increase in the heart rate; and based on the determined amplitude and the increase in the heart rate, adjust the ventricular post-atrial blanking period by reducing the ventricular post-atrial blanking period, or maintain the ventricular post-atrial blanking period unchanged.
57.根据条款46至56中任一项所述的医疗装置，其中该控制电路被进一步配置为：设置在该至少一个心室后心房消隐期的到期时间之前开始的心室后心房消隐结束时间间期；以及通过将在该心室后心房消隐结束时间间期期间感测的该运动信号与振幅阈值进行比较来确定该振幅。57. A medical device according to any one of clauses 46 to 56, wherein the control circuit is further configured to: set a ventricular post-atrial blanking end time interval starting before the expiration time of at least one ventricular post-atrial blanking period; and determine the amplitude by comparing the motion signal sensed during the ventricular post-atrial blanking end time interval with an amplitude threshold.
58.根据条款57所述的医疗装置，其中该控制电路被进一步配置为：58. The medical device of clause 57, wherein the control circuit is further configured to:
基于在该心室后心房消隐结束时间间期期间感测的该运动信号与该振幅阈值之间的该比较：响应于该运动信号未越过在该心室后心房消隐结束时间间期期间的该振幅阈值而减少该心室后心房消隐期，或者响应于该运动信号越过在该心室后心房消隐结束时间间期期间的该振幅阈值而保持该心室后心房消隐期不变。Based on the comparison between the motion signal sensed during the post-ventricular atrial blanking end time interval and the amplitude threshold: reducing the post-ventricular atrial blanking period in response to the motion signal not crossing the amplitude threshold during the post-ventricular atrial blanking end time interval, or maintaining the post-ventricular atrial blanking period unchanged in response to the motion signal crossing the amplitude threshold during the post-ventricular atrial blanking end time interval.
59.根据条款46至58中任一项所述的医疗装置，其中该控制电路被进一步配置为：在第一多个心室后心房消隐期中的每个心室后心房消隐期期间禁用该运动传感器的运动信号感测；检测心率的变化；响应于检测到该心率的该变化，在该至少一个心室后心房消隐期的至少一部分期间启用该运动传感器的运动信号感测。59. A medical device according to any one of clauses 46 to 58, wherein the control circuit is further configured to: disable motion signal sensing by the motion sensor during each of a first plurality of ventricular post-atrial blanking periods; detect changes in heart rate; and in response to detecting the changes in heart rate, enable motion signal sensing by the motion sensor during at least a portion of at least one of the ventricular post-atrial blanking periods.
60.根据条款46至59中任一项所述的医疗装置，其中该控制电路被进一步配置为：在该心室后心房消隐期之外从该运动信号中感测心房事件信号；检测从该运动信号中感测的该心房事件信号的频率和定时中的至少一者的变化；以及响应于检测到从该运动信号中感测的该心房事件信号的该频率和该定时中的至少一者的该变化而确定在该至少一个心室后心房消隐期期间感测的该运动信号的该振幅。60. A medical device according to any one of clauses 46 to 59, wherein the control circuit is further configured to: sense an atrial event signal from the motion signal outside the post-ventricular atrial blanking period; detect a change in at least one of the frequency and the timing of the atrial event signal sensed from the motion signal; and determine the amplitude of the motion signal sensed during at least one post-ventricular atrial blanking period in response to detecting the change in at least one of the frequency and the timing of the atrial event signal sensed from the motion signal.
61.根据条款46至60中任一项所述的医疗装置，其中该控制电路被进一步配置为：确定该运动信号的该振幅大于在从该至少一个心室后心房消隐期到期后的阈值时间间期期间的振幅阈值；以及通过响应于该运动信号的该振幅大于在从该至少一个心室后心房消隐期到期后的该阈值时间间期期间的该振幅阈值而增加该心室后心房消隐期来调整该心室后心房消隐期。61. A medical device according to any one of clauses 46 to 60, wherein the control circuit is further configured to: determine that the amplitude of the motion signal is greater than an amplitude threshold during a threshold time interval after expiration of the at least one ventricular post-atrial blanking period; and adjust the ventricular post-atrial blanking period by increasing the ventricular post-atrial blanking period in response to the amplitude of the motion signal being greater than the amplitude threshold during the threshold time interval after expiration of the at least one ventricular post-atrial blanking period.
62.根据条款46至61中任一项所述的医疗装置，其中该控制电路被进一步配置为在该心室后心房消隐期到期后从该运动信号中感测心房事件信号；并且该脉冲发生器被配置为响应于该控制电路感测到该心房事件信号而生成心室起搏脉冲。62. A medical device according to any one of clauses 46 to 61, wherein the control circuit is further configured to sense an atrial event signal from the motion signal after expiration of the post-ventricular atrial blanking period; and the pulse generator is configured to generate a ventricular pacing pulse in response to the control circuit sensing the atrial event signal.
63.一种方法，该方法包括：感测运动信号；标识多个心室事件；在多个心室事件中的每个心室事件之后设置心室后心房消隐期；确定在这些心室后心房消隐期中的至少一个心室后心房消隐期期间感测的该运动信号的振幅；以及基于所确定的该运动信号的振幅来调整该心室后心房消隐期。63. A method, comprising: sensing a motion signal; identifying a plurality of ventricular events; setting a post-ventricular atrial blanking period after each of the plurality of ventricular events; determining an amplitude of the motion signal sensed during at least one of the post-ventricular atrial blanking periods; and adjusting the post-ventricular atrial blanking period based on the determined amplitude of the motion signal.
64.根据条款63所述的方法，该方法还包括：生成心室起搏脉冲，其中标识该多个心室事件包括标识至少一个心室起搏脉冲。64. The method of clause 63, further comprising: generating a ventricular pacing pulse, wherein identifying the plurality of ventricular events comprises identifying at least one ventricular pacing pulse.
65.根据条款63至64中任一项所述的方法，该方法还包括：接收心脏电信号；从该心脏电信号中感测心室事件；以及通过标识从该心脏电信号中感测的至少一个心室事件来标识该多个心室事件。65. A method according to any one of clauses 63 to 64, further comprising: receiving a cardiac electrical signal; sensing a ventricular event from the cardiac electrical signal; and identifying the multiple ventricular events by identifying at least one ventricular event sensed from the cardiac electrical signal.
66.根据条款63至65中任一项所述的方法，该方法还包括：通过确定根据在该至少一个心室后心房消隐期的至少一部分期间感测的该运动信号的峰值振幅来确定该振幅；确定该峰值振幅是否小于振幅阈值；以及通过响应于该峰值振幅小于该振幅阈值而缩短该心室后心房消隐期来调整该心室后心房消隐期。66. A method according to any one of clauses 63 to 65, the method further comprising: determining the amplitude by determining a peak amplitude of the motion signal sensed during at least a portion of the at least one ventricular post-atrial blanking period; determining whether the peak amplitude is less than an amplitude threshold; and adjusting the ventricular post-atrial blanking period by shortening the ventricular post-atrial blanking period in response to the peak amplitude being less than the amplitude threshold.
67.根据条款63至66中任一项所述的方法，该方法还包括：通过确定根据在该至少一个心室后心房消隐期的至少一部分期间感测的该运动信号的峰值振幅来确定该振幅；确定该峰值振幅是否大于振幅阈值；以及通过响应于该峰值振幅大于该振幅阈值而增加该心室后心房消隐期来调整该心室后心房消隐期。67. A method according to any one of clauses 63 to 66, the method further comprising: determining the amplitude by determining a peak amplitude of the motion signal sensed during at least a portion of the at least one ventricular post-atrial blanking period; determining whether the peak amplitude is greater than an amplitude threshold; and adjusting the ventricular post-atrial blanking period by increasing the ventricular post-atrial blanking period in response to the peak amplitude being greater than the amplitude threshold.
68.根据条款63至67中任一项所述的方法，该方法还包括：通过调整可应用于未来心动周期的心室后心房消隐期的持续时间来调整该心室后心房消隐期。68. A method according to any one of clauses 63 to 67, further comprising adjusting the post-ventricular atrial blanking period by adjusting the duration of the post-ventricular atrial blanking period applicable to future cardiac cycles.
69.根据条款63至68中任一项所述的方法，该方法还包括：通过在该心室后心房消隐期期间检测到该运动信号的最晚振幅阈值跨越来确定该振幅；确定该振幅阈值跨越比从该心室后心房消隐期到期后的阈值时间间期提前；以及通过响应于该振幅阈值跨越比从该心室后心房消隐期到期后的该阈值时间间期提前而缩短该心室后心房消隐期来调整该心室后心房消隐期。69. A method according to any one of clauses 63 to 68, the method further comprising: determining the amplitude by detecting a latest amplitude threshold crossing of the motion signal during the post-ventricular atrial blanking period; determining that the amplitude threshold crossing is earlier than a threshold time interval from the expiration of the post-ventricular atrial blanking period; and adjusting the post-ventricular atrial blanking period by shortening the post-ventricular atrial blanking period in response to the amplitude threshold crossing being earlier than the threshold time interval from the expiration of the post-ventricular atrial blanking period.
70.根据条款69所述的方法，该方法还包括：基于用于调整该心室后心房消隐期的减量间期来设置该阈值时间间期。70. The method of clause 69, further comprising: setting the threshold time interval based on a decrement interval for adjusting the post-ventricular atrial blanking period.
71.根据条款63至70中任一项所述的方法，该方法还包括：检测心率的变化；以及响应于检测到该心率的该变化而确定该运动信号的该振幅。71. A method according to any one of clauses 63 to 70, further comprising: detecting a change in heart rate; and determining the amplitude of the motion signal in response to detecting the change in the heart rate.
72.根据条款63至71中任一项所述的方法，该方法还包括：在该至少一个心室后心房消隐期期间设置振幅分析窗口；通过在该振幅分析窗口期间确定峰值振幅来确定该振幅；确定该峰值振幅小于振幅阈值；以及通过响应于该峰值振幅小于该振幅阈值而缩短该心室后心房消隐期来调整该心室后心房消隐期。72. A method according to any one of clauses 63 to 71, the method further comprising: setting an amplitude analysis window during the at least one ventricular post-atrial blanking period; determining the amplitude by determining a peak amplitude during the amplitude analysis window; determining that the peak amplitude is less than an amplitude threshold; and adjusting the ventricular post-atrial blanking period by shortening the ventricular post-atrial blanking period in response to the peak amplitude being less than the amplitude threshold.
73.根据条款63至72中任一项所述的方法，该方法还包括：检测心率的减小；响应于检测到该心率的该减小而增加该心室后心房消隐期；检测该心率的增加；以及基于确定的振幅和该心率的该增加：73. A method according to any of clauses 63 to 72, further comprising: detecting a decrease in heart rate; increasing the post-ventricular atrial blanking period in response to detecting the decrease in heart rate; detecting an increase in the heart rate; and based on the determined amplitude and the increase in the heart rate:
通过减少该心室后心房消隐期来调整该心室后心房消隐期，或者adjusting the ventricular-atrial blanking period by decreasing the ventricular-atrial blanking period, or
保持该心室后心房消隐期不变。The post-ventricular atrial blanking period was kept constant.
74.根据条款63至73中任一项所述的方法，该方法还包括：设置在该至少一个心室后心房消隐期的到期时间之前开始的心室后心房消隐结束时间间期；以及通过将在该心室后心房消隐结束时间间期期间感测的该运动信号与振幅阈值进行比较来确定该振幅。74. A method according to any one of clauses 63 to 73, the method further comprising: setting a ventricular posterior atrial blanking end time interval starting before the expiration time of the at least one ventricular posterior atrial blanking period; and determining the amplitude by comparing the motion signal sensed during the ventricular posterior atrial blanking end time interval with an amplitude threshold.
75.根据条款74所述的方法，该方法还包括：基于该运动信号与在该心室后心房消隐结束时间间期期间的该振幅阈值的该比较：响应于该运动信号未越过在该心室后心房消隐结束时间间期期间的该振幅阈值而减少该心室后心房消隐期；或者响应于该运动信号越过在该心室后心房消隐结束时间间期期间的该振幅阈值而保持该心室后心房消隐期不变。75. The method according to clause 74 further includes: based on the comparison of the motion signal with the amplitude threshold during the end time interval of the ventricular post-atrial blanking: reducing the ventricular post-atrial blanking period in response to the motion signal not crossing the amplitude threshold during the end time interval of the ventricular post-atrial blanking; or keeping the ventricular post-atrial blanking period unchanged in response to the motion signal crossing the amplitude threshold during the end time interval of the ventricular post-atrial blanking.
76.根据条款63至75中任一项所述的方法，该方法还包括：在第一多个心室后心房消隐期中的每个心室后心房消隐期期间禁用该运动传感器的运动信号感测；检测心率的变化；以及响应于检测到该心率的该变化，在该至少一个心室后心房消隐期的至少一部分期间启用该运动传感器的运动信号感测。76. A method according to any one of clauses 63 to 75, the method further comprising: disabling motion signal sensing of the motion sensor during each of a first plurality of ventricular post-atrial blanking periods; detecting a change in heart rate; and in response to detecting the change in heart rate, enabling motion signal sensing of the motion sensor during at least a portion of at least one of the ventricular post-atrial blanking periods.
77.根据条款63至76中任一项所述的方法，该方法还包括：在该心室后心房消隐期之外从该运动信号中感测心房事件信号；检测从该运动信号中感测的该心房事件信号的频率和定时中的至少一者的变化；以及响应于检测到从该运动信号中感测的该心房事件信号的该频率和该定时中的至少一者的该变化而确定在该至少一个心室后心房消隐期期间感测的该运动信号的该振幅。77. A method according to any one of clauses 63 to 76, the method further comprising: sensing an atrial event signal from the motion signal outside the post-ventricular atrial blanking period; detecting a change in at least one of the frequency and the timing of the atrial event signal sensed from the motion signal; and determining the amplitude of the motion signal sensed during the at least one post-ventricular atrial blanking period in response to detecting the change in at least one of the frequency and the timing of the atrial event signal sensed from the motion signal.
78.根据条款63至77中任一项所述的方法，该方法还包括：确定该运动信号的该振幅大于在从该至少一个心室后心房消隐期到期后的阈值时间间期期间的振幅阈值；以及通过响应于该运动信号的该振幅大于在从该至少一个心室后心房消隐期到期后的该阈值时间间期期间的该振幅阈值而增加该心室后心房消隐期来调整该心室后心房消隐期。78. A method according to any one of clauses 63 to 77, the method further comprising: determining that the amplitude of the motion signal is greater than an amplitude threshold during a threshold time interval after expiration of the at least one ventricular post-atrial blanking period; and adjusting the ventricular post-atrial blanking period by increasing the ventricular post-atrial blanking period in response to the amplitude of the motion signal being greater than the amplitude threshold during the threshold time interval after expiration of the at least one ventricular post-atrial blanking period.
79.根据条款63至78中任一项所述的方法，该方法还包括：在该心室后心房消隐期到期后从该运动信号中感测心房事件信号；以及响应于感测到该心房事件信号而生成心室起搏脉冲。79. A method according to any one of clauses 63 to 78, further comprising: sensing an atrial event signal from the motion signal after expiration of the post-ventricular atrial blanking period; and generating a ventricular pacing pulse in response to sensing the atrial event signal.
80.一种存储指令的非暂态计算机可读介质，这些指令在由医疗装置的处理器执行时使该医疗装置：感测运动信号；标识多个心室事件；在该多个心室事件中的每个心室事件之后设置心室后心房消隐期；确定在这些心室后心房消隐期中的至少一个心室后心房消隐期期间感测的该运动信号的振幅；以及基于所确定的该运动信号的振幅来调整该心室后心房消隐期。80. A non-transitory computer-readable medium storing instructions that, when executed by a processor of a medical device, cause the medical device to: sense a motion signal; identify a plurality of ventricular events; set a post-ventricular atrial blanking period after each of the plurality of ventricular events; determine an amplitude of the motion signal sensed during at least one of the post-ventricular atrial blanking periods; and adjust the post-ventricular atrial blanking period based on the determined amplitude of the motion signal.
81.根据条款80所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：生成心室起搏脉冲；以及通过标识至少一个心室起搏脉冲来标识该多个心室事件。81. The non-transitory computer-readable medium of clause 80, wherein the instructions further cause the medical device to: generate a ventricular pacing pulse; and identify the plurality of ventricular events by identifying at least one ventricular pacing pulse.
82.根据条款80至81中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：接收心脏电信号；从该心脏电信号中感测心室事件；以及通过标识从该心脏电信号中感测的至少一个心室事件来标识该多个心室事件。82. A non-transitory computer-readable medium according to any one of clauses 80 to 81, wherein the instructions further cause the medical device to: receive a cardiac electrical signal; sense a ventricular event from the cardiac electrical signal; and identify the multiple ventricular events by identifying at least one ventricular event sensed from the cardiac electrical signal.
83.根据条款80至82中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：通过确定根据在该至少一个心室后心房消隐期的至少一部分期间感测的该运动信号的峰值振幅来确定该振幅；确定该峰值振幅是否小于振幅阈值；以及通过响应于该峰值振幅小于该振幅阈值而缩短该心室后心房消隐期来调整该心室后心房消隐期。83. A non-transitory computer-readable medium according to any one of clauses 80 to 82, wherein the instructions further cause the medical device to: determine the amplitude by determining a peak amplitude of the motion signal sensed during at least a portion of the at least one ventricular post-atrial blanking period; determine whether the peak amplitude is less than an amplitude threshold; and adjust the ventricular post-atrial blanking period by shortening the ventricular post-atrial blanking period in response to the peak amplitude being less than the amplitude threshold.
84.根据条款80至83中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：通过确定根据在该至少一个心室后心房消隐期的至少一部分期间感测的该运动信号的峰值振幅来确定该振幅；确定该峰值振幅是否大于振幅阈值；以及通过响应于该峰值振幅大于该振幅阈值而增加该心室后心房消隐期来调整该心室后心房消隐期。84. A non-transitory computer-readable medium according to any one of clauses 80 to 83, wherein the instructions further cause the medical device to: determine the amplitude by determining a peak amplitude of the motion signal sensed during at least a portion of the at least one ventricular post-atrial blanking period; determine whether the peak amplitude is greater than an amplitude threshold; and adjust the ventricular post-atrial blanking period by increasing the ventricular post-atrial blanking period in response to the peak amplitude being greater than the amplitude threshold.
85.根据条款80至84中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置通过调整可应用于未来心动周期的心室后心房消隐期的持续时间来调整该心室后心房消隐期。85. The non-transitory computer readable medium of any one of clauses 80 to 84, wherein the instructions further cause the medical device to adjust the post-ventricular atrial blanking period by adjusting the duration of the post-ventricular atrial blanking period applicable to future cardiac cycles.
86.根据条款80至85中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：通过在该心室后心房消隐期期间检测到该运动信号的最晚振幅阈值跨越来确定该振幅；确定该振幅阈值跨越比从该心室后心房消隐期到期后的阈值时间间期提前；以及通过响应于该振幅阈值跨越比从该心室后心房消隐期到期后的该阈值时间间期提前而缩短该心室后心房消隐期来调整该心室后心房消隐期。86. A non-transitory computer-readable medium according to any one of clauses 80 to 85, wherein the instructions further cause the medical device to: determine the amplitude by detecting a latest amplitude threshold crossing of the motion signal during the post-ventricular atrial blanking period; determine that the amplitude threshold crossing is earlier than a threshold time interval from the expiration of the post-ventricular atrial blanking period; and adjust the post-ventricular atrial blanking period by shortening the post-ventricular atrial blanking period in response to the amplitude threshold crossing being earlier than the threshold time interval from the expiration of the post-ventricular atrial blanking period.
87.根据条款86所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置基于用于调整该心室后心房消隐期的减量间期来设置该阈值时间间期。87. The non-transitory computer readable medium of clause 86, wherein the instructions further cause the medical device to set the threshold time interval based on a decrement interval for adjusting the post-ventricular atrial blanking period.
88.根据条款80至87中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：检测心率的变化；以及响应于检测到该心率的该变化而确定该运动信号的该振幅。88. The non-transitory computer-readable medium of any one of clauses 80 to 87, wherein the instructions further cause the medical device to: detect a change in heart rate; and determine the amplitude of the motion signal in response to detecting the change in heart rate.
89.根据条款80至88中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：在该至少一个心室后心房消隐期期间设置振幅分析窗口；通过在该振幅分析窗口期间确定峰值振幅来确定该振幅；确定该峰值振幅小于振幅阈值；以及通过响应于该峰值振幅小于该振幅阈值而缩短该心室后心房消隐期来调整该心室后心房消隐期。89. A non-transitory computer-readable medium according to any one of clauses 80 to 88, wherein the instructions further cause the medical device to: set an amplitude analysis window during the at least one ventricular post-atrial blanking period; determine the amplitude by determining a peak amplitude during the amplitude analysis window; determine that the peak amplitude is less than an amplitude threshold; and adjust the ventricular post-atrial blanking period by shortening the ventricular post-atrial blanking period in response to the peak amplitude being less than the amplitude threshold.
90.根据条款80至89中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：检测心率的减小；响应于检测到该心率的该减小而增加该心室后心房消隐期；检测该心率的增加；以及基于确定的振幅和该心率的该增加：通过减少该心室后心房消隐期来调整该心室后心房消隐期，或者保持该心室后心房消隐期不变。90. A non-transitory computer-readable medium as described in any of clauses 80 to 89, wherein the instructions further cause the medical device to: detect a decrease in heart rate; increase the ventricular post-atrial blanking period in response to detecting the decrease in heart rate; detect an increase in the heart rate; and based on the determined amplitude and the increase in the heart rate: adjust the ventricular post-atrial blanking period by reducing the ventricular post-atrial blanking period, or maintain the ventricular post-atrial blanking period unchanged.
91.根据条款80至90中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：设置在该至少一个心室后心房消隐期的到期时间之前开始的心室后心房消隐结束时间间期；以及通过将在该心室后心房消隐结束时间间期期间感测的该运动信号与振幅阈值进行比较来确定该振幅。91. A non-transitory computer-readable medium according to any one of clauses 80 to 90, wherein the instructions further cause the medical device to: set a ventricular posterior atrial blanking end time interval that starts before the expiration time of the at least one ventricular posterior atrial blanking period; and determine the amplitude by comparing the motion signal sensed during the ventricular posterior atrial blanking end time interval with an amplitude threshold.
92.根据条款91所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：基于该运动信号与在该心室后心房消隐结束时间间期期间的该振幅阈值的该比较：响应于该运动信号未越过在该心室后心房消隐结束时间间期期间的该振幅阈值而减少该心室后心房消隐期；或者响应于该运动信号越过在该心室后心房消隐结束时间间期期间的该振幅阈值而保持该心室后心房消隐期不变。92. A non-transitory computer-readable medium according to clause 91, wherein the instructions further cause the medical device to: based on the comparison of the motion signal with the amplitude threshold during the posterior ventricular atrial blanking time interval: reduce the posterior ventricular atrial blanking period in response to the motion signal not crossing the amplitude threshold during the posterior ventricular atrial blanking time interval; or maintain the posterior ventricular atrial blanking period unchanged in response to the motion signal crossing the amplitude threshold during the posterior ventricular atrial blanking time interval.
93.根据条款80至92中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：在第一多个心室后心房消隐期中的每个心室后心房消隐期期间禁用该运动传感器的运动信号感测；检测心率的变化；以及响应于检测到该心率的该变化，在该至少一个心室后心房消隐期的至少一部分期间启用该运动传感器的运动信号感测。93. A non-transitory computer-readable medium according to any one of clauses 80 to 92, wherein the instructions further cause the medical device to: disable motion signal sensing by the motion sensor during each of a first plurality of ventricular post-atrial blanking periods; detect a change in heart rate; and in response to detecting the change in heart rate, enable motion signal sensing by the motion sensor during at least a portion of at least one of the ventricular post-atrial blanking periods.
94.根据条款80至93中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：在该心室后心房消隐期之外从该运动信号中感测心房事件信号；检测从该运动信号中感测的该心房事件信号的频率和定时中的至少一者的变化；以及响应于检测到从该运动信号中感测的该心房事件信号的该频率和该定时中的至少一者的该变化而确定在该至少一个心室后心房消隐期期间感测的该运动信号的该振幅。94. A non-transitory computer-readable medium according to any one of clauses 80 to 93, wherein the instructions further cause the medical device to: sense an atrial event signal from the motion signal outside the post-ventricular atrial blanking period; detect a change in at least one of the frequency and the timing of the atrial event signal sensed from the motion signal; and determine the amplitude of the motion signal sensed during the at least one post-ventricular atrial blanking period in response to detecting the change in at least one of the frequency and the timing of the atrial event signal sensed from the motion signal.
95.根据条款80至94中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：确定该运动信号的该振幅大于在从该至少一个心室后心房消隐期到期后的阈值时间间期期间的振幅阈值；以及通过响应于该运动信号的该振幅大于在从该至少一个心室后心房消隐期到期后的该阈值时间间期期间的该振幅阈值而增加该心室后心房消隐期来调整该心室后心房消隐期。95. A non-transitory computer-readable medium according to any one of clauses 80 to 94, wherein the instructions further cause the medical device to: determine that the amplitude of the motion signal is greater than an amplitude threshold during a threshold time interval after expiration of the at least one ventricular post-atrial blanking period; and adjust the ventricular post-atrial blanking period by increasing the ventricular post-atrial blanking period in response to the amplitude of the motion signal being greater than the amplitude threshold during the threshold time interval after expiration of the at least one ventricular post-atrial blanking period.
96.根据条款80至95中任一项所述的非暂态计算机可读介质，其中这些指令进一步使该医疗装置：在该心室后心房消隐期到期之后，从该运动信号中感测心房事件信号；以及响应于感测到该心房事件信号而生成心室起搏脉冲。96. A non-transitory computer-readable medium according to any one of clauses 80 to 95, wherein the instructions further cause the medical device to: sense an atrial event signal from the motion signal after expiration of the post-ventricular atrial blanking period; and generate a ventricular pacing pulse in response to sensing the atrial event signal.
本公开的一个或多个方面的细节在以下附图和说明书中阐述。根据说明书和附图以及权利要求，本公开中描述的技术的其他特征、目的和优点将是显而易见的。The details of one or more aspects of the present disclosure are set forth in the following drawings and description. Other features, objectives, and advantages of the technology described in the present disclosure will be apparent from the description and drawings, and from the claims.
附图说明BRIEF DESCRIPTION OF THE DRAWINGS
图1是示出可以用于感测由心脏运动和流动血液诱导的心脏电信号和运动信号并向患者的心脏提供起搏疗法的医疗装置系统的概念图。1 is a conceptual diagram illustrating a medical device system that may be used to sense cardiac electrical signals and motion signals induced by cardiac motion and flowing blood and to provide pacing therapy to a patient's heart.
图2是图1所示的起搏器的概念图。FIG. 2 is a conceptual diagram of the pacemaker shown in FIG. 1 .
图3是图1所示的起搏器的示例配置的概念图。FIG. 3 is a conceptual diagram of an example configuration of the pacemaker shown in FIG. 1 .
图4是可以通过图1的起搏器中包括的运动传感器在心动周期内获取的运动传感器信号的示例。4 is an example of a motion sensor signal that may be acquired during a cardiac cycle by a motion sensor included in the pacemaker of FIG. 1 .
图5是在两个不同的心动周期内获取的运动传感器信号的示例。FIG. 5 is an example of motion sensor signals acquired during two different cardiac cycles.
图6是根据一个示例的用于调整PVAB期的方法的流程图。FIG. 6 is a flow chart of a method for adjusting a PVAB period according to one example.
图7是根据一些示例的运动信号的概念图，其示出了可以由图1的起搏器在PVAB期期间确定的振幅数据。7 is a conceptual diagram of a motion signal illustrating amplitude data that may be determined by the pacemaker of FIG. 1 during a PVAB period, according to some examples.
图8是根据另一示例的用于控制PVAB期调整的方法的流程图。FIG. 8 is a flow chart of a method for controlling PVAB period adjustment according to another example.
图9是根据另一示例的用于调整PVAB期的方法的流程图。FIG. 9 is a flow chart of a method for adjusting a PVAB period according to another example.
图10是根据另一示例的用于设置PVAB期和心房同步的心室起搏的方法的流程图。10 is a flow chart of a method for setting PVAB period and atrial synchronized ventricular pacing according to another example.
图11是心室事件和根据图10的示例技术调整的对应PVAB期的一个示例的时序图。11 is a timing diagram of one example of ventricular events and corresponding PVAB periods adjusted according to the example technique of FIG. 10 .
图12是根据一个示例的用于调整PVAB期和控制心房同步的心室起搏的方法的流程图。12 is a flow chart of a method for adjusting PVAB period and controlling ventricular pacing for atrial synchronization according to one example.
具体实施方式Detailed ways
通常，本公开描述了用于通过医疗装置调整PVAB期的技术。如下所述，对应于心房收缩期(例如，心房心肌去极化或心房收缩)的心房事件信号可由被配置为递送心房同步的心室起搏的心室起搏器从心脏信号中感测。可以例如通过从心脏电信号中感测伴随心房心肌去极化的心房P波或从心脏运动信号中感测伴随心房收缩的心房收缩事件信号而从各种心脏信号中感测心房事件信号。在一些示例中，心脏运动信号是由加速度计感测的加速度信号。In general, the present disclosure describes techniques for adjusting the PVAB period by a medical device. As described below, an atrial event signal corresponding to an atrial contraction period (e.g., atrial myocardial depolarization or atrial contraction) can be sensed from a cardiac signal by a ventricular pacemaker configured to deliver atrial synchronized ventricular pacing. The atrial event signal can be sensed from various cardiac signals, for example, by sensing an atrial P wave accompanying atrial myocardial depolarization from a cardiac electrical signal or sensing an atrial contraction event signal accompanying atrial contraction from a cardiac motion signal. In some examples, the cardiac motion signal is an acceleration signal sensed by an accelerometer.
可完全植入心室心脏腔室内的心室起搏器可以包括用于感测心脏运动信号(例如，心运动信号)的运动传感器(诸如加速度计)。对应于心房机械收缩和心室主动充盈期(有时称为“心房突跳”)的心房事件信号可以从运动信号中检测到，以用于控制与心房事件同步的心室起搏脉冲的定时，该运动信号是从心室内感测到的。本文公开的技术提供了用于在不会错误地感测与心室收缩期相关联的心室事件信号的情况下，通过设置和调整PVAB期来促进对心房事件信号的可靠感测的技术。A ventricular pacemaker fully implantable within a ventricular heart chamber may include a motion sensor (such as an accelerometer) for sensing cardiac motion signals (e.g., heart motion signals). Atrial event signals corresponding to atrial mechanical contraction and ventricular active filling periods (sometimes referred to as "atrial beats") may be detected from the motion signals sensed within the ventricles for use in controlling the timing of ventricular pacing pulses synchronized with the atrial events. The technology disclosed herein provides techniques for facilitating reliable sensing of atrial event signals by setting and adjusting the PVAB period without erroneously sensing ventricular event signals associated with ventricular contraction periods.
图1是示出可以用于感测由心脏运动和流动血液诱导的心脏电信号和运动信号并向患者的心脏8提供起搏疗法的可植入医疗装置(IMD)系统10的概念图。IMD系统10包括心室心脏内起搏器14。起搏器14可以是适于全部植入心脏腔室内(例如，全部植入心脏8的右心室(RV)内或全部植入左心室(LV)内)以用于感测心脏信号并递送心室起搏脉冲的经导管心脏内起搏器。起搏器14的尺寸与皮下植入的起搏器相比可以减小并且其形状可以是总体上圆柱形的，以使得能够通过递送导管进行经静脉植入。1 is a conceptual diagram showing an implantable medical device (IMD) system 10 that can be used to sense cardiac electrical signals and motion signals induced by cardiac motion and flowing blood and provide pacing therapy to a patient's heart 8. The IMD system 10 includes a ventricular intracardiac pacemaker 14. The pacemaker 14 can be a transcatheter intracardiac pacemaker adapted to be fully implanted in a cardiac chamber (e.g., fully implanted in the right ventricle (RV) of the heart 8 or fully implanted in the left ventricle (LV)) for sensing cardiac signals and delivering ventricular pacing pulses. The size of the pacemaker 14 can be reduced compared to a subcutaneously implanted pacemaker and its shape can be generally cylindrical to enable transvenous implantation via a delivery catheter.
尽管其他位置是可能的，但是起搏器14被示出沿心内膜壁定位在RV中，例如在RV顶点附近。本文公开的技术不限于图1的示例中示出的起搏器位置。例如，起搏器14可以沿室间间隔壁定位。起搏器14可以定位在RV或LV内或上面，以提供相应的右心室或左心室起搏并且用于通过心室位置处的运动传感器感测心脏运动信号，以用于提供心房同步的心室起搏。在一些示例中，起搏器14可适于植入右心房中，用于经由尖端电极递送心室起搏脉冲，该尖端电极前进到希氏束区域中，以便递送捕获天然心室传导系统和/或心室心肌组织的起搏脉冲。美国专利公开号2019/0083779(Yang等人)中总体描述了被配置用于从心房腔室内植入部位递送心房同步心室起搏的起搏器的各种示例。Although other positions are possible, the pacemaker 14 is shown positioned in the RV along the endocardial wall, for example, near the RV apex. The technology disclosed herein is not limited to the pacemaker positions shown in the example of FIG. 1. For example, the pacemaker 14 can be positioned along the interventricular septal wall. The pacemaker 14 can be positioned in or on the RV or LV to provide corresponding right ventricular or left ventricular pacing and to sense cardiac motion signals by motion sensors at ventricular positions for providing atrial synchronized ventricular pacing. In some examples, the pacemaker 14 may be suitable for implantation in the right atrium for delivering ventricular pacing pulses via a tip electrode that advances into the His bundle region to deliver pacing pulses that capture the native ventricular conduction system and/or ventricular myocardial tissue. Various examples of pacemakers configured to deliver atrial synchronized ventricular pacing from an implantation site within an atrial chamber are generally described in U.S. Patent Publication No. 2019/0083779 (Yang et al.).
起搏器14能够产生通过起搏器的外部壳体上的一个或多个电极递送到心脏8的电刺激脉冲(例如，起搏脉冲)。起搏器14可为无引线起搏器，该无引线起搏器被配置为递送心室起搏脉冲并使用基于壳体的电极感测心脏电信号以产生心内电描记图(EGM)信号。心脏电信号可以使用还用于递送心室起搏脉冲的基于壳体的电极来感测。The pacemaker 14 can generate electrical stimulation pulses (e.g., pacing pulses) that are delivered to the heart 8 through one or more electrodes on the external housing of the pacemaker. The pacemaker 14 can be a leadless pacemaker that is configured to deliver ventricular pacing pulses and sense cardiac electrical signals using housing-based electrodes to generate intracardiac electrogram (EGM) signals. The cardiac electrical signals can be sensed using housing-based electrodes that are also used to deliver ventricular pacing pulses.
根据本文所描述的技术，可能与主动心室充盈期相关联的心房收缩事件(例如，收缩)由起搏器14从运动传感器信号(诸如被起搏器14的壳体包围的加速度计感测到的加速度信号)中检测。由植入心室腔室内的加速度计产生的运动信号(其可以被称为“心室内运动信号”)包括由心室事件和心房事件引起的运动信号。例如，由心房收缩期引起的且被称为“心房突跳”的通过RA与RV之间的三尖瓣16流动到RV中的血液的加速度可以由起搏器14从由起搏器14中包括的加速度计产生的加速度信号中检测。下文结合图4描述了可以由起搏器14检测到的其他心脏运动信号，诸如由心室收缩、心室舒张和被动心室充盈引起的运动信号。According to the techniques described herein, an atrial contraction event (e.g., a systole) that may be associated with an active ventricular filling period is detected by the pacemaker 14 from a motion sensor signal (such as an acceleration signal sensed by an accelerometer enclosed by the housing of the pacemaker 14). The motion signal generated by the accelerometer implanted within the ventricular chamber (which may be referred to as an "intraventricular motion signal") includes motion signals caused by ventricular events and atrial events. For example, the acceleration of blood flowing through the tricuspid valve 16 between the RA and RV into the RV caused by the atrial contraction period and referred to as an "atrial beat" can be detected by the pacemaker 14 from the acceleration signal generated by the accelerometer included in the pacemaker 14. Other cardiac motion signals that can be detected by the pacemaker 14, such as motion signals caused by ventricular contraction, ventricular relaxation, and passive ventricular filling, are described below in conjunction with FIG. 4.
起搏器14被配置为以促进心房激活与心室激活之间的同步的方式(例如，通过维持心房事件与心室起搏脉冲之间的目标心房与心室(AV)间期)控制心室起搏脉冲的递送。也就是说，起搏器14控制起搏脉冲递送以维持感测对应于心房收缩期的心房事件信号的时间与生成被递送以引起心室去极化和心室收缩期的心室起搏脉冲的时间之间的期望的AV间期。The pacemaker 14 is configured to control the delivery of ventricular pacing pulses in a manner that promotes synchronization between atrial activation and ventricular activation (e.g., by maintaining a target atrial-ventricular (AV) interval between an atrial event and a ventricular pacing pulse. That is, the pacemaker 14 controls the delivery of pacing pulses to maintain a desired AV interval between the time an atrial event signal corresponding to atrial contraction is sensed and the time a ventricular pacing pulse is generated that is delivered to induce ventricular depolarization and ventricular contraction.
目标AV间期可以是由临床医生选择的默认值或编程值，并且可以是从心房事件的检测到心室起搏脉冲的递送的时间间期。在一些情况下，目标AV间期可以从基于运动传感器信号检测到心房收缩事件的时间开始，或者从心房事件信号的标识基准点开始。基于患者的临床测试或评估或基于来自患者群体的临床数据，可以将目标AV间期标识为对于给定患者而言血液动力学最佳。基于如从由起搏器14接收到的心脏电信号和由起搏器14接收到的运动传感器信号中标识的电事件和机械事件的相对定时，可以将目标AV间期确定为最佳。The target AV interval may be a default or programmed value selected by a clinician and may be the time interval from detection of an atrial event to delivery of a ventricular pacing pulse. In some cases, the target AV interval may begin at the time an atrial contraction event is detected based on a motion sensor signal, or from an identified reference point of an atrial event signal. The target AV interval may be identified as hemodynamically optimal for a given patient based on clinical testing or evaluation of the patient or based on clinical data from a patient population. The target AV interval may be determined to be optimal based on the relative timing of electrical and mechanical events as identified in the cardiac electrical signals received by the pacemaker 14 and the motion sensor signals received by the pacemaker 14.
起搏器14可以能够与外部装置20进行双向无线通信以对AV起搏间期和其他可以用于从运动传感器信号中检测心室机械事件和/或心房收缩事件的起搏控制参数以及心脏事件感测参数进行编程。外部装置20通常被称为“编程器”，因为其通常由内科医生、技术员、护士、临床医生或其他有资格的用户使用以对起搏器14中的操作参数进行编程。外部装置20可以定位于诊所、医院或其他医疗设施中。外部装置20可以替代地体现为可以在医疗设施中、患者的家中或另一个位置中使用的家用监测器或手持装置。可以使用外部装置20将包括感测和治疗递送控制参数的操作参数编程到起搏器14中。The pacemaker 14 may be capable of bidirectional wireless communication with an external device 20 to program AV pacing intervals and other pacing control parameters that may be used to detect ventricular mechanical events and/or atrial contractile events from motion sensor signals, as well as cardiac event sensing parameters. The external device 20 is often referred to as a "programmer" because it is often used by a physician, technician, nurse, clinician, or other qualified user to program operating parameters in the pacemaker 14. The external device 20 may be located in a clinic, hospital, or other medical facility. The external device 20 may alternatively be embodied as a home monitor or handheld device that may be used in a medical facility, in a patient's home, or in another location. Operating parameters, including sensing and therapy delivery control parameters, may be programmed into the pacemaker 14 using the external device 20.
外部装置20可以包括处理器52、存储器53、显示器54、用户接口56和遥测单元58。处理器52控制外部装置操作并处理从起搏器14接收到的数据和信号。显示单元54可以向用户生成涉及起搏器功能的数据和信息的显示(该显示可以包括图形用户界面)以审查起搏器操作和经过编程的参数以及心脏电信号、心脏运动信号或其他可以由起搏器14获取并在询问会话期间传输到外部装置20的生理数据。用户接口56可以包括鼠标、触摸屏、键盘等，以使得用户能够与外部装置20交互以发起与起搏器14的遥测会话，以用于从起搏器14检索数据和/或向起搏器传输数据，包括用于控制心脏事件感测和疗法递送的可编程参数。The external device 20 may include a processor 52, a memory 53, a display 54, a user interface 56, and a telemetry unit 58. The processor 52 controls the external device operation and processes data and signals received from the pacemaker 14. The display unit 54 may generate a display of data and information related to pacemaker function to a user (which display may include a graphical user interface) to review pacemaker operation and programmed parameters as well as cardiac electrical signals, cardiac motion signals, or other physiological data that may be acquired by the pacemaker 14 and transmitted to the external device 20 during an interrogation session. The user interface 56 may include a mouse, touch screen, keyboard, etc. to enable a user to interact with the external device 20 to initiate a telemetry session with the pacemaker 14 for retrieving data from and/or transmitting data to the pacemaker 14, including programmable parameters for controlling cardiac event sensing and therapy delivery.
外部装置遥测单元58被配置用于与起搏器14中包括的可植入遥测电路进行双向通信。遥测单元58包括用于与起搏器14建立无线通信链路24的收发器和天线，并且被配置为与处理器52结合操作以经由通信链路24发送和接收与起搏器功能相关的数据。通信链路24可以使用诸如Wi-Fi、医疗植入通信服务(MICS)或其他通信带宽的射频(RF)链路来建立。在一些示例中，外部装置20可以包括接近起搏器14放置以建立和维持通信链路24的编程头，并且在其他示例中，外部装置20和起搏器14可以被配置为使用不需要使用编程头并且不需要用户干预来维持通信链路的距离遥测算法和电路系统进行通信。The external device telemetry unit 58 is configured for bidirectional communication with implantable telemetry circuitry included in the pacemaker 14. The telemetry unit 58 includes a transceiver and an antenna for establishing a wireless communication link 24 with the pacemaker 14, and is configured to operate in conjunction with the processor 52 to send and receive data related to pacemaker function via the communication link 24. The communication link 24 may be implemented using a communication device such as a The external device 20 may be configured to establish a wireless communication link 24 using a Wi-Fi, Medical Implant Communications Service (MICS), or other radio frequency (RF) link of a communications bandwidth. In some examples, the external device 20 may include a programming header that is placed proximate to the pacemaker 14 to establish and maintain the communications link 24, and in other examples, the external device 20 and the pacemaker 14 may be configured to communicate using a distance telemetry algorithm and circuitry that does not require the use of a programming header and does not require user intervention to maintain the communications link.
可以设想，外部装置20可以经由包括收发器和天线的遥测电路或经由用于将数据传送到集中式数据库或计算机的硬连线通信线路有线或无线地连接到通信网络以允许对患者进行远程管理。包括集中式患者数据库的远程患者管理系统可以被配置为利用当前公开的技术来使得临床医生能够例如在查看EGM、运动传感器信号和标记物通道数据的视觉表示之后审查EGM、运动传感器信号和标记物通道数据并且授权对起搏器14中的感测和疗法控制参数的编程。It is contemplated that the external device 20 may be wired or wirelessly connected to a communication network via telemetry circuitry including a transceiver and antenna or via hardwired communication lines for transmitting data to a centralized database or computer to allow remote management of the patient. A remote patient management system including a centralized patient database may be configured to utilize the presently disclosed techniques to enable a clinician to review the EGM, motion sensor signals, and marker channel data and authorize programming of sensing and therapy control parameters in the pacemaker 14, for example, after viewing a visual representation of the EGM, motion sensor signals, and marker channel data.
图2是图1所示的起搏器14的概念图。起搏器14包括沿着起搏器14的壳体150间隔开的用于感测心脏电信号并递送起搏脉冲的电极162和164。电极164被示出为从起搏器14的远侧端部102延伸的尖端电极，并且电极162被示出为沿壳体150的中间部分(例如，邻近壳体近侧端部104)的环状电极。远侧端部102被称为“远侧”，因为期望其在起搏器14前进穿过递送工具(诸如导管)并抵靠目标植入和起搏部位放置时成为前端。FIG2 is a conceptual diagram of the pacemaker 14 shown in FIG1. The pacemaker 14 includes electrodes 162 and 164 spaced apart along a housing 150 of the pacemaker 14 for sensing cardiac electrical signals and delivering pacing pulses. Electrode 164 is shown as a tip electrode extending from a distal end 102 of the pacemaker 14, and electrode 162 is shown as a ring electrode along a mid-portion of the housing 150 (e.g., adjacent the housing proximal end 104). The distal end 102 is referred to as "distal" because it is expected to become the leading end when the pacemaker 14 is advanced through a delivery tool (such as a catheter) and placed against a target implantation and pacing site.
电极162和164形成用于双极心脏起搏和感测到的阳极和阴极对。在替代性实施方案中，起搏器14可以包括沿起搏器壳体150暴露的两个或更多个环形电极、两个尖端电极和/或其他类型的电极，以用于将电刺激递送到心脏8并感测心脏电信号。电极162和164可以是但不限于钛、铂、铱或它们的合金，并且可以包括低偏振涂层，诸如氮化钛、氧化铱、氧化钌、铂黑等。电极162和164可以定位于沿着起搏器14的除所示位置之外的位置处。Electrodes 162 and 164 form an anode and cathode pair for bipolar cardiac pacing and sensing. In alternative embodiments, the pacemaker 14 may include two or more ring electrodes, two tip electrodes, and/or other types of electrodes exposed along the pacemaker housing 150 for delivering electrical stimulation to the heart 8 and sensing cardiac electrical signals. Electrodes 162 and 164 may be, but are not limited to, titanium, platinum, iridium, or alloys thereof, and may include low polarization coatings such as titanium nitride, iridium oxide, ruthenium oxide, platinum black, etc. Electrodes 162 and 164 may be positioned at locations along the pacemaker 14 other than those shown.
壳体150由生物相容性材料(诸如不锈钢或钛合金)形成。在一些示例中，壳体150可以包括绝缘涂层。绝缘涂层的示例包括聚对二甲苯、尿烷、PEEK或聚酰亚胺等。整个壳体150可以是绝缘的，但是仅电极162和164是不绝缘的。电极164可以充当阴极电极并经由跨越壳体150的电馈通耦接到被壳体150封装的内部电路，例如起搏脉冲发生器和心脏电信号感测电路。在各种示例中，电极164可以是纽扣电极、半球形电极、环形电极、分段电极、螺旋电极、鱼钩电极或其他组织穿刺电极或其他形状或配置。The housing 150 is formed of a biocompatible material such as stainless steel or titanium alloy. In some examples, the housing 150 may include an insulating coating. Examples of insulating coatings include polyparaxylene, urethane, PEEK or polyimide, etc. The entire housing 150 may be insulated, but only electrodes 162 and 164 are not insulated. Electrode 164 may act as a cathode electrode and be coupled to an internal circuit encapsulated by the housing 150 via an electrical feedthrough across the housing 150, such as a pacing pulse generator and a cardiac electrical signal sensing circuit. In various examples, electrode 164 may be a button electrode, a hemispherical electrode, a ring electrode, a segmented electrode, a spiral electrode, a fishhook electrode or other tissue puncture electrode or other shape or configuration.
如图2总体所示，电极162可以形成为壳体150的限定围绕壳体150的侧向侧壁的环形电极的导电部分，该导电部分与壳体150的其他部分电隔离。侧向侧壁从壳体150的近侧端部104延伸到远侧端部102。在其他示例中，代替提供局部环状电极(诸如阳极电极162)，壳体150的整个周边可以充当与尖端电极164电隔离的电极。在用充当阴极电极的电极164的起搏和感测期间，沿壳体150的导电部分形成的电极162可以充当返回阳极。电极162可以可替代地围绕侧向侧壁的一部分，或者被配置为纽扣式、分段式或其他类型的电极。As generally shown in FIG. 2 , the electrode 162 can be formed as a conductive portion of the housing 150 that defines a ring electrode around the lateral sidewall of the housing 150, which is electrically isolated from other portions of the housing 150. The lateral sidewall extends from the proximal end 104 of the housing 150 to the distal end 102. In other examples, instead of providing a localized ring electrode (such as the anode electrode 162), the entire periphery of the housing 150 can serve as an electrode electrically isolated from the tip electrode 164. During pacing and sensing with the electrode 164 acting as a cathode electrode, the electrode 162 formed along the conductive portion of the housing 150 can serve as a return anode. The electrode 162 can alternatively surround a portion of the lateral sidewall, or be configured as a button, segmented, or other type of electrode.
壳体150可以包封控制电子器件子组件152和向控制电子器件子组件152提供电力的电池子组件160。电池子组件160可包括一个或多个可充电或不可充电电池，用于为控制电子器件子组件152的一个或多个处理器、传感器、脉冲发生器、感测电路和其他电路供电。控制电子器件子组件152容纳如下文结合图3所描述的用于感测心脏信号、生成起搏脉冲并控制起搏器14的疗法递送和其他功能的电子器件。在一些示例中，运动传感器可以被实施为封装在壳体150内的加速度计。加速度计可以向控制电子器件子组件152中包括的处理器提供感测的加速度信号以进行信号处理和分析，以检测如下文所描述的例如用于控制定时心室起搏脉冲的心房收缩事件。The housing 150 can enclose a control electronics subassembly 152 and a battery subassembly 160 that provides power to the control electronics subassembly 152. The battery subassembly 160 can include one or more rechargeable or non-rechargeable batteries for powering one or more processors, sensors, pulse generators, sensing circuits, and other circuits of the control electronics subassembly 152. The control electronics subassembly 152 houses electronics for sensing cardiac signals, generating pacing pulses, and controlling therapy delivery and other functions of the pacemaker 14 as described below in conjunction with FIG. 3. In some examples, the motion sensor can be implemented as an accelerometer encapsulated within the housing 150. The accelerometer can provide a sensed acceleration signal to a processor included in the control electronics subassembly 152 for signal processing and analysis to detect atrial contraction events, for example, for controlling timed ventricular pacing pulses as described below.
加速度计可以是三维加速度计。在一些示例中，加速度计可以具有与起搏器14的纵向轴108平行或对齐的一个“纵向”轴和相对于纵向轴108在径向方向上延伸的两个正交轴。然而，本文所公开的技术的实践不限于在壳体150内或沿该壳体的加速度计的特定取向。在其他示例中，可以使用一维加速度计来感测从其中检测到心房收缩事件的运动信号。在又其他示例中，可以使用二维加速度计或其他多维加速度计。单维或多维加速度计的每个轴可以由能够响应于施加在传感器元件上的加速度的改变而产生电信号(例如，通过将加速度转换成被转换成电信号的力或位移)的压电元件、微机电系统(MEMS)装置或其他传感器元件来限定。在多维加速度计中，传感器元件可以正交地布置，其中每个传感器元件轴相对于其他传感器元件轴正交。然而，不一定需要多轴加速度计的元件的正交布置。The accelerometer may be a three-dimensional accelerometer. In some examples, the accelerometer may have a "longitudinal" axis parallel or aligned with the longitudinal axis 108 of the pacemaker 14 and two orthogonal axes extending in a radial direction relative to the longitudinal axis 108. However, the practice of the technology disclosed herein is not limited to a specific orientation of the accelerometer within or along the housing 150. In other examples, a one-dimensional accelerometer may be used to sense a motion signal from which an atrial contraction event is detected. In yet other examples, a two-dimensional accelerometer or other multi-dimensional accelerometer may be used. Each axis of a one-dimensional or multi-dimensional accelerometer may be defined by a piezoelectric element, a micro-electromechanical system (MEMS) device, or other sensor element capable of generating an electrical signal in response to a change in acceleration applied to the sensor element (e.g., by converting the acceleration into a force or displacement that is converted into an electrical signal). In a multi-dimensional accelerometer, the sensor elements may be arranged orthogonally, with each sensor element axis being orthogonal to the other sensor element axes. However, an orthogonal arrangement of the elements of a multi-axis accelerometer is not necessarily required.
每个传感器元件可以产生对应于与传感器元件的轴对齐的向量的加速度信号。起搏器14可被配置为选择用于感测心房收缩事件的多维加速度计(也被称为“多轴”加速度计)的向量信号。在一些情况下，可以选择由三维加速度计产生的一个、两个或所有三个轴信号作为向量信号以用于检测例如用于控制由起搏器14递送的心房同步的心室起搏的心房收缩事件。Each sensor element can generate an acceleration signal corresponding to a vector aligned with an axis of the sensor element. The pacemaker 14 can be configured to select a vector signal of a multi-dimensional accelerometer (also referred to as a "multi-axis" accelerometer) for sensing atrial contraction events. In some cases, one, two, or all three axis signals generated by a three-dimensional accelerometer can be selected as vector signals for detecting atrial contraction events, for example, for controlling atrial synchronized ventricular pacing delivered by the pacemaker 14.
起搏器14可以包括一组固定尖齿166以例如通过与心室心内膜主动接合和/或与心室骨小梁相互作用来将起搏器14固定到患者组织。固定尖齿166被配置为锚定起搏器14以将电极164定位成操作性地接近目标组织以递送治疗性电刺激脉冲。可以采用多种类型的主动和/或被动固定构件来将起搏器14锚定或稳定在植入定位中。应当理解，电极162和164和固定时间166的大小、形状和位置(如果存在的话)根据需要可以根据起搏器14的植入位置而变化，以用于感测心脏信号并将心室起搏脉冲递送至目标组织。起搏器14可以任选地包括递送工具接口158。递送工具接口158可以定位于起搏器14的近侧端部104处并且被配置为连接到递送装置(诸如导管)，用于在植入程序期间，将起搏器14定位在植入位置处(例如，在心脏腔室内)。The pacemaker 14 may include a set of fixed tines 166 to fix the pacemaker 14 to the patient tissue, for example, by actively engaging with the ventricular endocardium and/or interacting with the ventricular trabeculae. The fixed tines 166 are configured to anchor the pacemaker 14 to position the electrode 164 to be operatively close to the target tissue to deliver therapeutic electrical stimulation pulses. Various types of active and/or passive fixation members may be used to anchor or stabilize the pacemaker 14 in an implanted position. It should be understood that the size, shape, and position (if present) of the electrodes 162 and 164 and the fixed time 166 may vary according to the implantation position of the pacemaker 14 as needed for sensing cardiac signals and delivering ventricular pacing pulses to the target tissue. The pacemaker 14 may optionally include a delivery tool interface 158. The delivery tool interface 158 may be positioned at the proximal end 104 of the pacemaker 14 and configured to be connected to a delivery device (such as a catheter) for positioning the pacemaker 14 at the implantation position (e.g., in a heart chamber) during the implantation procedure.
图3是图1中所示出的起搏器14的示例性配置的概念图。起搏器14包括脉冲发生器202、心脏电信号感测电路204、控制电路206、存储器210、遥测电路208、运动传感器212和电源214。图3中表示的各种电路可以组合在一个或多个集成电路板上，该集成电路板包括专用集成电路(ASIC)、电子电路、处理器(共享、专用或组)和执行一个或多个软件或固件程序的存储器、组合逻辑电路、状态机或提供所描述的功能的其他合适的部件。FIG3 is a conceptual diagram of an exemplary configuration of the pacemaker 14 shown in FIG1. The pacemaker 14 includes a pulse generator 202, a cardiac electrical signal sensing circuit 204, a control circuit 206, a memory 210, a telemetry circuit 208, a motion sensor 212, and a power supply 214. The various circuits represented in FIG3 may be combined on one or more integrated circuit boards including application specific integrated circuits (ASICs), electronic circuits, processors (shared, dedicated, or groups) and memory executing one or more software or firmware programs, combinational logic circuits, state machines, or other suitable components that provide the described functionality.
在本文描述的示例中，运动传感器212包括加速度计。然而，运动传感器212不限于加速度计，并且根据本文所描述的技术，其他运动传感器可以成功地用于起搏器14中以检测心脏运动信号。可以实施于运动传感器212中的运动传感器的示例包括压电传感器和MEMS装置。在其他示例中，能够感测响应于机械功能(例如，心室收缩和舒张、心脏瓣膜打开和关闭等)的信号的传感器可以包括在运动传感器212中。例如，可以包括在起搏器中的传感器的其他示例包括阻抗传感器和压力传感器，该起搏器被配置为执行本文公开的用于控制PVAB期的技术。在一些示例中，起搏器14可以包括用于感测阻抗信号的阻抗测量电路，从阻抗信号中可以检测到心房事件信号。在其他示例中，起搏器14可包括用于感测压力信号并从压力信号中检测心房事件信号的压力传感器。在这些示例中，可在心室事件之后设置PVAB期，并基于心率和/或在PVAB期期间根据本文公开的技术确定的信号的振幅来调整该PVAB期。In the examples described herein, the motion sensor 212 includes an accelerometer. However, the motion sensor 212 is not limited to an accelerometer, and other motion sensors can be successfully used in the pacemaker 14 to detect cardiac motion signals according to the techniques described herein. Examples of motion sensors that can be implemented in the motion sensor 212 include piezoelectric sensors and MEMS devices. In other examples, sensors capable of sensing signals in response to mechanical functions (e.g., ventricular contraction and relaxation, heart valve opening and closing, etc.) can be included in the motion sensor 212. For example, other examples of sensors that can be included in a pacemaker include impedance sensors and pressure sensors, and the pacemaker is configured to perform the techniques disclosed herein for controlling the PVAB period. In some examples, the pacemaker 14 may include an impedance measurement circuit for sensing an impedance signal, from which an atrial event signal can be detected. In other examples, the pacemaker 14 may include a pressure sensor for sensing a pressure signal and detecting an atrial event signal from the pressure signal. In these examples, the PVAB period can be set after a ventricular event and adjusted based on the heart rate and/or the amplitude of a signal determined according to the techniques disclosed herein during the PVAB period.
运动传感器212可以包括多轴加速度计，例如二维加速度计或三维加速度计，其中每个轴提供可以独立地或组合地分析的用于检测心脏机械事件的轴信号。运动传感器212例如在经受流动血液和/或心脏运动时产生与传感器212(和起搏器14)的运动或振动相关的电信号。运动传感器212可以包括一个或多个滤波器、放大器、整流器、模数转换器(ADC)和/或用于产生传递到控制电路206的运动信号的其他部件。例如，由多轴加速度计的每个单独轴产生的每个向量信号或一个或多个所选轴信号可以由高通滤波器(例如，10Hz高通滤波器)来滤波。经滤波的信号可以由ADC数字化并且被整流以供心房事件检测器电路240用于检测心房收缩事件。如果需要检测具有较低频率内容的心房信号，则高通滤波器可以降低(例如，到5Hz)。在一些示例中，在没有低通滤波的情况下，执行高通滤波。在其他示例中，在有或没有高通滤波的情况下，每个加速度计轴信号由低通滤波器(例如，30Hz低通滤波器)来滤波。The motion sensor 212 may include a multi-axis accelerometer, such as a two-dimensional accelerometer or a three-dimensional accelerometer, wherein each axis provides an axis signal for detecting a cardiac mechanical event that can be analyzed independently or in combination. The motion sensor 212 generates an electrical signal related to the movement or vibration of the sensor 212 (and the pacemaker 14), for example, when subjected to flowing blood and/or cardiac motion. The motion sensor 212 may include one or more filters, amplifiers, rectifiers, analog-to-digital converters (ADCs), and/or other components for generating motion signals that are transmitted to the control circuit 206. For example, each vector signal or one or more selected axis signals generated by each individual axis of the multi-axis accelerometer may be filtered by a high-pass filter (e.g., a 10 Hz high-pass filter). The filtered signal may be digitized by the ADC and rectified for use by the atrial event detector circuit 240 to detect atrial contraction events. If it is necessary to detect atrial signals with lower frequency content, the high-pass filter may be reduced (e.g., to 5 Hz). In some examples, high-pass filtering is performed without low-pass filtering. In other examples, each accelerometer axis signal is filtered by a low pass filter (eg, a 30 Hz low pass filter), with or without high pass filtering.
用于可以与本文所公开的技术结合实施的可植入医疗装置中的加速度计的一个示例总体上公开在美国专利号5,885,471(Ruben等人)中。在例如美国专利号4,485,813(Anderson等人)和美国专利号5,052,388(Sivula等人)中公开了包括用于检测患者运动的压电式加速度计的可植入医疗装置布置，这两个美国专利据此以引用方式整体并入本文。可以使用当前公开的技术在起搏器14中实施并用于检测心脏机械事件的三维加速度计的示例总体上公开在美国专利号5,593,431(Sheldon)和美国专利号6,044,297(Sheldon)中。其他加速度计设计可以用于产生与由于心室和心房事件而施加在起搏器14上的运动(例如，加速度)相关的电信号。One example of an accelerometer for use in an implantable medical device that may be implemented in conjunction with the techniques disclosed herein is generally disclosed in U.S. Pat. No. 5,885,471 (Ruben et al.). Implantable medical device arrangements including piezoelectric accelerometers for detecting patient motion are disclosed, for example, in U.S. Pat. No. 4,485,813 (Anderson et al.) and U.S. Pat. No. 5,052,388 (Sivula et al.), both of which are hereby incorporated by reference in their entirety. Examples of three-dimensional accelerometers that may be implemented in a pacemaker 14 using the presently disclosed techniques and used to detect cardiac mechanical events are generally disclosed in U.S. Pat. No. 5,593,431 (Sheldon) and U.S. Pat. No. 6,044,297 (Sheldon). Other accelerometer designs may be used to generate electrical signals related to motion (e.g., acceleration) imposed on the pacemaker 14 due to ventricular and atrial events.
心脏电信号感测电路204(在本文也称为“感测电路”204)被配置为通过预滤波器和放大器电路220经由电极162和164接收心脏电信号。预滤波器和放大器电路可以包括用于去除DC偏移的高通滤波器(例如，2.5Hz至5Hz高通滤波器)或具有2.5Hz至100Hz的通带以去除DC偏移和高频率噪声的宽带滤波器。预滤波器和放大器电路220还可以包括放大器以放大传递到模数转换器(ADC)226的“原始”心脏电信号。ADC 226可以将多位数字EGM信号传递到控制电路206，以对EGM信号执行形态分析，将EGM信号段存储在存储器210中以传输到外部装置或进行其他处理和分析。例如，EGM信号可由心房事件检测器电路240接收，用于标识心室电事件(例如，R波或T波)和/或心房电事件(例如，P波)。心脏电事件的标识可以在用于建立心房感测控制参数和用于从运动传感器信号中检测心房收缩事件的算法中使用。来自ADC 226的数字信号可以传递到可以包括用于将心脏信号传递到心脏事件检测器224的整流器、带通滤波器和放大器的整流器和放大器电路222。The cardiac electrical signal sensing circuit 204 (also referred to herein as "sensing circuit" 204) is configured to receive cardiac electrical signals via electrodes 162 and 164 through a pre-filter and amplifier circuit 220. The pre-filter and amplifier circuit may include a high-pass filter (e.g., a 2.5 Hz to 5 Hz high-pass filter) for removing DC offset or a wideband filter with a passband of 2.5 Hz to 100 Hz to remove DC offset and high-frequency noise. The pre-filter and amplifier circuit 220 may also include an amplifier to amplify the "raw" cardiac electrical signal passed to an analog-to-digital converter (ADC) 226. The ADC 226 may pass a multi-bit digital EGM signal to the control circuit 206 to perform morphological analysis on the EGM signal, store the EGM signal segments in the memory 210 for transmission to an external device or perform other processing and analysis. For example, the EGM signal may be received by the atrial event detector circuit 240 for identifying ventricular electrical events (e.g., R waves or T waves) and/or atrial electrical events (e.g., P waves). The identification of cardiac electrical events can be used in algorithms for establishing atrial sensing control parameters and for detecting atrial contraction events from the motion sensor signal. The digital signal from ADC 226 can be passed to a rectifier and amplifier circuit 222 that can include a rectifier, a bandpass filter, and an amplifier for passing the cardiac signal to a cardiac event detector 224.
心脏事件检测器224可以包括感测放大器或将输入的经整流的心脏电信号与可以是自动调整阈值的R波感测阈值进行比较的其他检测电路，以感测伴随固有心室心肌去极化的固有R波。当输入信号越过R波感测阈值时，心脏事件检测器224感测心室事件并产生传递到控制电路206的心室感测事件信号。在其他示例中，心脏事件检测器224可以接收ADC226的数字输出，以用于通过比较器、数字EGM信号的形态信号分析或其他R波检测技术来检测R波。控制电路206的处理器244可以将感测控制信号提供给感测电路204，以例如控制包括R波感测敏感性的R波感测阈值以及可以应用于心脏电信号以控制R波感测的各种消隐间期和不应期间期。The cardiac event detector 224 may include a sense amplifier or other detection circuit that compares the input rectified cardiac electrical signal to an R-wave sensing threshold, which may be an automatically adjusted threshold, to sense an intrinsic R-wave that accompanies intrinsic ventricular myocardial depolarization. When the input signal crosses the R-wave sensing threshold, the cardiac event detector 224 senses a ventricular event and generates a ventricular sensed event signal that is communicated to the control circuit 206. In other examples, the cardiac event detector 224 may receive the digital output of the ADC 226 for use in detecting an R-wave via a comparator, morphological signal analysis of the digital EGM signal, or other R-wave detection techniques. The processor 244 of the control circuit 206 may provide sensing control signals to the sensing circuit 204 to, for example, control the R-wave sensing threshold including the R-wave sensing sensitivity and various blanking intervals and refractory intervals that may be applied to the cardiac electrical signal to control R-wave sensing.
从心脏事件检测器224传递到控制电路206的心室感测事件信号可以用于由起搏定时电路242调度心室起搏脉冲并用于标识心室电事件的定时。例如，心室事件间期(RRI)(有时称为VV间期(或“VVI”，但不与VVI起搏模式混淆))可由控制电路206确定为连续接收的心室感测事件信号之间的时间间期。根据本文公开的技术，可确定RRI(或对应心率)并将其用于设置或调整PVAB期。The ventricular sensed event signals communicated from cardiac event detector 224 to control circuit 206 may be used to schedule ventricular pacing pulses by pacing timing circuit 242 and to identify the timing of ventricular electrical events. For example, a ventricular event interval (RRI), sometimes referred to as a VV interval (or "VVI", but not to be confused with a VVI pacing mode), may be determined by control circuit 206 as the time interval between consecutively received ventricular sensed event signals. According to the techniques disclosed herein, the RRI (or corresponding heart rate) may be determined and used to set or adjust the PVAB period.
在一些示例中，感测电路204可包括多个感测通道，包括用于由心脏事件检测器224感测R波的心室感测通道和用于例如由心脏事件检测器224感测伴随心房心肌去极化的P波的心房感测通道。在这些示例中，心脏事件检测器224可同时生成心室感测事件信号和心房感测事件信号，这两种信号可以被传递到控制电路206以用于控制心房同步的心室起搏脉冲定时。心房事件信号可从由相同电极162和164感测的心脏电信号中感测到，但可能经历与从中感测R波的心脏电信号不同的滤波、放大和消隐。心脏事件检测器224可以包括感测放大器、比较器或被配置用于响应于心脏电信号越过P波感测阈值而感测心房P波的其他检测电路。在一些示例中，本文呈现的用于控制PVAB期以禁止在心室事件之后从运动信号中感测心房事件信号的说明性示例可适用于控制应用于心脏电信号的PVAB期。PVAB期可响应于标识的心室事件(例如，来自感测电路204的心室起搏脉冲或心室感测事件信号)而开始。感测电路204的心房P波感测可以在PVAB期期间被抑制。根据本文公开的技术，可以基于在PVAB期期间对心脏电信号振幅的分析来调整PVAB期。In some examples, the sensing circuit 204 may include multiple sensing channels, including a ventricular sensing channel for sensing R waves by the cardiac event detector 224 and an atrial sensing channel for sensing P waves accompanying atrial myocardial depolarization, for example, by the cardiac event detector 224. In these examples, the cardiac event detector 224 may simultaneously generate a ventricular sensed event signal and an atrial sensed event signal, both of which may be transmitted to the control circuit 206 for controlling the timing of ventricular pacing pulses for atrial synchronization. The atrial event signal may be sensed from the cardiac electrical signal sensed by the same electrodes 162 and 164, but may undergo filtering, amplification, and blanking different from the cardiac electrical signal from which the R wave is sensed. The cardiac event detector 224 may include a sense amplifier, a comparator, or other detection circuitry configured to sense an atrial P wave in response to the cardiac electrical signal crossing a P wave sensing threshold. In some examples, the illustrative examples presented herein for controlling the PVAB period to prohibit sensing an atrial event signal from a motion signal after a ventricular event may be applicable to controlling the PVAB period applied to the cardiac electrical signal. The PVAB period may be initiated in response to an identified ventricular event (e.g., a ventricular pacing pulse or a ventricular sensed event signal from sensing circuit 204). Atrial P wave sensing by sensing circuit 204 may be suppressed during the PVAB period. According to the techniques disclosed herein, the PVAB period may be adjusted based on an analysis of the amplitude of cardiac electrical signals during the PVAB period.
控制电路206可以包括心房事件检测器电路240、起搏定时电路242和处理器244。控制电路206可以从感测电路204接收心室感测事件信号和/或数字心脏电信号以用于检测和确认心脏事件并控制心室起搏。例如，当起搏器14在以非心房跟踪心室起搏模式操作时，心室感测事件信号可以传递到起搏定时电路242以用于通过开始起搏逸搏间期来抑制经调度的心室起搏脉冲或调度心室起搏脉冲。心室感测事件信号可以传递到心房事件检测器电路240，以用于设置由控制电路206在从运动传感器信号中感测心房事件信号时使用的PVAB期以及在一些示例中的不应期和/或一个或多个时间窗口。The control circuit 206 may include an atrial event detector circuit 240, a pacing timing circuit 242, and a processor 244. The control circuit 206 may receive a ventricular sensed event signal and/or a digital cardiac electrical signal from the sensing circuit 204 for detecting and confirming cardiac events and controlling ventricular pacing. For example, when the pacemaker 14 is operating in a non-atrial tracking ventricular pacing mode, the ventricular sensed event signal may be transmitted to the pacing timing circuit 242 for suppressing scheduled ventricular pacing pulses or scheduling ventricular pacing pulses by initiating a pacing escape interval. The ventricular sensed event signal may be transmitted to the atrial event detector circuit 240 for setting the PVAB period and, in some examples, the refractory period and/or one or more time windows used by the control circuit 206 when sensing an atrial event signal from a motion sensor signal.
心房事件检测器电路240被配置为根据从运动传感器212接收到的运动信号检测心房事件信号。下文例如结合图5描述了用于检测心房事件信号的技术。在一些示例中，可以在给定的心动周期中从运动传感器信号检测一个或多个心室机械事件信号，以促进在心室周期期间从运动传感器信号中肯定地检测心房事件信号。如本文所公开的，控制电路206可被配置为确定运动传感器信号的振幅，该振幅可对应于运动信号中心室事件信号的振幅或相对定时，以用于设置或调整PVAB期的持续时间。Atrial event detector circuit 240 is configured to detect atrial event signals based on the motion signal received from motion sensor 212. Techniques for detecting atrial event signals are described below, for example, in conjunction with FIG. 5. In some examples, one or more ventricular mechanical event signals can be detected from the motion sensor signal in a given cardiac cycle to facilitate positive detection of atrial event signals from the motion sensor signal during the ventricular cycle. As disclosed herein, control circuit 206 can be configured to determine an amplitude of the motion sensor signal, which can correspond to an amplitude or relative timing of a ventricular event signal in the motion signal for setting or adjusting the duration of the PVAB period.
心房事件检测器电路240接收来自运动传感器212的运动信号，并可响应于心室电事件而开始PVAB期。心室电事件可以是感测电路204感测的心室事件，该心室事件可以由控制电路206基于从感测电路204接收的与感测电路204感测的固有R波相对应的心室感测的事件信号来标识。心室电事件可以是脉冲发生器202递送心室起搏脉冲。PVAB期可以在心室电事件之后延长一段时间，在此期间，预期会发生心室机械事件，例如心室收缩以及随后的主动脉瓣和肺动脉瓣关闭，这标志着心室机械收缩期的大致偏移或结束。当心室起搏与心房事件适当同步时，预期在PVAB期期间不会出现通常对应于心室收缩期的心房事件信号。因此，在PVAB期期间可能出现的运动信号峰值不会被心房事件检测器电路240检测为心房事件信号。Atrial event detector circuit 240 receives motion signals from motion sensor 212 and may initiate a PVAB period in response to a ventricular electrical event. The ventricular electrical event may be a ventricular event sensed by sensing circuit 204, which may be identified by control circuit 206 based on a ventricular sensed event signal received from sensing circuit 204 corresponding to an intrinsic R wave sensed by sensing circuit 204. The ventricular electrical event may be the delivery of a ventricular pacing pulse by pulse generator 202. The PVAB period may extend for a period of time following the ventricular electrical event, during which a ventricular mechanical event is expected to occur, such as ventricular contraction and subsequent closure of the aortic and pulmonary valves, which marks a general offset or end of the ventricular mechanical contraction period. When ventricular pacing is properly synchronized with atrial events, atrial event signals that typically correspond to ventricular contraction periods are not expected to occur during the PVAB period. Therefore, motion signal peaks that may occur during the PVAB period are not detected as atrial event signals by atrial event detector circuit 240.
然而，在一些示例中，运动传感器信号仍然可以在PVAB期期间的全部或一部分期间被感测到。控制电路206可以在至少一些心室周期的PVAB期期间接收运动传感器信号，以用于处理和分析以设置或调整PVAB期。如下所述，可以在PVAB期期间确定运动传感器信号的振幅，该振幅可以是最大峰值振幅或预定振幅阈值跨越。在一些示例中，可以确定所确定的振幅的相关联时间(例如，在PVAB期期间的最大峰值振幅时间和/或预定振幅阈值跨越的最晚时间)以用于设置或调整PVAB期。However, in some examples, the motion sensor signal may still be sensed during all or a portion of the PVAB period. The control circuit 206 may receive the motion sensor signal during the PVAB period of at least some ventricular cycles for processing and analysis to set or adjust the PVAB period. As described below, the amplitude of the motion sensor signal may be determined during the PVAB period, which may be a maximum peak amplitude or a predetermined amplitude threshold crossing. In some examples, the associated time of the determined amplitude (e.g., the maximum peak amplitude time during the PVAB period and/or the latest time of the predetermined amplitude threshold crossing) may be determined for setting or adjusting the PVAB period.
心房事件检测器电路240确定运动传感器信号是否满足PVAB期之外的心房收缩事件检测标准。心房事件检测器电路240可以基于先前心室电事件(从感测电路204接收的心室感测事件信号或由脉冲发生器202递送的心室起搏脉冲)的定时来设置与心动周期的被动心室充盈期和主动心室充盈期相对应的时间窗口。运动传感器信号跨越在这些窗口中的任一个窗口期间的心房事件感测阈值可以被检测为心房事件。如下文所描述的，可以建立两个不同的心房事件感测阈值以在被动充盈期窗口(本文中也称为“A3窗口”)期间应用第一较高阈值并在被动充盈期窗口之后(在主动充盈期窗口(在下文也称为“A4窗口”)期间)应用第二较低阈值。运动信号提前越过心房事件感测阈值可以被心房事件检测器电路240检测为心房事件信号。Atrial event detector circuit 240 determines whether the motion sensor signal meets the atrial contraction event detection criteria outside the PVAB period. Atrial event detector circuit 240 can set time windows corresponding to the passive ventricular filling period and the active ventricular filling period of the cardiac cycle based on the timing of previous ventricular electrical events (ventricular sensed event signals received from sensing circuit 204 or ventricular pacing pulses delivered by pulse generator 202). Atrial event sensing thresholds during which the motion sensor signal crosses over any of these windows can be detected as an atrial event. As described below, two different atrial event sensing thresholds can be established to apply a first higher threshold during the passive filling period window (also referred to herein as the "A3 window") and a second lower threshold after the passive filling period window (during the active filling period window (also referred to below as the "A4 window")). A motion signal crossing the atrial event sensing threshold in advance can be detected as an atrial event signal by atrial event detector circuit 240.
心房事件检测器电路240可以响应于感测到心房事件信号而将心房事件检测信号传递到处理器244和/或起搏定时电路242。起搏定时电路242(或处理器244)可以另外从心脏事件检测器224接收心室感测事件信号，以用于控制由脉冲发生器202递送的起搏脉冲的定时。处理器244可以包括用于生成由起搏定时电路242用来使在从心房事件检测器电路240接收到心房事件检测信号时开始的AV起搏间期超时的时钟信号的一个或多个时钟。起搏定时电路242可以包括用于使AV起搏间期(其可以是存储在存储器210中并且可以由处理器244检索的可编程间期)超时的一个或多个逸搏间期定时器或计数器以用于设置起搏定时电路242所使用的AV起搏间期。Atrial event detector circuit 240 may communicate an atrial event detection signal to processor 244 and/or pacing timing circuit 242 in response to sensing an atrial event signal. Pacing timing circuit 242 (or processor 244) may additionally receive a ventricular sensed event signal from cardiac event detector 224 for use in controlling the timing of pacing pulses delivered by pulse generator 202. Processor 244 may include one or more clocks for generating clock signals used by pacing timing circuit 242 to time out an AV pacing interval that begins upon receipt of an atrial event detection signal from atrial event detector circuit 240. Pacing timing circuit 242 may include one or more escape interval timers or counters for timeout of an AV pacing interval (which may be a programmable interval stored in memory 210 and retrievable by processor 244) for setting the AV pacing interval used by pacing timing circuit 242.
起搏定时电路242可以另外地包括用于控制最小心室起搏速率的较低起搏速率间期定时器。例如，如果未从在经编程的AV起搏间期处触发心室起搏脉冲的运动传感器信号中感测到心房事件信号，则心室起搏脉冲可以在较低起搏速率间期到期时由脉冲发生器202来递送以防止心室停搏并维持最小心室速率。可以基于最近的RRI将较低的起搏速率调整为速率平滑间期，以避免心室速率的突然变化。有时，控制电路206可在非心房追踪心室起搏模式(也称为“异步心室起搏”)下，例如当心房速率大于追踪速率上限时、在速率响应起搏期间或在控制电路206可执行以建立用于从运动信号中感测心房事件信号的感测控制参数的各种过程期间来控制脉冲发生器202。The pacing timing circuit 242 may additionally include a lower pacing rate interval timer for controlling the minimum ventricular pacing rate. For example, if an atrial event signal is not sensed from the motion sensor signal that triggers a ventricular pacing pulse at a programmed AV pacing interval, a ventricular pacing pulse may be delivered by the pulse generator 202 at the expiration of the lower pacing rate interval to prevent ventricular asystole and maintain the minimum ventricular rate. The lower pacing rate may be adjusted to a rate smoothing interval based on the most recent RRI to avoid sudden changes in the ventricular rate. Sometimes, the control circuit 206 may control the pulse generator 202 in a non-atrial tracking ventricular pacing mode (also known as "asynchronous ventricular pacing"), such as when the atrial rate is greater than the tracking rate upper limit, during rate response pacing, or during various processes that the control circuit 206 may perform to establish sensing control parameters for sensing atrial event signals from motion signals.
在一些情况下，起搏器14可在具有双腔室感测的非心房跟踪心室起搏模式下操作，该模式可以被表示为VDI起搏模式，在该起搏模式下，心室起搏脉冲在不存在感测到的R波的情况下被递送并响应于来自感测电路204的心室感测事件信号而被抑制。双腔室感测可以在非心房跟踪心室起搏模式期间通过由感测电路204感测心室电事件并且从由心房事件检测器电路240从运动传感器212接收的运动信号中感测心房事件信号来执行。可以在VDI起搏模式期间建立一些心房事件感测参数，这些心房事件感测参数可以包括用于产生从中感测到心房事件信号的运动信号的运动传感器的心房事件感测向量、被动心室充盈窗口的结束以及在被动心室充盈窗口期间和之后应用的心房事件感测阈值振幅值。美国专利号10,449,366(Splett等人)、美国公开号2021/0236825(Sheldon等人)和美国公开号2021/0236826(Sheldon等人)中总体上公开了用于建立和调整心房事件感测控制参数的技术。In some cases, pacemaker 14 may be operated in a non-atrial tracking ventricular pacing mode with dual chamber sensing, which may be denoted as a VDI pacing mode, in which ventricular pacing pulses are delivered in the absence of a sensed R wave and are suppressed in response to a ventricular sensed event signal from sensing circuit 204. Dual chamber sensing may be performed during the non-atrial tracking ventricular pacing mode by sensing ventricular electrical events by sensing circuit 204 and sensing atrial event signals from a motion signal received from motion sensor 212 by atrial event detector circuit 240. Certain atrial event sensing parameters may be established during the VDI pacing mode, which may include an atrial event sensing vector for a motion sensor that generates a motion signal from which the atrial event signal is sensed, an end of a passive ventricular filling window, and an atrial event sensing threshold amplitude value applied during and after the passive ventricular filling window. Techniques for establishing and adjusting atrial event sensing control parameters are generally disclosed in U.S. Patent No. 10,449,366 (Splett et al.), U.S. Publication No. 2021/0236825 (Sheldon et al.), and U.S. Publication No. 2021/0236826 (Sheldon et al.).
脉冲发生器202产生经由阴极电极164和返回阳极电极162递送到患者的心脏的电起搏脉冲。除了向起搏定时电路242和脉冲发生器202提供控制信号以用于控制心室起搏脉冲的定时之外，处理器244可以从存储器210中检索可编程起搏控制参数，诸如起搏脉冲振幅和起搏脉冲宽度，这些参数被传递到脉冲发生器202以用于控制起搏脉冲递送。Pulse generator 202 generates electrical pacing pulses that are delivered to the patient's heart via cathode electrode 164 and return anode electrode 162. In addition to providing control signals to pacing timing circuit 242 and pulse generator 202 for controlling the timing of ventricular pacing pulses, processor 244 can retrieve programmable pacing control parameters, such as pacing pulse amplitude and pacing pulse width, from memory 210, which are communicated to pulse generator 202 for controlling pacing pulse delivery.
脉冲发生器202可以包括充电电路230、开关电路232和输出电路234。充电电路230可以包括保持电容器，该保持电容器可以在电压调节器的控制下以电源214的电池电压信号的倍数被充电到起搏脉冲振幅。起搏脉冲振幅可以基于来自控制电路206的控制信号来设置。开关电路232可以控制何时充电电路230的保持电容器被耦合到输出电路234以用于递送起搏脉冲。例如，开关电路232可以包括在AV起搏间期(或较低速率起搏间期)到期时由从起搏定时电路242接收的定时信号激活并且在经过编程的起搏脉冲宽度内保持闭合以使得充电电路230的保持电容器能够放电的开关。在经过编程的起搏脉冲持续时间内，预先充电到起搏脉冲电压振幅的保持电容器通过输出电路234的输出电容器跨电极162和164放电。美国专利号5,507,782(Kieval等人)和美国专利号8,532,785(Crutchfield等人)中总体上公开的起搏电路系统的示例可以在起搏器14中实施以用于在控制电路206的控制下将起搏电容器充电到预定起搏脉冲振幅并递送起搏脉冲。The pulse generator 202 may include a charging circuit 230, a switching circuit 232, and an output circuit 234. The charging circuit 230 may include a holding capacitor that may be charged to a pacing pulse amplitude at a multiple of the battery voltage signal of the power supply 214 under the control of a voltage regulator. The pacing pulse amplitude may be set based on a control signal from the control circuit 206. The switching circuit 232 may control when the holding capacitor of the charging circuit 230 is coupled to the output circuit 234 for delivery of a pacing pulse. For example, the switching circuit 232 may include a switch that is activated by a timing signal received from the pacing timing circuit 242 at the expiration of an AV pacing interval (or a lower rate pacing interval) and remains closed for a programmed pacing pulse width to enable the holding capacitor of the charging circuit 230 to discharge. During the programmed pacing pulse duration, the holding capacitor, which is pre-charged to the pacing pulse voltage amplitude, is discharged across the electrodes 162 and 164 through the output capacitor of the output circuit 234. Examples of pacing circuit systems generally disclosed in U.S. Pat. No. 5,507,782 (Kieval et al.) and U.S. Pat. No. 8,532,785 (Crutchfield et al.) may be implemented in a pacemaker 14 for charging a pacing capacitor to a predetermined pacing pulse amplitude and delivering pacing pulses under the control of a control circuit 206.
存储器210可以包括计算机可读指令，这些计算机可读指令在由控制电路206执行时使得控制电路206执行在整个本公开中归因于起搏器14的各种功能。计算机可读指令可以被编码在存储器210内。存储器210可以包括任何非暂态计算机可读存储介质，包括任何易失性介质、非易失性介质、磁性介质、光学介质或电介质，诸如随机存取存储器(RAM)、只读存储器(ROM)、非易失性RAM(NVRAM)、电可擦除可编程ROM(EEPROM)、闪存或其他数字介质，唯一的例外是暂态传播信号。存储器210可以存储定时间期以及控制电路206例如通过以下方式控制由脉冲发生器202对起搏脉冲的递送所使用的其他数据：根据本文公开的技术设置PVAB期、由心房事件检测器电路240从运动传感器信号中感测在PVAB期之外的心房事件信号以及响应于感测到的心房事件信号而将包括在起搏定时电路242中的逸搏间期定时器设置为AV起搏间期。The memory 210 may include computer readable instructions that, when executed by the control circuit 206, cause the control circuit 206 to perform various functions attributed to the pacemaker 14 throughout the present disclosure. The computer readable instructions may be encoded within the memory 210. The memory 210 may include any non-transitory computer readable storage medium, including any volatile medium, non-volatile medium, magnetic medium, optical medium, or electrical medium, such as random access memory (RAM), read-only memory (ROM), non-volatile RAM (NVRAM), electrically erasable programmable ROM (EEPROM), flash memory, or other digital medium, with the sole exception of transient propagation signals. The memory 210 may store timing periods and other data used by the control circuit 206 to control the delivery of pacing pulses by the pulse generator 202, for example, by setting the PVAB period according to the techniques disclosed herein, sensing an atrial event signal outside the PVAB period from the motion sensor signal by the atrial event detector circuit 240, and setting the escape interval timer included in the pacing timing circuit 242 to the AV pacing interval in response to the sensed atrial event signal.
电源214在需要时向起搏器14的其他电路和部件中的每一者供电。电源214可以包括一个或多个储能装置，诸如一个或多个可再充电或不可再充电电池。为了清楚起见，电源214与其他起搏器电路和部件之间的连接未在图3中示出，但是应从图3的总体框图理解。例如，电源214可以按需向脉冲发生器202中包括的充电和开关电路、放大器、ADC 226以及感测电路204、遥测电路208、存储器210和运动传感器212的其他部件供电。电源214可对应于图2所示的电池子组件160。The power supply 214 provides power to each of the other circuits and components of the pacemaker 14 as needed. The power supply 214 may include one or more energy storage devices, such as one or more rechargeable or non-rechargeable batteries. For clarity, the connections between the power supply 214 and the other pacemaker circuits and components are not shown in FIG3 , but should be understood from the overall block diagram of FIG3 . For example, the power supply 214 may provide power to the charging and switching circuits, amplifiers, ADC 226 included in the pulse generator 202 as needed, as well as other components of the sensing circuit 204, telemetry circuit 208, memory 210, and motion sensor 212. The power supply 214 may correspond to the battery subassembly 160 shown in FIG2 .
遥测电路208包括用于经由射频(RF)通信链路传送和接收数据的收发器209和天线211。如上文所描述的，遥测电路208可以能够与外部装置20(图1)进行双向通信。可以由遥测电路208将运动传感器信号和心脏电信号和/或由这些信号所导出的数据传输到外部装置20。用于执行心房事件感测和心室起搏控制的可编程控制参数和算法可以由遥测电路208来接收并存储在存储器210中以供控制电路206访问。Telemetry circuit 208 includes a transceiver 209 and an antenna 211 for transmitting and receiving data via a radio frequency (RF) communication link. As described above, telemetry circuit 208 can be capable of bidirectional communication with external device 20 ( FIG. 1 ). Motion sensor signals and cardiac electrical signals and/or data derived from these signals can be transmitted by telemetry circuit 208 to external device 20. Programmable control parameters and algorithms for performing atrial event sensing and ventricular pacing control can be received by telemetry circuit 208 and stored in memory 210 for access by control circuit 206.
本文中归因于起搏器14的功能可以体现为一个或多个处理器、控制器、硬件、固件、软件或它们的任何组合。将不同特征部描绘为特定电路旨在突出不同的功能方面，并且不一定暗示必须通过单独的硬件、固件或软件部件或通过任何特定的电路架构来实现此类功能。相反，与本文所描述的一个或多个电路相关联的功能性可以通过单独的硬件、固件或软件部件来执行，或者集成在通用硬件、固件或软件部件内。例如，从运动传感器信号中感测心房事件信号以及由起搏器14执行的心室起搏控制操作可以在控制电路206中以执行存储在存储器210中的指令并依赖于来自感测电路204和运动传感器212的输入的硬件、固件和/或软件的形式实施。鉴于本文的公开内容，提供软件、硬件和/或固件以在任何现代起搏器的背景下完成所述功能性在本领域技术人员的能力范围内。The functions attributed to the pacemaker 14 herein may be embodied as one or more processors, controllers, hardware, firmware, software, or any combination thereof. Depicting different feature portions as specific circuits is intended to highlight different functional aspects and does not necessarily imply that such functions must be implemented by separate hardware, firmware, or software components or by any particular circuit architecture. Instead, the functionality associated with one or more circuits described herein may be performed by separate hardware, firmware, or software components, or integrated within general hardware, firmware, or software components. For example, sensing atrial event signals from motion sensor signals and ventricular pacing control operations performed by the pacemaker 14 may be implemented in the control circuit 206 in the form of hardware, firmware, and/or software that executes instructions stored in the memory 210 and relies on inputs from the sensing circuit 204 and the motion sensor 212. In view of the disclosure herein, it is within the capabilities of those skilled in the art to provide software, hardware, and/or firmware to accomplish the functionality described in the context of any modern pacemaker.
图4是可以通过运动传感器212在心动周期内获取的运动传感器信号250的示例。竖直虚线252和262表示两个连续心室事件的定时(固有心室去极化或心室起搏脉冲)，其标记了心室周期251的相应的开始和结束。运动信号包括A1事件254、A2事件256、A3事件258和A4事件260。A1事件254是在心室收缩期间发生并标记心室机械收缩期的近似发作的加速度信号(在该示例中，当运动传感器212被实施为加速度计时)。A1事件在本文中也被称为“心室收缩事件”。A2事件256是可能随着主动脉瓣和肺动脉瓣的闭合而发生的加速度信号，标记了心室机械收缩期的近似偏移或结束。A3事件258是在被动心室充盈期间发生并标记心室机械舒张期的加速度信号。A3事件在本文中也被称为“心室被动充盈事件”。A1至A3事件是与心室心肌收缩和舒张相关联的心室事件。4 is an example of a motion sensor signal 250 that can be acquired by the motion sensor 212 within the cardiac cycle. The vertical dashed lines 252 and 262 represent the timing of two consecutive ventricular events (intrinsic ventricular depolarization or ventricular pacing pulses), which mark the corresponding start and end of the ventricular cycle 251. The motion signal includes an A1 event 254, an A2 event 256, an A3 event 258, and an A4 event 260. The A1 event 254 is an acceleration signal that occurs during ventricular contraction and marks the approximate onset of the ventricular mechanical contraction period (in this example, when the motion sensor 212 is implemented as an accelerometer). The A1 event is also referred to as a "ventricular contraction event" in this article. The A2 event 256 is an acceleration signal that may occur with the closure of the aortic valve and the pulmonary valve, marking the approximate offset or end of the ventricular mechanical contraction period. The A3 event 258 is an acceleration signal that occurs during passive ventricular filling and marks the ventricular mechanical diastole period. The A3 event is also referred to as a "ventricular passive filling event" in this article. A1 to A3 events are ventricular events associated with ventricular myocardial contraction and relaxation.
A4事件260是在心房收缩和主动心室充盈期间发生并标记心房机械收缩期的加速度信号。A4事件260在本文中也称为从运动传感器信号250中感测或检测到的“心房事件信号”。参考图3，心房事件检测器电路240可以被配置为根据从运动传感器212接收到的运动信号250检测A4事件260。处理器244可以响应于检测到A4事件260而通过开始AV起搏间期来控制起搏定时电路242以触发心室起搏脉冲。The A4 event 260 is an acceleration signal that occurs during atrial contraction and active ventricular filling and marks a period of mechanical contraction of the atria. The A4 event 260 is also referred to herein as an "atrial event signal" sensed or detected from the motion sensor signal 250. Referring to FIG3, the atrial event detector circuit 240 can be configured to detect the A4 event 260 based on the motion signal 250 received from the motion sensor 212. The processor 244 can control the pacing timing circuit 242 to trigger a ventricular pacing pulse by starting an AV pacing interval in response to detecting the A4 event 260.
图5是在两个不同的心动周期内获取的运动传感器信号400和410的示例。心室起搏脉冲在两个心动周期的时间0.0秒处被递送。在一个心动周期内接收顶部传感器信号400，并在不同的心动周期内接收底部传感器信号410。两个信号400和410在0.0秒(心室起搏脉冲递送的时间)处在时间上对齐。虽然图4的运动信号400和410和运动信号250示出为原始加速度计信号，但是应认识到控制电路206可以从运动传感器212中接收经数字化滤波、经放大且经整流的信号以进行处理和分析。FIG. 5 is an example of motion sensor signals 400 and 410 acquired during two different cardiac cycles. Ventricular pacing pulses are delivered at time 0.0 seconds in both cardiac cycles. Top sensor signal 400 is received during one cardiac cycle, and bottom sensor signal 410 is received during a different cardiac cycle. The two signals 400 and 410 are aligned in time at 0.0 seconds (the time of ventricular pacing pulse delivery). Although motion signals 400 and 410 and motion signal 250 of FIG. 4 are shown as raw accelerometer signals, it should be recognized that control circuit 206 can receive digitally filtered, amplified, and rectified signals from motion sensor 212 for processing and analysis.
观察到在心室收缩期间发生的相应的运动传感器信号400和410的A1事件402和412在心室起搏脉冲后在时间0.0秒处在时间上较好地对齐。类似地，A2事件404和414(其可以标记心室收缩期的结束)和A3事件406和416(在被动心室充盈期间发生)在时间上较好地对齐。由于A1事件、A2事件和A3事件是分别在心室收缩期间、在心室收缩期结束和在被动心室充盈期间发生的心室事件，因此预期这些事件在心室电事件之后相对于彼此以相对一致的间期发生。心室起搏脉冲之后的A1事件、A2事件和A3事件的时间关系可以与感测到的固有R波之后的时间关系有所不同；然而，在稳定的起搏或固有心室节律期间，预期心室A1事件、A2事件和A3事件彼此之间以及与紧接着在前的心室电事件之间的相对定时与心跳到心跳是一致的。It is observed that the A1 events 402 and 412 of the corresponding motion sensor signals 400 and 410 occurring during ventricular contraction are well aligned in time at time 0.0 seconds after the ventricular pacing pulse. Similarly, the A2 events 404 and 414 (which may mark the end of the ventricular systolic period) and the A3 events 406 and 416 (occurring during passive ventricular filling) are well aligned in time. Since the A1 event, A2 event, and A3 event are ventricular events occurring during ventricular contraction, at the end of the ventricular systolic period, and during passive ventricular filling, respectively, these events are expected to occur at relatively consistent intervals relative to each other after ventricular electrical events. The temporal relationship of the A1 event, A2 event, and A3 event after the ventricular pacing pulse may differ from the temporal relationship after the sensed intrinsic R wave; however, during stable pacing or intrinsic ventricular rhythm, the relative timing of the ventricular A1 event, A2 event, and A3 event to each other and to the immediately preceding ventricular electrical event is expected to be consistent from heartbeat to heartbeat.
第一运动传感器信号400和第二运动传感器信号410的A4事件408和418在时间上未对齐。A4事件发生在心房收缩期期间，并且因此，紧接着在前的心室电事件(感测的R波或心室起搏脉冲)和先前A1至A3事件之后的A4事件的时间间期可能在心动周期之间随着心房速率发生变化或在心室起搏与心房事件不同步时发生变化。The A4 events 408 and 418 of the first motion sensor signal 400 and the second motion sensor signal 410 are not aligned in time. The A4 event occurs during atrial systole, and therefore, the time interval between the immediately preceding ventricular electrical event (a sensed R-wave or ventricular pacing pulse) and the A4 event following the previous A1 to A3 events may vary between cardiac cycles as the atrial rate varies or when ventricular pacing is not synchronized with the atrial events.
可以设置PVAB期436来禁止感测心室电事件(在时间0.0)之后的A4事件，以避免感测A1信号和A2信号并促进对A4事件408和418的可靠感测。PVAB期436可被设置为延长至心室舒张的估计开始时间(例如，至少超过A2事件404和414的预期时间)，使得PVAB期436包括A1事件和A2事件两者。A2事件404和414被示为该未整流信号中的负向峰，但是在与A4感测阈值相比整流的信号中，如果PVAB期436过短，则A2事件404和414可能因具有足够大的振幅而被错误地感测为A4事件。The PVAB period 436 may be set to inhibit sensing of the A4 event after the ventricular electrical event (at time 0.0) to avoid sensing the A1 and A2 signals and to facilitate reliable sensing of the A4 events 408 and 418. The PVAB period 436 may be set to extend to the estimated start time of ventricular diastole (e.g., at least beyond the expected time of the A2 events 404 and 414) so that the PVAB period 436 includes both the A1 and A2 events. The A2 events 404 and 414 are shown as negative-going peaks in the unrectified signal, but in the rectified signal, if the PVAB period 436 is too short compared to the A4 sensing threshold, the A2 events 404 and 414 may be erroneously sensed as A4 events due to having sufficiently large amplitudes.
在PVAB期436期间，运动传感器212可以断电和/或运动传感器212和/或控制电路206对运动信号的处理可以被禁用。控制电路206可以在PVAB期436期间禁用对运动信号的感测和/或处理，以节省电源214(如图4所示)。例如，在PVAB期436开始时，控制电路206可以例如通过禁用或减少从电源214向运动传感器212(或至少一个运动传感器轴)供电来禁用运动传感器212或运动传感器212的至少一个轴。控制电路206可以在PVAB期436到期时或之前(例如，前10毫秒至20毫秒)例如通过从电源214供电给运动传感器212上电来启用运动传感器212，使得运动信号可用于在PVAB期436到期之后感测心房事件信号。During the PVAB period 436, the motion sensor 212 may be powered off and/or the processing of the motion signal by the motion sensor 212 and/or the control circuit 206 may be disabled. The control circuit 206 may disable the sensing and/or processing of the motion signal during the PVAB period 436 to conserve the power supply 214 (as shown in FIG. 4 ). For example, at the beginning of the PVAB period 436, the control circuit 206 may disable the motion sensor 212 or at least one axis of the motion sensor 212, for example, by disabling or reducing the power supplied to the motion sensor 212 (or at least one motion sensor axis) from the power supply 214. The control circuit 206 may enable the motion sensor 212, for example, by powering up the motion sensor 212 with power from the power supply 214 at or before the expiration of the PVAB period 436 (e.g., 10 milliseconds to 20 milliseconds), so that the motion signal may be used to sense an atrial event signal after the expiration of the PVAB period 436.
在图5所示的示例中，为了节省电源214，在节电时间段435内禁用运动信号感测。节电时间段435可在导致控制电路206开始PVAB期436的心室事件发生时开始，并可在PVAB期436到期之前终止。在时间点437，在时间段435到期时，控制电路206可以给运动传感器212上电，使得到PVAB期436到期时，运动信号400或410可用于在PVAB期436之后的任何时间感测A4事件408和418。因为在向运动传感器212供电与控制电路206接收运动信号之间可能存在固有延迟，所以节电时间段435可以比PVAB期436到期提前终止，例如，提前10毫秒(ms)至100毫秒，或者例如80ms至90ms。在其他示例中，运动信号可以在节电时间段435期间由控制电路206接收，但是控制电路206可以禁用对运动信号的处理和分析，直到节电时间段435到期为止。在这种情况下，节电时间段435可以与PVAB期436同时到期。在与外部装置20的遥测会话期间，可以禁用节电时间段435，以使得能够将运动信号传输到外部装置20，以用于无中断或不连续地向用户显示。In the example shown in FIG5 , in order to conserve power supply 214, motion signal sensing is disabled during power saving time period 435. Power saving time period 435 may begin when a ventricular event occurs that causes control circuit 206 to begin PVAB period 436, and may terminate before expiration of PVAB period 436. At time point 437, upon expiration of time period 435, control circuit 206 may power up motion sensor 212 so that by the time PVAB period 436 expires, motion signal 400 or 410 may be used to sense A4 events 408 and 418 at any time after PVAB period 436. Because there may be an inherent delay between powering motion sensor 212 and control circuit 206 receiving the motion signal, power saving time period 435 may terminate earlier than expiration of PVAB period 436, for example, 10 milliseconds (ms) to 100 ms, or, for example, 80 ms to 90 ms. In other examples, the motion signal may be received by the control circuit 206 during the power saving period 435, but the control circuit 206 may disable processing and analysis of the motion signal until the power saving period 435 expires. In this case, the power saving period 435 may expire at the same time as the PVAB period 436. During a telemetry session with the external device 20, the power saving period 435 may be disabled to enable the transmission of the motion signal to the external device 20 for display to the user without interruption or discontinuity.
A3窗口424可以被设置为具有与PVAB期436结束相对应的开始时间420的时间间期。A3窗口424在结束时间422到期。结束时间422可以被认为是A4感测窗口450的开始时间，尽管在一些情况下可以在A3窗口期间感测到A4事件。因为心房收缩期的定时可能在心室周期之间变化，所以A4事件有时可能在心室周期中较早发生，使得心房跳动可能在对应于A3窗口的被动心室充盈期期间发生。可以使用在A3窗口期间应用的比A3窗口结束时间之后更高的A4感测阈值振幅444而在A3窗口期间感测A4事件。The A3 window 424 can be set to a time interval having a start time 420 corresponding to the end of the PVAB period 436. The A3 window 424 expires at an end time 422. The end time 422 can be considered the start time of the A4 sensing window 450, although in some cases an A4 event can be sensed during the A3 window. Because the timing of the atrial contraction period can vary between ventricular cycles, an A4 event can sometimes occur earlier in the ventricular cycle, such that an atrial beat can occur during the passive ventricular filling period corresponding to the A3 window. An A4 event can be sensed during the A3 window using a higher A4 sensing threshold amplitude 444 applied during the A3 window than after the A3 window end time.
A4事件408和418可以基于多级A4感测阈值444来检测。如通过较低运动传感器信号410看出的，由于心房速率的变化，A4事件418可以在A3窗口424之后较早发生。在一些情况下，当心房速率增加时，A4事件418可以在A3窗口424内发生。当这发生时，A3事件416和A4事件418可以在被动心室充盈和主动心室充盈一起发生时融合。经融合的A3/A4事件可以具有高振幅，甚至大于A3事件416或A4事件418在其单独发生时的振幅。因此，在一些示例中，可以建立第一较高A4感测阈值振幅446以用于检测在A3窗口424期间与A3信号融合的早期A4信号。可以建立第二较低A4感测阈值振幅448以用于检测在A4窗口450期间的在A3窗口424的结束时间422之后的相对较晚的A4事件。A4窗口450可以从A3窗口424的结束时间422延长，直到感测到心房事件或直到下一个感测到的或起搏的心室电事件。在A3窗口的开始时间420之后(或在PVAB期436到期之后)，运动传感器信号最早越过A4感测阈值444可以被感测为心房事件信号。以上并入的美国专利号10,449,366(Splett等人)、美国公开号2021/0236825(Splett等人)和美国公开号2021/0236826(Splett等人)中总体上描述了用于建立A3窗口结束时间422、在A3窗口424期间使用的早期A4感测阈值振幅446和在A4窗口450期间使用的晚期A4感测阈值振幅448的示例技术。A4 events 408 and 418 can be detected based on a multi-level A4 sensing threshold 444. As seen by the lower motion sensor signal 410, the A4 event 418 can occur earlier after the A3 window 424 due to changes in the atrial rate. In some cases, the A4 event 418 can occur within the A3 window 424 when the atrial rate increases. When this occurs, the A3 event 416 and the A4 event 418 can fuse when passive ventricular filling and active ventricular filling occur together. The fused A3/A4 event can have a high amplitude, even greater than the amplitude of the A3 event 416 or the A4 event 418 when it occurs alone. Therefore, in some examples, a first higher A4 sensing threshold amplitude 446 can be established for detecting an early A4 signal that fuses with the A3 signal during the A3 window 424. A second lower A4 sensing threshold amplitude 448 can be established for detecting a relatively late A4 event after the end time 422 of the A3 window 424 during the A4 window 450. The A4 window 450 can be extended from the end time 422 of the A3 window 424 until an atrial event is sensed or until the next sensed or paced ventricular electrical event. After the start time 420 of the A3 window (or after the expiration of the PVAB period 436), the earliest crossing of the A4 sensing threshold 444 by the motion sensor signal can be sensed as an atrial event signal. Example techniques for establishing the A3 window end time 422, the early A4 sensing threshold amplitude 446 used during the A3 window 424, and the late A4 sensing threshold amplitude 448 used during the A4 window 450 are generally described in the above-incorporated U.S. Patent No. 10,449,366 (Splett et al.), U.S. Publication No. 2021/0236825 (Splett et al.), and U.S. Publication No. 2021/0236826 (Splett et al.).
随着心率增加，从心室电事件到心室收缩期结束的时间可减少，使得从心室电事件(例如，起搏脉冲或感测到的R波)到A2信号404或414以及A3信号406或416的时间可缩短。当心室速率正确跟踪心房速率时，随着心室速率的增加，A4事件也可能在心室电事件后更早发生。当心率增加时，PVAB期436可以适当缩短，使得A3窗口420可以在心室电事件之后更早开始。当心率降低时，PVAB期436可能需要增加，以延长至A2事件404或414，使得A3窗口420不在A2事件404或414之前或期间开始。使用本文公开的技术，当心室速率增加和减少时，可以在两个或更多个预定时间段之间调整PVAB期436。在一些示例中，当心率越过阈值速率时，PVAB期436可以步长变化在最小和最大PVAB期之间调整。在其他示例中，随着心率增加和降低，PVAB期436可以更线性的方式在最小和最大PVAB期之间调整。在一些示例中，控制电路206可以基于对消隐期436期间的运动信号振幅的分析来控制PVAB期436的调整。As the heart rate increases, the time from the ventricular electrical event to the end of the ventricular systolic period can be reduced, so that the time from the ventricular electrical event (e.g., a pacing pulse or a sensed R wave) to the A2 signal 404 or 414 and the A3 signal 406 or 416 can be shortened. When the ventricular rate correctly tracks the atrial rate, as the ventricular rate increases, the A4 event may also occur earlier after the ventricular electrical event. When the heart rate increases, the PVAB period 436 can be appropriately shortened so that the A3 window 420 can start earlier after the ventricular electrical event. When the heart rate decreases, the PVAB period 436 may need to be increased to extend to the A2 event 404 or 414 so that the A3 window 420 does not start before or during the A2 event 404 or 414. Using the techniques disclosed herein, the PVAB period 436 can be adjusted between two or more predetermined time periods when the ventricular rate increases and decreases. In some examples, when the heart rate crosses a threshold rate, the PVAB period 436 can be adjusted between the minimum and maximum PVAB periods with step changes. In other examples, PVAB period 436 may adjust in a more linear manner between minimum and maximum PVAB periods as heart rate increases and decreases. In some examples, control circuit 206 may control adjustment of PVAB period 436 based on analysis of motion signal amplitude during blanking period 436.
图6是根据一个示例的用于调整PVAB期的方法的流程图300。在框301处，控制电路206设置响应于每个心室电事件而开始的PVAB期。控制电路206可以通过标识由感测电路204感测的心室感测事件信号(例如，R波)和/或通过标识由脉冲发生器202产生的心室起搏脉冲来标识心室电事件。控制电路206可以响应于每个标识的心室事件而设置PVAB期。例如，在心室电事件之后，PVAB期可延长400ms至600ms或500ms至550ms。应认识到，在感测后设置的PVAB期和在起搏后设置的PVAB期可能不同，因为在心室感测事件信号之后的A2和A3事件信号的相对定时与在递送的心室起搏脉冲时间之后的A2和A3事件信号的相对定时相比不同。FIG6 is a flow chart 300 of a method for adjusting the PVAB period according to an example. At box 301, the control circuit 206 sets the PVAB period that starts in response to each ventricular electrical event. The control circuit 206 can identify the ventricular electrical event by identifying the ventricular sensed event signal (e.g., R wave) sensed by the sensing circuit 204 and/or by identifying the ventricular pacing pulse generated by the pulse generator 202. The control circuit 206 can set the PVAB period in response to each identified ventricular event. For example, after the ventricular electrical event, the PVAB period can be extended by 400ms to 600ms or 500ms to 550ms. It should be recognized that the PVAB period set after sensing and the PVAB period set after pacing may be different because the relative timing of the A2 and A3 event signals after the ventricular sensed event signal is different from the relative timing of the A2 and A3 event signals after the delivered ventricular pacing pulse time.
在框302处，控制电路206可在PVAB期的至少一部分期间启用对运动信号的感测。如上文结合图5所述，在包括心房事件感测的心室起搏模式期间，运动传感器或运动信号的处理可在节电时间段期间被禁用，该节电时间段可延长至PVAB期的全部或一部分。然而，在调整PVAB期之前，控制电路206可以在至少一个或多个PVAB期中的PVAB期期间在框302处启用运动信号感测和分析。可以在整个PVAB期内或在PVAB期的至少一个最晚部分内启用运动信号感测和分析。例如，运动信号感测和分析可以在最晚的100ms、最晚的200ms、最晚的300ms或PVAB期的其他所选部分内启用。At box 302, the control circuit 206 may enable sensing of motion signals during at least a portion of the PVAB period. As described above in conjunction with FIG. 5, during a ventricular pacing mode including atrial event sensing, the motion sensor or processing of the motion signal may be disabled during a power saving period that may extend to all or a portion of the PVAB period. However, before adjusting the PVAB period, the control circuit 206 may enable motion signal sensing and analysis at box 302 during the PVAB period of at least one or more PVAB periods. Motion signal sensing and analysis may be enabled throughout the PVAB period or within at least one latest portion of the PVAB period. For example, motion signal sensing and analysis may be enabled within the latest 100ms, the latest 200ms, the latest 300ms, or other selected portions of the PVAB period.
在框302处，虽然在PVAB期期间启用运动信号感测，但是在PVAB期期间可能不启用心房事件信号感测。当在PVAB期间启用运动信号感测和分析时，控制电路206可以将A4感测阈值振幅设置为最大振幅，以在PVAB期期间抑制A4事件感测，以用于调整PVAB期。可替代地，如果运动信号在PVAB期期间越过A4感测阈值振幅，则控制电路206可检测到阈值跨越，但被配置为通过忽略心房事件检测器电路240在PVAB期期间检测到的任何心房事件来拒绝开始AV起搏间期。At block 302, although motion signal sensing is enabled during the PVAB period, atrial event signal sensing may not be enabled during the PVAB period. When motion signal sensing and analysis are enabled during the PVAB period, the control circuit 206 may set the A4 sensing threshold amplitude to a maximum amplitude to suppress A4 event sensing during the PVAB period for adjusting the PVAB period. Alternatively, if the motion signal crosses the A4 sensing threshold amplitude during the PVAB period, the control circuit 206 may detect the threshold crossing, but is configured to refuse to start an AV pacing interval by ignoring any atrial events detected by the atrial event detector circuit 240 during the PVAB period.
在框304处，控制电路206可在一个或多个心室周期中在PVAB期期间确定运动信号振幅数据。当控制电路206设置单独的感测后和起搏后PVAB期时，在框304处确定的多个心室周期的振幅数据可被分成感测后振幅数据和起搏后振幅数据，这些数据可被存储在分配用于存储振幅数据的存储器缓冲器中。At block 304, control circuit 206 may determine motion signal amplitude data during the PVAB period in one or more ventricular cycles. When control circuit 206 sets separate post-sensing and post-pacing PVAB periods, the amplitude data for the plurality of ventricular cycles determined at block 304 may be separated into post-sensing amplitude data and post-pacing amplitude data, which may be stored in a memory buffer allocated for storing amplitude data.
在一些示例中，振幅数据可以在PVAB期的最晚部分期间(例如，PVAB期的最晚的50ms至300ms)确定。振幅数据可以包括运动信号的绝对最大峰值振幅、绝对最大峰值振幅的时间、在PVAB期期间是否发生振幅阈值跨越、振幅阈值跨越的时间和/或运动信号振幅是否大于或等于在PVAB期的最晚部分期间的振幅阈值。当控制电路206在多个心室周期的每个PVAB期期间确定运动信号振幅数据时，控制电路206可以确定所确定振幅的平均值、中值、最大值、最小值或其他代表值和/或相对于先前心室电事件的时间和/或相对于PVAB期到期的峰值振幅或振幅阈值跨越的相关联时间。可以确定代表值以用于调整PVAB期。In some examples, the amplitude data may be determined during the latest portion of the PVAB period (e.g., the latest 50 ms to 300 ms of the PVAB period). The amplitude data may include the absolute maximum peak amplitude of the motion signal, the time of the absolute maximum peak amplitude, whether an amplitude threshold crossing occurred during the PVAB period, the time of the amplitude threshold crossing, and/or whether the motion signal amplitude is greater than or equal to the amplitude threshold during the latest portion of the PVAB period. When the control circuit 206 determines the motion signal amplitude data during each PVAB period of multiple ventricular cycles, the control circuit 206 may determine the average, median, maximum, minimum, or other representative value of the determined amplitude and/or the associated time of the peak amplitude or amplitude threshold crossing relative to the time of the previous ventricular electrical event and/or relative to the expiration of the PVAB period. The representative value may be determined for use in adjusting the PVAB period.
图7是根据一些示例的运动信号502的概念图500，该概念图展示了用于在一个心室周期的PVAB期期间由控制电路206确定振幅数据的技术。运动信号502包括A1事件504、A2事件506、A3事件508和A4事件510。在心室起搏脉冲560之后，PVAB期536开始。被动心室充盈窗口(A3窗口)524在PVAB期536到期时开始。在A3窗口524期间，对运动信号502施加第一较高A4感测阈值振幅546。在可以延长至感测到A4事件510或直到递送了心室起搏脉冲或由感测电路204感测到心室事件信号为止的A4感测窗口550期间，在A3窗口524到期之后，A4感测阈值544减小到第二较低A4感测阈值振幅548。FIG. 7 is a conceptual diagram 500 of a motion signal 502 illustrating a technique for determining amplitude data by the control circuit 206 during the PVAB period of a ventricular cycle according to some examples. The motion signal 502 includes an A1 event 504, an A2 event 506, an A3 event 508, and an A4 event 510. After a ventricular pacing pulse 560, the PVAB period 536 begins. The passive ventricular filling window (A3 window) 524 begins at the expiration of the PVAB period 536. During the A3 window 524, a first higher A4 sensing threshold amplitude 546 is applied to the motion signal 502. During an A4 sensing window 550, which may extend until an A4 event 510 is sensed or until a ventricular pacing pulse is delivered or a ventricular event signal is sensed by the sensing circuit 204, after the expiration of the A3 window 524, the A4 sensing threshold 544 is reduced to a second lower A4 sensing threshold amplitude 548.
在所示的示例中，在运动信号502越过第二较低A4感测阈值振幅548时感测到A4事件510。控制电路206响应于由心房事件检测器电路240产生的心房事件检测信号562而设置AV起搏间期566。脉冲发生器202在AV起搏间期566到期时产生心室起搏脉冲564。In the example shown, an A4 event 510 is sensed when the motion signal 502 crosses the second lower A4 sensing threshold amplitude 548. The control circuit 206 sets an AV pacing interval 566 in response to an atrial event detection signal 562 generated by the atrial event detector circuit 240. The pulse generator 202 generates a ventricular pacing pulse 564 when the AV pacing interval 566 expires.
如上所述，运动信号502的感测和分析可以在节电时间段535期间被禁用，该节电时间段可以延长直到或刚好在PVAB期536到期之前以启用对运动传感器上电，使得对运动信号502的处理和分析可以在PVAB期536到期时开始。然而，当控制电路206正在确定是否调整PVAB期536时，节电时间段535可以缩短或完全取消，使得控制电路206可以至少在PVAB期536的最晚部分538期间接收运动信号502以用于处理和分析。在所示的示例中，运动传感器可以在PVAB期536期间被上电，使得对运动信号502进行处理和分析以确定振幅数据可以在时间点537开始。PVAB期536的较晚部分538可以是PVAB期536的最晚50ms、100ms、200ms、300ms或其他预定部分或百分比。PVAB期536的较晚部分538在本文也称为“振幅分析窗口”，因为控制电路206可以在图6的框304处根据在PVAB期536的该较晚部分538期间接收的运动信号502来确定运动信号振幅数据。在示例中，节电时间段535通常可以在PVAB期536到期之前的85ms到期。当在框304处确定振幅数据时，控制电路206可在振幅分析窗口538之前的85ms终止节电时间段535。然而，应当理解，在各种示例中，振幅分析窗口538可以延长至PVAB期536的全部或任何部分，并且不一定仅限于PVAB期536的较晚部分。在一些示例中，振幅分析窗口538可以由控制电路206间歇地或在PVAB期536内的多个间期期间启用。As described above, sensing and analysis of the motion signal 502 can be disabled during the power saving period 535, which can be extended until or just before the expiration of the PVAB period 536 to enable powering on the motion sensor so that processing and analysis of the motion signal 502 can begin when the PVAB period 536 expires. However, when the control circuit 206 is determining whether to adjust the PVAB period 536, the power saving period 535 can be shortened or completely eliminated so that the control circuit 206 can receive the motion signal 502 for processing and analysis during at least the latest portion 538 of the PVAB period 536. In the example shown, the motion sensor can be powered on during the PVAB period 536 so that processing and analysis of the motion signal 502 to determine amplitude data can begin at time point 537. The later portion 538 of the PVAB period 536 can be the latest 50ms, 100ms, 200ms, 300ms, or other predetermined portion or percentage of the PVAB period 536. The later portion 538 of the PVAB period 536 is also referred to herein as an “amplitude analysis window” because the control circuit 206 may determine motion signal amplitude data at block 304 of FIG. 6 based on the motion signal 502 received during the later portion 538 of the PVAB period 536. In an example, the power saving time period 535 may generally expire 85 ms before the expiration of the PVAB period 536. When the amplitude data is determined at block 304, the control circuit 206 may terminate the power saving time period 535 85 ms before the amplitude analysis window 538. However, it should be understood that in various examples, the amplitude analysis window 538 may extend to all or any portion of the PVAB period 536 and is not necessarily limited to the later portion of the PVAB period 536. In some examples, the amplitude analysis window 538 may be enabled by the control circuit 206 intermittently or during multiple intervals within the PVAB period 536.
控制电路206可以在振幅分析窗口538期间确定经整流的运动传感器信号502的最大峰值振幅570。控制电路206可以确定相对于PVAB期536到期的最大峰值振幅570的时间。例如，在图6的框304处，到PVAB期到期时间间期572的峰值振幅可以被确定为振幅数据。The control circuit 206 may determine a maximum peak amplitude 570 of the rectified motion sensor signal 502 during the amplitude analysis window 538. The control circuit 206 may determine the time of the maximum peak amplitude 570 relative to the expiration of the PVAB period 536. For example, at block 304 of FIG. 6 , a peak amplitude during a time interval 572 to the expiration of the PVAB period may be determined as the amplitude data.
另外或可替代地，控制电路206可以通过确定运动信号502在振幅分析窗口538期间是否越过振幅阈值578在图6的框304处确定振幅数据。控制电路206可基于第一较高A4感测阈值振幅546或基于第二较低感测阈值振幅548或者在一些示例中基于两者的组合来设置振幅阈值578。例如，振幅阈值578可以是第一较高A4感测阈值振幅546的百分比，例如，50％、60％、70％、80％、90％或100％。可替代地，控制电路206可以将振幅阈值578设置为第一较高A4感测阈值振幅546减去偏移量。Additionally or alternatively, the control circuit 206 may determine amplitude data at block 304 of FIG. 6 by determining whether the motion signal 502 crosses an amplitude threshold 578 during the amplitude analysis window 538. The control circuit 206 may set the amplitude threshold 578 based on the first higher A4 sensing threshold amplitude 546 or based on the second lower sensing threshold amplitude 548, or in some examples based on a combination of both. For example, the amplitude threshold 578 may be a percentage of the first higher A4 sensing threshold amplitude 546, such as 50%, 60%, 70%, 80%, 90%, or 100%. Alternatively, the control circuit 206 may set the amplitude threshold 578 to the first higher A4 sensing threshold amplitude 546 minus an offset.
当运动信号502在振幅分析窗口538期间确实越过振幅阈值578时，控制电路206可以确定从振幅阈值跨越574到PVAB期536的到期时间的时间间期576。在图7所示的示例中，阈值跨越574是振幅分析窗口538期间最晚的负向阈值跨越。在其他示例中，控制电路206可以另外或可替代地确定从最晚的正向阈值跨越到PVAB期536到期的时间间期。When the motion signal 502 does cross the amplitude threshold 578 during the amplitude analysis window 538, the control circuit 206 can determine a time interval 576 from the amplitude threshold crossing 574 to the expiration time of the PVAB period 536. In the example shown in Figure 7, the threshold crossing 574 is the latest negative-going threshold crossing during the amplitude analysis window 538. In other examples, the control circuit 206 can additionally or alternatively determine the time interval from the latest positive-going threshold crossing to the expiration of the PVAB period 536.
再次参考图6并继续参考图7，控制电路206确定在框304处确定的振幅数据在框306处是否满足PVAB调整标准。PVAB调整标准可以包括一个或多个阈值、范围或其他基于振幅或基于时间的要求，这些要求应用于振幅数据以确定运动信号的振幅在PVAB期之外是否可能大于A4感测阈值振幅。控制电路206可以通过确定是否满足基于振幅的要求，例如通过将最大峰值振幅与振幅阈值进行比较和/或确定是否和/或何时检测到振幅阈值跨越来应用PVAB调整标准。控制电路206可以通过确定是否满足基于时间的要求，例如通过将最大峰值振幅的时间和/或振幅阈值跨越时间(例如，相对于当前PVAB期的到期)与如以下示例中所述的阈值时间间期进行比较来应用PVAB调整标准。Referring again to FIG. 6 and continuing to refer to FIG. 7 , the control circuit 206 determines whether the amplitude data determined at block 304 satisfies the PVAB adjustment criteria at block 306. The PVAB adjustment criteria may include one or more thresholds, ranges, or other amplitude-based or time-based requirements that are applied to the amplitude data to determine whether the amplitude of the motion signal is likely to be greater than the A4 sensing threshold amplitude outside of the PVAB period. The control circuit 206 may apply the PVAB adjustment criteria by determining whether the amplitude-based requirements are met, such as by comparing the maximum peak amplitude to the amplitude threshold and/or determining whether and/or when an amplitude threshold crossing is detected. The control circuit 206 may apply the PVAB adjustment criteria by determining whether the time-based requirements are met, such as by comparing the time of the maximum peak amplitude and/or the amplitude threshold crossing time (e.g., relative to the expiration of the current PVAB period) to a threshold time interval as described in the following examples.
在一些示例中，控制电路206可以将振幅分析窗口538期间的最大峰值振幅570与振幅阈值(例如，振幅阈值578)进行比较。当振幅分析窗口538期间的最大峰值振幅小于振幅阈值时，在框306处可以确定满足PVAB调整标准。控制电路206可在框308处通过缩短PVAB期，例如通过减少从心室电事件到PVAB期到期的PVAB期的持续时间来调整PVAB期。然而，当PVAB期的振幅分析窗口期间的最大峰值振幅大于振幅阈值时，控制电路206可以在框306处确定不满足PVAB调整标准。当如基于在框306处不满足PVAB调整标准而确定的，运动信号振幅在PVAB期期间相对较晚的时间相对较高时，控制电路206在框310处可以不调整PVAB期。在其他示例中，例如，如下文结合图8所述，控制电路206可以响应于确定运动信号振幅大于或等于在振幅分析窗口期间(或在当前PVAB期的至少一部分期间)的振幅阈值而增加PVAB期的持续时间。经调整的PVAB期(例如，减少或增加的PVAB期)可适用于一个或多个未来的心动周期。In some examples, the control circuit 206 may compare the maximum peak amplitude 570 during the amplitude analysis window 538 to an amplitude threshold (e.g., an amplitude threshold 578). When the maximum peak amplitude during the amplitude analysis window 538 is less than the amplitude threshold, it may be determined at block 306 that the PVAB adjustment criteria are met. The control circuit 206 may adjust the PVAB period at block 308 by shortening the PVAB period, for example, by reducing the duration of the PVAB period from the ventricular electrical event to the expiration of the PVAB period. However, when the maximum peak amplitude during the amplitude analysis window of the PVAB period is greater than the amplitude threshold, the control circuit 206 may determine at block 306 that the PVAB adjustment criteria are not met. When the motion signal amplitude is relatively high at a relatively late time during the PVAB period, as determined based on the PVAB adjustment criteria not being met at block 306, the control circuit 206 may not adjust the PVAB period at block 310. In other examples, control circuit 206 may increase the duration of the PVAB period in response to determining that the motion signal amplitude is greater than or equal to an amplitude threshold during the amplitude analysis window (or during at least a portion of the current PVAB period), e.g., as described below in conjunction with FIG8. The adjusted PVAB period (e.g., a reduced or increased PVAB period) may be applicable to one or more future cardiac cycles.
最大峰值振幅570与之比较的振幅阈值(例如，振幅阈值578)可以基于第一较高A4感测阈值振幅546。振幅阈值可以被设置为等于在A3窗口524期间施加的第一较高A4感测阈值振幅546，或者等于第一较高A4感测阈值振幅的百分比，例如40％至80％。在当前PVAB期的振幅分析窗口538期间的最大峰值振幅570小于振幅阈值时，控制电路206可以确定满足PVAB调整标准。PVAB期536可以被安全地缩短，例如缩短等于或短于振幅分析窗口538的预定减量。当运动信号振幅小于振幅分析窗口538期间的振幅阈值时，PVAB期536的持续时间可以减小，而将A2事件过度感测为融合的A3/A4事件的可能性较低。The amplitude threshold (e.g., amplitude threshold 578) to which the maximum peak amplitude 570 is compared can be based on the first higher A4 sensing threshold amplitude 546. The amplitude threshold can be set equal to the first higher A4 sensing threshold amplitude 546 applied during the A3 window 524, or equal to a percentage of the first higher A4 sensing threshold amplitude, such as 40% to 80%. When the maximum peak amplitude 570 during the amplitude analysis window 538 of the current PVAB period is less than the amplitude threshold, the control circuit 206 can determine that the PVAB adjustment criteria are met. The PVAB period 536 can be safely shortened, such as by a predetermined decrement equal to or shorter than the amplitude analysis window 538. When the motion signal amplitude is less than the amplitude threshold during the amplitude analysis window 538, the duration of the PVAB period 536 can be reduced, and the likelihood of oversensing an A2 event as a fused A3/A4 event is low.
另外或可替代地，控制电路206可以将从最大峰值振幅570到当前PVAB期536的到期时间的时间间期572与阈值时间间期580进行比较。当最大峰值振幅570在当前PVAB期536到期时间之前的阈值时间间期580内时，控制电路206可以在框306处确定不满足PVAB调整标准。在框310处，控制电路206可以拒绝对PVAB期的调整。如果控制电路206确定运动信号502在振幅分析窗口538期间的最大峰值振幅570出现在比从当前PVAB期536的到期时间的阈值时间间期580更早的时间，则可以确定满足PVAB调整标准。在框308处，可以安全地缩短PVAB期536。作为示例，PVAB期536可以减少10ms至100ms，并且在一些示例中减少20ms至60ms。Additionally or alternatively, the control circuit 206 may compare a time interval 572 from the maximum peak amplitude 570 to the expiration time of the current PVAB period 536 to a threshold time interval 580. When the maximum peak amplitude 570 is within the threshold time interval 580 before the expiration time of the current PVAB period 536, the control circuit 206 may determine at block 306 that the PVAB adjustment criteria are not met. At block 310, the control circuit 206 may reject the adjustment of the PVAB period. If the control circuit 206 determines that the maximum peak amplitude 570 of the motion signal 502 during the amplitude analysis window 538 occurs at a time earlier than the threshold time interval 580 from the expiration time of the current PVAB period 536, it may be determined that the PVAB adjustment criteria are met. At block 308, the PVAB period 536 may be safely shortened. As an example, the PVAB period 536 may be reduced by 10 ms to 100 ms, and in some examples by 20 ms to 60 ms.
在一些示例中，阈值时间间期580可以根据PVAB期536将被缩短的时间量来设置。例如，当满足PVAB调整标准时，控制电路206可被配置为将PVAB期536调整预定减量间期，作为示例，该减量间期可以是50ms。控制电路206可以将阈值时间间期580设置为等于减量间期加上安全间期，例如0ms至30ms的安全间期。例如，如果PVAB期要缩短50ms，则阈值时间间期580可以被设置为延长比PVAB期536的到期时间提前50ms加20ms或总共70ms。以这种方式，在框308处，PVAB期536可以缩短预定减量间期，该减量间期等于或小于阈值时间间期580，A2事件506在PVAB期的经调整的到期时间之后被过度感测为融合A的A3/A4事件的可能性较低。在一些示例中，阈值时间间期580表示在PVAB期536到期之前开始并延长至该到期的时间间期，并且因此在本文中也称为“PVAB结束时间间期”。In some examples, the threshold time interval 580 can be set according to the amount of time that the PVAB period 536 is to be shortened. For example, when the PVAB adjustment criteria are met, the control circuit 206 can be configured to adjust the PVAB period 536 by a predetermined decrement interval, which can be 50 ms as an example. The control circuit 206 can set the threshold time interval 580 equal to the decrement interval plus a safety interval, such as a safety interval of 0 ms to 30 ms. For example, if the PVAB period is to be shortened by 50 ms, the threshold time interval 580 can be set to extend 50 ms plus 20 ms or a total of 70 ms ahead of the expiration time of the PVAB period 536. In this way, at box 308, the PVAB period 536 can be shortened by a predetermined decrement interval that is equal to or less than the threshold time interval 580, and the A2 event 506 is less likely to be over-sensed as an A3/A4 event of fusion A after the adjusted expiration time of the PVAB period. In some examples, threshold time interval 580 represents a time interval that begins before expiration of PVAB period 536 and extends to that expiration, and is therefore also referred to herein as a “PVAB end time interval.”
另外或可替代地，控制电路206可以在框306处确定运动信号502在振幅分析窗口538期间是否越过振幅阈值578。当运动信号502在振幅分析窗口538期间没有越过振幅阈值578时，控制电路206可以在框306处确定满足PVAB调整标准。在框308处，控制电路206可缩短PVAB期536。PVAB期536可以缩短等于或小于振幅分析窗口538的间期，当运动信号502在振幅分析窗口期间没有越过振幅阈值578时，过度感测A2事件506的可能性较低。Additionally or alternatively, the control circuit 206 may determine at block 306 whether the motion signal 502 crosses the amplitude threshold 578 during the amplitude analysis window 538. When the motion signal 502 does not cross the amplitude threshold 578 during the amplitude analysis window 538, the control circuit 206 may determine at block 306 that the PVAB adjustment criteria are met. At block 308, the control circuit 206 may shorten the PVAB period 536. The PVAB period 536 may be shortened by an interval equal to or less than the amplitude analysis window 538, and when the motion signal 502 does not cross the amplitude threshold 578 during the amplitude analysis window, the likelihood of oversensing the A2 event 506 is low.
在一些示例中，控制电路206可以确定相对于当前PVAB期536到期的最晚阈值跨越574的时间，以选择用于缩短PVAB期536的持续时间的递减时间间期。例如，控制电路206可以确定从最晚的阈值跨越574到PVAB期536到期的时间间期576。控制电路206可以将PVAB期减少时间间期576的一部分，例如，时间间期576的40％、50％、60％、70％或80％。以这种方式，控制电路206可以缩短PVAB期536，使其比当前PVAB期536更早到期，但在最晚的阈值跨越574之后到期，以安全地最小化在未来心室事件后应用的经调整的PVAB消隐期到期后过度感测A2事件506的可能性。In some examples, the control circuit 206 can determine the time of the latest threshold crossing 574 relative to the expiration of the current PVAB period 536 to select a decreasing time interval for shortening the duration of the PVAB period 536. For example, the control circuit 206 can determine the time interval 576 from the latest threshold crossing 574 to the expiration of the PVAB period 536. The control circuit 206 can reduce the PVAB period by a portion of the time interval 576, for example, 40%, 50%, 60%, 70%, or 80% of the time interval 576. In this way, the control circuit 206 can shorten the PVAB period 536 so that it expires earlier than the current PVAB period 536, but after the latest threshold crossing 574 to safely minimize the possibility of oversensing an A2 event 506 after the expiration of the adjusted PVAB blanking period applied after a future ventricular event.
在仍其他示例中，控制电路206可以将阈值时间间期580与从运动信号在振幅分析窗口538期间的最晚阈值跨越574到PVAB消隐期536到期的时间间期576进行比较。用于确定阈值跨越574的振幅阈值578可以基于如上所述在A3窗口524期间应用的第一较高A4感测阈值振幅546。控制电路206可以将最晚的阈值跨越574确定为振幅阈值578的最晚正向或最晚负向跨越。当最晚阈值跨越574早于从当前PVAB期536到期开始的阈值时间间期580时，控制电路206可以在框306处确定满足PVAB调整标准。控制电路206可以在框308处缩短PVAB期536。当最晚阈值跨越574的时间在PVAB结束时间间期580内时，例如在从当前PVAB期536到期开始的阈值时间间期内时，控制电路206可以在框306处确定不满足PVAB调整标准。作为响应，在框310处，控制电路206可将PVAB期保持在当前设置不变。在其他示例中，当最晚的阈值跨越574在PVAB结束时间间期580内时，控制电路206可以延长或加长PVAB期536的持续时间。如上所述，PVAB结束时间间期580可以基于要在框308处调整的PVAB期536的时间量进行设置。例如，当PVAB期536要被调整50ms的时间间期时，PVAB结束时间间期580可被设置为50ms或50ms加上大于50ms的预定偏移量或百分比。作为示例，PVAB结束时间间期580可以在20ms与100ms之间。In still other examples, the control circuit 206 can compare the threshold time interval 580 to the time interval 576 from the latest threshold crossing 574 of the motion signal during the amplitude analysis window 538 to the expiration of the PVAB blanking period 536. The amplitude threshold 578 used to determine the threshold crossing 574 can be based on the first higher A4 sensing threshold amplitude 546 applied during the A3 window 524 as described above. The control circuit 206 can determine the latest threshold crossing 574 as the latest positive or latest negative crossing of the amplitude threshold 578. When the latest threshold crossing 574 is earlier than the threshold time interval 580 from the expiration of the current PVAB period 536, the control circuit 206 can determine at block 306 that the PVAB adjustment criteria are met. The control circuit 206 can shorten the PVAB period 536 at block 308. When the time of the latest threshold crossing 574 is within the PVAB end time interval 580, such as within the threshold time interval from the expiration of the current PVAB period 536, the control circuit 206 may determine at block 306 that the PVAB adjustment criteria are not met. In response, at block 310, the control circuit 206 may maintain the PVAB period at the current setting. In other examples, when the latest threshold crossing 574 is within the PVAB end time interval 580, the control circuit 206 may extend or lengthen the duration of the PVAB period 536. As described above, the PVAB end time interval 580 may be set based on the amount of time of the PVAB period 536 to be adjusted at block 308. For example, when the PVAB period 536 is to be adjusted by a time interval of 50 ms, the PVAB end time interval 580 may be set to 50 ms or 50 ms plus a predetermined offset or percentage greater than 50 ms. As an example, the PVAB end time interval 580 may be between 20 ms and 100 ms.
再次参考图6，当确定满足PVAB调整标准时，控制电路206可以通过将PVAB期缩短预定的减量间期在框308处调整PVAB期536。作为示例，减量间期可以是10ms、20ms、30ms、40ms、50ms、60ms、70ms、80ms、90ms或100ms。在其他示例中，PVAB期536可减少预定百分比或基于当前心室速率减少，当前心室速率可以是心室起搏速率或感测到的心室速率。例如，可以在两次心率之间以线性方式调整PVAB期536。为了说明，PVAB期536可以在心率下限为每分钟80次时的最大PVAB期550ms与减少到心率上限为每分钟110次时的最小值500ms之间进行调整。在心率低于心率下限时，PVAB期536可以保持在最大值550ms处。在心率高于心率上限时，PVAB期536可以保持在最小值500ms处。作为示例，PVAB期可以被设置为500ms到800ms。作为示例，心率下限可以在每分钟60次到90次之间。作为示例，最小PVAB期可以被设置为400ms到700ms。作为示例，心率上限可以在每分钟90次到120次之间。Referring again to FIG. 6 , when it is determined that the PVAB adjustment criteria are met, the control circuit 206 can adjust the PVAB period 536 at box 308 by shortening the PVAB period by a predetermined decrement interval. As an example, the decrement interval can be 10 ms, 20 ms, 30 ms, 40 ms, 50 ms, 60 ms, 70 ms, 80 ms, 90 ms, or 100 ms. In other examples, the PVAB period 536 can be reduced by a predetermined percentage or based on the current ventricular rate, which can be a ventricular pacing rate or a sensed ventricular rate. For example, the PVAB period 536 can be adjusted in a linear manner between two heart rates. For illustration, the PVAB period 536 can be adjusted between a maximum PVAB period of 550 ms when the heart rate lower limit is 80 beats per minute and a minimum value of 500 ms when the heart rate upper limit is 110 beats per minute. When the heart rate is below the heart rate lower limit, the PVAB period 536 can remain at the maximum value of 550 ms. When the heart rate is higher than the upper heart rate limit, the PVAB period 536 can be maintained at a minimum value of 500ms. As an example, the PVAB period can be set to 500ms to 800ms. As an example, the heart rate lower limit can be between 60 and 90 beats per minute. As an example, the minimum PVAB period can be set to 400ms to 700ms. As an example, the heart rate upper limit can be between 90 and 120 beats per minute.
振幅分析窗口538和阈值时间间期580在图7中示出为两个不同的时间间期。在一些示例中，PVAB调整标准可以包括同时利用振幅分析窗口538和阈值时间间期580的多个要求。例如，用于缩短PVAB期536的PVAB调整标准可以要求振幅分析窗口538期间的最大峰值振幅小于第一振幅阈值，并且运动信号在阈值时间间期580期间不越过第二振幅阈值，第二振幅阈值可以等于或小于第一振幅阈值。在这种情况下，控制电路206可以同时将振幅分析窗口538和阈值时间间期580设置为两个不同的时间间期，并且可以设置在PVAB期536期间应用于运动信号的一个或两个不同的振幅阈值以确定振幅数据。The amplitude analysis window 538 and the threshold time interval 580 are shown in FIG. 7 as two different time intervals. In some examples, the PVAB adjustment criteria may include multiple requirements that utilize both the amplitude analysis window 538 and the threshold time interval 580. For example, the PVAB adjustment criteria for shortening the PVAB period 536 may require that the maximum peak amplitude during the amplitude analysis window 538 is less than a first amplitude threshold, and that the motion signal does not cross a second amplitude threshold during the threshold time interval 580, and the second amplitude threshold may be equal to or less than the first amplitude threshold. In this case, the control circuit 206 may simultaneously set the amplitude analysis window 538 and the threshold time interval 580 to two different time intervals, and may set one or two different amplitude thresholds applied to the motion signal during the PVAB period 536 to determine the amplitude data.
然而，应当理解，在一些示例中，振幅分析窗口538可以等于阈值时间间期580。控制电路206可以在PVAB期536的较晚部分期间设置单个窗口或时间间期，以基于振幅数据确定何时满足PVAB调整标准。例如，控制电路206可以将PVAB结束时间间期580同时设置为延长到PVAB期536到期的阈值时间间期以及振幅分析窗口。在一些示例中，当运动信号振幅在PVAB结束时间间期580期间不大于振幅阈值578或者运动信号502不越过振幅阈值时，控制电路206可以确定满足PVAB调整标准。However, it should be understood that in some examples, the amplitude analysis window 538 can be equal to the threshold time interval 580. The control circuit 206 can set a single window or time interval during the later portion of the PVAB period 536 to determine when the PVAB adjustment criteria are met based on the amplitude data. For example, the control circuit 206 can set the PVAB end time interval 580 to both the threshold time interval and the amplitude analysis window that extend to the expiration of the PVAB period 536. In some examples, the control circuit 206 can determine that the PVAB adjustment criteria are met when the motion signal amplitude is not greater than the amplitude threshold 578 or the motion signal 502 does not cross the amplitude threshold during the PVAB end time interval 580.
已经关于PVAB期调整描述了图6的流程图300，该调整是在框308处减小PVAB期536。控制电路206可以响应于检测到心室速率的增加而执行流程图300的过程。当心室速率增加，例如使得心房同步的心室起搏脉冲之间的时间间期缩短时，则可以保证PVAB期缩短。为了避免过度感测A2事件，控制电路206可以执行流程图300的方法来验证在当前PVAB消隐期到期附近或者在可能缩短的PVAB消隐期到期之后的阈值时间间期(诸如PVAB结束时间间期580)期间的运动信号的振幅不接近或大于第一较高A4感测阈值振幅546或另一选定振幅阈值。在一些示例中，当心室速率再次降低时，可以在不分析PVAB期期间的运动信号的振幅的情况下增加PVAB期。通过增加PVAB期，过度感测A2事件的可能性降低，因为PVAB期到期在心室周期中较晚发生，并且最有可能在A2事件之后发生。因此，在一些示例中，控制电路206可仅在对PVAB期的潜在调整(例如，由于心室速率增加)是减少或缩短PVAB期时执行流程图300的方法。然而，在其他示例中，控制电路206可以确定和分析运动信号振幅数据，以验证当前PVAB期是适当的还是应该缩短(减少)或加长(增加)以避免A2事件的过度感测，这可以例如响应于心室速率的增加和减少两种情况和/或响应于A4事件感测的频率和/或定时的变化。6 has been described with respect to PVAB period adjustment, which is to reduce the PVAB period 536 at box 308. The control circuit 206 can perform the process of flowchart 300 in response to detecting an increase in the ventricular rate. When the ventricular rate increases, such as to shorten the time interval between ventricular pacing pulses that synchronize the atria, then the PVAB period can be guaranteed to be shortened. To avoid oversensing A2 events, the control circuit 206 can perform the method of flowchart 300 to verify that the amplitude of the motion signal during a threshold time interval (such as PVAB end time interval 580) near the expiration of the current PVAB blanking period or after the expiration of the potentially shortened PVAB blanking period is not close to or greater than the first higher A4 sensing threshold amplitude 546 or another selected amplitude threshold. In some examples, when the ventricular rate decreases again, the PVAB period can be increased without analyzing the amplitude of the motion signal during the PVAB period. By increasing the PVAB period, the likelihood of oversensing A2 events is reduced because the PVAB period expiration occurs later in the ventricular cycle and is most likely to occur after the A2 event. Thus, in some examples, the control circuit 206 may only perform the method of flowchart 300 when the potential adjustment to the PVAB period (e.g., due to an increase in ventricular rate) is to reduce or shorten the PVAB period. However, in other examples, the control circuit 206 may determine and analyze the motion signal amplitude data to verify whether the current PVAB period is appropriate or should be shortened (reduced) or lengthened (increased) to avoid excessive sensing of A2 events, which may be, for example, in response to both increases and decreases in ventricular rate and/or in response to changes in the frequency and/or timing of A4 event sensing.
图8是根据另一示例的用于控制PVAB期调整的方法的流程图600。在框601处，控制电路206可以确定是时候调整PVAB期。控制电路206可以定期(例如，每分钟一次、每小时一次、每四小时一次、每八小时一次、每十二小时一次、每天一次或其他计划的频率)在植入起搏器时执行流程图600的方法。在一些示例中，控制电路206可以响应于一天中的计划时间或PVAB调整定时器的到期而在框601处确定是时候调整PVAB期。FIG8 is a flowchart 600 of a method for controlling PVAB period adjustment according to another example. At block 601, the control circuit 206 may determine that it is time to adjust the PVAB period. The control circuit 206 may perform the method of flowchart 600 when the pacemaker is implanted periodically (e.g., once a minute, once an hour, once every four hours, once every eight hours, once every twelve hours, once a day, or other scheduled frequencies). In some examples, the control circuit 206 may determine at block 601 that it is time to adjust the PVAB period in response to a scheduled time of day or the expiration of a PVAB adjustment timer.
另外或可替代地，控制电路206可以响应于检测到心率的变化而在框601处确定是时候调整PVAB期，该心率可以是心房速率和/或心室速率。控制电路206可将RRI确定为心房同步的心室起搏模式期间(或包括心房感测的异步心室起搏模式期间)连续起搏脉冲和/或感测到的心室事件信号之间的时间间期。可以将最近的X RRI的均值或中值确定为对应于当前心室速率的代表值，并与先前确定的RRI进行比较。为了说明，可以在每8个RRI之后将中值RRI确定为8个RRI的中值。可以将最近的中值RRI与先前确定的中值RRI进行比较，以说明心室速率可能发生的相对较快和较慢的变化，先前确定的中值RRI可以是最近的先前的中值RRI和/或可以表示较早时间(例如，早大约30秒、早一分钟、早两分钟、早五分钟等)的心室速率的一个或多个较早中值RRI。在当前中值RRI和先前确定的中值RRI之间的差异大于速率变化阈值，例如对应于心室速率增加或减少每分钟10次(bpm)、20bpm、30bpm或其他速率变化阈值时，控制电路206可以在框601处确定是时候调整PVAB期。Additionally or alternatively, the control circuit 206 may determine at block 601 that it is time to adjust the PVAB period in response to detecting a change in heart rate, which may be an atrial rate and/or a ventricular rate. The control circuit 206 may determine the RRI as the time interval between consecutive pacing pulses and/or sensed ventricular event signals during atrial-synchronized ventricular pacing mode (or during an asynchronous ventricular pacing mode including atrial sensing). The mean or median of the most recent X RRI may be determined as a representative value corresponding to the current ventricular rate and compared with the previously determined RRI. For illustration, the median RRI may be determined as the median of the 8 RRIs after every 8 RRIs. The most recent median RRI may be compared with the previously determined median RRI to account for relatively faster and slower changes that may occur in the ventricular rate, the previously determined median RRI may be the most recent previous median RRI and/or may represent one or more earlier median RRIs of the ventricular rate at an earlier time (e.g., approximately 30 seconds earlier, one minute earlier, two minutes earlier, five minutes earlier, etc.). When the difference between the current median RRI and the previously determined median RRI is greater than a rate change threshold, such as corresponding to an increase or decrease in the ventricular rate of 10 beats per minute (bpm), 20 bpm, 30 bpm, or other rate change threshold, the control circuit 206 can determine at box 601 that it is time to adjust the PVAB period.
另外或可替代地，当心率越过一个或多个速率阈值时，控制电路206可以确定是时候调整PVAB期了。例如，控制电路206可确定心室速率已在大于或等于100bpm至小于100bpm之间变化。控制电路206可基于心室速率越过100bpm的速率阈值而在框601处确定是时候调整PVAB期。例如，控制电路206可确定中值RRI(这可基于在连续心室事件之间确定的起搏和/或感测RRI)并将中值RRI与阈值间期进行比较。阈值间期可以是500ms、600ms、700ms或对应于心室速率阈值的其他选定阈值间期。当中值RRI从小于或等于阈值间期变为大于阈值间期时，反之亦然，控制电路206可以在框601处确定是时候调整PVAB期。Additionally or alternatively, the control circuit 206 may determine that it is time to adjust the PVAB period when the heart rate crosses one or more rate thresholds. For example, the control circuit 206 may determine that the ventricular rate has changed between greater than or equal to 100 bpm and less than 100 bpm. The control circuit 206 may determine at box 601 that it is time to adjust the PVAB period based on the ventricular rate crossing the rate threshold of 100 bpm. For example, the control circuit 206 may determine the median RRI (which may be based on the pacing and/or sensing RRI determined between consecutive ventricular events) and compare the median RRI with the threshold interval. The threshold interval may be 500ms, 600ms, 700ms, or other selected threshold intervals corresponding to the ventricular rate threshold. When the median RRI changes from less than or equal to the threshold interval to greater than the threshold interval, or vice versa, the control circuit 206 may determine at box 601 that it is time to adjust the PVAB period.
在一些示例中，控制电路206可以将中值RRI与另外两个阈值间期进行比较，诸如与心率从小于或等于60bpm、在60bpm与约85bpm之间、在约86bpm与120bpm之间以及大于120bpm的变化相对应的1000ms阈值、700ms阈值和500ms阈值。可以选择对应于其他心率阈值的其他阈值间期。当与先前确定的中值RRI相比，中值RRI越过阈值间期时，控制电路206可以在框601处确定是时候调整PVAB期。虽然前述与心率变化相关的示例是指基于RRI确定的心室速率的变化，但在一些示例中，心率或心率变化可基于感测到的心房事件的速率来确定。In some examples, the control circuit 206 can compare the median RRI to two other threshold intervals, such as a 1000ms threshold, a 700ms threshold, and a 500ms threshold corresponding to changes in heart rate from less than or equal to 60bpm, between 60bpm and approximately 85bpm, between approximately 86bpm and 120bpm, and greater than 120bpm. Other threshold intervals corresponding to other heart rate thresholds can be selected. When the median RRI crosses the threshold interval compared to the previously determined median RRI, the control circuit 206 can determine at box 601 that it is time to adjust the PVAB period. Although the aforementioned examples related to changes in heart rate refer to changes in ventricular rate determined based on RRI, in some examples, the heart rate or heart rate changes may be determined based on the rate of sensed atrial events.
在仍其他示例中，控制电路206可基于对感测到的心房事件信号的频率和/或定时的分析来在框601处确定是时候调整PVAB期。在一些示例中，控制电路206可以响应于以与心室事件1:1的比例发生在A3窗口之后(在A4窗口期间)的常规心房事件感测而确定是时候调整PVAB了。当在A4窗口期间在逐拍基础上持续可靠地感测到心房事件时，控制电路80可以分析在PVAB期期间的运动信号振幅。如果运动信号振幅低于阈值振幅，例如小于在A3窗口期间应用的第一A4感测阈值振幅的一半，则PVAB期可以缩短，因为当运动信号振幅在PVAB期期间很低时，过度感测A2事件的可能性相对较低。In still other examples, the control circuit 206 may determine at block 601 that it is time to adjust the PVAB period based on an analysis of the frequency and/or timing of the sensed atrial event signals. In some examples, the control circuit 206 may determine that it is time to adjust the PVAB in response to conventional atrial event sensing occurring after the A3 window (during the A4 window) at a 1:1 ratio with ventricular events. When atrial events are continuously and reliably sensed on a beat-by-beat basis during the A4 window, the control circuit 80 may analyze the motion signal amplitude during the PVAB period. If the motion signal amplitude is below a threshold amplitude, such as less than half of the first A4 sensing threshold amplitude applied during the A3 window, the PVAB period may be shortened because the likelihood of oversensing an A2 event is relatively low when the motion signal amplitude is low during the PVAB period.
在另一示例中，如果在一个或多个心室周期内没有感测到心房事件信号，则控制电路206可以在框601处确定是时候调整PVAB期。控制电路260可以确定在Y个最近心室周期中少于X个周期(例如，八个最近心室周期中少于四个周期、八个最近心室周期中少于两个周期或预定数量的最近心室周期的其他比率或百分比)内是否感测到心房事件信号。当从最近预定数量的心室周期中检测到少于阈值数量或百分比的心房事件信号时，控制电路206可在框601处确定是时候调整PVAB期。在一些示例中，当心房事件感测不常规或丢失时，控制电路206可在调整PVAB期之前调整其他心房事件感测控制参数，例如A3窗口的结束时间和/或A4感测阈值振幅。控制电路206可在对其他心房事件感测控制参数的调整已经用尽之后确定是时候调整PVAB期。In another example, if no atrial event signals are sensed within one or more ventricular cycles, the control circuit 206 may determine at block 601 that it is time to adjust the PVAB period. The control circuit 260 may determine whether an atrial event signal is sensed within less than X cycles of the Y most recent ventricular cycles (e.g., less than four cycles of the eight most recent ventricular cycles, less than two cycles of the eight most recent ventricular cycles, or other ratios or percentages of a predetermined number of most recent ventricular cycles). When less than a threshold number or percentage of atrial event signals are detected from the most recent predetermined number of ventricular cycles, the control circuit 206 may determine at block 601 that it is time to adjust the PVAB period. In some examples, when atrial event sensing is irregular or missing, the control circuit 206 may adjust other atrial event sensing control parameters, such as the end time of the A3 window and/or the A4 sensing threshold amplitude, before adjusting the PVAB period. The control circuit 206 may determine that it is time to adjust the PVAB period after adjustments to other atrial event sensing control parameters have been exhausted.
另外或可替代地，控制电路206可以确定在心室周期期间何时感测到心房事件信号。再次参考图7，控制电路206可确定在A3窗口524的早期部分582内感测到心房事件信号的频率。由于PVAB期过短，在A3窗口524的早期部分期间感测到的心房事件信号可能对应于过度感测的A2信号。因此，控制电路206可以对在A3窗口的早期部分582(如图7所示)期间感测到的心房事件信号的数量进行计数。A3窗口524的早期部分582在本文中也称为“A3窗口开始时间间期”，因为该早期部分从A3窗口524的开始延长至PVAB期536到期之后的预定时间间期。A3窗口开始时间间期582的持续时间可以是50ms、100ms、150ms或其他选定的时间间期，并且可以基于用于增加PVAB期的预定增量、最大可允许PVAB期或可以应用于PVAB期536以增加心室事件后的PVAB期的持续时间的其他调整进行设置。当在A3窗口开始时间间期582期间在预定时间间期或预定数量的心室周期内感测到阈值数量或百分比的所有感测到的心房事件时，控制电路206可确定是时候调整PVAB期536了。为了说明，当在A3窗口开始时间间期582期间感测到八个最近感测到的心房事件信号中的两个、三个、四个、六个或八个心房事件信号时，控制电路206可以确定是时候调整PVAB期。Additionally or alternatively, the control circuit 206 may determine when an atrial event signal is sensed during the ventricular cycle. Referring again to FIG. 7 , the control circuit 206 may determine the frequency with which an atrial event signal is sensed within the early portion 582 of the A3 window 524. Because the PVAB period is too short, an atrial event signal sensed during the early portion of the A3 window 524 may correspond to an over-sensed A2 signal. Therefore, the control circuit 206 may count the number of atrial event signals sensed during the early portion 582 of the A3 window (as shown in FIG. 7 ). The early portion 582 of the A3 window 524 is also referred to herein as the “A3 window start time interval” because the early portion extends from the start of the A3 window 524 to a predetermined time interval after the expiration of the PVAB period 536. The duration of the A3 window start time interval 582 may be 50 ms, 100 ms, 150 ms, or other selected time interval, and may be set based on a predetermined increment for increasing the PVAB period, a maximum allowable PVAB period, or other adjustments that may be applied to the PVAB period 536 to increase the duration of the PVAB period following a ventricular event. When a threshold number or percentage of all sensed atrial events are sensed within a predetermined time interval or a predetermined number of ventricular cycles during the A3 window start time interval 582, the control circuit 206 may determine that it is time to adjust the PVAB period 536. For illustration, the control circuit 206 may determine that it is time to adjust the PVAB period when two, three, four, six, or eight of the eight most recently sensed atrial event signals are sensed during the A3 window start time interval 582.
在仍其他示例中，控制电路206可被配置为在心房同步的心室起搏模式期间基于以心室较低速率间期(例如，由于没有感测到的心房事件信号)递送的阈值数量的心室起搏脉冲来在框601处确定是时候调整PVAB期。当递送阈值数量的异步心室起搏脉冲时，PVAB期可能过长，从而导致错过度感测心房事件信号。In still other examples, the control circuit 206 can be configured to determine that it is time to adjust the PVAB period at block 601 based on a threshold number of ventricular pacing pulses delivered at a ventricular lower rate interval (e.g., due to an absence of sensed atrial event signals) during an atrial synchronized ventricular pacing mode. When the threshold number of asynchronous ventricular pacing pulses is delivered, the PVAB period can be too long, resulting in missed sensing of atrial event signals.
在各种示例中，控制电路206可以被配置为基于一个或多个要求在框601处确定是时候调整PVAB期，该一个或多个需求可以被单独或组合地满足并且可以包括上述示例中的任何示例。控制电路206可以基于以下项来确定是时候开始从运动信号中确定振幅数据的过程了：一天中的时间、计划的PVAB期调整频率、心室速率、心房感测事件信号的速率或定时、达到的其他心房事件感测控制参数的最大调整次数、异步心室起搏脉冲的频率或次数或它们的任何组合。可设想，可以使用除上述示例标准之外的其他标准来使控制电路206确定可能是时候调整PVAB期并开始从运动信号中确定振幅数据了。In various examples, the control circuit 206 can be configured to determine at block 601 that it is time to adjust the PVAB period based on one or more requirements, which can be met individually or in combination and can include any of the examples described above. The control circuit 206 can determine that it is time to begin the process of determining amplitude data from the motion signal based on the time of day, the planned frequency of PVAB period adjustments, the ventricular rate, the rate or timing of atrial sensed event signals, the maximum number of adjustments to other atrial event sensing control parameters reached, the frequency or number of asynchronous ventricular pacing pulses, or any combination thereof. It is contemplated that other criteria other than the example criteria described above can be used to cause the control circuit 206 to determine that it may be time to adjust the PVAB period and begin determining amplitude data from the motion signal.
当在框601处确定是时候调整PVAB期时，控制电路206可以响应于标识的心室事件(例如，由脉冲发生器202递送的心室起搏脉冲或由感测电路204从心脏电信号中感测的心室事件信号)而在框602处将PVAB期设置为当前活动设置。在框604处，控制电路206可以在PVAB期期间或者至少在PVAB期的振幅分析窗口期间启用对运动信号的感测和分析。如上所述，控制电路206可以在心房同步的心室起搏期间的PVAB期间禁用运动传感器212或至少禁用对运动信号的处理以节省电源214。控制电路206可以在逐拍的基础上启用从PVAB期(或节电时间段)到期开始直到下一个PVAB期开始的对运动信号的感测和分析，直到控制电路206在框601处确定是时候调整PVAB期。在框604处，响应于确定是时候调整PVAB期，控制电路206可在一个或多个心室周期中维持对运动传感器212的供电，以使得能够在框606处在PVAB期期间确定振幅数据。在一些示例中，控制电路206可以在PVAB消隐期的早期部分期间禁用运动传感器212，以在PVAB期的一部分期间仍能节省电力，并且在一个或多个心室周期的PVAB期的较晚部分期间出现的至少一个振幅分析窗口期间向运动传感器212供电。When it is determined at block 601 that it is time to adjust the PVAB period, the control circuit 206 may set the PVAB period to the current active setting at block 602 in response to an identified ventricular event (e.g., a ventricular pacing pulse delivered by the pulse generator 202 or a ventricular event signal sensed from the cardiac electrical signal by the sensing circuit 204). At block 604, the control circuit 206 may enable sensing and analysis of motion signals during the PVAB period or at least during an amplitude analysis window of the PVAB period. As described above, the control circuit 206 may disable the motion sensor 212 or at least disable processing of motion signals during the PVAB period during atrial synchronized ventricular pacing to save power 214. The control circuit 206 may enable sensing and analysis of motion signals from the expiration of the PVAB period (or power saving time period) until the start of the next PVAB period on a beat-by-beat basis until the control circuit 206 determines at block 601 that it is time to adjust the PVAB period. At block 604, in response to determining that it is time to adjust the PVAB period, control circuit 206 may maintain power to motion sensor 212 during one or more ventricular cycles to enable amplitude data to be determined during the PVAB period at block 606. In some examples, control circuit 206 may disable motion sensor 212 during an early portion of the PVAB blanking period to still conserve power during a portion of the PVAB period, and provide power to motion sensor 212 during at least one amplitude analysis window that occurs during a later portion of the PVAB period of the one or more ventricular cycles.
在框606处，控制电路206根据上文例如结合图7描述的任何示例在振幅分析窗口期间从运动信号中确定振幅数据。在框608处，控制电路206可例如基于上文结合框601整体描述的RRI来确定心率是否增加。无论是什么触发控制电路206来确定是时候调整PVAB期，例如，计划的时间或减少的和/或提前心房事件感测，控制电路206都可以例如通过确定中值RRI并基于与先前确定的中值RRI的比较来确定中值RRI是否代表心率增加来确定心率。以这种方式，控制电路206可以确定可能需要减少PVAB期。在一些情况下，是在框601处确定的心率变化触发控制电路206确定是时候调整PVAB期并开始流程图600的过程了。在这种情况下，控制电路206不必在框608处重新确定心室速率是增加还是减少，而是可以依赖于较早的确定。在其他示例中，控制电路206可在框608处确定心率是否已经越过速率阈值(例如，从较低心率到较高心率)。At block 606, the control circuit 206 determines amplitude data from the motion signal during the amplitude analysis window according to any of the examples described above, for example, in conjunction with FIG. 7. At block 608, the control circuit 206 may determine whether the heart rate has increased, for example, based on the RRI described above as a whole in conjunction with block 601. Regardless of what triggers the control circuit 206 to determine that it is time to adjust the PVAB period, for example, the planned time or reduced and/or early atrial event sensing, the control circuit 206 may determine the heart rate, for example, by determining the median RRI and determining whether the median RRI represents an increase in heart rate based on a comparison with a previously determined median RRI. In this way, the control circuit 206 can determine that the PVAB period may need to be reduced. In some cases, it is the change in heart rate determined at block 601 that triggers the control circuit 206 to determine that it is time to adjust the PVAB period and start the process of flowchart 600. In this case, the control circuit 206 does not have to re-determine whether the ventricular rate is increasing or decreasing at block 608, but can rely on an earlier determination. In other examples, control circuit 206 may determine at block 608 whether the heart rate has crossed a rate threshold (eg, from a lower heart rate to a higher heart rate).
除了在框608处确定心室速率是否增加之外或作为其替代，控制电路206还可在框608处确定是否偶尔感测到心房事件。控制电路206可确定心房事件的频率是否降低，例如与心室事件的比率低于1:1。在这种情况下，PVAB期可能过长并干扰心房事件感测，尤其是当在A3窗口的早期部分期间(例如，在A3窗口开始时间间期582期间(图7所示))仅感测到或主要感测到减少数量的感测的心房事件时。在其他情况下，如果在A3窗口期间在常规感测心房事件一段时间之后出现心房事件的间歇感测(例如，与心室事件的比率小于1:1)并且与心室事件的比率为1:1，则可能需要缩短PVAB期。在框608处，控制电路206可以使用上述用于确定在A3窗口期间的频率降低和/或早期心房事件信号感测的任何示例方法。在一些情况下，对在A3窗口期间心房事件感测的频率降低和/或早期心房事件感测的确定被控制电路206在框601处确定为是对开始确定用于调整PVAB期的振幅数据的过程的触发。在这种情况下，控制电路206不一定需要在框608处重新确定心房事件感测的频率和/或定时，并且可以依赖于在框601处作出的先前确定。In addition to or as an alternative to determining whether the ventricular rate is increasing at box 608, the control circuit 206 may also determine at box 608 whether atrial events are occasionally sensed. The control circuit 206 may determine whether the frequency of atrial events is reduced, such as a ratio of less than 1:1 to ventricular events. In this case, the PVAB period may be too long and interfere with atrial event sensing, especially when only or primarily a reduced number of sensed atrial events are sensed during the early portion of the A3 window (e.g., during the A3 window start time interval 582 (shown in FIG. 7)). In other cases, if intermittent sensing of atrial events (e.g., a ratio of less than 1:1 to ventricular events) occurs during the A3 window after a period of conventionally sensed atrial events and the ratio to ventricular events is 1:1, the PVAB period may need to be shortened. At box 608, the control circuit 206 may use any of the example methods described above for determining a reduced frequency and/or early atrial event signal sensing during the A3 window. In some cases, a determination of a decrease in the frequency of atrial event sensing and/or early atrial event sensing during the A3 window is determined by the control circuit 206 at block 601 as a trigger to begin the process of determining amplitude data for adjusting the PVAB period. In this case, the control circuit 206 does not necessarily need to redetermine the frequency and/or timing of atrial event sensing at block 608, and can rely on the previous determination made at block 601.
当控制电路206确定心率增加和/或心房事件感测的频率降低时(框608的“是”分支)，控制电路206可以确定可能需要缩短PVAB期来恢复或维持可靠的心房事件感测。在框612处缩短PVAB期之前，控制电路206分析在框606处确定的振幅数据。例如，控制电路206可以验证运动信号的振幅小于在PVAB结束时间间期(例如，图7所示的时间间期580)期间的振幅阈值。上文结合图6和图7描述的用于确定是否满足用于缩短PVAB期的PVAB调整标准的任何技术可以在框610处用于确定可以在框612处缩短PVAB期。When the control circuit 206 determines that the heart rate has increased and/or the frequency of atrial event sensing has decreased (the "yes" branch of box 608), the control circuit 206 may determine that the PVAB period may need to be shortened to restore or maintain reliable atrial event sensing. Before shortening the PVAB period at box 612, the control circuit 206 analyzes the amplitude data determined at box 606. For example, the control circuit 206 may verify that the amplitude of the motion signal is less than an amplitude threshold during the PVAB end time interval (e.g., time interval 580 shown in Figure 7). Any of the techniques described above in conjunction with Figures 6 and 7 for determining whether the PVAB adjustment criteria for shortening the PVAB period are met can be used at box 610 to determine that the PVAB period can be shortened at box 612.
在各种示例中个，当振幅数据满足在框610处应用的用于启用缩短PVAB期的标准时，控制电路206可将PVAB期调整预定的减量间期或百分比、调整为预定的缩短的PVAB期、一定百分比的当前PVAB期或基于当前心室周期间期进行调整。例如，当心室速率增加到阈值速率以上，并且运动信号振幅小于PVAB结束时间间期580(图7)期间的振幅阈值时，控制电路206可以将PVAB期减少到预定的缩短的PVAB期，例如减少到500ms。可以根据上文给出的示例中的任何示例来减少PVAB期。应当理解，最小PVAB期限值可以由控制电路206例如基于心室速率来设置，或者作为固定的最小值存储在存储器210中。当PVAB期处于最小PVAB期限值时，控制电路206不再进一步减小PVAB期。在框612处调整PVAB期之后，控制电路206返回到框601等待，直到下一次确定是时候调整PVAB期为止。In various examples, when the amplitude data meets the criteria for enabling shortening the PVAB period applied at box 610, the control circuit 206 may adjust the PVAB period by a predetermined decrement interval or percentage, to a predetermined shortened PVAB period, a percentage of the current PVAB period, or based on the current ventricular cycle period. For example, when the ventricular rate increases above a threshold rate and the motion signal amplitude is less than the amplitude threshold during the PVAB end time interval 580 (Figure 7), the control circuit 206 may reduce the PVAB period to a predetermined shortened PVAB period, for example, to 500ms. The PVAB period may be reduced according to any of the examples given above. It should be understood that the minimum PVAB period value may be set by the control circuit 206, for example, based on the ventricular rate, or stored in the memory 210 as a fixed minimum value. When the PVAB period is at the minimum PVAB period value, the control circuit 206 does not further reduce the PVAB period. After adjusting the PVAB period at box 612, the control circuit 206 returns to box 601 to wait until the next time it is determined that it is time to adjust the PVAB period.
如果运动信号的振幅不满足在框610处应用的标准，例如，如果运动信号振幅等于或大于在PVAB结束时间间期期间的阈值振幅，则控制电路206可以确定PVAB期不应缩短。控制电路206可以在框616处将PVAB期保持在当前设置下不变，并且拒绝对PVAB期作出调整。然后，控制电路206可返回到框601以等待下一次确定是时候调整PVAB期。If the amplitude of the motion signal does not meet the criteria applied at block 610, for example, if the motion signal amplitude is equal to or greater than the threshold amplitude during the PVAB end time interval, the control circuit 206 may determine that the PVAB period should not be shortened. The control circuit 206 may maintain the PVAB period unchanged at the current setting at block 616 and refuse to make an adjustment to the PVAB period. The control circuit 206 may then return to block 601 to wait for the next time it is determined that it is time to adjust the PVAB period.
返回到框608，当心室速率减少或相对不变(“否”分支)和/或发生常规心房事件信号感测(例如，与心室事件1:1)时，尤其是当常规心房事件信号感测仅发生在或大部分发生在非常早的时候，例如在A3窗口开始时间间期582(如图7所示)中时，PVAB期的增加可能适于降低过度感测A2事件的可能性。控制电路206可以前进到框614，以在框628处增加PVAB期之前确定振幅数据是否满足用于增加PVAB期的标准。Returning to block 608, when the ventricular rate is decreasing or relatively unchanged ("No" branch) and/or conventional atrial event signal sensing occurs (e.g., 1:1 with ventricular events), especially when conventional atrial event signal sensing occurs only or mostly very early, such as in the A3 window start time interval 582 (as shown in FIG. 7), an increase in the PVAB period may be appropriate to reduce the likelihood of oversensing A2 events. The control circuit 206 may proceed to block 614 to determine whether the amplitude data meets the criteria for increasing the PVAB period before increasing the PVAB period at block 628.
在框614处，控制电路206可将振幅数据与用于证明PVAB期增加的标准进行比较。例如，控制电路206可以确定运动信号振幅是否大于在PVAB结束时间间期580(图7所示)期间的阈值。当运动信号振幅大于接近PVAB期结束时的振幅阈值时，可以保证增加PVAB期以降低A2事件信号延长到A3窗口中并导致心房事件信号的错误感测的可能性。响应于确定运动信号振幅大于在PVAB结束时间间期580期间的振幅阈值，控制电路206可在框628处增加PVAB期。At block 614, the control circuit 206 may compare the amplitude data to a criterion for justifying an increase in the PVAB period. For example, the control circuit 206 may determine whether the motion signal amplitude is greater than a threshold value during the PVAB end time interval 580 (shown in FIG. 7 ). When the motion signal amplitude is greater than the amplitude threshold value near the end of the PVAB period, an increase in the PVAB period may be warranted to reduce the likelihood that the A2 event signal extends into the A3 window and causes erroneous sensing of an atrial event signal. In response to determining that the motion signal amplitude is greater than the amplitude threshold value during the PVAB end time interval 580, the control circuit 206 may increase the PVAB period at block 628.
在其他示例中，当心室速率减少时，控制电路206可在不分析所确定的振幅数据的情况下直接前进至框628以增加PVAB期。PVAB期可以在框628处增加预定增量、基于当前中值RRI增加一定百分比的当前PVAB期或增加至预定的延长PVAB期，例如增加至550ms。如果PVAB期已经处于最大限值，则控制电路206可能不会将PVAB期增加到长于最大限值。最大限值可存储在存储器210中或由控制电路206基于心室速率来确定。In other examples, when the ventricular rate decreases, the control circuit 206 may proceed directly to box 628 to increase the PVAB period without analyzing the determined amplitude data. The PVAB period may be increased at box 628 by a predetermined increment, by a percentage of the current PVAB period based on the current median RRI, or to a predetermined extended PVAB period, such as 550 ms. If the PVAB period is already at a maximum limit, the control circuit 206 may not increase the PVAB period to be longer than the maximum limit. The maximum limit may be stored in the memory 210 or determined by the control circuit 206 based on the ventricular rate.
当运动信号在PVAB结束时间间期期间(或在如图7所示的振幅分析窗口期间)的振幅小于振幅阈值(框614的“否”分支)，则控制电路206可在框616处维持当前PVAB期而不作出调整。在将PVAB期保持在当前设置(框616)或增加PVAB期(框628)之后，控制电路206可以返回到框601以等待下一次确定是时候调整PVAB期。When the amplitude of the motion signal during the PVAB end time interval (or during the amplitude analysis window as shown in FIG. 7 ) is less than the amplitude threshold (the “No” branch of block 614), the control circuit 206 may maintain the current PVAB period without making an adjustment at block 616. After maintaining the PVAB period at the current setting (block 616) or increasing the PVAB period (block 628), the control circuit 206 may return to block 601 to wait for the next determination that it is time to adjust the PVAB period.
图9是根据另一示例的用于调整PVAB期的方法的流程图700。在框701处，控制电路206确定中值RRI。如上所述，在每X个RRI之后，控制电路206可以确定X个RRI的中值，作为示例，X可以是4、8、16或32，但不限于此。X RRI可包括起搏和/或感测到的心室事件。应当认识到，可以使用其他方法来确定代表性RRI或相关联的心室速率(或心率)。其他方法可以包括：确定预定数量的RRI的运行平均值、均值、修整后的中值、最小值、最大值或其他度量。其他方法可以包括：确定在预定时间间期(例如，30秒、1分钟、2分钟、5分钟或其他时间间期)内发生的所有RRI的运行平均值、均值、修整后的中值、最小值、最大值或其他度量，这可以导致可变数量的RRI。FIG9 is a flowchart 700 of a method for adjusting the PVAB period according to another example. At box 701, the control circuit 206 determines the median RRI. As described above, after every X RRIs, the control circuit 206 can determine the median of the X RRIs, where X can be 4, 8, 16, or 32, as examples, but not limited to this. The X RRIs may include paced and/or sensed ventricular events. It should be appreciated that other methods can be used to determine a representative RRI or an associated ventricular rate (or heart rate). Other methods may include determining a running average, mean, trimmed median, minimum, maximum, or other metric of a predetermined number of RRIs. Other methods may include determining a running average, mean, trimmed median, minimum, maximum, or other metric of all RRIs occurring within a predetermined time interval (e.g., 30 seconds, 1 minute, 2 minutes, 5 minutes, or other time intervals), which can result in a variable number of RRIs.
在框702处，控制电路206基于中值(或其他代表性)RRI确定是否检测到心室速率变化。在一些示例中，控制电路206可在框702处将中值RRI与速率间期阈值进行比较。如果中值RRI越过了速率间期阈值，则在框702处，检测到心室速率变化。例如，如果当前中值RRI大于速率间期阈值并且先前中值RRI小于或等于速率间期阈值，或者反之亦然，则控制电路206可以在框702处检测心室速率变化。在说明性示例中，控制电路206确定对应于当前中值RRI的心室速率是否已经从先前确定的心室速率增加到大于诸如100bpm的阈值率的速率或者已经减少到小于或等于100bpm的阈值速率。如果在框702处未检测到心室速率变化，则控制电路206返回到框701。当未检测到心室速率变化时，控制电路206可将PVAB期保持在当前设置下而无需任何调整。应认识到，在一些示例中，基于确定感测到的心房事件的速率，例如通过确定连续感测到的心房事件信号之间的时间间期，可在框702处检测到心率变化。At box 702, the control circuit 206 determines whether a ventricular rate change is detected based on the median (or other representative) RRI. In some examples, the control circuit 206 may compare the median RRI with the rate interval threshold at box 702. If the median RRI crosses the rate interval threshold, then at box 702, a ventricular rate change is detected. For example, if the current median RRI is greater than the rate interval threshold and the previous median RRI is less than or equal to the rate interval threshold, or vice versa, the control circuit 206 may detect a ventricular rate change at box 702. In an illustrative example, the control circuit 206 determines whether the ventricular rate corresponding to the current median RRI has increased from a previously determined ventricular rate to a rate greater than a threshold rate such as 100 bpm or has decreased to a threshold rate less than or equal to 100 bpm. If a ventricular rate change is not detected at box 702, the control circuit 206 returns to box 701. When no ventricular rate change is detected, the control circuit 206 may keep the PVAB period at the current setting without any adjustment. It should be appreciated that in some examples, heart rate changes may be detected at block 702 based on determining a rate of sensed atrial events, such as by determining a time interval between consecutive sensed atrial event signals.
当控制电路206在框702处检测到心率变化时，控制电路206可以如上所述在框704处在PVAB期期间启用运动信号感测和分析。应当理解的是，虽然在PVAB期间启用对运动信号的感测和分析，但是心房事件信号的感测仍然被禁用，或者在消隐期期间感测到的任何心房事件信号都被控制电路206忽略，以便开始AV起搏间期。When the control circuit 206 detects a heart rate change at block 702, the control circuit 206 may enable motion signal sensing and analysis during the PVAB period at block 704 as described above. It should be understood that while the sensing and analysis of motion signals are enabled during the PVAB period, sensing of atrial event signals is still disabled, or any atrial event signals sensed during the blanking period are ignored by the control circuit 206 in order to start the AV pacing interval.
在框706处，控制电路206根据上述任何示例从在PVAB期的至少一部分期间接收的运动信号中确定振幅数据。在框708处，控制电路206确定当前心率是否大于速率阈值。如果在框702处检测到速率增加，则在框708处心率大于速率阈值。如果在框702处检测到速率减少，则在框708处心率小于或等于速率阈值。At block 706, the control circuit 206 determines amplitude data from the motion signal received during at least a portion of the PVAB period according to any of the examples described above. At block 708, the control circuit 206 determines whether the current heart rate is greater than a rate threshold. If a rate increase is detected at block 702, then the heart rate is greater than the rate threshold at block 708. If a rate decrease is detected at block 702, then the heart rate is less than or equal to the rate threshold at block 708.
当心率(例如，心室速率)大于速率阈值时(框708的“是”分支)时，控制电路206可在框710处确定运动信号的振幅是否小于在PVAB结束时间间期期间的振幅阈值。在框710处，可以使用上文结合图6和图7描述的任何技术基于所确定的振幅数据来确定满足调整标准，以允许在框712处缩短PVAB期的持续时间。When the heart rate (e.g., ventricular rate) is greater than the rate threshold ("yes" branch of block 708), the control circuit 206 may determine whether the amplitude of the motion signal is less than the amplitude threshold during the PVAB end time interval at block 710. At block 710, any of the techniques described above in conjunction with FIGS. 6 and 7 may be used to determine based on the determined amplitude data that an adjustment criterion is met to allow the duration of the PVAB period to be shortened at block 712.
当运动信号的振幅小于PVAB结束时间间期(例如，图7所示的时间间期580)期间的振幅阈值时，控制电路206在框712处将PVAB期调整为短消隐期。每当控制电路206确定心室速率已经增加到大于速率阈值(例如，90bpm至120bpm的速率阈值)的速率，并且运动信号的振幅不大于在当前PVAB期的PVAB结束时间间期期间的振幅阈值时，控制电路206可在框712处将PVAB期调整到预定的短消隐期。作为示例，短消隐期可以是500ms至550ms。When the amplitude of the motion signal is less than the amplitude threshold during the PVAB end time interval (e.g., time interval 580 shown in FIG. 7 ), the control circuit 206 adjusts the PVAB period to a short blanking period at block 712. Whenever the control circuit 206 determines that the ventricular rate has increased to a rate greater than a rate threshold (e.g., a rate threshold of 90 bpm to 120 bpm), and the amplitude of the motion signal is not greater than the amplitude threshold during the PVAB end time interval of the current PVAB period, the control circuit 206 may adjust the PVAB period to a predetermined short blanking period at block 712. As an example, the short blanking period may be 500 ms to 550 ms.
当控制电路206确定运动信号的振幅大于或等于在PVAB结束时间间期期间的振幅阈值(框710的“否”分支)时，控制电路206响应于检测到的心室速率的增加而拒绝对PVAB期的调整。当运动信号振幅大于或等于在PVAB期期间的振幅阈值(其当前可被设置为长消隐期持续时间)时，控制电路206可响应于心率快于阈值速率，例如基于代表性RRI小于阈值间期而拒绝选择短消隐期持续时间。在框716处，可将PVAB期维持在当前的PVAB期，该当前的PVAB期可以是预定的长消隐期，只要心室速率小于或等于速率阈值(例如，当RRI大于或等于对应阈值间期时)和/或运动信号振幅在PVAB期期间很高，就可以设置该长消隐期。作为示例，长消隐期可以是550ms至600ms。控制电路206可响应于确定振幅大于或等于在一个或多个PVAB期(其可被设置为长消隐期持续时间)期间的阈值振幅(框710的“否”分支)并且心室速率比速率阈值快(框708的“是”分支)，例如基于心室事件间期小于阈值间期而在框716处选择长消隐期持续时间。When the control circuit 206 determines that the amplitude of the motion signal is greater than or equal to the amplitude threshold during the PVAB end time interval (the "No" branch of box 710), the control circuit 206 refuses to adjust the PVAB period in response to the detected increase in the ventricular rate. When the motion signal amplitude is greater than or equal to the amplitude threshold during the PVAB period (which can currently be set to a long blanking period duration), the control circuit 206 may refuse to select a short blanking period duration in response to a heart rate faster than a threshold rate, for example, based on a representative RRI being less than a threshold interval. At box 716, the PVAB period can be maintained at the current PVAB period, which can be a predetermined long blanking period, which can be set as long as the ventricular rate is less than or equal to the rate threshold (e.g., when the RRI is greater than or equal to the corresponding threshold interval) and/or the motion signal amplitude is high during the PVAB period. As an example, the long blanking period can be 550ms to 600ms. The control circuit 206 may select a long blanking period duration at box 716 in response to determining that the amplitude is greater than or equal to a threshold amplitude during one or more PVAB periods (which may be set as a long blanking period duration) (the "No" branch of box 710) and the ventricular rate is faster than a rate threshold (the "Yes" branch of box 708), for example, based on the ventricular event interval being less than the threshold interval.
返回到框708，当控制电路206确定心率(例如，心室速率)已经减少到小于或等于速率阈值的速率时(框708的“否”分支)时，控制电路206可在框714处将PVAB期从短消隐期增加到长消隐期。在所示的示例中，当检测到心室速率减少至小于或等于速率阈值时，控制电路206不一定对振幅数据进行分析。将PVAB期延长至预定的长消隐期预期将安全地维持可靠的心房事件感测，因为长消隐期可能涵盖A2事件，并且长消隐期被选择为在A3事件的预期时间之前到期。例如，只有当检测到心室速率增加到大于阈值速率时，控制电路206才可以对振幅数据进行分析，因为即使运动信号的振幅在长消隐期结束附近相对较高，响应于心室速率增加而将PVAB期从长消隐期缩短到短消隐期也可能导致对A2事件的过度感测。Returning to block 708, when the control circuit 206 determines that the heart rate (e.g., ventricular rate) has decreased to a rate less than or equal to the rate threshold (the "No" branch of block 708), the control circuit 206 may increase the PVAB period from the short blanking period to the long blanking period at block 714. In the example shown, the control circuit 206 does not necessarily analyze the amplitude data when a decrease in the ventricular rate to less than or equal to the rate threshold is detected. Extending the PVAB period to a predetermined long blanking period is expected to safely maintain reliable atrial event sensing because the long blanking period may cover A2 events and the long blanking period is selected to expire before the expected time of an A3 event. For example, the control circuit 206 may analyze the amplitude data only when an increase in the ventricular rate to greater than the threshold rate is detected because shortening the PVAB period from the long blanking period to the short blanking period in response to an increase in the ventricular rate may result in oversensing of A2 events even if the amplitude of the motion signal is relatively high near the end of the long blanking period.
结合图9将控制电路206描述为检测大于或小于用于在长消隐期与短消隐期之间切换PVAB期的单个速率阈值的心室速率。然而，当运动信号振幅大于在长消隐期的晚期部分期间的阈值时，拒绝调整到短消隐期。然而，应当理解，控制电路206可检测三个或更多个速率区之间(例如，小于或等于60bpm的低速率区、大于60bpm且小于或等于100bpm的中等速率区以及大于100bpm的高速率区)的心室速率变化。在这种情况下，控制电路206可以响应于检测到从一个区到另一个区的心率变化而在长消隐期(例如，600ms)、中等消隐期(例如，550ms)和短消隐期(例如，500ms)之间调整PVAB期。PVAB期(例如，短的或最小的PVAB期和长的或最大的PVAB期以及任何中间的PVAB期)可以由用户例如使用外部装置20来编程。另外或可选地，在一个PVAB期与另一个PVAB期之间切换的心率可由用户编程。In conjunction with FIG. 9 , the control circuit 206 is described as detecting a ventricular rate greater than or less than a single rate threshold for switching the PVAB period between a long blanking period and a short blanking period. However, when the motion signal amplitude is greater than the threshold during the late portion of the long blanking period, the adjustment to the short blanking period is rejected. However, it should be understood that the control circuit 206 can detect ventricular rate changes between three or more rate zones (e.g., a low rate zone less than or equal to 60 bpm, a medium rate zone greater than 60 bpm and less than or equal to 100 bpm, and a high rate zone greater than 100 bpm). In this case, the control circuit 206 can adjust the PVAB period between a long blanking period (e.g., 600 ms), a medium blanking period (e.g., 550 ms), and a short blanking period (e.g., 500 ms) in response to detecting a heart rate change from one zone to another. The PVAB period (e.g., a short or minimum PVAB period and a long or maximum PVAB period and any intermediate PVAB period) can be programmed by a user, for example, using an external device 20. Additionally or alternatively, the heart rate at which to switch between one PVAB period to another PVAB period may be programmable by the user.
当PVAB期从长消隐期缩短到中等或短消隐期时，控制电路206可以首先验证运动信号振幅小于在长消隐期的PVAB期结束时间期间的振幅阈值。如上所述，可以将PVAB期结束事件设置为PVAB期要减少的时间量。继续在低心室速率区期间应用的长600ms消隐期、在中等速率区期间应用的中等550ms消隐期以及在高速率区期间应用的短500ms消隐期的说明性示例，当心室速率已经从低速率区增加到中等速率区或者从中等速率区增加到高等速率区时，在框710处执行的运动信号振幅分析期间所使用的PVAB期结束时间可被设置为50ms加上可选的安全偏移量。当运动信号振幅小于在相应PVAB期结束时间期间的振幅阈值时，PVAB期可以安全地从长消隐期减少到中等消隐期或中等消隐期减少到短消隐期。当心室速率已经从低速率区增加到高速率区时，PVAB期结束时间可以被设置为100ms加上可选的安全偏移量，以在运动信号振幅小于相对较长的PVAB期结束时间期间的振幅阈值时，允许PVAB消隐期安全地从长消隐期减少到短消隐期。When the PVAB period is shortened from the long blanking period to the medium or short blanking period, the control circuit 206 can first verify that the motion signal amplitude is less than the amplitude threshold during the PVAB period end time of the long blanking period. As described above, the PVAB period end event can be set to the amount of time the PVAB period is to be reduced. Continuing with the illustrative example of a long 600ms blanking period applied during the low ventricular rate zone, a medium 550ms blanking period applied during the medium rate zone, and a short 500ms blanking period applied during the high rate zone, when the ventricular rate has increased from the low rate zone to the medium rate zone or from the medium rate zone to the high rate zone, the PVAB period end time used during the motion signal amplitude analysis performed at box 710 can be set to 50ms plus an optional safety offset. When the motion signal amplitude is less than the amplitude threshold during the corresponding PVAB period end time, the PVAB period can be safely reduced from the long blanking period to the medium blanking period or the medium blanking period to the short blanking period. When the ventricular rate has increased from the low rate zone to the high rate zone, the PVAB period end time can be set to 100 ms plus an optional safety offset to allow the PVAB blanking period to be safely reduced from the long blanking period to the short blanking period when the motion signal amplitude is less than the amplitude threshold during the relatively long PVAB period end time.
图10是根据另一示例的用于设置PVAB期的方法的流程图800。流程图800的过程可由控制电路206在各种操作或起搏模式期间执行。以这种方式，可将PVAB期的选定持续时间设置为当前相关值，以用于在当前操作模式期间和/或在后续操作模式期间(例如，在起搏模式切换之后)进行心房事件信号感测。例如，控制电路206可以被配置为在心房同步的心室起搏模式下操作，该模式可以表示为VDD起搏模式。另外，控制电路206可被配置为在一种或多种异步心室起搏模式下操作，该模式可包括双腔室或单腔室感测并可包括速率响应心室起搏模式。异步起搏模式的示例可以表示为VDI起搏模式、VVI起搏模式和VDIR起搏模式。另外，控制电路206可被配置为在无起搏感测模式下操作，该模式可包括单腔室或双腔室感测，可分别表示为OVO模式或ODO模式。应当理解，在包括双腔室感测的操作模式期间，心房事件感测可由心房事件检测器电路240(图3)使用从运动传感器212接收的运动信号来执行，而心室事件感测可以由感测电路204使用例如从电极162和164感测的心脏电信号来执行。FIG. 10 is a flowchart 800 of a method for setting a PVAB period according to another example. The process of flowchart 800 may be performed by the control circuit 206 during various operating or pacing modes. In this way, the selected duration of the PVAB period may be set to a current relevant value for atrial event signal sensing during the current operating mode and/or during a subsequent operating mode (e.g., after a pacing mode switch). For example, the control circuit 206 may be configured to operate in a ventricular pacing mode of atrial synchronization, which may be represented as a VDD pacing mode. In addition, the control circuit 206 may be configured to operate in one or more asynchronous ventricular pacing modes, which may include dual-chamber or single-chamber sensing and may include a rate-responsive ventricular pacing mode. Examples of asynchronous pacing modes may be represented as a VDI pacing mode, a VVI pacing mode, and a VDIR pacing mode. In addition, the control circuit 206 may be configured to operate in a non-pacing sensing mode, which may include single-chamber or dual-chamber sensing, which may be represented as an OVO mode or an ODO mode, respectively. It should be understood that during an operating mode including dual chamber sensing, atrial event sensing may be performed by atrial event detector circuit 240 ( FIG. 3 ) using motion signals received from motion sensor 212 , while ventricular event sensing may be performed by sensing circuit 204 using cardiac electrical signals sensed, for example, from electrodes 162 and 164 .
流程图800的过程可以在包括无起搏感测模式的任何起搏模式期间执行，以用于持续地选择和更新PVAB期。如下所述，可以基于最近确定的代表性RRI来选择PVAB期的持续时间。当起搏模式从任何其他起搏模式(例如，异步心室起搏模式、单腔室感测模式或可以包括上文列出的VDI、VVI、VVIR、OVO或ODO起搏模式中任何一种起搏模式的任何其他起搏模式)切换到心房同步的心室起搏模式(例如，VDD起搏模式)时，基于最近确定的RRI将PVAB期设置为当前相关的持续时间，从而在心房同步的心室起搏模式期间促进可靠的心房事件感测。此外，在任何异步心室起搏模式或包括双腔室感测的单感测模式(例如，VDI或ODO)期间，可基于最晚确定的RRI将PVAB期设置为当前相关的持续时间，以促进可靠的心房事件信号感测。心房事件信号感测可在异步心室起搏模式期间执行，以用于诊断功能或其他装置功能，诸如设置心房事件感测控制参数，例如，如上文并入的美国专利号10,449,366(Splett等人)、美国专利申请序列号17/159,596(Sheldon等人)和美国专利申请序列号17/159,635(Sheldon等人)中所述。The process of flowchart 800 can be performed during any pacing mode including a no-pacing sensing mode to continuously select and update the PVAB period. As described below, the duration of the PVAB period can be selected based on the most recently determined representative RRI. When the pacing mode is switched from any other pacing mode (e.g., an asynchronous ventricular pacing mode, a single chamber sensing mode, or any other pacing mode that may include any of the VDI, VVI, VVIR, OVO, or ODO pacing modes listed above) to an atrial-synchronized ventricular pacing mode (e.g., a VDD pacing mode), the PVAB period is set to the currently relevant duration based on the most recently determined RRI, thereby facilitating reliable atrial event sensing during the atrial-synchronized ventricular pacing mode. In addition, during any asynchronous ventricular pacing mode or a single sensing mode including dual-chamber sensing (e.g., VDI or ODO), the PVAB period can be set to the currently relevant duration based on the latest determined RRI to facilitate reliable atrial event signal sensing. Atrial event signal sensing may be performed during an asynchronous ventricular pacing mode for diagnostic functions or other device functions, such as setting atrial event sensing control parameters, for example, as described in the above-incorporated U.S. Patent No. 10,449,366 (Splett et al.), U.S. patent application serial number 17/159,596 (Sheldon et al.), and U.S. patent application serial number 17/159,635 (Sheldon et al.).
在框802处，控制电路206标识N个心室事件，例如，在一些示例中1个至12个心室事件或6个至8个心室事件。如上所述，心室事件可由控制电路206例如响应于从感测电路204接收到的心室感测事件信号或由脉冲发生器202递送的心室起搏脉冲而标识为感测事件。在框804处，控制电路206可从N个心室事件中确定代表性RRI，例如，如图10所示的中值RRI。在说明性示例中，控制电路206可在存储器210中缓存最近的8个RRI。在框804处，控制电路206可将8个缓存间期中的第4最短间期标识为“中值”RRI。在其他示例中，在框804处确定的代表性RRI可以是平均值、最小、最大、第n长(或短)或修整后的均值或中值RRI。At box 802, the control circuit 206 identifies N ventricular events, for example, 1 to 12 ventricular events or 6 to 8 ventricular events in some examples. As described above, the ventricular events may be identified as sensed events by the control circuit 206, for example, in response to a ventricular sensed event signal received from the sensing circuit 204 or a ventricular pacing pulse delivered by the pulse generator 202. At box 804, the control circuit 206 may determine a representative RRI from the N ventricular events, for example, a median RRI as shown in FIG. 10. In an illustrative example, the control circuit 206 may cache the most recent 8 RRIs in the memory 210. At box 804, the control circuit 206 may identify the 4th shortest interval of the 8 cached intervals as a "median" RRI. In other examples, the representative RRI determined at box 804 may be an average, minimum, maximum, nth longest (or short), or trimmed mean or median RRI.
在框806处，控制电路206可以将代表性RRI与阈值间期进行比较。阈值间期可以是存储在存储器210中的预定值或可编程值，并且可以在例如800ms与500ms之间，并且可以在750ms与600ms之间。阈值间期可以对应于例如75bpm到120bpm或约80bpm到110bpm的心室速率。作为示例，阈值间期的默认值可以是665ms，这对应于约90bpm的心室速率。At box 806, the control circuit 206 can compare the representative RRI to a threshold interval. The threshold interval can be a predetermined value or a programmable value stored in the memory 210, and can be, for example, between 800ms and 500ms, and can be between 750ms and 600ms. The threshold interval can correspond to a ventricular rate of, for example, 75bpm to 120bpm or about 80bpm to 110bpm. As an example, a default value for the threshold interval can be 665ms, which corresponds to a ventricular rate of about 90bpm.
当RRI小于阈值间期时，在框808处，控制电路206可将PVAB期设置为最小PVAB期。作为示例，最小PVAB期可以是400ms到650ms的持续时间，并且在一些示例中可在425ms与575ms之间编程，默认值为500ms。在其他示例中，最小PVAB期可由控制电路206基于根据以上给出的任何示例确定的运动信号振幅数据来建立。控制电路206可确定运动信号在一个或多个PVAB期期间的振幅，在一些情况下，该一个或多个PVAB期可被设置为最大PVAB期。控制电路206可基于运动信号的所确定的振幅来设置PVAB期的最小持续时间。When the RRI is less than the threshold interval, at box 808, the control circuit 206 may set the PVAB period to a minimum PVAB period. As an example, the minimum PVAB period may be a duration of 400ms to 650ms, and in some examples may be programmable between 425ms and 575ms, with a default value of 500ms. In other examples, the minimum PVAB period may be established by the control circuit 206 based on the motion signal amplitude data determined according to any of the examples given above. The control circuit 206 may determine the amplitude of the motion signal during one or more PVAB periods, and in some cases, the one or more PVAB periods may be set to a maximum PVAB period. The control circuit 206 may set the minimum duration of the PVAB period based on the determined amplitude of the motion signal.
例如，如果运动信号峰值振幅小于在最大PVAB期期间的阈值振幅，则最小PVAB期可被设置为可用的最短PVAB期或默认PVAB期。然而，在一些示例中，如果运动信号峰值振幅大于阈值振幅，则可以基于振幅定时数据将最小PVAB期设置成相对较长。例如，控制电路206可以确定运动信号在一个或多个PVAB期期间的最大峰值振幅或最晚阈值跨越的时间，该一个或多个PVAB期当前可被设置为最大PVAB期。控制电路206可基于最大峰值振幅或最晚阈值跨越的所确定时间来设置最小PVAB期。在一个示例中，最小PVAB期被设置为比最大峰值振幅或最晚阈值跨越的时间更长的至少一个安全间期或偏移量。For example, if the motion signal peak amplitude is less than the threshold amplitude during the maximum PVAB period, the minimum PVAB period may be set to the shortest available PVAB period or the default PVAB period. However, in some examples, if the motion signal peak amplitude is greater than the threshold amplitude, the minimum PVAB period may be set to be relatively long based on the amplitude timing data. For example, the control circuit 206 may determine the maximum peak amplitude or the time of the latest threshold crossing of the motion signal during one or more PVAB periods, and the one or more PVAB periods may currently be set to the maximum PVAB period. The control circuit 206 may set the minimum PVAB period based on the determined time of the maximum peak amplitude or the latest threshold crossing. In one example, the minimum PVAB period is set to at least one safety interval or offset that is longer than the maximum peak amplitude or the latest threshold crossing time.
虽然未在图10中明确示出，但是如上文结合图9所述，在一些示例中，在响应于代表性RRI小于阈值间期而在框808处选择最小PVAB期之前，控制电路206可启用在一个或多个PVAB期期间对运动信号的感测以检查运动信号的振幅。当运动信号的振幅大于阈值振幅时，例如，在如结合图7所述的PVAB期结束时间期间，控制电路206可响应于代表性RRI小于阈值间期而拒绝选择最小PVAB期。当RRI小于阈值间期时，控制电路206可响应于确定运动信号振幅大于或等于在一个或多个PVAB期期间的阈值振幅而选择最大PVAB期(框810)。Although not explicitly shown in FIG. 10 , as described above in conjunction with FIG. 9 , in some examples, before selecting the minimum PVAB period at block 808 in response to the representative RRI being less than the threshold interval, the control circuit 206 may enable sensing of the motion signal during one or more PVAB periods to check the amplitude of the motion signal. When the amplitude of the motion signal is greater than the threshold amplitude, for example, during the PVAB period end time as described in conjunction with FIG. 7 , the control circuit 206 may refuse to select the minimum PVAB period in response to the representative RRI being less than the threshold interval. When the RRI is less than the threshold interval, the control circuit 206 may select the maximum PVAB period in response to determining that the motion signal amplitude is greater than or equal to the threshold amplitude during one or more PVAB periods (block 810).
当代表性RRI大于或等于阈值间期时(框806的“否”分支)，在框810处，控制电路206可将PVAB期设置为最大PVAB期。作为示例，最大PVAB期可以是450ms至800ms的持续时间，并且可以在450ms至600ms之间进行编程，其中550ms作为默认最大PVAB期或比最小PVAB期更长的其他预定持续时间。基于个体患者的心率和收缩期间期特征以及在如上文给出的任何示例中描述的PVAB期间确定的运动信号的振幅，可选择阈值间期以及最小和最大PVAB期。在该示例中，当代表性RRI等于阈值间期时，控制电路206可选择最大PVAB期。应当理解，在其他示例中，当代表性RRI等于阈值间期时，控制电路206可以被配置为选择最小PVAB期。When the representative RRI is greater than or equal to the threshold interval (the "No" branch of box 806), at box 810, the control circuit 206 may set the PVAB period to the maximum PVAB period. As an example, the maximum PVAB period may be a duration of 450ms to 800ms and may be programmed between 450ms and 600ms, with 550ms as the default maximum PVAB period or other predetermined duration longer than the minimum PVAB period. The threshold interval and the minimum and maximum PVAB periods may be selected based on the heart rate and systolic period characteristics of the individual patient and the amplitude of the motion signal determined during the PVAB period as described in any of the examples given above. In this example, when the representative RRI is equal to the threshold interval, the control circuit 206 may select the maximum PVAB period. It should be understood that in other examples, when the representative RRI is equal to the threshold interval, the control circuit 206 may be configured to select the minimum PVAB period.
在将PVAB期设置为最小值或最大值后，控制电路206可返回至框802以标识接下来的N个心室事件。可以响应于接下来的N个心室事件中的每个心室事件来开始在框808处设置为最小值或在框810处设置为最大值的PVAB期。PVAB期的当前设置可对接下来的N个心室事件保持有效，直到确定下一个代表性RRI。如果PVAB期当前被设置为最小值，并且下一个代表性RRI仍然小于阈值间期(框806)，则PVAB期仍可设置为框808处的最小PVAB期并且在接下来的N个心室事件中的每个心室事件之后应用。如果PVAB期当前被设置为最大值，并且下一个代表性RRI仍然大于或等于阈值间期(框806)，则PVAB期仍可设置为框808处的最大PVAB期并且在接下来的N个心室事件中的每个心室事件之后应用。应当理解，在一些示例中，根据阈值间期的值，框806处的标准可以小于或等于间期阈值。当代表性RRI从小于阈值间期变为大于(或等于)阈值间期时，或者反之亦然，控制电路206将PVAB期从最小PVAB期变为最大PVAB期，或者反之亦然。After setting the PVAB period to a minimum or maximum value, the control circuit 206 may return to box 802 to identify the next N ventricular events. The PVAB period set to a minimum value at box 808 or to a maximum value at box 810 may be started in response to each of the next N ventricular events. The current setting of the PVAB period may remain valid for the next N ventricular events until the next representative RRI is determined. If the PVAB period is currently set to a minimum value and the next representative RRI is still less than the threshold interval (box 806), the PVAB period may still be set to the minimum PVAB period at box 808 and applied after each of the next N ventricular events. If the PVAB period is currently set to a maximum value and the next representative RRI is still greater than or equal to the threshold interval (box 806), the PVAB period may still be set to the maximum PVAB period at box 808 and applied after each of the next N ventricular events. It should be understood that in some examples, depending on the value of the threshold interval, the criterion at box 806 may be less than or equal to the interval threshold. When the representative RRI changes from less than the threshold interval to greater than (or equal to) the threshold interval, or vice versa, the control circuit 206 changes the PVAB period from the minimum PVAB period to the maximum PVAB period, or vice versa.
图11是心室事件和根据图10的示例技术调整的对应PVAB期的一个示例的时序图900。心室事件901在图11中示出为心室起搏脉冲(VP)，这些VP在心房同步心室起搏模式期间在AV起搏间期(图11中未示出)与感测到的心房事件信号(AS)同步。然而，应当理解，在其他情况下，心室事件901可以包括所有或任何数量的感测到的心室事件，例如由感测电路204感测到的R波。此外，根据有效的起搏模式，控制电路206可以感测或不感测心房事件，并且如果感测到心房事件，则心室事件901可以是或不是与感测到的心房事件同步的心室起搏脉冲。FIG11 is a timing diagram 900 of an example of ventricular events and corresponding PVAB periods adjusted according to the example technique of FIG10. Ventricular events 901 are shown in FIG11 as ventricular pacing pulses (VP) that are synchronized with sensed atrial event signals (AS) during an AV pacing interval (not shown in FIG11) during an atrial synchronized ventricular pacing mode. However, it should be understood that in other cases, ventricular events 901 may include all or any number of sensed ventricular events, such as R waves sensed by sensing circuit 204. In addition, depending on the effective pacing mode, control circuit 206 may or may not sense atrial events, and if an atrial event is sensed, ventricular event 901 may or may not be a ventricular pacing pulse synchronized with the sensed atrial event.
在N(例如，8)个RRI的第一组902中的心室事件901中的每个心室事件之后的PVAB期908被设置为最大PVAB期持续时间。控制电路206可在对应的最大节电时间段910期间禁用心房事件感测，该最大节电时间段可被设置为比最大PVAB期908提前固定时间间期(例如，在示例中提前20ms至100ms或提前85ms)结束。在节电时间段910期间，可例如通过禁用或断电包括在运动传感器212中的多轴加速度计的至少一个轴来禁用心房事件信号感测。The PVAB period 908 after each ventricular event in the ventricular events 901 in the first group 902 of N (e.g., 8) RRIs is set to the maximum PVAB period duration. The control circuit 206 may disable atrial event sensing during a corresponding maximum power saving period 910, which may be set to end a fixed time interval earlier than the maximum PVAB period 908 (e.g., 20 ms to 100 ms earlier or 85 ms earlier in the example). During the power saving period 910, atrial event signal sensing may be disabled, for example, by disabling or powering off at least one axis of a multi-axis accelerometer included in the motion sensor 212.
如上文结合图3所述，心房事件检测器电路240可从包括在运动传感器212中的三轴加速度计接收一个、两个或所有三个轴信号。被选择用于产生运动信号的轴信号可以由控制电路206选择或由用户编程，从该运动信号中感测心房事件信号。美国公开号2020/0179708(Splett等人)中总体描述了用于选择用于感测心房事件信号的轴信号的示例技术。当接收两个或更多个轴信号时，轴信号可以以另一种方式相加或组合以用于产生运动信号，从该运动信号中感测心房事件信号。As described above in conjunction with FIG. 3 , atrial event detector circuit 240 may receive one, two, or all three axis signals from a three-axis accelerometer included in motion sensor 212. The axis signal selected for generating a motion signal may be selected by control circuit 206 or programmed by a user, from which an atrial event signal is sensed. Example techniques for selecting an axis signal for sensing an atrial event signal are generally described in U.S. Publication No. 2020/0179708 (Splett et al.). When two or more axis signals are received, the axis signals may be added or combined in another manner to generate a motion signal from which an atrial event signal is sensed.
用于感测心房事件信号的至少一个轴信号可由控制电路206在最大节电时间段910内断电，以在最大PVAB期908期间节省电源214。断电的至少一个轴信号可以在最大PVAB期908到期之前再次通电。以这种方式，用于心房事件信号感测的运动信号(其可包括一个或多个加速度计轴信号的组合)可在最大PVAB期908到期时或恰好在此之前传递给控制电路206。参考图10，在框810处，除了设置最大PVAB期之外，控制电路206还可将节电时间段设置为最大时间段910，该最大时间段是比最大PVAB期908更短的预定时间间期。最大PVAB期908和最大节电时间段910可由控制电路206在第一组902N个RRI期间响应于每个心室事件901来开始。At least one axis signal for sensing an atrial event signal may be powered off by the control circuit 206 during the maximum power saving period 910 to save power 214 during the maximum PVAB period 908. The powered off at least one axis signal may be powered on again before the maximum PVAB period 908 expires. In this way, a motion signal for atrial event signal sensing (which may include a combination of one or more accelerometer axis signals) may be delivered to the control circuit 206 at or just before the maximum PVAB period 908 expires. Referring to FIG. 10 , at block 810, in addition to setting the maximum PVAB period, the control circuit 206 may also set the power saving period to a maximum period 910, which is a predetermined time interval shorter than the maximum PVAB period 908. The maximum PVAB period 908 and the maximum power saving period 910 may be started by the control circuit 206 in response to each ventricular event 901 during the first group 902N of RRIs.
控制电路206可标识N个连续心室事件(每个心室事件结束一个RRI)，以用于确定第一组902N个连续RRI。在所示的示例中，由控制电路206确定第一组902 8个连续RRI并将其缓存在存储器210中。在第一组902之后，确定第二组904 8个连续RRI并将其缓存在存储器210中。第二组904 8个连续RRI可覆写存储器缓冲器中的第一组902。虽然N个RRI的组902和904在图11中示出为连续的、非重叠的RRI组，但是在其他示例中，N个RRI的组可以是重叠的或连续的RRI组。在仍其他示例中，N个RRI的组可能不是连续的。例如，控制电路206可标识N个连续RRI，例如3个至12个连续RRI，以用于在每M个连续心室事件之后，例如在每8个至100个心室事件或大于N的任何选定数量M之后确定代表性RRI。为了说明，控制电路206可在每30个连续RRI或大于8的任何其他选定数量的RRI之后从最近的8个连续RRI中确定代表性RRI。以这种方式，PVAB期可基于N个最近的RRI来更新，但可以比N个RRI更新得更少，例如每M个RRI更新一次，或者在预定时间间期之后更新，例如每30秒、每60秒、每2分钟或在任何其他选定的时间间期之后更新。The control circuit 206 may identify N consecutive ventricular events (each ventricular event ends an RRI) for determining a first group 902 of N consecutive RRIs. In the example shown, a first group 902 of 8 consecutive RRIs is determined by the control circuit 206 and cached in the memory 210. After the first group 902, a second group 904 of 8 consecutive RRIs is determined and cached in the memory 210. The second group 904 of 8 consecutive RRIs may overwrite the first group 902 in the memory buffer. Although the groups 902 and 904 of N RRIs are shown in FIG. 11 as consecutive, non-overlapping RRI groups, in other examples, the groups of N RRIs may be overlapping or consecutive RRI groups. In still other examples, the groups of N RRIs may not be consecutive. For example, the control circuit 206 may identify N consecutive RRIs, e.g., 3 to 12 consecutive RRIs, for determining a representative RRI after every M consecutive ventricular events, e.g., after every 8 to 100 ventricular events, or any selected number M greater than N. For illustration, the control circuit 206 may determine a representative RRI from the most recent 8 consecutive RRIs after every 30 consecutive RRIs, or any other selected number of RRIs greater than 8. In this way, the PVAB period may be updated based on the N most recent RRIs, but may be updated less frequently than the N RRIs, e.g., once every M RRIs, or after a predetermined time interval, e.g., every 30 seconds, every 60 seconds, every 2 minutes, or after any other selected time interval.
在第一组902N个RRI之后，控制电路206确定组902的代表性RRI。在所示的示例中，代表性RRI被确定为第四短的RRI 912。控制电路206将RRI 912与阈值间期进行比较，以选择响应于下一组心室事件(例如，在第二组904的8个RRI中的每个心室事件901之后)而应用于运动信号的PVAB期。在所示的示例中，控制电路206确定RRI 912小于阈值间期，例如小于665ms或任何其他选定的阈值。响应于代表性RRI 912小于阈值间期，控制电路206将PVAB期从最大PVAB期908调整到最小PVAB期918。在第二组904的RRI期间，控制电路206响应于每个心室事件901而开始最小PVAB期918。第一组902的RRI的最后一个心室事件930限定了第一组902中的最后一个RRI的结束以及第二组904的RRI中的第一RRI的开始。如此，响应于心室事件930设置的PVAB期可基于前一组902的第四短RRI 912小于阈值间期而设置为最小PVAB期918。After the first group 902N RRIs, the control circuit 206 determines a representative RRI for the group 902. In the example shown, the representative RRI is determined to be the fourth shortest RRI 912. The control circuit 206 compares the RRI 912 to the threshold interval to select a PVAB period to be applied to the motion signal in response to the next group of ventricular events (e.g., after each ventricular event 901 in the 8 RRIs of the second group 904). In the example shown, the control circuit 206 determines that the RRI 912 is less than the threshold interval, such as less than 665ms or any other selected threshold. In response to the representative RRI 912 being less than the threshold interval, the control circuit 206 adjusts the PVAB period from the maximum PVAB period 908 to the minimum PVAB period 918. During the second group 904 of RRIs, the control circuit 206 starts the minimum PVAB period 918 in response to each ventricular event 901. The last ventricular event 930 of the RRI of the first group 902 defines the end of the last RRI in the first group 902 and the beginning of the first RRI in the RRI of the second group 904. In this way, the PVAB period set in response to the ventricular event 930 can be set to the minimum PVAB period 918 based on the fourth short RRI 912 of the previous group 902 being less than the threshold interval.
当在图10的框808处将PVAB期设置为最小PVAB期时，控制电路206可以设置对应的最小节电时间段920。最小节电时间段920可被设置为比最小PVAB期918提前预定间期到期。运动传感器的至少一部分(例如，多轴加速度计的至少一个轴)可以在节电时间段期间被禁用或断电，以减少从电源214中的电流汲取。运动传感器212的至少一个轴可在最小节电时间段920期间被禁用，并在时间段920到期时被重新启用，使得运动传感器212在最小PVAB期918到期时产生用于感测心房事件信号的运动信号。应当理解，在节电时间段910和920(以及本文所述的其他节电时间段)期间，包括在运动传感器212中的多轴加速度计的一个或多个轴可以保持通电并被启用以产生加速度信号，该加速度信号可被控制电路206用于除感测心房事件信号之外的其他目的。When the PVAB period is set to the minimum PVAB period at block 808 of FIG. 10 , the control circuit 206 may set a corresponding minimum power saving period 920. The minimum power saving period 920 may be set to expire a predetermined interval earlier than the minimum PVAB period 918. At least a portion of the motion sensor (e.g., at least one axis of the multi-axis accelerometer) may be disabled or powered off during the power saving period to reduce current draw from the power supply 214. At least one axis of the motion sensor 212 may be disabled during the minimum power saving period 920 and re-enabled when the period 920 expires, so that the motion sensor 212 generates a motion signal for sensing an atrial event signal when the minimum PVAB period 918 expires. It should be understood that during the power saving periods 910 and 920 (as well as other power saving periods described herein), one or more axes of the multi-axis accelerometer included in the motion sensor 212 may remain powered on and enabled to generate acceleration signals, which may be used by the control circuit 206 for purposes other than sensing an atrial event signal.
例如，控制电路206可被配置为根据加速度信号来确定患者身体活动度量，该加速度信号可以来自包括在运动传感器212中的加速度计的单个轴。控制电路206可例如在VVIR或VDIR起搏模式期间使用患者身体活动度量来设置速率响应起搏速率。在这种情况下，用于确定患者身体活动的一个轴可以在节电时间段910和920期间保持通电，但是用于感测心房事件信号的一个或多个其他轴可以在节电时间段910和920期间断电。因此，当运动传感器在节电时间段期间被禁用时，应当理解，运动传感器的一部分(例如，多轴加速度计的至少一个轴)可以被断电和禁用，而另一部分(例如，多轴加速度计的不同的轴)可以在节电时间段910和920期间保持通电或启用，以向控制电路206提供运动信号，该运动信号可以不用于感测心房事件信号，但可以用于其他目的。For example, the control circuit 206 may be configured to determine a patient physical activity metric based on an acceleration signal, which may be from a single axis of an accelerometer included in the motion sensor 212. The control circuit 206 may use the patient physical activity metric to set a rate-responsive pacing rate, for example, during a VVIR or VDIR pacing mode. In this case, one axis used to determine the patient's physical activity may remain powered on during the power saving time periods 910 and 920, but one or more other axes used to sense atrial event signals may be powered off during the power saving time periods 910 and 920. Therefore, when the motion sensor is disabled during the power saving time period, it should be understood that a portion of the motion sensor (e.g., at least one axis of a multi-axis accelerometer) may be powered off and disabled, while another portion (e.g., a different axis of the multi-axis accelerometer) may remain powered on or enabled during the power saving time periods 910 and 920 to provide a motion signal to the control circuit 206, which may not be used to sense atrial event signals, but may be used for other purposes.
在一些情况下，用于确定患者身体活动的轴信号也可以单独使用或与一个或多个附加轴信号结合使用，以用于感测心房事件信号。在一些示例中，当一个(或多个)轴信号用于感测心房事件信号并且相同的一个(或多个)轴信号用于确定患者身体活动度量时，控制电路206可以使用于监测患者身体活动的加速度计轴在节电时间段910和920期间保持通电并且启用(或者有效地取消节电时间段910和920)。当两个或更多个轴信号的组合用于感测心房事件信号并且两个或更多个轴信号中的一个轴信号也用于确定患者身体活动度量时，用于心房事件信号感测而不用于监测患者身体活动的至少一个轴可以在节电时间段910和920期间断电。在其他情况下，当用于监测患者身体活动的加速度计轴不用于心房事件信号感测时，用于心房事件信号感测的所有轴信号可以在节电时间段910和920期间断电。例如，如果运动传感器212的加速度计包括轴1、轴2和轴3，并且轴1用于患者身体活动监测，而轴2和轴3用于感测心房事件信号，则轴2和3可以在节电时间段910和920期间被禁用。在另一说明性示例中，当轴1用于患者身体活动监测并且轴1和2组合用于心房事件信号感测时，轴2可以在节电时间段910和920期间断电。美国专利号11,207,526(Sheldon等人)中总体公开了可以结合本文公开的用于调整PVAB期的方法用于在PVAB期期间减少电源214的电流汲取的技术。In some cases, the axis signal used to determine the patient's physical activity may also be used alone or in combination with one or more additional axis signals for sensing atrial event signals. In some examples, when one (or more) axis signals are used to sense atrial event signals and the same one (or more) axis signals are used to determine a patient's physical activity metric, the control circuit 206 may cause the accelerometer axis used to monitor the patient's physical activity to remain powered on and enabled (or effectively cancel the power saving time period 910 and 920) during the power saving time period 910 and 920. When a combination of two or more axis signals is used to sense atrial event signals and one of the two or more axis signals is also used to determine a patient's physical activity metric, at least one axis used for atrial event signal sensing but not for monitoring the patient's physical activity may be powered off during the power saving time period 910 and 920. In other cases, when the accelerometer axis used to monitor the patient's physical activity is not used for atrial event signal sensing, all axis signals used for atrial event signal sensing may be powered off during the power saving time period 910 and 920. For example, if the accelerometer of the motion sensor 212 includes axis 1, axis 2, and axis 3, and axis 1 is used for patient physical activity monitoring, while axis 2 and axis 3 are used for sensing atrial event signals, then axes 2 and 3 may be disabled during power saving time periods 910 and 920. In another illustrative example, when axis 1 is used for patient physical activity monitoring and axes 1 and 2 are used in combination for atrial event signal sensing, axis 2 may be powered off during power saving time periods 910 and 920. U.S. Pat. No. 11,207,526 (Sheldon et al.) generally discloses techniques for reducing the current draw of the power supply 214 during the PVAB period that may be used in conjunction with the method for adjusting the PVAB period disclosed herein.
在图11的示例中，示出了最小节电时间段920和最大节电时间段910。在其他示例中，单个节电时间段可以比最小PVAB期918短的固定时间间期，在该单个节电时间段期间，在最小和最大PVAB期期间至少部分地禁用运动传感器以节省电源214。例如，当应用最大PVAB期908时，可不增加节电时间段920。11, a minimum power saving time period 920 and a maximum power saving time period 910 are shown. In other examples, a single power saving time period may be a fixed time period shorter than the minimum PVAB period 918, during which the motion sensor is at least partially disabled during the minimum and maximum PVAB periods to save power 214. For example, when the maximum PVAB period 908 is applied, the power saving time period 920 may not be increased.
在缓存第二组904的RRI之后，控制电路206将第二组904的代表性RRI确定为第四短RRI 922。控制电路206可以将代表性RRI 922与阈值间期进行比较，并且在该示例中，确定RRI 922大于阈值间期。响应于RRI 922大于阈值间期，控制电路206将PVAB期调整回最大PVAB期908，该最大PVAB期响应于第二组904的RRI的最后一个心室事件932而开始。另外，控制电路206可以设置最大节电时间段910。After buffering the RRI of the second group 904, the control circuit 206 determines the representative RRI of the second group 904 as the fourth short RRI 922. The control circuit 206 can compare the representative RRI 922 with the threshold interval, and in this example, determine that the RRI 922 is greater than the threshold interval. In response to the RRI 922 being greater than the threshold interval, the control circuit 206 adjusts the PVAB period back to the maximum PVAB period 908, which begins in response to the last ventricular event 932 of the RRI of the second group 904. In addition, the control circuit 206 can set a maximum power saving time period 910.
在图10和图11的示例中，单个阈值间期用于选择是将PVAB期设置为最大PVAB期还是最小PVAB期。在其他示例中，可以将多于一个阈值间期应用于代表性RRI。如上所述，RRI的多个范围(对应于多个心室速率)可以由两个或更多个阈值间期分开，以使得控制电路206能够在最小PVAB期、最大PVAB期和一个或多个中间PVAB期之间进行选择。In the examples of Figures 10 and 11, a single threshold interval is used to select whether to set the PVAB period to the maximum PVAB period or the minimum PVAB period. In other examples, more than one threshold interval may be applied to a representative RRI. As described above, multiple ranges of RRI (corresponding to multiple ventricular rates) may be separated by two or more threshold intervals to enable the control circuit 206 to select between the minimum PVAB period, the maximum PVAB period, and one or more intermediate PVAB periods.
在仍其他示例中，控制电路206可以使用多于一个阈值间期来控制最大PVAB期与最小PVAB期之间(或者更一般地，在相对较长的PVAB期与相对较短的PVAB期之间)的切换。例如，当中值RRI(或其他代表性RRI)长于第一阈值间期时，PVAB期可以增加到最大PVAB期。当中值RRI下降到小于第一阈值间期的第二阈值间期以下时，PVAB期可以减小到最小PVAB期。以这种方式，与用于使PVAB期减小的阈值间期相比，可以使用不同的阈值间期来使PVAB期增加。In still other examples, the control circuit 206 may use more than one threshold interval to control switching between a maximum PVAB period and a minimum PVAB period (or more generally, between a relatively long PVAB period and a relatively short PVAB period). For example, when the median RRI (or other representative RRI) is longer than a first threshold interval, the PVAB period may be increased to a maximum PVAB period. When the median RRI drops below a second threshold interval that is less than the first threshold interval, the PVAB period may be decreased to a minimum PVAB period. In this way, a different threshold interval may be used to increase the PVAB period than the threshold interval used to decrease the PVAB period.
例如，参考图10，控制电路206可以在框806处选择RRI阈值间期，例如通过从第一相对较长的阈值间期和第二相对较短的阈值间期中基于PVAB期的当前持续时间进行选择。当PVAB期处于最小持续时间时，可以选择相对较长的RRI阈值间期来确定何时将PVAB期增加到最大持续时间。当PVAB期当前被设置处于最大持续时间时，可以选择相对较短的RRI阈值间期来确定何时将PVAB期减小到最小持续时间。通过使用用于在两个不同的PVAB期持续时间之间切换的两个不同的阈值间期，可以采用滞后效应来降低在波动的心率期间(例如，当代表性RRI从大于单个阈值间期到小于单个阈值间期来回变化时)频繁调整PVAB期的可能性。For example, referring to FIG10, the control circuit 206 may select an RRI threshold interval at box 806, for example by selecting from a first relatively long threshold interval and a second relatively short threshold interval based on the current duration of the PVAB period. When the PVAB period is at a minimum duration, a relatively long RRI threshold interval may be selected to determine when to increase the PVAB period to a maximum duration. When the PVAB period is currently set to a maximum duration, a relatively short RRI threshold interval may be selected to determine when to reduce the PVAB period to a minimum duration. By using two different threshold intervals for switching between two different PVAB period durations, a hysteresis effect may be employed to reduce the likelihood of frequent adjustments to the PVAB period during fluctuating heart rates (e.g., when the representative RRI changes back and forth from greater than a single threshold interval to less than a single threshold interval).
在其他示例中，通过使用相对较高数量的RRI(例如，12个至30个RRI)来确定与阈值间期相比具有代表性的RRI，可以避免在最大PVAB期与最小PVAB期之间的频繁调整。在仍其他示例中，通过允许仅在预定数量的RRI(例如，20个至100个RRI)或任何其他选定数量的RRI(其可以是比用于确定中值或其他代表性RRI的RRI数量更多的RRI数量)之后进行调整，可以避免对PVAB期的频繁调整。在另一示例中，可以计划的预定时间间期(例如，不超过每30秒一次、每60秒一次或任何其他选定的时间间期)调整PVAB期。In other examples, frequent adjustments between the maximum PVAB period and the minimum PVAB period can be avoided by using a relatively high number of RRIs (e.g., 12 to 30 RRIs) to determine a representative RRI compared to a threshold interval. In still other examples, frequent adjustments to the PVAB period can be avoided by allowing adjustments only after a predetermined number of RRIs (e.g., 20 to 100 RRIs) or any other selected number of RRIs (which can be a greater number of RRIs than the number of RRIs used to determine a median or other representative RRI). In another example, the PVAB period can be adjusted at a scheduled predetermined time interval (e.g., no more than once every 30 seconds, once every 60 seconds, or any other selected time interval).
在图11的示例中，所有心室事件都显示为心室起搏脉冲。如本文先前所述，在心室起搏脉冲之后与在感测电路204感测到的心室事件之后，PVAB期(以及相关联的节电时间段)可以进行不同地设置。如此，可以基于从第一组RRI(大于或小于阈值间期)确定的代表性RRI选择起搏后最大PVAB期或起搏后最小PVAB期中的一者，并且可响应于在第一组RRI之后的第二组RRI期间发生的每个心室起搏脉冲而开始选定的起搏后PVAB期(最小值或最大值)。另外，可基于从第一组RRI确定的代表性RRI选择感测后最大PVAB期或感测后最小PVAB期中的一者，并且可响应于在第一组RRI之后的第二组RRI期间发生的由感测电路204感测到的每个心室事件而开始选定的感测后PVAB期(最大值或最小值)。In the example of FIG. 11 , all ventricular events are displayed as ventricular pacing pulses. As previously described herein, the PVAB period (and the associated power saving period) can be set differently after a ventricular pacing pulse and after a ventricular event sensed by the sensing circuit 204. In this way, one of the maximum PVAB period after pacing or the minimum PVAB period after pacing can be selected based on a representative RRI determined from a first set of RRIs (greater than or less than a threshold interval), and the selected post-pacing PVAB period (minimum or maximum) can be started in response to each ventricular pacing pulse occurring during a second set of RRIs following the first set of RRIs. In addition, one of the maximum PVAB period after sensing or the minimum PVAB period after sensing can be selected based on a representative RRI determined from the first set of RRIs, and the selected post-sensing PVAB period (maximum or minimum) can be started in response to each ventricular event sensed by the sensing circuit 204 occurring during a second set of RRIs following the first set of RRIs.
起搏后最大PVAB期和感测后最大PVAB期可以彼此不同。控制电路206可以基于代表性RRI大于或等于阈值间期来选择最大PVAB期，但是基于心室事件是起搏脉冲还是感测事件，响应于单独的心室事件而开始一个或另一个起搏后或感测后最大PVAB期。起搏后最小PVAB期和感测后最小PVAB期可以彼此不同。控制电路206可以基于代表性RRI小于阈值间期来选择最小PVAB期，但是基于心室事件是起搏脉冲还是感测事件，响应于给定的心室事件而开始一个或另一个起搏后或感测后最小PVAB期。The maximum PVAB period after pacing and the maximum PVAB period after sensing may be different from each other. The control circuit 206 may select the maximum PVAB period based on the representative RRI being greater than or equal to the threshold interval, but initiate one or another maximum PVAB period after pacing or after sensing in response to a separate ventricular event based on whether the ventricular event is a pacing pulse or a sensing event. The minimum PVAB period after pacing and the minimum PVAB period after sensing may be different from each other. The control circuit 206 may select the minimum PVAB period based on the representative RRI being less than the threshold interval, but initiate one or another minimum PVAB period after pacing or after sensing in response to a given ventricular event based on whether the ventricular event is a pacing pulse or a sensing event.
在一些示例中，最大PVAB期或最小PVAB期中的一者在感测后或起搏后可以是相同的。例如，可以设置不同于感测后最大PVAB期的起搏后最大PVAB期，但是起搏后最小PVAB期和感测后最小PVAB期可以相等。在另一示例中，可以设置不同于感测后最小PVAB期的起搏后最小PVAB期，但是起搏后最大PVAB期和感测后最大PVAB周期可以相等。In some examples, one of the maximum PVAB period or the minimum PVAB period may be the same after sensing or after pacing. For example, a maximum PVAB period after pacing different from the maximum PVAB period after sensing may be set, but the minimum PVAB period after pacing and the minimum PVAB period after sensing may be equal. In another example, a minimum PVAB period after pacing different from the minimum PVAB period after sensing may be set, but the maximum PVAB period after pacing and the maximum PVAB period after sensing may be equal.
图12是根据一个示例的用于调整PVAB期和控制心房同步的心室起搏的方法的流程图850。框802至810对应于图10所示并且上文所述的相同编号的框。在框808或810处选择最大或最小PVAB期后，控制电路206响应于下一个心室事件而开始选定PVAB期，并在框812处确定是否在PVAB期后从运动信号中感测到心房事件信号(A4事件)。如上所述，例如结合图5或图7，控制电路206可响应于最早A4感测阈值跨越A3窗口期间的第一较高A4感测阈值振幅或A3窗口之后的第二较低A4感测阈值振幅而在PVAB期到期后从运动信号中感测到心房事件信号。FIG. 12 is a flow chart 850 of a method for adjusting the PVAB period and controlling atrial synchronized ventricular pacing according to an example. Boxes 802 to 810 correspond to the same numbered boxes shown in FIG. 10 and described above. After selecting the maximum or minimum PVAB period at box 808 or 810, the control circuit 206 begins selecting the PVAB period in response to the next ventricular event and determines at box 812 whether an atrial event signal (A4 event) is sensed from the motion signal after the PVAB period. As described above, for example, in conjunction with FIG. 5 or FIG. 7, the control circuit 206 may sense an atrial event signal from the motion signal after the PVAB period expires in response to the earliest A4 sensing threshold crossing the first higher A4 sensing threshold amplitude during the A3 window or the second lower A4 sensing threshold amplitude after the A3 window.
响应于在PVAB期之外感测到心房事件信号，控制电路206可在框816处生成输出，例如心房感测事件信号，该输出可由存储器82存储，例如带有时间戳。可以确定心房感测事件信号和相关联的数据(诸如心房感测事件间期)并将其存储在存储器210中，用于各种功能，诸如自动设置或调整心房感测控制参数、确定心房速率、控制起搏模式切换或其他功能。In response to sensing an atrial event signal outside of the PVAB period, the control circuit 206 may generate an output, such as an atrial sensed event signal, at block 816, which may be stored, e.g., with a time stamp, by the memory 82. The atrial sensed event signal and associated data, such as an atrial sensed event interval, may be determined and stored in the memory 210 for various functions, such as automatically setting or adjusting atrial sensing control parameters, determining an atrial rate, controlling pacing mode switching, or other functions.
应当理解，在本文呈现的任何示例中，除了开始PVAB期之外，控制电路206还可以响应于每个心室事件而开始心室后心房不应期(PVARP)。在一些示例中，PVARP可以晚于PVAB期到期，并且可以在图5所示的被动心室充盈(A3)窗424期间到期。控制电路206可以在一些心室周期期间在PVAB期到期之后但在PVARP到期之前感测心房事件信号。控制电路206可在框816处产生不应期心房感测事件信号，例如用于存储在存储器210中以确定心房速率或用于其他诊断或感测和/或治疗控制目的。当在PVAB期到期后但在PVARP期间感测到心房事件信号时，起搏定时电路242可响应于不应期感测心房事件信号而拒绝开始AV起搏间期。It should be understood that in any of the examples presented herein, in addition to starting the PVAB period, the control circuit 206 may also start a post-ventricular atrial refractory period (PVARP) in response to each ventricular event. In some examples, the PVARP may expire later than the PVAB period and may expire during the passive ventricular filling (A3) window 424 shown in FIG. 5 . The control circuit 206 may sense an atrial event signal after the PVAB period expires but before the PVARP expires during some ventricular cycles. The control circuit 206 may generate a refractory atrial sensed event signal at box 816, for example for storage in the memory 210 to determine the atrial rate or for other diagnostic or sensing and/or therapeutic control purposes. When an atrial event signal is sensed after the PVAB period expires but during the PVARP, the pacing timing circuit 242 may refuse to start the AV pacing interval in response to the refractory sensed atrial event signal.
当在PVAB期和任何PVARP之外感测到心房事件信号时，起搏定时电路242(图3)可在框816处从心房事件检测器电路240接收心房感测事件信号，并且作为响应，开始AV起搏间期。在框818处，脉冲发生器202响应于感测到的心房事件信号，例如在AV起搏间期到期时，产生并递送心房同步心室起搏脉冲。响应于递送的心室起搏脉冲，控制电路206在框820处开始PVAB期，该PVAB期被设置为先前在框808或810处选择的最小或最大PVAB期。在框818处递送的心室起搏脉冲被控制电路206标识为下一组N个心室事件中的心室事件，并可确定是否已在框822处标识出与存储器210中缓存的下一组N个RRI相对应的N个心室事件。When an atrial event signal is sensed outside of the PVAB period and any PVARP, the pacing timing circuit 242 (FIG. 3) may receive the atrial sensed event signal from the atrial event detector circuit 240 at box 816 and, in response, begin an AV pacing interval. At box 818, the pulse generator 202 generates and delivers an atrial synchronized ventricular pacing pulse in response to the sensed atrial event signal, such as when the AV pacing interval expires. In response to the delivered ventricular pacing pulse, the control circuit 206 begins a PVAB period at box 820, which is set to the minimum or maximum PVAB period previously selected at box 808 or 810. The ventricular pacing pulse delivered at box 818 is identified by the control circuit 206 as a ventricular event in the next set of N ventricular events, and it may be determined whether N ventricular events corresponding to the next set of N RRIs buffered in the memory 210 have been identified at box 822.
再次参考框812，如果在框814处标识出另一心室事件之前在框812处未感测到心房事件信号，则控制电路206可在框814处标识出心室事件，并响应于标识出的心室事件在框820处开始PVAB期(而不递送心房同步的心室起搏脉冲)。如果心室事件还没有发生，则控制电路206可以返回到框812继续等待感测的心房事件信号或心室事件，以先发生者为准。在一些情况下，在感测到心房事件信号之前，在框814处，感测电路204感测到心室事件。在其他情况下，心室较低速率起搏间期可能在感测到心房事件信号之前到期。在框814处，可在较低速率起搏间期(LRI)下递送异步心室起搏脉冲。控制电路206可将心室感测事件或心室起搏脉冲标识为心室事件，并在框820处开始PVAB期。Referring again to box 812, if an atrial event signal is not sensed at box 812 before another ventricular event is identified at box 814, the control circuit 206 may identify a ventricular event at box 814 and start a PVAB period at box 820 in response to the identified ventricular event (without delivering an atrial synchronized ventricular pacing pulse). If a ventricular event has not occurred, the control circuit 206 may return to box 812 to continue waiting for a sensed atrial event signal or a ventricular event, whichever occurs first. In some cases, the sensing circuit 204 senses a ventricular event at box 814 before the atrial event signal is sensed. In other cases, the ventricular lower rate pacing interval may expire before the atrial event signal is sensed. At box 814, an asynchronous ventricular pacing pulse may be delivered at a lower rate pacing interval (LRI). The control circuit 206 may identify the ventricular sensed event or the ventricular pacing pulse as a ventricular event and start a PVAB period at box 820.
在框822处，控制电路206可确定是否已经标识出接下来N个心室事件。如果否，则控制电路206可以返回到框812并继续根据最近选择的当前最大或最小周期(在框808或810处)来设置PVAB期。当在框822处标识出接下来N个心室事件时，控制电路206可以返回到框804以从N个心室事件中确定代表性RRI。基于阈值间期与最近确定的代表性RRI的比较，控制电路206在框808或810中的一者处将PVAB期设置为最小周期或最大周期。At box 822, the control circuit 206 may determine whether the next N ventricular events have been identified. If not, the control circuit 206 may return to box 812 and continue to set the PVAB period based on the most recently selected current maximum or minimum cycle (at box 808 or 810). When the next N ventricular events are identified at box 822, the control circuit 206 may return to box 804 to determine a representative RRI from the N ventricular events. Based on a comparison of the threshold interval with the most recently determined representative RRI, the control circuit 206 sets the PVAB period to the minimum cycle or the maximum cycle at one of boxes 808 or 810.
在图12的示例中，控制电路206可以基于RRI在最大PVAB期与最小PVAB期之间调整PVAB期，该RRI可以是从多个RRI中确定的代表性RRI。在一些示例中，PVAB期可从最大PVAB期调整到最小PVAB期，而不需要分析运动信号在最大PVAB期期间的振幅。在其他示例中，本文描述的用于确定PVAB期期间的运动信号振幅数据的技术可以由控制电路206执行，以分析运动信号在最大PVAB期期间(例如，在基于代表性RRI小于阈值间期来缩短至最小PVAB期之前)的振幅。结合图10至图12总体描述的技术可以与本文公开的任何示例技术相结合，以用于在控制电路206决定缩短或加长PVAB期和/或PVAB期缩短或加长多少(例如，最大减量或增量)之前分析运动信号振幅。In the example of FIG. 12 , the control circuit 206 may adjust the PVAB period between a maximum PVAB period and a minimum PVAB period based on an RRI, which may be a representative RRI determined from a plurality of RRIs. In some examples, the PVAB period may be adjusted from a maximum PVAB period to a minimum PVAB period without analyzing the amplitude of the motion signal during the maximum PVAB period. In other examples, the techniques described herein for determining motion signal amplitude data during the PVAB period may be performed by the control circuit 206 to analyze the amplitude of the motion signal during the maximum PVAB period (e.g., before shortening to the minimum PVAB period based on a representative RRI being less than a threshold interval). The techniques generally described in conjunction with FIGS. 10 to 12 may be combined with any of the example techniques disclosed herein to analyze the motion signal amplitude before the control circuit 206 decides to shorten or lengthen the PVAB period and/or how much the PVAB period is shortened or lengthened (e.g., a maximum decrement or increment).
应当理解，取决于示例，本文所述的方法中的任一方法的某些动作或事件可按不同顺序来执行，可进行添加、合并或完全省略(例如，并非所有所述动作或事件对于实践该方法来说都是必须的)。此外，在某些示例中，动作或事件可以同时执行，例如，通过多线处理、中断处理或多个处理器，而不是顺序地执行。除此之外，出于清楚的目的，虽然本公开的某些方面被描述为由单个电路或单元来执行，但是应当理解，本公开的技术可以由与例如医疗装置相关联的单元或电路的组合来执行。It should be understood that, depending on the example, certain actions or events of any of the methods described herein may be performed in a different order, may be added, combined, or omitted entirely (e.g., not all of the actions or events described are necessary to practice the method). In addition, in some examples, actions or events may be performed simultaneously, for example, through multi-threaded processing, interrupt processing, or multiple processors, rather than sequentially. In addition, for the purpose of clarity, although certain aspects of the present disclosure are described as being performed by a single circuit or unit, it should be understood that the techniques of the present disclosure may be performed by a combination of units or circuits associated with, for example, a medical device.
在一个或多个示例中，所描述的功能可在硬件、软件、固件或它们的任何组合中实施。如果在软件中实施，则功能可作为一个或多个指令或代码存储在计算机可读介质上并且由基于硬件的处理单元执行。计算机可读介质可包括计算机可读存储介质，其对应于有形介质，诸如数据存储介质(例如，RAM、ROM、EEPROM、闪存存储器或可用于存储指令或数据结构形式的期望程序代码并且可由计算机访问的任何其他介质)。In one or more examples, the functions described may be implemented in hardware, software, firmware, or any combination thereof. If implemented in software, the functions may be stored as one or more instructions or codes on a computer-readable medium and executed by a hardware-based processing unit. A computer-readable medium may include a computer-readable storage medium, which corresponds to a tangible medium, such as a data storage medium (e.g., RAM, ROM, EEPROM, flash memory, or any other medium that can be used to store desired program code in the form of instructions or data structures and can be accessed by a computer).
指令可由一个或多个处理器执行，诸如一个或多个数字信号处理器(DSP)、通用微处理器、专用集成电路(ASIC)、现场可编程逻辑阵列(FPLA)或其他等效的集成或离散逻辑电路。因此，如本文所用的术语“处理器”可指代任何前述结构或适于实施本文所描述的技术的任何其他结构。另外，这些技术可在一个或多个电路或逻辑元件中完全实施。Instructions may be executed by one or more processors, such as one or more digital signal processors (DSPs), general purpose microprocessors, application specific integrated circuits (ASICs), field programmable logic arrays (FPLAs), or other equivalent integrated or discrete logic circuits. Thus, the term "processor" as used herein may refer to any of the foregoing structures or any other structure suitable for implementing the techniques described herein. Additionally, these techniques may be fully implemented in one or more circuits or logic elements.
因此，已经参考具体示例在前述描述中呈现医疗装置。应当理解，本文公开的各个方面可以与附图中呈现的具体组合不同的组合进行组合。应当理解，在不脱离本公开和以下权利要求的范围的情况下，可以对参考示例进行各种修改。Therefore, medical devices have been presented in the foregoing description with reference to specific examples. It should be understood that the various aspects disclosed herein may be combined in combinations different from the specific combinations presented in the drawings. It should be understood that various modifications may be made to the referenced examples without departing from the scope of the present disclosure and the following claims.
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