RYTHMIQ TM for INCEPTA™ Episode Based Education

1. RYTHMIQTMfor INCEPTA™Episode Based Education

2. RYTHMIQ™ vs. AV SEARCH + Based on IBP Recommendations RYTHMIQ™ & AV Search + give you options to appropriately manage RV pacing in patients with varying degrees of conduction block Sinus Node status does not affect IBP recommendations on RYTHMIQ, AV SEARCH + or Paced and Sensed AV Delays, unless Neurovascular Syndromes is selected

3. AV Search +Two Refinements of the Algorithm

4. AV Search + Programming AV Delay Extension with Higher Maximum Tracking Rates For AV Search +, the Maximum Tracking Rate limit is determined by the programmed AV Delay and PVARP (TARP), but the Search AV Delay is allowed to be longer since the rhythm will typically be a conducted ventricular sense following the atrial event.

5. RYTHMIQTM: Programmer Screens

6. RYTHMIQTM Operation • “The following occurs during the RYTHMIQ™ stage of AAI(R) with VVI backup: • The device provides AAI(R) at the LRL and/or sensor indicated rate according to the normal brady DDD(R) mode. • The device provides backup VVI pacing at a rate of 15 ppm slower than the LRL. The backup VVI pacing rate is limited to no slower than 30 ppmand no faster than 60 ppm. When there is good conduction, ventricular pacing does not occur as the VVI backup mode runs in the background at a reduced LRL. • The device monitors for loss of AV synchrony. If 3 slow ventricular beats are detected in a window of 11 beats, then the device automatically switches to DDD(R) mode. A slow beat for RYTHMIQ™ is defined as a ventricular pace or ventricular sensed event that is at least 150 ms slower than the AAI(R) pacing rate.”1 The 150 ms value is used to allow for normal variations between cardiac cycles. 1Reference Guide, INCEPTA ICD, Page 4-28, 358430-003 EN US 01/11

7. RYTHMIQTM Example 1 The atrial lower rate limit is 55 bpm, which then makes the VVI rate limit 55 – 15 bpm, or 40 ppm.

8. RYTHMIQTM Example 1 A PVC occurs which is not sensed because it falls in the atrial pacing blanking period.

9. RYTHMIQTM Example 1 Pacing occurs at the VVI lower rate limit of 40 ppm or 1,500 ms. Slow ventricular beat #1. Beat 1

10. RYTHMIQTM Example 1 Pacing occurs again at the VVI lower rate limit of 40 ppm or 1,500 ms. Slow ventricular beat #2. Beat 2

11. RYTHMIQTM Example 1 A ventricular senses beat then occurs at 1,338 ms, which is slower than the atrial LRL of 55 bpm plus 150 ms (1090 ms + 150 ms= 1240 ms). This is slow ventricular beat #3 in the last 11. Beat 3

12. RYTHMIQTM Example 1 RYTHMIQ™ transitions from AAI(R) mode to DDD(R) and an event with electrogram is stored. DDD(R) EGM Stored

13. RYTHMIQTM Operation AAI(R) at programmed LRL VVI backup at LRL – 15 ppm, bounded by [30,60] Sustained conduction detected 3 slow ventricular beats in moving window of last 11 Declare Event/Record EGM DDD(R) at programmed LRL Reference Guide, INCEPTA ICD, Page 4-28, 358430-003 EN US 01/11

14. RYTHMIQTM Operation AAI(R) at programmed LRL VVI backup at LRL – 15 ppm, bounded by [30,60] RYTHMIQ can detect AFib from either AAI(R) or DDD(R) Sustained conduction detected 3 slow ventricular beats in moving window of last 11 Declare Event/Record EGM DDD(R) at programmed LRL ATR Mode Switch Reference Guide, INCEPTA ICD, Page 4-28, 358430-003 EN US 01/11