First check-up

Went for 6 week PM check-up today and there were a few surprises.
Firstly, I didn't see the cardiologist who implanted the pacemaker - my check-up was in the "diagnostics unit" (where they do treadmill/ECG, etc tests).
In the atrium, my PM is just "sensing" (i.e. not pacing) meaning my heart is initiating beats correctly in the top. The ventricle is being paced 99% (hence my condition - 2nd degree heart block - beats are not efficiently relayed top-to-bottom).
I said I was still short of breath, e.g. walking up hills. I had assumed the rate response was on and the upper limit for heart rate needed increasing. I was told my PM showed my heart rate had naturally increased on occasions to 130, i.e. not as a result of the PM, indicating there wasn't a problem. I pointed out that on treadmill test in Feb (carried out by same person I saw today) my rate did not go above 78 and I was disorientated (felt close to passing out) at that stage. During that test I had worked far harder than at any time since I have had the PM, as I knew if I passed out I was in the right place. After further insistence on my part the nurse said she would ask the cardiologist if I could have a 24 hour tape to record heart rate including during walking up hills. I asked if my rate response was "on" and I was told no (in which case Mode: DDDR does not mean rate response is on!) The nurse said they like to leave your heart to do as much as possible on its own. I'll wait with interest for 24 hour test/result, but wonder if the time sccale is long enough to pick up changes in way my heart deals with exercise.
Andrew

5 Comments

DDDR

by Pookie - 2010-08-04 09:08:25

I remember that post and never knew the answer, so I just went through several websites and all of them cited the same:

DDD pacemaker
an artificial cardiac pacemaker that can sense and pace both the atria and ventricles; it is capable of operating in both triggered and inhibited modes as necessary.
Found on http://www.mercksource.com/pp/us/cns/cns


DDDR pacemaker
a universal pacemaker that is responsive to the patient's respiratory rate and thus to exercise and metabolic needs.
Found on http://www.mercksource.com/pp/us/cns/cns



So, my conclusion, is that the "R" at the end doesn't mean your rate response is turned ON, rather the "R" means your pacemaker is capable of more than just the DDD pacemaker.

But hey, I could be wrong....wouldn't be the first time :)

Perhaps, just for fun, everyone should ask their EP, PM Tech, cardiologist, or whoever they see the next time they have their pacemakers "interrogated" (love that term) what exactly does the "R" mean at the end of the 3 Ds and see what answers we get!!!!!!!!!!!!!!

However, I know mine is ON as I am allowed a copy of my report.

Pookie

DDDR meaning

by ElectricFrank - 2010-08-05 01:08:55

I have the manuals for both the Kappa and Adapta Medronic series pacers. The R at the end of any mode definitely signifies Rate Response is ON.

Having your HR increase to above the upper pacing limit setting only means that part of the time you have conduction from atrium to ventricles. It also means that during times when you don't have conduction and require pacing your upper HR is limited. These could be the times when you experience shortness of breath.

Something is strange about what they are telling you. I would expect the unit where you are getting the information would be knowledgeable so maybe it is a communication issue.

frank

similar problem

by Pollyanna - 2010-08-05 04:08:35

Hi Andrew,
My PM (St Jude 5826, DDDR mode) was implanted for complete heart block in September 2009. I have continued to have the same symptoms as you: shortness of breath, difficulty exercising, difficulty climbing stairs etc. After six months of waiting to feel “great” as everybody told me I would I went back to the pace maker clinic and insisted on a treadmill test. This revealed that there was a problem with my atrium which was not seen before. As I started to run my heart rate suddenly dropped instead of rising. The cardiologist said that I had a sino-atrial exit block- my sinus node was reacting to the exercise but the signal was being blocked from passing through to my atrium. The rate response had been set at minimum as my initial diagnosis of complete heart block suggested that my atrium didn’t need any help. My rate response was then increased from the lowest setting to the highest. This has made a big difference to day to day activities (stairs etc) but exercising (swimming, running and cycling) is still not consistently good. Like you I wonder if the top part of my heart is not responding in the same way each time. I will be having another treadmill test later this month and then hopefully some more “re-tuning”.
I am sorry that I don’t have any answers for you, just sharing a similar problem!
I hope that the 24 hour monitor gives some indication of what is going on and that you can get your settings sorted out soon.
Best wishes
Pollyanna

Thanks

by andyuk - 2010-08-05 06:08:51

Thanks for the replies.
Pookie - good idea to ask at check-up as you suggested so we get a more general picture.
Frank, my PM is a St Jude but I would have thought terminology on all PM cards would be standardised for safety's sake. Agree with your comments re communication - the nurse was insistent my heart could naturally respond to exercise because interrogating the PM showed HR of 130 at times (remembering she says RR is off); this despite results of her earlier treadmill test on me (Feb, prior to PM implant in June) showing a max HR during hard exercise of 78. For me there must be one of two reasons - either RR is on, or, if it's off then my natural pacemaker is not responding in the same way each time.
Andrew

Not always the same

by ElectricFrank - 2010-08-06 07:08:44

This is common with both sinus and ventricular conduction. I'm not real familiar with all the variations on sinus problems. With the ventricular only what is referred to as 3rd degree block (or sometimes "complete block") will consistently need the pacemakers help.

The one of the most common problems is the setting of the Upper Ventricular Limit. This determines the maximum rate that the pacer is allowed to pace the ventricles. Natural pacing still allows faster if it is working. There is a tendency to use conservative settings which are too low for those of us that are in good shape.

As an example I am 80yrs old. A conservative max for me is in the 90-100 range. For most 80yr olds this would likely be true. For me 120 is easy going, 130 I'm breathing pretty good but no discomfort. I look at 140 as workable for short bursts. I have the Upper Ventricular Limit set at 150. I control my own HR and don't want the pacer doing it for me. In the mountains I would rather die of fibrillation than be eaten by the bear chasing me. LOL

Don't mix up the meaning of Upper Ventricular Limit with the Upper Rate Response Setting. Also be aware that the Rate Response settings are meaningless unless it is turned on. The best way to tell is by looking at the mode.

frank

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You have a maintenance schedule just like your car.

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A properly implanted and adjusted pacemaker will not even be noticeable after you get over the surgery.