St. Jude PM2210 Response

I saw cardiologist today and learned during a stress test/echo that my pace maker is not elevating heart rate as needed during exertion/exercise. He's reduced bisoprolol to 2.5 mg. 3 times per week and said if I don't feel better in 3-4 weeks, we will call the company to investigate response issues. Help! Has anyone else had a similar problem with this pacemaker? If so, what's the fix? I'm a 67 year old female and a tad unnerved by this situation.

15 Comments

Yes, same thing with a 2210

by ldebaugh - 2012-09-28 02:09:11

Hi,
I've had several EP's and am starting with a new one next Friday. My cardiologist has given me a treadmill stress test (bruce protocol) and said "you failed miserably". I'm a walker and with a 53% EF I should be able to walk well. But, as I do, I am terribly short of breath and I use a monitor to see what's happening. My HR will go up, usually to about 110, sometimes as high as 120 and then drops to 80, so here I am hoofing it around our hilly park nearby and I'm really bad off. Today I was out of breath the entire walk (a very slow one) and then just had to stop when I thought I would collapse (legs and everything went weak from lack of O2). Stood still for 5 minutes and then was breathing ok again, and started up. So yes, the least exertion and I'm very sob. I have a St. Jude Accent 2210 which is supposed to be a DDDR meaning it's in the atrium and one ventricle, my doc put it in as VVIR or 2 ventricles. Is that how yours is?

This was done after an AV-node ablation and I'm in permanent A-flutter. (regular atrium, but fast).

Oh, by the way my range is from a low of 70 to a high of 160 BPM, but of course it never goes that high. I have a slope of 10, which is pretty steep (how fast it gets to the high) and a fast pick up and a slow recovery rate. I've had many many changes to this PM and it doesn't work!!!
Keep me informed and if your doctor wants to talk with my cardiologist, I'll help connect them.
Also if you want any more detailed nfo, don' t hesitate to send me a private message.
M'Liz

I didn't answer your question..

by ldebaugh - 2012-09-28 02:09:36

The fix is a new pacemaker, a CRT-P with 3 leads, Atrium, Ventricle, Ventricle or one with 3 leads + a minute ventilation (breathing sensor) system too.
M'Liz

Exercise

by golden_snitch - 2012-09-28 03:09:22

Hi!
May I ask what kind of exercise the test included? Bicycling? And is your pacer's rate response function switched on? If it was a bicycle ergometry, I'd be careful to conclude that the rate response is not reacting properly, because the sensor for that typically needs upper body movement to realize that you are exercising. If you do a bicycle ergometry (with an echo), there is NO upper body movement, and so the pacemaker cannot react appropriately. Sad, but true, most doctors do not realize this problem, and continue to put each and every pacer patient on the ergometre.
If the pacemaker is not reacting properly, reducing the betablocker will probably not help, because the betablocker doesn't influence the pacer's rate response. It does, however, make sense to reduce it, if your sinus node is still functioning, but is slowed down by the betablocker, and therefore doesn't react well to exercise.
Hope this helps.
Best wishes
Inga

Why CRT?

by golden_snitch - 2012-09-29 03:09:43

M'Liz,

VVIR means one ventricle only, and that is being sensed and paced (VV), waits to check if the ventricle is doing something on its on (I), and has the rate response turned on (R).

Don't understand why you keep telling people that a CRT-P is the solution. A CRT re-synchronizes the ventricles, and with your EF is does not sound like you're in heart failure due to dissynchrony. Plus a CRT does not have a different/better rate response than a normal pacer. If you want an accelerometer plus minute ventilation, then you have to ask for a Sorin or Boston Scientific pacer.

CRT is not always better. It's one more lead in your veins plus it's quite difficult to place (in the coronary sinus). The risk of blocked veins is higher the more leads are in, and then some patients to do respond at all to re-synchronization; not all heart failure patients have ventricles not beating insync, some "just" have a weak heart muscle.

You have problems with the rate response, but not with ventricles not beating insync. So, a CRT won't help, a second rate response sensor might.

Best
Inga

You have a normal dual-chamber pacer

by golden_snitch - 2012-09-29 03:09:46

But if you had leads in 2 ventricles, you'd have a CRT device. Again, the two VVs stand for ventricle sensed and paced. I looked up your pacer model, and it is no CRT device. A pacemaker that can pace both ventricles always has three connectors to put the three leads in, and it's bigger than a normal pacemaker. Your model only has two connectors, and it's labled DR which clearly indicates that it's a normal pacer for dual-chamber (atrium + ventricle) therapy. You can get an info sheet about your pacer at:
http://www.sjmprofessional.com/Products/US/Pacing-Systems/Accent-Pacemaker.aspx

I had AV-node ablation, too, but a bi-ventricular pacemaker is not the standard pacer to do after such an ablation. VVI(R) mode is the standard, but again in this mode it's just one, usually the right ventricle in which the pacer stimulates.

Best
Inga

M'Liz

by golden_snitch - 2012-09-29 04:09:10

To you, M'Liz. In a post about two weeks ago, you said that you wanted an upgrade to a CRT system. Now you claim that you have a pacemaker that paces both ventricles which would mean that you already have a CRT. But a VVIR-mode is none that paces both ventricles, and your pacer model is no CRT device. So, I'm confused what you really have. Why do you want an upgrade if you already have bi-vent pacer?
Never mind. I mean it's not really important at this point. I just had the feeling that you got something wrong or your doctor didn't explain things well to you that's why I kept replying and insisting that what you have is a normal dual-chamber pacer.
No offense intended.
Inga

2210 bi-V

by ldebaugh - 2012-09-29 04:09:23

Inga,
Were you speaking to me or to Janhpat? I'm the one with the bi-vent. PM. And yes, a 2210 is not meant to be used that way. What can I say?
M'Liz

Add

by golden_snitch - 2012-09-29 05:09:29

Just never heard that one can use a normal DDD pacer as a bi-vent pacer. Can't imagine how that will work, because the DDD pacer does not have certain parameters that need to be programmed, if both ventricles shall be paced. I know that one can program/downgrade every CRT device to a normal pacer (switch off the LV lead), but the other way around? Again, the DDD pacer doesn't offer the parameters needed for re-synchronisation. And I also thought that the lead for the left ventricle which goes in via coronary sinus differs from a normal pacer lead, so does it really fit into that normal connector in a DDD pacer?
Sorry, I'm VERY confused. Maybe you can shed some light on how that works.

minute ventilation sensor

by ldebaugh - 2012-09-29 08:09:55

I have leads in 2 ventricles and am told it's done in VVIR mode. I'm 100% paced (AV node ablation) with Aflutter due to an enlarged L atrium.

The St. Jude 2210 is designed to be used as a DDDR with a lead in the atrium and one in the ventricle. Hmm. I think you are on to something and a minute ventilation sensor might be my answer.

M'Liz

Interesting

by golden_snitch - 2012-09-30 04:09:05

Ok, interesting, never heard that you can program a DDD pacer to act as a bi-ventricular pacer. There is no literature about that, and I also wonder why anyone would do this when there are "real" CRT devices on the market. Did you doctor say why he decided to do it this way?
Still wondering why you ask for a CRT upgrade? Because of the atrial lead? That won't do anything, if you are in atrial flutter all the time; the flutter inhibits the atrial lead.
But a better rate response sensor might be something to look into when you go for replacement one day.
Best
Inga

St.Jude 2210

by ldebaugh - 2012-09-30 12:09:10

I'm 100% paced with a St. Jude 2210 after an AV node ablation. Typically(based on the way it's designed and intended) it's put in as a dual chamber with atrial/ventricle positioning. Mine is in the right and left ventricles. I was told I have "permanent afib" but now it's aflutter, not afib.
Sorry to confuse!

VVR not working....

by ldebaugh - 2012-10-01 04:10:04

What would be a "better rate response sensor"? Are you talking about the Anthem by St. Jude which is listed as a CRT-P with 3 leads? Or are you referring to one with two sensors, that includes a minute ventilation sensor?

Also, because I'm 100% paced I'm in VVR mode, not VVIR, right? My St. Jude Accent is intended to be DDDR but that's not how the doctor did it. Why? We never got a satisfactory answer, but this is what he said--he needed to do it because I was in permanent Afib (now I'm in aflutter) and because I'm so small, he picked the Accent because it's small. That's it. It would be ok if I could breathe when I walk, which I should be able to do with a 53% EF. I'm 118 lbs, with no other problems/health issues. I'm very very frustrated.

I have spent a fair amount of time on the phone with the St. Jude Techs, and have 2 other programming changes that possibly might help, but I'm not very hopeful. The EP and the Techs all call them (ST. Jude Tech folks) every time I get a PM tweak, but nothing has helped, and I've had about 10 tweaks at this point.

Thus, I get back to my first paragraph. What type/model would give me a better rate response senor?
M'Liz

asfasf

by boxxed - 2012-10-03 09:10:00

"The indication for a CRT device is roughly an EF 130ms. Could be as high as 150ms."

EDIT: Correction to above post.

asfafasf

by boxxed - 2012-10-03 09:10:17

Disclaimer: please do not quote me on this. The gist of what I'm saying I'm confident about, not necessarily the exact details, especially the numbers.

The indications for a CRT device is roughly an EF 130ish. Could be as high as 150ms. It's meant for heart failure. It's meant for LV dyssynchrony.

VVIR means a few things. The first letter indications pacing, second letter indicates sensing, third letter indicates inhibit OR both inhibit and track(D). Fourth letter indicates whether or not rate response is on.

So yes, VVIR CAN be CRT-P's with a capped atrial lead, or an atrial lead not dropped in, and have 2 ventricular leads in the RV and CS pacing both ventricles. But at the same time VVIR isn't ALWAYS a BiV system.

And it's not unheard of to have a faux BiV setup with a typical dual chamber pacer. I'd have to work out the timing cycles in my head and I'm only speculating on the technical stuff, but I'd imagine you just put the Atrial Lead in the typical LV position and set the AV delay to something very short like 30ms to get that synchronized squeeze. Most nominal setups for CRT have a programmable LV offset anyway (0-50ish ms), and I think the LV typically needs to contract first to get the sync squeeze for most people. Not to say there aren't RV first cases either. Since it's a VVIR setup and it's not tracking and ignoring any of the intrinsic heart activity, since you'd set the HR pretty high to ensure as close to 100% pacing as possible, I don't think off the top of my head that there would be a big mess of having a lead designed for the A being used for LV from a sensing/timing cycle perspective.

SJM PM2210 Issues 5/2016

by djohnston - 2016-05-24 04:05:06

1371
Paradoxical Atrial Undersensing: Noise Rate Reversion or
Amplifier Ringing?
BERRY M. VAN GELDER, PH.D.,
∗
WALDY VAN DEN BROEK, B.S.,†
FRANK A. BRACKE, M.D., PH.D.,
∗
and ALBERT MEIJER, M.D., PH.D.
∗
From The
∗
Catharina Hospital, Eindhoven, The Netherlands; and †MEDTRONIC Trading NL, B.V., Heerlen, The Netherlands
Paradoxical Atrial Undersensing. Atrial tachy-arrhythmias may give rise to mode switching or
noise rate reversion in dual-chamber pacemakers. In case of high amplitude of the atrial electrogram
during tachycardia, a paradoxical behavior of atrial sensitivity programming can be observed. Two patients
with implanted dual-chamber pacemakers showed intermittent and complete loss of atrial sensing during
atrial tachycardia during device programming to a higher atrial sensitivity setting. This phenomenon is
caused by amplifier ringing and can be considered as a state of amplifier saturation, which disables atrial
sensing in spite of the high amplitude of the atrial signal. In patients with high amplitude of the atrial
electrogram during atrial tachycardia, a paradoxical behavior of sensitivity programming resulting in
atrial undersensing can be observed. (J Cardiovasc Electrophysiol, Vol. 17, pp. 1371-1374, December 2006)
paradoxical atrial undersensing, amplifier ringing, high-amplitude atrial electrogram, noise rate reversion
Introduction
Inappropriate ventricular pacing response in dual-
chamber devices caused by atrial arrhythmias can be pre-
vented by a mode switching algorithm. The mode switch is
activated when the atrial rate higher than a (programmable)
limit is detected in the atrial channel. For proper mode switch
function, it is essential that the atrial channel senses the atrial
depolarization during tachycardia. The choice of a relatively
low sensitivity may lead to undersensing by fluctuations in
P-wave amplitudes due to physiological changes or to the
lower amplitude of the signal during atrial arrhythmias.
1,2
Selection of the atrial sensitivity setting for proper sensing
during atrial arrhythmias at the time that the patient is still in
sinus rhythm may be difficult, and often a relative high sen-
sitivity is chosen to assure sensing of the atrial arrhythmia,
leading to appropriate mode switching. A high sensitivity
setting in the atrial channel also has some drawbacks. It may
lead to inappropriate mode switching due to far-field R-wave
sensing,
3,4
but also to DOO pacing due to noise rate rever-
sion
5
and complete ignorance of atrial signals by amplifier
ringing.
6
In this article, we present two cases of amplifier
ringing leading to complete atrial undersensing at high atrial
sensitivity settings.
Case report
Patient 1
A 67-year-old male had a Medtronic Kappa 701, dual-
chamber pacemaker implanted because of complete atrioven-
tricular (A-V) block after aortic valve replacement in 1998. A
Medtronic 4024 bipolar lead was implanted in the right ventric-
ular apex and a Medtronic 4524 bipolar lead in the right atrial
Address for correspondence: Berry M. Van Gelder, Ph.D., Department of
Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven,
The Netherlands. Fax: +31-40-2447885; E-mail: carlgr@cze.nl
Manuscript received 24 April 2006; Revised manuscript received 7 July
2006; Accepted for publication 10 July 2006.
doi: 10.1111/j.1540-8167.2006.00597.x
appendage (Medtronic, Inc., Minneapolis, MN, USA). The stim-
ulation threshold measured at the ventricular lead was 0.4 V, 0.9
mA and the amplitude of the intracardiac electrogram (EGM)
was 7.0 mV. The stimulation threshold measured at the atrial
lead was 0.3 V, 0.8 mA and the amplitude of the intracardiac
EGM was 9.8 mV. A total of 5 years after implant, the patient
developed atrial flutter for which he was treated with a right
atrial isthmus ablation. Recently, the patient presented with a
history of “fast pulse” and palpitations. The atrial EGM re-
vealed an atrial tachycardia with a cycle length of 160 msec;
the pacemaker was in mode switch (Fig. 1). However, the pace-
maker diagnostics showed predominant fast ventricular pacing
rates up to the programmed upper rate limit of 130 ppm (Fig.
2A). The pacemaker was programmed in the rate-responsive
mode, but the sensor indicated rate profile excluded abnor-
mal sensor behavior as the cause of rapid ventricular pacing
(Fig. 2B). Inappropriate atrial tracking without mode switch-
ing was one of the remaining diagnoses. Therefore, the pacing
system was programmed to higher atrial sensitivity, from 0.5
mV to 0.18 mV. At this setting, the ECG showed A-V sequential
pacing at the lower rate of 70 ppm. The marker annotations
showed no atrial sense events but only atrial pace events as rec-
ognized from the surface ECG (Fig. 3). Decreasing atrial sensi-
tivity from 0.18 to 0.25, 0.35 and 0.50 mV, respectively, gradually
restored normal function with intermittent atrial sensing at 0.25
and 0.35 mV and normal atrial sensing with mode switching at
0.5 mV.
Because of the high amplitude of the atrial signal (4.5–6.5
mV) during tachycardia the sensitivity was programmed to 1.0
mV. This setting relieved the patient’s symptoms of “fast pulse”
and palpitations during follow-up.
Patient 2
A 42-year-old male had a Medtronic Enpulse E2DR01, dual-
chamber pacemaker implanted because of sick sinus syndrome
with episodes of atrial tachycardia. A Medtronic 5092 bipo-
lar lead was implanted in the right ventricular apex and a
Medtronic 4592 bipolar lead in the right atrial appendage
(Medtronic, Inc.). Pacing and sensing values for the ventric-
ular lead were 1V at 0.4 msec, and the R wave measured with
the device was >22.4mV. Stimulation threshold for the atrial
lead was 0.375 V at 0.4 msec, and all measured P waves by
the device were >2.8 mV. Direct measurement with the pacing








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