poor pacemaker selection

Hello everyone, I'm finally getting around to posing a question about pm's that I am surprised not to have seen posted yet. Perhaps that is because I am a relative newbie to the pm world. I'm a 71 y/o guy with 2 prior aortic valve replacements, now looking at a third one because of bacterial endocarditis I had last Fall, resulting in major valve damage. Before the docs realized that the valve was rapidly deteriorating, I began to have various arrhythmias culminating in rapid atrial tachycardia with a 4:1 A/V block ...a type of tachy/brady syndrome. Got a Medtronic AADR01 pm (again before my valve got severely incompetent) and quickly realized that the only way I could get my heart rate above 105 ( Max was set at 130, then 160) was by running, as opposed to climbing hills, biking, or skiing powder. After many consults with the EP, the Medtronic rep, calls to other Medtronic reps and reps for Biotronik and Boston Scientific and other athlete/pm people, I realized that other choices exist that DO incorporate ways to respond better to actual physiologic needs other than simply the number of foot-strikes....such as respiratory rate or a closed-loop stimulator.

My valve issues take priority over maximizing my pm for exercise capacity, but once that is taken care of , I would like to get back to my world of outside adventures...which I don't seem to be able to do with this pm.....unless one of you out there has a solution that my local ep and rep can't figure out. At this time I am assuming that will require a different pm, even though this one has only been in for 2 months. This presents all sorts of procedural and political issues as well as just which other pm works better for this situation (Medtronic no longer makes one with a respiratory rate sensor). Any advice on any portion of this conundrum will be greatly appreciated.
Dennis

10 Comments

Pacemaker selection

by philip.thecyclist - 2014-03-03 08:03:10

Hello Dennis.

Our conditions are different, so I'll avoid medical comparisons, but I can give you my experiences of different pm types. My first was a Medtronic device whose rate response was determined by the accelerometer method. This did respond well to footfall, and some inappropriate impulses like being in road vehicles with over-firm suspension or travelling over roads where surface vibrations could be picked up. It also responded better walking downstairs (heavier footfalls) than going up, and it responded to playing the piano (says a lot about my piano style!). When it came to cycling, it did not respond well to uphill effort, because pedalling cadence is reduced, and the frequency of road impulses lowered. This was recognised in the literature at the time. I don't mean to criticise the device itself - this was 20 years ago when technology was less advanced. When it came time to change the pm because of battery life, I knew respiratory rate response sensors had been developed, and my cardiogy team agreed to implant a dual sensor device from Boston Scientific that had both an accelerometer sensor and a respiratory rate response sensor, where the response from each can be blended. This made quite a difference to my cycling as my paced heart rate now followed a more natural pattern, and the inappropriate responses were largely eliminated. At that time I was still running as well, and I detected better running tolerance as well. I am now on my third pm, as I needed bi-ventricular device for cardiac resyncronisation therapy (crt). This also has a blended accelerometer/respiratory response (or minute ventialtion, MV, as it used to be referred to). This is also from Boston Scientific, and may be the only one yet to have both CRT and MV. I feel the MV working because thre is a 20 second delay before it kicks in, and the effect is noticable. I use a HR monitor from time-to-time, and my HR now responds quite well to the degree of effort. The accelerometer is still required so that your HR can respond to immediate demands like stair climbing.

I won't pretend that my cycling capacity is anything like it was in my pre-pm days, but but I am now 70, and the blended sensor approach is definitely helping to keep my pedals turning.

Hope this helps,

Philip.

Old comment

by golden_snitch - 2014-03-04 02:03:27

Following is something I wrote in response to someone else's question a few weeks ago. It's not that negative about Medtronic's accelerometer as you can do quite a lot of fine tuning with that one. However, if you have the choice, I'd not go for it, but get a blended sensor or CLS. Here's the old comment:

"Among all the accelerometers on the market, I have only heard the best about the Medtronic accelerometer. Medtronic has about 9 rate response parameters that can be optimized either automatically or manually. So, there is a lot of room for optimization, which I'm pretty sure you have not yet exhausted in the three weeks that you have your device. However, as all accelerometers, the Medtronic one has its limitations because it needs upper body movement to sense activity. Consequently, riding your bike will be difficult, but walking, running, swimming should be fine. So, my first suggestion is that you give your Medtronic device and your cardio some time to optimize your rate response settings. That should be done using a treadmill, probably also a holter monitor, and Medtronic pacers also have an exercise test that the cardio can activate. When activated this test runs for 15 minutes so that you can make a quick walk, run up and down some stairs etc., and then afterwards the pacer shows what the RR has done, what your own rhythm has done, and then the cardio can optimize settings accordingly.

If you cannot get the Medtronic rate response optimized so that it fit your needs, a dual-sensor rate response with accelerometer and minute ventilation or a CLS sensor might be better for you. From my personal experience I can say that I have had accelerometer plus minute ventilation for many years - first in my old Medtronic Kappa 401, then in my Sorin Reply -, and was doing well with this combination. It did need quite a lot of fine tuning, too, but then worked well. All the heart rhythm specialists I know say it's the best rate response sensor with the most physiologic response.

I now have a Biotronik Evia with CLS. This is because the minute ventilation sensor in my Sorin Reply kind of quit its job when I was switched to epicardial pacing; this sensor does not work with epi-leads. So, I was left with the Sorin accelerometer only, and that turned out to not fit my needs at all (unlike Medtronic pacers, it had very limited RR optimization options).

My first days with CLS were rough. I was going into tachycardia and actually up to my max programmed rate of 140bpm basically whenever I moved. Fortunately, the automatic optimization has done a pretty good job in the past two weeks, so now I'm getting much more appropriate heart rates. I no longer go for walks with 140bpm, but am down to somewhere between 90-120. Also, I can move around my apartment without going into tachy all the time. But it's only been two weeks, and I have not really exercised, yet, due to soreness and the muscle (subpectoral implant) needing time to heal. So, for now I cannot tell you how CLS responds to running or cycling or anything like that. It is doing a good job at the moment, and I'm actually surprised how well the automatic optimization has worked, but with regards to "real" exercising I have no experiences, yet.

I have read, I believe, all studies that have been published about CLS. And from those studies I understand that CLS does indeed respond to mental stress, but when it comes to physical exercise I have not found any data that would support superiority of CLS to dual-sensor RR or a good accelerometer. The studies have often concentrated on CLS response to mental stress, because this is what's unique in rate response sensor. CLS should however be better for physical exercise, too, since it does not need upper body movement to sense activity, and therefore allows for a greater variety of sports. But I really have no data on this and no personal experience just now."

Inga

Choices

by golden_snitch - 2014-03-04 02:03:37

Tracey,

that's not true: You have Boston Scientific in the U.S. and you have Biotronik pacers, too. So, you can get a CLS sensor and you can get a minute ventilation + accelerometer sensor. "Common" is not only Medtronic! Yes, they do have the highest market share, but you do have alternatives. I do, to some degree, understand your argument that you need someone who's able to program the device. However, it is really not that difficult. If someone like me can aquire the knowledge with regards to rate response programming, a cardio should be able to do that, too. There are manuals, you can call the manufacturer, and you can have a rep come in.

Manaman, every pacemaker has a rate response sensor. Glad to hear that for you Medtronic with an accelerometer only works well. But if you are very chronotopically incompetent and want to do other exercises than just walking and running, the accelerometer has its limits. That's just a technical fact. So, again, happy to hear that it works for you, but it doesn't work for everyone.

Dennis, since you have had this device for two months only, I'd give the fine tuning a chance. Like I said, the Medtronic accelerometer has lots of options for optimization, so maybe they can make it work better for you? But of course, if you want to be able to do all the sports you mentioned in the beginning, it might very well turn out that you just don't get anywhere with this pacer. And I understand that it would be easier to do both surgeries, valve and pacer, at the same time. Is there any chance to talk this through with your doctors before the valve surgery?

Rate response sensors

by golden_snitch - 2014-03-04 02:03:40

Hi Dennis!

If you use the search button in the upper right corner of the site, and type in "rate response", you'll find loads of messages/comments regarding the different types of rate response sensors. I have written about this what feels like a hundred times. It's a question discussed here quite regularly. If people need the rate response sensor - usually that's only people with sinus node issues, not with heart block -, I always advise them to talk to their cardio about what kind of exercise they'd like to be able to do, and to discuss the pros and cons of the different sensors.

I have had accelerometer only, accelerometer + minute ventilation, and now have closed-loop stimulation. I'd always prefer either the accelerometer + minute ventilation or the CLS. Unfortunately, haven't been able to put my CLS sensor to the test, yet, because of some setbacks in my recovery process. The accelerometer + minute ventilation, however, worked really well as compared to accelerometer alone. It's just that I can no longer have the minute ventilation sensor, because my epicardial pacer leads don't work with it. This is why I now chose the CLS sensor. An accelerometer alone, like in all the Medtronic pacers, sucks. It has lots of limitations. Would never suggest to anyone, who really needs the rate response, to go for an accelerometer only.

Inga

Pacemaker selection - pt 2

by philip.thecyclist - 2014-03-04 03:03:57

Hello Dennis,

You've had some long replies, including mine, and I'm loth to complicate things further, but there is something I forgot to mention in my earlier reply. When I learnt that I needed a bi-ventricular PM for CRT, I did a literature search to see if there were PMs that combined CRT with MV sensors so I could continue to benefit from MV/respiratory rate pacing. It appeared that there were, but it was only when I downloaded the medics' manuals that I realised that these had MV sensors only to MONITOR respiratory rate, NOT to provide pacing. This is clearly of use in diagnostics of respiratory conditions, but not what I had hoped for. This fact can easily be overlooked when looking at the manufacturers' descriptions of the devices - the presence of an MV sensor led me to think that MV pacing would be implicit - not so. This was a bit of a shock to me, as I thought I might be faced with having to receive a CRT PM without the MV pacing I had come to rely on. It turned out that Boston Scientific were planning to get approval for a CRT PM with MV rate response (in Europe) around April last year, so I had to wait a few more months before receiving one.

I realise the CRT connection may not be of concern to you, but if you do any of your own research, or take advice, please be aware that the presence of an MV sensor may not imply MV rate response.

Philip

follow-up to Inga and Philip

by RDD - 2014-03-04 06:03:35

Inga,I realize that I'm pushing the time envelop and would be willing to give the Medtronic rep some more time to fiddle with the accelerometer but I am (and have been since I found out how the unit was made) pretty certain that they can't make it work FOR ME.....and the time of my valve replacement is rapidly approaching. I will write you a private message with more details and questions rather than occupy any more time here. As always (except for that unfortunate first time) Your knowledge and assistance are greatly valued.

Philip, Thank you for the comments. I don't need the CRT as of yet, but your warnings about not assuming that MV rate response means that implies that the respiratory rate is used it setting the response is timely and will be thoroughly checked. The Boston Scientific rep on the East Coast said that it was used in setting the HR......bur he also said that for my particular multi-sport needs that I might well look into Biotronik....Hmmmm,selling his competition's product or just being a nice guy????
Dennis

Pacemaker selection - pt 3.

by philip.thecyclist - 2014-03-04 07:03:03

For what it's worth, Dennis, from my recent dealings with Boston Scientific reps here in London, I would say they ARE nice guys. Because my new CRT + MV RR device was a new model, they were on hand during my implantation, and at two subsequent pacing checks to sort out some initial fine tuning. They were good. One was even a keen cyclist - what more can I say :-)

Also, for what it's worth, the BS PM I had before the CRT device was called Insignia and most definitely had blended accelerometer and MV rate response sensors. This may well have been superseded now by later models.

I can't comment on Biotronic. I understand that the hospital that looks after me uses Medtronic, BS, and St. Jude.

Philip.

wrong choice

by manaman - 2014-03-04 08:03:22

Unless my EP doctor is jerking my chain I just had a
ADDR01 impanted on 12/11/13. I asked the direct question "does this PM have RR and is it turned on".
I was assured that the PM had it and it was in fact turned on.
My settings of 60 and 135 treat this 71 year od body fine!
Cecil

Thanks to Inga and Philip...

by RDD - 2014-03-04 11:03:10

Inga, I knew that you would chime in there....you are so incredibly knowledgable. And, Philip, sounds like you have gone through what I am just beginning to experience. I strongly believe that the most important aspect of all these pm vagueries is that we patients MUST take charge and educate ourselves as best we can on every aspect of their function. Most of us won't become an amazing expert like Inga, but we can learn enough to ask some appropriate questions of our docs and reps and use this forum wisely. At least in the US, personal medicine has virtually disappeared (and I saw that as a retired MD) so if you can find it anywhere,hang onto it.

My biggest dilemma at this time is how to integrate my impending third aortic valve replacement which is eminent with the new (2 months old) pm, which I believe was not the right one for me. I could have my cardiac surgeon replace the Medtronic AADR01 with one that has either a minute volume respiratory calculator or a closed loop stimulator....but that requires me (and the ep's) to decide which pm is the best for me and I'm not sure that I have the time to do that before my surgery. Or I could have the AVR and then look at the pm issue after I have sufficiently recovered from that. I am convinced (at least theoretically) that the accelerometer only Medtronics will never get me where I hope to return to when all is said and done. Any advice from you experienced heart patients? Thanks

programming

by Tracey_E - 2014-03-04 12:03:50

Devils advocate, just throwing this out there ... your pm can have all the amazing features in the world, but if you don't have anyone local who can program it, it won't do you much good. I think what has happened to you is fairly common not because the drs are thoughtless but because most everyone in the US gets one of a small number of models. That's what our drs know, for the most part because that's who has the contracts with the hospitals. None of the ones common here make RR that deals with a sport like biking well. A friend of mine (met through here) had a smaller company's pm. After many months of frustration, the rep was not able to get her feeling good. She lives in a rural area and no one else would come to her, it was a 4 hour drive to the city so that got old fast. She ended up replacing it with a Medtronic. She's still not feeling 100%, but she's running again and she has resources when she needs them.

Good luck finding a solution!

You know you're wired when...

You have a new body part.

Member Quotes

I swim, scuba, garden, hike, climb, workout, play with the kids, play tennis, baseball, basket ball and rollerblade with mine with no problem.