Delay between chambers

(This is an update from my "Help interpreting report" post).
As a recap, pm implanted two years ago (2/2012). My chief complaint is fatigue.


Answers from EP at today's appointment:

1. What was the reason I got the pm? SSS
AFTER the implant they discovered 2nd Degree block. And this is a much more serious problem than the slow heartbeats.


2. Do I have Wenkebach? Yes. My 2nd Degree is progressing to 3rd Degree.
(I don't have Wenkebach behavior Golden_snitch-- I have Wenkebach).


3. Is the RR on or off? ON
Why? to help with exercise. Also raised max bpm from 130 to 140.
This means I have to get off my butt and exercise to see if I actually need this feature.
I do not think I do. My understanding is that RR helps if your heart rate will not increase on it's own. My feeling is that my heart is fine with activity. The problems seem to occur at rest.



4. Why did you lower bpm from 60 to 50? to save battery
I showed him pulse readings from my doctor for years 2008-present which show a PRE- PM lowest bpm of 60* and highest of 74. Even after looking at these figures he declined to increase the bpm setting. Instead, he has taken me off of the beta blocker (Atenolol*).

* POST-PM lowest was 64, highest was 80.
** I was put on taken this medication in 2004 after my heart attack.


5. Why was MED setting changed to MED-HIGH? To help with exercise


6. Should I have exercise test? will do this if no improvement in 3 months. Changes in pm settings take 2-4 weeks to produce results. (My husband thinks he said 4-6 weeks)



The EP said his main concern is addressing the delay between my chambers, which is why he reduced both the sensed and paced times. He thinks he may need to decrease these even more.

And he stressed that I really need to start exercising again. Which is easier said than done, since I'm so tired all the time.

I'm hoping to get replies-- especially from my buddy DonR, and also from Golden_snitch, Boxxed. I welcome all input! It's great to get different perspectives!!!

Thanks,
CK

8 Comments

Wenckebach = Mobitz type 1

by golden_snitch - 2014-03-26 02:03:05

Hi!

Just very briefly as I'm recovering from a pacer surgery myself (last Friday), and am not fit enough to write long replies.

I did explain this before. But again: A Wenckebach block is a 2nd degree heart block, also called "Mobitz type 1". The PQ interval prolongs with every beat until one beat is skipped/one p-wave is blocked. This usually does not progress to third degree heart block. 2nd degree heart block Mobitz type 2 progresses. This is a block where, without prior PQ-interval prolongation, P-waves are blocked.

Also, if your pacer is set in DDDR, you can no longer have a Wenckebach block because the pacer paces you out of every single block that ever occurs. But you can very well have a Wenckebach behaviour, tied to the upper tracking rate or, in some pacers, to a certain range of the atrial rate (in my case 180-210).

This is just to cheer you up a bit. If you have Wenckebach, it is definitely not said that you'll one day end up with complete (third degree) blockage.

Best wishes

Inga

@golden

by Ck - 2014-03-26 03:03:29

Sorry about your surgery. And hope you recover quickly!

What you say goes completely against what my EP said.

I asked my husband to go with me to the visit-- because I knew I would be asking lots of questions. And I wanted to make sure I got the answers correct!

My husband verified what I wrote as the answers.

I think next time I will take a tape recorder!!!

Wishing you an uneventful healing time,
Ck

Some links

by golden_snitch - 2014-03-26 03:03:41

Just google it, and you'll see that I'm right about the Mobitz type 1 (Wenckebach):

http://my.clevelandclinic.org/heart/disorders/electric/heart_block.aspx

http://ecg.utah.edu/lesson/6#Wenckebach

http://www.nhlbi.nih.gov/health/health-topics/topics/hb/types.html

I was just wrong about the regular pattern of Mobitz type 2 block. Mobitz type 1 (Wenckebach) often has a regular pattern; Mobitz type 2 hasn't. Going to correct that in my first comment, so that no one gets confused.

Inga

asfasf

by boxxed - 2014-03-27 03:03:17

You both are saying the same thing.

There's a difference between a physiological Wenchkebach and pseudo-wenchkebach that is upper rate behavior. That being that the PM itself is doing a wenckebach. What I think your EP is saying, is that the pacemaker is not doing a Pseudo-Wenckebach that your PM can only track so many atrial signals (when your sinus rate goes high enough) that you eventually drop beats because the atrial signals fall into device refractory,

So what your EP is saying is that you have physiological wenckebach, where your PR interval extends and extends until there is a dropped beat. And it's the HEART naturally doing it. But you don't have a wenckebach upper rate behavior where the PM can't catch up with all the atrial signals and drops beats. Where the PACEMAKER is the one doing it.

Thx Boxxed!

by Ck - 2014-03-27 07:03:15

Thank you for replying!

Do you understand why the EP is so reluctant to raise my bpm? It seems it me that if my natural resting rate is in the 60's, that the pm setting should also be in the 60's.

Ck

by Grateful Heart - 2014-03-27 08:03:14

If you have SSS (me too), RR is usually turned on. You may need an adjustment for the RR parameters.....me too I think.

In the beginning, my resting rate was set for 60 and I was struggling so my EP raised it to 70 a few years ago. It may use more battery but if it would make you feel better I don't see why your Doc won't at least try it. I have an ICD for 5 years and my battery level shows 5 more left.....I can only hope!

I couldn't get an appt. with my EP until July at this point but I do have another appt. in the same office in a few weeks. They told me they would have him "pop in"......the only problem is he doesn't know this so I hope they remember to tell him.

I can see how this is going to go. :-(

It seems it's easier to get an audience with the Pope than an appt. with my EP these days.

Grateful Heart

umm

by boxxed - 2014-03-27 10:03:01

I typically avoid answering questions that specific. But generally, you want to set the PM so that it's used only when needed. If @ rest you're on your own just fine @ an acceptable heart rate, but need a bit of a bump from the pacemaker during activity, there may not be much of a reason to be pacing you @ rest either.

@Grate

by Ck - 2014-03-28 08:03:27

This EP is the first one I've had who doesn't have a fairly flexible schedule. My appt with him this week was "squeezed in". Otherwise it would have been June before I got to see him.

Thanks for the input on raising the bpm.

I seriously doubt stopping the Atenolol will do anything. I've been on it 10 years, but my fatigue didn't occur until after the first "testing" of my pm.

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