Managed Ventricular Pacing

Why minimize a needed therapy?

by Terry - 2021-03-25 13:48:21

The reason to minimize V pacing is to prevent what your doctor calls "pacing induced cardiomyopathy" due to ventricular "remodeling" when bypassing the cardiac conduction system (the His/Purkinje system). More recently, doctors are now activating the cardiac conduction system by pacing it at the His bundle (or sometimes at the left bundle branch). By eliminating remodeling, they intend to eliminate "pacing induced cardiomyopathy" while pacing as much as is appropriate, for natural, physiological ventricular activation / contractions.

No super informed pacemaker settings person here John . . .

by Gemita - 2021-03-25 21:25:53

but looking at it simply, it seems to me that with your block condition and with the settings you currently have - especially the long AV delay/PR interval - these would seem to be the likely reasons for your high percentage of right ventricular pacing rather than a poorly functioning MVP (managed ventricular pacing) feature, wouldn't you say?  However it does question the value of the MVP function in the first place in a total block situation and how it should be set but you are clearly not there yet.  Good question for your EP though.

If you need heavy right ventricular pacing support John, you obviously need it.  Perhaps your block has progressed?  Blocks like all electrical disturbances can fluctuate.  I recall a member noticing a massive reduction in her % right ventricular pacing over a longer period whereas initially at start of her pacing, her % pacing in the right ventricle was much higher and worrying her, similar to your situation now.  I believe your period of monitoring up to your last download checks was only brief (? a few months), so it could well be that a longer period will show very different % right ventricular pacing figures.  So yes, give it time and do not be in a hurry to change too much at once.  One setting at a time.  

And remember that while our pacing percentages may fluctuate what really counts is how we feel.  If I feel unwell with bad symptoms, this would concern me more than my % pacing figures, although you are clearly not symptom free are you so perhaps heavy RV pacing doesn't suit you and is causing some unwanted symptoms.  At least you can now start to get answers John.  How many parameter settings were you sent ?

all parameter settings were sent

by quikjraw - 2021-03-26 07:33:46

Hi Therese,

I was sent all the Parameters

I can see that a lot of the settings are simply the default settings which I assume is something that they always start with.

For example my Paced AV is 180ms and my sensed AV is 150ms. If I remember rightly this was exactly the same as yours? Clearly my PR interval is sometimes as long as 400ms so I would have expected to have a longer paced AV.

Thanks

Parameter Settings

by Gemita - 2021-03-26 08:31:08

Hi John,

Yes I was just trying to get an idea of how many A4 pages of settings you might have received by Email.  I know my clinic doesn't usually like to send by electronic mail because of patient confidentiality.

I can share with you by private message my full summary sheet information whenever you wish, although the info I have seems to be mainly about the Leads.  Can you see on your data where your RV lead was placed:  septal area ?

Yes my bradycardia parameters are:

Mode AAI to DDD

Mode Switch On

Base rate 70 bpm

Upper tracking rate 130 bpm

Upper sensor rate 130 bpm

AV delay (sensed) in (ms) 150

AV delay (paced) in (ms) 180

Rate Adaptive Yes

Aai or aair

by quikjraw - 2021-03-29 11:02:56

Hi Therese

I appear to have settings in the RR section but it cannot be switched on as my mode is clearly set to AAI DDD not AAIR DDDR.

Would you agree?

 thanks John

AAI OR AAIR

by Gemita - 2021-03-29 15:49:29

John,

If RR is on they usually record it as AAIR<=>DDDR.  Mine is even recorded as AAI<=>DDD, so that makes me wonder if my RR is switched on, although they clearly say Rate Adaptive Yes.  

From your parameter settings sheets in Gallery John, I can clearly see your mode being AAI<=>DDD.  It doesn't mean that RR cannot be switched on. It  just looks like your RR is switched off and in your settings parameter sheets it clearly shows this under AV therapies:  Rate Adaptive AV, Rate Response:  Off.  Did they tell you it was off or on?  I thought they mentioned it was off, then on, but from your settings sheet it is clearly showing as OFF?  

Were you able to open my email settings file?  

Therese

AAI

by quikjraw - 2021-03-30 04:34:37

They said it was OFF but then I saw values in the section which suggested it was ON

I now think that looking at how they programme the settings it RR can only be on if the mode is set to something with an R in it. If you don't have an R in your mode it is RR is not on would bey conclusion.

I did not receive your settings by the way Therese only Frank's advice sheet.

I will post in the gallery John

by Gemita - 2021-03-30 05:23:42

I didn't send my own summary sheets by email, only my correspondence with Frank (2 pages sent) since I thought this would be more interesting/relevant for you.  I will post my summary sheets in Gallery in next hour or so.  I will also post my full pacemaker parameter settings when they are received.  

Hope you found Frank's comments reassuring that Medtronic can give us what we need?  I did since I was beginning to think that we were limited with a pacemaker from Medtronic?

Yes John we think the same, (I think) without the final R displayed/shown at the end of the mode we are operating in, say AAI would be displayed as AAIR, this would signify RR is not switched on.  However my notes clearly tell me that my pacemaker is rate adaptive and I was told RR was on, but until I receive my parameter settings I cannot confirm this and I am beginning to think it may not be on afterall now.

update

by Gemita - 2021-03-30 06:08:33

John, settings (2 pages) now sent by Email

Received

by quikjraw - 2021-03-30 06:36:44

Therese

I have received them thanks and I think what you sent through is not a Medtronic output but manually filled in sheet?

I understand that rate adaptive is associated with Rate Adaptive AV response ?

John I believe you are correct in all respects

by Gemita - 2021-03-30 07:05:32

John I have just re-read your details in the Gallery and yes, you are correct.  Your RR  details are clearly shown, so your RR must be ON and yet they do not show the R under your Parameter Summary, since your Mode is shown as AAI<=>DDD (like mine), so "why not" show the R?  Perhaps it is just the way they display things.  The Rate Adaptive AV therapies for you is clearly shown OFF.  I wonder if this is an area which needs questioning too (whether it needs to be ON for you?

Yes it looks as though what I sent by email is pacemaker clinic generated following my Pacing & ICD check on 6.7.2020 rather than being direct from a Medtronic output.  Yes Rate Adaptive is associated with Rate Adaptive AV response, but you might like to read the Medtronic Academy link below for further explanation.

John I have now written to my EP's secretary and I am sure I will be hearing from her soon, so I will hopefully be able to send more info.  Well you have certainly opened my eyes a little more, so thank you.

https://www.medtronicacademy.com/features/rate-adaptive-av-raav-feature

MVP

by PacedNRunning - 2021-04-05 00:17:08

I studied this also. From my understanding MVP should be used for patients with SND or SSS to minimize RV pacing.  Since you  pace 86%, it should be off because you shouldn't attempt to minimize pacing in higher grade blocks.  Interesting. It's really just a waste of battery switching back and forth.  I don't have fixed delays. I have dynamic it's dynamic from 160-80ms with a HR range of 50-185.  HOpefully they have the rate adaptive delay set on yours also.