What's Normal in the First 6 Weeks?

Hi!

by Lavender - 2023-10-02 21:59:28

I can only tell you what happened with me. I had a pacemaker interrogation in the hospital the morning that I was being discharged. 
 

I saw the cardiologist for a wound check in one week. At five weeks post surgery, I had an inperson pacemaker interrogation. The settings were adjusted then. They were also adjusted six months later, after a stress test. 
 

I have remote interrogations every six months. The alternate six months, it's done inperson. So my CRT-P is tested every three months. 
 

You might be on factory settings. My understanding is that all pacemakers can be adjusted to suit the individual needs. 
 

Your DDDR means rate response is turned on. Mine isn't turned on because I don't need it. I'm 100% dependent on my device due to AV node block. I'm set at 60-130. 
 

Settings

by Penguin - 2023-10-03 05:12:15

Is it normal for a Device Clinic to wait 90 days for the first in-person session? I'm in the UK so I will defer to Lavender's answer above. This isn't set in stone, but remote interrogations are often done because 'events' show up which need to be looked at.  This would not be unusual with your diagnoses as the implant itself may have triggered events. 

What is considered normal vs. a worrisome frequency/number of PMT events?  6 PMT events daily would certainly botther me. Note: the number on your report are the PMT events that the pacemaker has detected. This means that PMT detection has been programmed and that the device will terminate any PMT that it finds. It can detect PMT within a range of h/rates starting at 90  bpm. Check your interrogation papers it will be listed as 'PMT detection' and then a heart rate. 

Note: PMT can be triggered by inappropriate settings but PVCs, rate response settings, atrial arrhythmia, and abruptly changing heart rates are the most common triggers.  

How about AMS events?  AMS = Automatic Mode Switch. AMS events on your interrogation papers mean that the device is recognising your atrial arrhythmia and switching to a mode which will not track the uncoordinated beats down to your ventricles. That's good!  The amount of AMS events will give your doctors an idea of your arrhythmia burden. 

Note: the Assurity device will only be able to detect AT above 170 bpm on your device because you have your max tracking rate set at 150 bpm.  This is because the AT detection rate (which triggers a mode switch / AMS) has to be programmed at 20 bpm above your max tracking rate.

You can have your max tracking rate reduced if your atrial arrhythmia occur at rates lower than 170 bpm. E.g. MTR of 130 bpm and ATDR of 150 bpm. This would mean that atrial arrhythmia above 150 bpm would trigger a mode switch which 'may' reduce symptoms and capture more atrial arrhythmia. You would need to discuss how this reduction in MTR affects your exercise capacity. 

Should I insist on visiting the Device Clinic right away to have them adjust levels?  Which 'levels' are you referring to? Levels of PMT / AMS? If that's the case, it depends on how symptomatic you are and whether or not the device is detecting the PMT and Atrial arrhythmia already.  

Are my pacing and sensing levels even adjustable (the report suggests they are automatically set)?  Yes they are adjustable although the techs often leave them on an automatic setting, so that the device can work out the optimal settings for itself. 

What else might they be able to do? That's a huge question.  The Assurity device has a great many features / settings and you have quite a complex set of diagnoses. I think it would be wise to speak to your clinic at this stage.

Suggestions:

Rate response can be a trigger for atrial arrhythmia and PMT.  Maybe discuss this setting with your techs initially as it can be altered to bring your heart rate back to normal more slowly after exercise. Changes in heart rate (abrupt ones) can trigger PMT. 

I'd also ask about your atrial arrhythmia and the ATDR (AT detection rate) and the PMT detection rate for now.  

It's usually best to have one settings change at a time to see how each change affects symptoms, although multiple settings may be implicated. 

Btw you mention settings, but don't mention any symptoms.  Symptoms are usually an indication that something needs to be adjusted. How are you feeling?

Take one step at a time

by Gemita - 2023-10-03 07:02:22

Doingmybest, I see you have already received good advice from both Lavender and Penguin.  What is normal in the first 6 weeks?  Just about anything!  It will be different for each one of us depending on our condition being treated and on our other health conditions present and how well we respond to being paced for the first time?  

I struggled being paced initially and my heart rhythm disturbances were far worse than before pacemaker implant.  I too have Paroxsymal Atrial Fibrillation, as well Paroxysmal Atrial Flutter, Non sustained Ventricular Tachycardia and Multi focal Atrial Tachycardia, and these disturbances continued for several months before my heart finally settled.  Don’t forget lead tips have been attached to heart tissue and that can be traumatic for some of us and cause our heart to react in strange ways especially while our leads are settling in and before scar tissue has formed to hold leads firmly in place.  When this stage has been reached, initial higher lead settings can be safely reduced.

My clinic wanted to wait 3 months before making any changes because it can take up to 3 months to see how well we are coping, whether our settings are working well for us.  Why change anything early, when with time perhaps no further changes (except lead settings) need adjusting?  

During the first three months I experienced a worsening of all my arrhythmias and this was considered perfectly normal for me.  Numerous Automatic Mode Switches and Pacemaker Mediated Tachycardia (high heart rate events) were also seen during the first three months.  What is important at this stage is that any Atrial or Ventricular high rate arrhythmia episode is firmly controlled and that you are taking other appropriate meds like anticoagulants if needed although I see you are already on beta blockers and calcium channel blockers so these should be helping?

I would speak to your doctors for advice and ask if you need better control of your disturbances, or whether early settings adjustments are needed?  Your settings are all adjustable.  You could ask for a summary copy of your main settings and please keep a note of any changes that are made, so that if the changes don’t work for a particular setting, you will know what to ask about.  In my experience my technicians only like to change one setting at a time.  Changing too many all at once can make it difficult to keep track of what is going on with a particular setting that might be causing the problem.

You ask:  What is considered normal vs. a worrisome frequency/number of PMT events?  How about AMS events?  Be guided by your symptoms is what emergency doctors have always told me in the past.  If you are not symptomatic, the data is not always an indication that any intervention is needed.  When your symptoms tell you that you are in trouble, seek help.  If your symptoms are tolerable, then try to stay calm but seek medical advice as soon as possible.  This has always kept me safe and is the best advice I can offer you.  As an arrhythmia sufferer like yourself, you will already know when your symptoms are not well controlled.  No one other than you can possibly know what you can and cannot tolerate.  I am very symptomatic when in AF but with a beta blocker my heart is calmer and I can just about cope without the need to seek assistance but it certainly wasn’t always like this.  I was often afraid of collapsing with such high heart rates and occasionally I did.  How things have changed and I am finding my pacemaker is a great support.  I hope it will be the same for you very soon too.

My First Six Weeks

by DoingMyBest - 2023-10-03 11:05:23

Thank you all for the quick responses.

How am I feeling? It's been a range from poor to fine. The tachycardia hasn't bothered me. The PM terminates that quickly. I feel the worst when my PVCs hit 10% or more while resting. This can force my resting rate down past my base rate and can be quite unsettling. However, the PVCs have improved greatly in the last few weeks and I'm feeling pretty good at present. It helps that they've restarted me on a beta-blocker last week.

Honestly, the pacemaker seems to do pretty well considering all the arrhythmias I throw at it. I've no doubt that my PVCs trigger the PMT events. I'm not sure about the AMS. I don't know if it is an atrial event (AF or AT) causing it or the the PM getting caught in another type of feedback loop. It seems to me that the atrial sense level may be too low/sensitive and/or the VP level too high, allowing a retrograde P wave to trigger inappropriate feedback. These are things I'll ask the EP doc about today.

It's reassuring to know that it takes time for the heart to settle into a calmer state. I realize that and I try to be patient. What I'm still learning is when to self-advocate should things be getting too crazy. And what is considered "too crazy."  I don't have any personal relationship with my Device Clinic yet, and my doc tends to be a "just trust me" kind of guy who doesn't communicate all that well either. All that is a little tough on a person like me that tends toward too anxious to begin with.

You are 'on it' !

by Penguin - 2023-10-03 14:46:10

It sounds to me like I may be asking for your advice soon DoingMyBest! You clearly have a good handle on what may be causing any symptoms / problems. 

If the atrial sense level is too low / sensitive you are likely to be symptomatic. 

If the VP level is too high and there is another inappropriate feedback loop going on, I don't understand that one and can't explain it to you I'm afraid. You may very well know a lot more than me. 

I agree with Gemita that it takes some time to settle the heart down. I don't think that Gemita will mind me stating that she has a considerable arrhythmia burden.  Mine is not anywhere near as high and at lower rates.  Mine took much less time to settle down - so there is hope for some respite soon. 

I'm sure you'll develop a relationship with all of your doctors / techs over time. I've found techs particularly helpful at  resolving symptoms. 

PS: Anxiety is a very normal reaction. You've got this! 

Something like Pacemaker Crosstalk

by DoingMyBest - 2023-10-03 23:48:01

The inappropriate feedback loop I was speculating about is probably a known form of pacemaker crosstalk. The classic description I found spoke of AP-VS inappropriately causing  VP to be inhibited. This is because the P-wave propogates to the too-sensitive ventricle lead where it is wrongly interpreted as an R-wave. Inhibited VP is very serious and can be fatal.

In my case, I was wondering if retrograde conduction of an R-wave might be sensed by a too-sensitive atrial lead as a P-wave. AP would be inhibited, but in this case is immaterial. The presumed presence of a P-wave would result in triggering a short AVI period followed by another VP and R-wave. This kind of loop could result in VT or PMT.

These kind of loops are supposed to be mitigated by programmed "blanking" and "refractory" periods during which sensing is turned off. From what I've read, it is a juggling act to properly balance all the sense and pacing levels with the appropriate sensing periods. Often there are fine adjustments to be made.

Don't take my word for any of this. I'm just spewing what I've read. Kinda like a human version of ChatGPT, LoL.

Googling

by Penguin - 2023-10-04 05:58:29

Hi again, 

I see what you mean.  Blanking periods and how these settings all fit together are above my pay grade currently! It is indeed a balancing act and that's why we see technicians and EPs - for their expertise. 

I think that if you have a specific problem / set of symptoms and you are getting nowhere with your medical team, it isn't a bad idea at all to try and get to the bottom of what may be happening yourself.  Sometimes, as patients, we have more time to poke around and find out more and sometimes that can point us in the right direction. Forums like this can be super helpful. 

However, in the absence of symptoms and as a new patient it can be a great deal healthier to trust your techs / EP to sort out these technical issues for you and simply to got to them with any problems as they arise. It's their job to make you comfortable and as unaware of the device as possible, so that you can get on with life. 

A good relationship with your team can result in obtaining this information directly from the horses mouth and directly in relation to your own case and concerns. That is the ideal IMO. 

However, please keep posting for information if you'd like to.  I find your posts interesting.

Best Wishes

normal

by dwelch - 2023-10-07 04:56:51

there is pre take home box (monitor) normal and post take home box normal.

Pre-take home box normal is an office visit after a few weeks and a visit after a few months, but a lot of "normal" has gone away with these boxes.  Some folks in one country in particular seems like no more office visits at all (year after year) until the box says so.  And i suspect that is where we are all headed...

Having the first visit be a box check in the first few weeks and then an in office at a few months, does not surprise me and would not necessarily concern me.

Making Good Progress Now

by DoingMyBest - 2023-10-07 14:42:40

A week ago at cardiac rehab I exhibited a tachycardia while exercising and the nurses sent off a report to my EP. This resulted in seeing the EP this week. That was really helpful since I was able to quiz him about my pacemaker and 30-day interrogation questions. Among other things we discussed Rest Rate and Base Rate. He agreed to put in an order with the device clinic to enable my Rest Rate feature.

To my amazement, I was able to get right into the Device Clinic a couple days later. The tech was very friendly and helpful. Not only did we enable the rest rate feature, but we discussed other issues seen in the 30-day report. He did an on-the-spot interrogation with the Merlin PCS system and confirmed recent events, He checked sensing and pacing levels and then extended my PVARP setting to address the PMT events I'd been having.

I mentioned that they really need to schedule an orientation session with new patients within a short time after their implants so as to educate us on where they are, what they do, and what we can expect - particularly given how stressful and anixety provoking this period is. He agreed, but shrugged and said he suspected it is an insurance issue. Disappointing answer.

Anyway, there is a lesson or two here. For those with arrhythmia issuse like mine, I recommend getting into cardiac rehab where you are monitored and you can stress yourself in a controlled environment. Better to discover your limits there than to be left wondering what you can and can't do. Secondly, if you are clever enough to realize you have a disabled feature you'd like turned on, you should be able to use that as an excuse to get into the device clinic early rather than having to wait 90 days or whatever until they normally get around to you.

I'm much happer today that I got some attention and am no longer feeling as though I'm dangling, waiting for 90 days until someone will see me.