settings

Following up on the postings explaining DDDR etc
Can someone explain the Rate Optimization function on my Medtronic Adapta DR
Settings,,,
Optimization On
ADL Response 3
Execrations Response 3
ADLR Percent 2.0%
Activity Threshold med/low
Activity Accel. 60 sec
Activity Decel. Exercise
High Rate % 0.2%
ADL Rate Setpoint 61
Upper Rate Setpoint 151
In another section of the report it states
RATES:
lower 60 upper tracking 140 , upper sensor 140
ADL Rate 95
I feel when I run that after 20 min or a certain exertion level my PM detects something and makes a calculation and adjusts so that I cannot continue at that same level, therefore forcing me to slow down or walk, after this it's a on/off battle to fight through my runs till I'm done,,,,
Thanks if anyone can explain, or even comment to what might be happening based on these settings and what I might ask for
They tell me they have worked with runners but each time it's trial and error ????

8 Comments

Response

by PacerRep - 2013-09-20 02:09:21

Your response 3 is a pretty low setting, not very aggressive. There is a bunch of data missing here for me to analyze how everything is reacting and I would need to see the histograms.

If you are fatigued, you can request to have the slope changed for your Rate Response to give you more cardiac output.

Unfortunately the activity sensor's in medtronic devices are pretty inferior to what the other guys have, but have them keep tweaking it, they maybe able to get it better for you.

PacerRep

by golden_snitch - 2013-09-20 04:09:32

What would you consider to be the best sensor, minute ventilation + accelerometer? What are your experiences with closed-loop stimulation?

I can no longer have MV + accelerometer, because the MV sensor doesn't work with epicardial pacemaker leads. So, I'm now considering CLS or the Adapta, because at least the Adapta's accelerometer allows for manual optimization of around 9 different RR-parameters; in my Sorin Reply you have only three that you can work with. I guess from all the accelerometers manufacturers use, Medtronic's is rather advanced, or am I wrong? I heard one EP say that since I had SA and AV-node ablated, I should be the ideal candidate for CLS.

Your input would be greatly appreciated. Thanks a lot!

Inga

Are both of your leads epicardial?

by PacerRep - 2013-09-20 09:09:44

Personally the blended sensor of the MV and G sensors is the best (accelerometer). Your Sorin has more than 3 settings. They have

Very Low
Low
Medium
High
Very High

The reply can have

G only
MV only
G+MV.

Sorin also has an "automatic" mode, which in my experience is the best damn sensor algorithm on the market today. I very rarely need to optimize a Sorin device, I just use the "auto setting". If I understand it correctly, it takes readings at rest and peak exercise and customizes your slope to your own specific exertion, its works really really good.

CLS is a good sensor as well, it looks at how the heart physically contracts. I would say that it is inferior to MV in terms of peak exercise...but for neurocardiogenic syncope it is the best sensor.

You only need 1 lead to be endocardial for MV to work. I am rather surprised having the Sorin Reply that the tech can't figure it out for you....I love that devices algorithm, I wish they would clone it all devices.

If your going to be G only, your not going to get better results with an adapta.

Manual

by golden_snitch - 2013-09-20 10:09:26

Hi!

Please have a look at the Adapta Manual at:
http://www.medtronicfeatures.com/wcm/groups/mdtcom_sg/@emanuals/@era/@crdm/documents/documents/wcm_prod064182.pdf

The rate response features start on page 35. Every parameter and option is explained in detail and in a language even someone who's not a technician can understand.

Hope this helps.

Inga

My experience with the Sorin...

by golden_snitch - 2013-09-21 01:09:35

Thanks!

Yes, both of my leads are epicardial, and there is absolutely no way that I get a new transvenous lead. I So, no MV-sensor for me. It has to be accelerometer or CLS.

The only three settings you can change in the Sorin rate response are:
Level of activity (very low, low etc.)
Automatic or fixed
Choice of sensors
(and of course the upper/lower rate)
That's what I meant. In an Adapta you can also program acceleration and deceleration for exercise and for the ADL, and you have an ADL rate (Sorin doesn't).

The automatic optimization doesn't work well for me, because whenever I don't exercise for a few days, the pacemaker will lower the level of activity automatically. In my case that leads to tachycardia whenever I start to move. At the moment, my level of activity is set high, because with every setting that is lower than that, I'll end up at my max. upper rate in no time and with just daily life activities. I walk down the stairs, cross the street, and my heart rate is up at 160bpm (paced). This rate response really sucks. It's way too sensitive.

We have tried all settings, I spent quite some time with a Sorin tech on the phone, then we had a tech come in to adjust the settings, but nothing works. We have to program a high activity level, and set the mode of response to "fixed", because otherwise I'll get inappropriate tachycardia whenever I move around.

Doesn't matter how high or low you program the upper rate, the pacemaker will always end up there with minimal exertion. And I need an upper rate of around 160bpm, because I go running, and I'm only 32.

Another problem with the Sorin accelerometer: When I climb the stairs, my heart rate decreases. I'm getting arrhythmias now whenever I walk some stairs, because the rate response doesn't react, and then my heart starts producing PVCs/PACs.

So, sorry, but the Sorin accelerometer sucks. The MV + accelerometer works great - when I got my Sorin I had one transvenous lead and one epicardial, so back then it worked well (then the transvenous broke) -, but the accelerometer only is a nightmare. Personally I believe that something is wrong with the sensor, but although the Sorin people say that they haven't seen their RR behave like mine does, they also keep saying that the sensor is fine. One of the techs told me that he once had a patient in whom they had to set the activity level to very low and fixed, because with all other settings his heart rate would not increase at all. I have exactly the same pacemaker, but the problem is the opposite: My RR races with minimal exertion, if you don't set it to high/very high activity level and fixed.

I hope you understand what the problem is. Great that you're having no trouble with your Sorin patients, but I'm really fed up with this RR.

Best wishes
Inga

Yeah this is an Anamoly

by PacerRep - 2013-09-21 09:09:35

I haven't seen this kinda problem with the Sorin, but if you say it's so I believe you.

My experience with ADL is that it doesn't work any better than the other's. So based on your situation I would highly consider the Biotronik device, CLS will work with epicardials. The new devices Sorin has have 5 fixed settings, although it doesn't sound like it would matter in your case. That battery in the Reply seems to never want to die, how much longer til you can get a new one?

Replacement

by golden_snitch - 2013-09-22 04:09:53

Hi!

That's what I keep hearing from everyone, except the Sorin people. And we have really tried every setting. Even the Sorin tech can't explain what's going on. We also found out that the pacemaker saved very old RR data, and - while still in the automatic mode - worked with those to adjust the RR. After a RR-reset, with exactly the same settings, all of a sudden I had on average 10-15bpm less than before the reset. Like I said, personally I think that something's wrong with the sensor/pacer.

My Sorin was implanted five years ago, and has about 5 years of battery left, although it's pacing 100% in both the atria and ventricles. So, yes, the battery is a good one. However, with the RR failure, I'll be able to get a new pacemaker when I need it, and not only when the battery runs low. EP already stated that he's willing to replace it this year, but he also says, if we do that, we need to be sure that the new model fits my needs better and will really do a better job with regard to rate response.

I got in touch with an Italian EP who published a case study on CLS in a small infant with epicardial leads. He told me that he implanted this system in two more kids, but the thing with small kids is that they can't really say, if the RR works well for them. He's currently looking for a patient like me, with AV- and Sinus node dysfunction + epicardial leads, to implant with a CLS, because he thinks I'm the ideal patient. I'll definitely not let him do the implant; my EP here (Germany) is also considering CLS, so he can do it, no need to travel to Italy.

I just don't like the idea of being the guinea pig. Since 1999 I have had 8 catheter ablations, 6 pacemaker surgeries and one open-heart, and most of these interventions were trial and error, because I'm such a rare and complicated case. If they are going to replace the pacemaker now, I need something that works.

Thanks again for your input!

Inga

Best of luck

by PacerRep - 2013-09-22 10:09:33

Sounds like an interesting case. Worst case scenario with the Biotronik is the CLS doesn't work and your just back to the G sensor you have now. It can't get worse.

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