Pacer v. Life Style

I am a 72-year young 40-year road racing bicyclist. Currently, during the summer season, I ride, every second day weather permitting, a rigorous 30-mile loop which includes several 1-mile to 1.3-mile ascents (6 to 8% grades) and numerous lesser ascents. The 30-mile loop is accomplished within two-hours. During the winter season, I lap-swim and cross-country ski.

In 2009, during a routine physical, an intermittent atrial flutter was revealed. A month later, an ablation procedure was performed which resulted in four-second heart pauses. After an angiography revealed a strong heart muscle and clear arteries, accompanied by excellent blood lipids, a two-wire St. Jude pace maker was implanted. After approximately one-year, the St. Jude pacemaker was replaced with a Medtronic’s Adapta which paces the ventricle only when required… less than 10% of the time.

However, neither of the pacers responds to “respiratory” rates resulting in lactic acid buildup and muscle fatigue during exercise periods. Medical staff suggested “tapping” on the pacer to increase the heart rate, but that requires almost constant tapping, unsafe riding/skiing conditions and virtually impossible during lap-swimming. Additionally, the pacemaker’s representatives do not endorse “banging away” on the device… (seems like a primitive method in our age of technology, in my retired engineer’s opinion!).

Various tweaking of the Adapta has resulted in either marginally higher BPM for bicycle riding, but with very uncomfortable conditions during regular daily and “at rest” activities (or) comfortable daily and “at rest” times, but with 30-35 BPM slower on bicycle rides, unless I’m banging away on the device. In my lay opinion, it appears that the current device does not have the functional range or capabilities to match my active life style.

Recently, I read a number of positive comments regarding Boston Scientific’s “life style adaptive pacing technology” and “chrono-tropic competence” systems. During research, it appears that the Boston Scientific Altura 60 also limits unnecessary ventricle pacing.

However, in discussing the medical feasibility and potential benefits, not only for my exercise regiments, but also for daily activities, my E/P first invoked the potential of procedure infection and secondly, did not feel that the ventilation response technology was of justifying benefit for a change-out.

I would welcome all medical and user experience advice and comments.

Thank you…

5 Comments

Pacer v Lifestyle & cycling

by philip.thecyclist - 2013-09-15 06:09:19

I'm a 69 year old life-long cyclist & ex-racer, and I've always tried to get the best out of my 3 PMs since I had my first one 17 years ago. I can confirm that since I've had first a Guidant and now a Boston Scientific PM with dual sensor pacing there has been significant improvements in my cyling. These PMs have what is known as Minute Ventilation (MV) sensor as well as the conventional accelerometer. The MV sensor responds to your rate of breathing by monitoring the changes in impedance across your chest. With my earliest accelerometer-only PM, the lack of upper body movement during cycling limited the pacing response, and the compromise was to have the response set at a quite sensitive level, which meant I got inappropriately high pacing rates on occasions when I was not expending much energy. With my current PM, a BS Inliven CRT-P, the overall response is much more natural. On occasion, I wear a heart rate monitor, and I can see how the pacing rate matches much more closely my changes in breathing, and I get less breathless climbing hills than in my pre-MV days. I must say, though, I can't perform at anything like the level at which I could prior to having atrial fibrillation followed by AV nodal ablation - I've just had to accept that.

I understand why your medical team might be reluctant to change your PM unless it is really necessry. In my case, the MV PMs where impanted when I needed new devices anyway. As you are being paced only 10% of the time, does this mean that any improvement you get may not be significant enough to risk a change?

Philip

Interesting

by mike thurston - 2013-09-15 08:09:05

I am 61 yrs old and road ride and mountain bike. I do not ride at the speed you guys are riding and let me say it is very impressive to say the least. I am totally ablated, PM dependent, have defibrillator, a stent and lost 1/3 of heart muscle. I am also in permanent a-fib and have been for some time now. A year ago January I had my PM replaced (Medtronic) and for a year I had to do the tapping thing or it would not go beyond 100 bpm. Finally this past Jan. I asked to have the Medtronic Tech present and took my oldest son with me for back up :0) They had me walk around the building and after several attempts he could not get it to respond. He called the Medtronic people twice at which point we got things working. I made 1 additional visit to tone things down just a little. My performance is definitely improved but I drop into granny gear on any substantial hill and spin my way up. If you can get atop notch tech. involved. My settings are 80bpm to 150 bpm. Last visit my EP talked about using a St Judes with minute ventilation next time. I for sure struggle walking or riding uphill.I also take an Ace Inhibitor, a Beta Blocker and and a Calcium Channel Blocker. These probably hold me back the most but I am afraid to mess with the meds my Doc recommends although I did cut the Beta Blocker to 1 dose a day instead of 2.

Pacer v life style

by Jackcoul - 2013-09-25 05:09:22

This is an interesting conversation. I am in the same situation. I'm 74, and an avid cyclist mostly mountain bike and I do some racing. I have had my Medtronics pacer for a little over a year (for bradycardia only) and am not happy with it. It does just fine on the low setting (60bpm) but under heave exertion it stops my rate at 150bpm and I know this is holding me back. I just sent a request to my cardiologist to have it changed to a Boston Scientific but I'm afraid medicare may not approve it.
Jack Coul

Rate response or not rate response

by Blecha - 2013-09-26 07:09:36

Hi, rdman,
My question is: Why you need the rate responsive mode ? What is your diagnostic ?

I am in a similar situation: few days after (over)burned flutter (end of August 2013) I was back to hospital with sever bradycardia <30 BPM, 5 seconds pauses and AV block of 1-st degree. I was always slow ~40 but this time it was too much. Less then week later I was fitted with Sorin Reply DR pacemaker. The surgeon left my device to base rate 70 (factory) without rate response (RR), than the local Sorin Dr. to 60 WITH RR made me uncomfortable since the BPM raised to 120 as soon as I walked. Eventually my Dr set it to 50 base rate without RR, i.e. technically speaking mode AAI/DDD. Note that RR is based on the ventilation measurement + accelerometer.

Now, after 4 weeks under PM I increased my exercise to 400m denivelation rapid uphill walk with BPM ~120 which for me used to be around 225 Watts. I feel well under effort when supposedly the PM is just listening but when going downhill as soon as I am close to the base-rate of 50 BPM I could be sometimes quite unwell, dizzy close to fainting. This state disappears after 10-20 minutes. My blood pressure is close to normal in this situation (100-110/70 mm-Hg).

Update to 2013-09-15 Post

by rdman - 2015-04-12 03:04:33

(To further clarify my 2013-09-15 post, the RF ablation for the intermittent atrial flutter that was performed in 2009 also resulted in an apparent “over-burn” 1st degree AV Block.)

Subsequent to my 2013-09-15 post, one year later, I again mentioned the Boston Scientific pacemaker (BS) with Minute Ventilator (MV) sensor to my E/P. Since he had poo-pooed it in 2013, I was very surprised when he now enthusiastically endorsed the MV sensor feature for my active life and agreed to schedule a pacemaker exchange during the following month.

Since I felt very good with the Medtronic Adapta (except that I could not attain a heart rate to match my rigorous bicycle rides without banging-on-the-can), at this point, I asked a number of questions including… did BS’s algorithms match Medtronic’s Managed Ventricle Pacing (MVP). The E/P stated that BS was virtually the same. Satisfied that the BS pacer would mimic the Medronic including their MVP algorithm, the BS pacemaker implant date was set.

Following the BS implant and initial settings, I felt lousy… chest pressure and discomfort, throat sensations, PMT, PVC’s, palpitations. Thinking these symptoms would resolve with further “tweaking,” I went through at least six comprehensive adjustments with senior technicians without significant improvement. It was during these adjustments when an very knowledgeable, independent pacemaker technician informed me that “virtually the same” is not the same thing as identical, explaining that BS’s methodology to pace the ventricle only when necessary is very different from Medtronic’s patented, proprietary MVP. While the Medtronic was pacing at about 10%, the BS was now pacing the ventricle at 40% more.

During subsequent consults with the E/P, he agreed to remove the BS pacer after just four months and re-implant another Medtronic Adapta with MVP (four pacemaker implants within the last six years). However, at virtually the 11th hour while I was in surgery-prep, the E/P informed me that he was going to conduct an E/P mapping study instead of more “guess-work!”

After the five-hour mapping procedure, the E/P informed me while I was still foggy from sedation, then later when I was clear-headed, that the mapping study had revealed retrograde circuits in and around the AV node and dis-synchrony between the right and left ventricles. He proposed the following:

* He would attempt to ablate the source of the aberrant circuits within the AV node utilizing the cryogenic method which is more precise and forgiving than the RF method.

* Since he felt it was a long-shot to isolate the exact “sweet spot” on/in the AV node, the only other option would be to completely ablate the AV node which would result in total pacemaker dependency.

* If total dependency would result, a Medtronic CRT-P, 3-wire would be implanted. The 3rd lead, which was described as a very fine, thin wire, would be attached on the right ventricle septum wall near the ablated AV node.

Aside from not fully understanding how this array works and having a very difficult time mentally having to go totally depend as apparently the last option, I have several other concerns.

* The original St. Jude leads are going on six years old. About a year ago, I was informed that the ventricle lead had slightly backed out of its attachment requiring signal strength adjustments. The recent mapping study revealed that this lead is not optimal.

With the advent of the Spectranetic power laser sheath that now provides safe extraction of old leads, would it not be good practice to remove these old, non-optimal leads and replace them with new leads?? This procedure is relatively new and requires highly skilled experience.

* The cryogenic ablation method also requires highly skilled experience. I have been informed that as of a month ago, my E/P has used the cryogenic method just one time.

I would be very appreciative and thankful for all members who wish to offer counsel, advice and support. Is total dependency my last option??? Thank you all!!

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