Help interpreting report

I am soooo confused with the pacemaker report. And after searching for answers online, I'm even MORE confused! Hoping someone can help interpret what all this means.

At the clinic today they made several adjustments.

To catch you up on me and my trials/woes: I've been having problems with fatigue/lightheaded since my implant 2 years ago. After a year of trying to correct it, I gave up and stopped seeing my EP- just sent in my quarterly downloads. With the new year I decided life was too short to waste it sitting in a chair, so I am "interviewing" EPs in hopes of finding a good one.

Feb 14 (ironic, right?!) was my first visit with the EP. Met with him and then did the clinic where she changed my rate response from med to med high. Not sure if other changes were made. I was told I did not need to return to the office unless I had a problem.

Monday I got a call saying that after reviewing the records from my previous EPs, the doc wants to activate the Winky Bock feature, so I need to come back. I had an MRI at the hospital that afternoon and told the Medtronic tech, so he activated it. But I went ahead and kept the appt to see the EP b/c I was getting more bouts of near syncope.

(The report from the hospital tech says the mode was changed from AAIR to DDDR, and Sensed AV Interval was increased from 250ms to 260ms. Not sure what these mean, so maybe it's just because of what he had to do to the pacemaker to allow me to get the MRI)

Today was the appt with the clinic. Even though I asked, they did not put the rate response back to med.
What they did do was
*increased lead impedance for atrial from 432 to 488, and *decreased ventricle from 544 to 488.
WHAT??? Why would they do that? I guess I understand you want both parts of the heart equally impeded, but I don't get why this wouldn't have been done at the initial clinic.
*increased measured P/R wave for atrial from 5.9 to 7.0, and
*increased ventricle from 7.9 to 8.6
No idea what this means
*changed mode from DDDR to DDD
No idea why this was changed, and how this will/will not affect me.
*lowered rate from 60bpm to 50
I would think lowering the bpm threshold would increase my odds of being fatigued. When I was at the initial clinic the tech and nurse discussed putting it at 70. So I'm confused as to why the EP would want to lower it.
*lowered paced AV from 300ms to 200
*lowered sensed AV from 260ms to 180
I'm guessing this was done to make the pacemaker more sensitive to missed beats, and to react to said beats

I know many of you will tell me I should have asked the nurse what changes were being made, and why. I did. The only thing she said was "He wants to turn off the rate response, and I don't know why". Only after I read the report did I see that other changes were made.

Sorry for the long post. I have a gazillion other questions, but feel these are the most important right now.
Thanks for any and all help!!


17 Comments

answers

by Tracey_E - 2014-02-28 07:02:28

It took me years to figure out that Winky Bock (exactly how my rep and cardio pronounce it!) is Wenckebach
http://en.wikipedia.org/wiki/Second-degree_atrioventricular_block

Most of the rest is over my head but since no one has jumped in yet, here goes what I nkow...

DDDR to DDD, R stands for rate response, so they turned it off.

impedence has to do with how much juice it takes to get the pm to make a signal that makes the heart beat. I think that's what it's called, someone will correct me if I'm wrong. They like to adjust it so it's as low as possible to conserve battery life. This can change over time as scar tissue builds, and I think some reps just pay more attention to conserving power than others.

Do you have just av block? If yes, then you probably don't need or want rate response on. RR is for when the heart doesn't go up on its own with activity, then it paces the atria.With av block, the atria works just fine, you only need the pm to make sure the ventricles beat when the atria does. RR can interfere with your own sinus rate (atrial rate) and make you feel bad.

If you only pace ventricle, lower limit is irrelevant so turning it from 60 to 50 would be, my guess, for battery preservation.

Does it say somewhere the percentages atrial paced, atrial sensed, ventricle paced, ventricle sensed?



Tracey

by Ck - 2014-02-28 07:02:57

Thanks for your reply!

Yes I have heart block. Today they also said I have sick sinus, which I had NEVER heard before! I think they're wrong, but the tech was looking at my records on the computer and said "yeah, you also have sick sinus." Amazing that no one ever told me that....

I had read up on Winky Bock. Basically another arrhythmia. I already have PVCs and PACs, so what's one more, right?! Lol!
What I don't know is if they turned the feature on or off. When the nurse called on the phone she said "you don't need that", but when I was at the hospital the tech said the feature would now help with the Winky Bock.

My concern with the impendence is that it wasn't "even" between the two chambers, so why change it now. And I couldn't care less about battery life. My concern is feeling better. This sitting in a chair all day is crap!!
So if they changed it only to conserve the battery I'm gonna be doing some fussing.

I asked the nurse what percentage I was pacing and she said with Mondays change I was 76% atrial and 29% ventrical. Thought that was strange since the problem is with the bottom part of my heart. But them again, I didn't know I had sick sinus until today....

Thanks again!

Impedance

by Theknotguy - 2014-02-28 09:02:07

It takes a certain amount of power to push electricity through a wire. If you don't have enough power the electrical signal will just disappear. Then, when the electricity to the end of the wire, does it have enough power to make your heart beat? So the amount of resistance in the wire and the amount of resistance at the end is impedance.

Looks like they balanced out your atrial and ventricle impedance. You need more power in the atrial and less in the ventricle. Why that is, I don't know.

Hope this helps.

Theknotguy

How are you

by Jonny - 2014-02-28 09:02:11

All way above my head Ck, but the main question is do you feel any better for all this messing around? Best of luck. John

Jonny

by Ck - 2014-02-28 10:02:20

Lol! Glad I'm not the only one who is confused by all this cardiac talk!!!

Not feeling better, but it's only been a few hours. But I'm not feeling worse!

asfasf

by boxxed - 2014-02-28 10:02:35

Okay, there's some stuff that I think needs clarification. I'll just start going from top down about stuff I see.

First impedance is not a programmable setting. It is a measurement. Slightly varying impedance values is no different than having slightly different values when you have lab work done. It measures the resistance down the lead. If say there was a fracture of the lead, impedance goes dramatically up. If there is a breach in the insulation, impedance goes dramatically down. A "normal" value of impedance is inbetween 300-1500. I would not worry about impedance unless there is a sudden and dramatic shift. It doesn't matter too much whether the number is on the high side, or low side, or if one impedance is higher than the other. What matters is that they stay consistently the same (relatively), inside the 300-1500ish range, and no dramatic swings.

"*increased measured P/R wave for atrial from 5.9 to 7.0, and
*increased ventricle from 7.9 to 8.6"

The quoted above is also a measurement. It's not a programmed setting. It is measuring sensing capability of your leads. If the numbers are very small, then it would suggest that the ability for your leads to sense have diminished, and this could lead to alot of quirky things with pacemaker function. It could also (potentially! not always) suggest lead damage and then someone has to look at impedance and capture to see how well the lead is functioning. As an FYI, I would consider a P-Wave > 2mV is good. And a R-Wave > 5mV is good. Again, the whole idea of relatively consistency plays again too. I would be okay with an R-Wave of 3mV if it consistently stayed that way and it didn't hinder pacemaker function. I'd be more concerned about a drop from 20mV to 5.5mV. Or a slow but steady decrease downwards.

I am not exactly sure what programming setting they are talking about that addressed Wenkebach specifically. That's the problem with talking to varying people who have varying understanding of devices who talk to patient's in varying degrees of complexity. From the way you described it in the OP, you almost suggest that the MDT Tech answered your request about the "Winkybock feature" @ the MRI Test center, and then turned on MVP Mode. Which is (AAIR=>DDDR).

MVP is a mode that switches between AAIR and DDDR back and forth as needed. It's a mode that tries to promote intrinsic conduction, and gives your heart a longer of a chance to do the work itself before it jumps in to intervene. The fact that he also increased the AV Delays also seems to suggest that they're trying to promote intrinsic conduction/reduce RV Pacing.

And that's all I'm sure about. None of the rest really makes sense to me. I think they're not being overly generous with information, and that you're also talking to various people, who all have a varying understanding of devices. And it sounds like the people you are talking to are giving you differing levels of "patient talk". I would really consider just sitting down with your EP and clearing everything up from beginning to end, and ask for a rationalization for these changes and the thought process to revert some of them. Because I think you're just going to end up going around in circles with differing input from multiple people and just end up horribly confused, and potentially mis-informed.

If you have any more questions, by all means fire away.

the million dollar question

by Tracey_E - 2014-02-28 10:02:44

how do you feel since the adjustments? If you feel better, then they're on the right track.

You won't feel the difference if they made little changes to conserve the battery. It's a good thing. If they can set it to eliminate unnecessary pacing, that's also a good thing. Turning off RR and lowering your lower limit will both reduce unnecessary pacing, which is better for your heart, assuming you feel good. If we need paced more, so be it, but on our own is always best.

76% atrial pacing sounds like SSS or maybe inappropriate RR pacing. Will be interesting to see how you do with it off. SSS, if you haven't looked it up yet, is when the sinus node gets lazy at rest so your resting rate will drop. Often it jumps back up as soon we get active so for SSS where they put your lower limit is important because that's how low it'll let you get before pacing.

If it doesn't go up appropriately with activity, that's called chronotropic incompetence, that's when RR is helpful.

Wenkebach is a type of av block, I don't understand the details of it but it has to do with where the signal breaks down. All av block is the signal not getting from the atria to the ventricles, but it can get lost at different places.

It's not at all uncommon to have a little bit of several conditions. Some things may be intermittent, some may be all the time. It's possible to have atrial problems but we didn't know about it because the block hid it. With the block, we don't really know what the atria is doing unless we're on a monitor because the signal isn't getting through and being reflected in our pulse. I have other things aside from the block I was born with, didn't know about it until I got the block fixed with the pm then passed out at the mall one day. Oops! Now we know sometimes my atrial rate takes a nosedive at random. The pm is programmed now to not let that happen.

What it comes down to is the heart's electrical system is out of whack, sometimes the problem is simple, sometimes it's a mixed bag. The good thing whatever problems we come up with, the fix is all the same- the pm- it's just a matter of getting the settings figured out. No two of us are alike, and having more than one thing going on complicates things so often a lot of it is educated guesses and trial and error. It really sounds to me like your new doc is on the ball and trying to fix it. If you don't feel better, don't be shy about calling and asking to be seen again.

My current settings took half a dozen trips back, two treadmill tests, the rep researching the database with other reps, and finally faxing my mile-high stack of records to SJM to make me a case study. The engineers that designed it had a powwow and came back with recommended settings. All of the reps under my main rep are afraid to touch me :) They may do the check, but if anything is the least bit off they pull out their phone and calling my main guy. Even my doc is afraid to touch it, everyone defers to main SJM rep because he's the only one who understands all the nuances of my programming. Not everyone is this complicated, just letting you know don't give up hope. Just because it's not simple doesn't mean it can't be done, it just takes time and patience and someone willing to work at it.

Impedance, I think it's dependent on the lead and where it's placed. Pretty sure keeping the two leads the same is irrelevant. If one is in a great place and the other is in a so/so place, they will have different needs. If one has a lot of scar tissue and the other does not, etc, etc.

You asked for it!

by donr - 2014-02-28 10:02:50

This Comment has been edited significantly on 7 March 2014. There were significant errors in its original version.

Ok, here goes. I've talked w/ three Cardio nurses I know well, so they level w/ me & tell me if I'm all wet, just damp, wet behind the ears or dry as an Arizona August.

Here's what I see in your report, in the order you reported in in your post (Oh, BTW: Thanks for all the detail!):

YOU: (The report from the hospital tech says the mode was changed from AAIR to DDDR, and Sensed AV Interval was increased from 250ms to 260ms. Not sure what these mean, so maybe it's just because of what he had to do to the pacemaker to allow me to get the MRI)

ME: AAIR = Atria paced, Atria sensed, Atria Inhibited, Rate Response ON. Means that the capability of the PM to pace the Atria in turned ON; the PM senses what is happening in the Atria as far as voltages are concerned; the Atria pacing capability of the PM is STOPPED (Inhibited) when the PM senses electrical activity in the Atrial area. And the Rate Response is turned ON.

I was ALL WRONG in my first discussion. Here is the CORRECT interpretation of the report: Since you have a DUAL chamber PM, you NEED TWO different defined AV delays for the PM to function. Paced AV & Sensed AV delays. They are BOTH adjustable. The Paced AV Delay is always LONGER than the Sensed AV Delay. Conceptually, everything I told you before is correct - just that the details were dead wrong. A sketch of an ECG plot would be helpful here. But - here goes: If the Atria are contracted by the heart's P wave, timing starts essentially at the wave's HUMP. If the Atria are contracted by the PM spike of voltage, timing starts at the spike - which ALWAYS comes at the spot where the P Wave would start increasing, so it's a longer time.
Apparently the Sensed AV delay was increased from 250 to 260 milliseconds (1 millisecond = 1/1000 second. SO, that means it is about 1/4 of a second between the time the Atria contract & the Ventricles contract WHEN your heart's Atria are working on their own. This makes no sense to me - My Sensed AV is 120 ms when my HR is somewhere above 75 BPM (my base Rate).

YOU: Today was the appt with the clinic. Even though I asked, they did not put the rate response back to med.
What they did do was *increased lead impedance for atrial from 432 to 488, and *decreased ventricle from 544 to 488.
WHAT??? Why would they do that? I guess I understand you want both parts of the heart equally impeded, but I don't get why this wouldn't have been done at the initial clinic.

ME: Lead Impedance is a MEASUREMENT. It cannot be changed. Impedance is an electrical term for the resistance of the lead to conduct the current from the PM to the heart. The HIGHER the Impedance, the more difficult for the PM to push current through the lead.

Apparently your lead impedances changed & the report is highlighting that fact. BTW: the Impedances are DIFFERENT for the Atria & Ventricles. Just the nature of the beast, and they vary with time. That's why they are measured frequently by the PM in its self checks - to show any trends in the value..

All they can do is change the voltages applied to the leads to cause chamber contractions.

YOU: *increased measured P/R wave for atrial from 5.9 to 7.0, and
*increased ventricle from 7.9 to 8.6
No idea what this means

ME: I think I figured it out!!!!!

The P wave is the little blip on an ECG that shows that the Atria has contracted. For the PM to do its job, it MUST be able to sense the existence of the P Wave. So - they set a sensitivity for the PM's sensing circuits - measured in millivolts (1 mv = 1/1000 Volt) That's what this number is. Unfortunately, the number is NOT a voltage, it is merely a sensitivity NUMBER. The higher the number, the less sensitive the PM is at detecting the waves.

The R wave is the humongous squiggle on an ECG - it shows that the ventricles have contracted. The numbers listed are the sensitivities for sensing the R Wave. Again just numbers indicating decreasing sensitivity.

This is confusing to me, also. I'd have to see the entire original report to figure it out. Here's what really happens - the same procedure for Atria & ventricles, but DIFFERENT values for voltages. The single lead going into each chamber can perform two duties. 1) deliver a pacing signal & 2) sense any electrical activity in that chamber. While the PM is performing its self checks, the leads sense (Measure ) the voltages present. Those intrinsic voltages typically are measured in milli Volts. (With the voltages measured in the Ventricles being larger than in the Atria.) Next the PM performs a test to determine the MINIMUM voltage required FROM the PM that will make the appropriate chambers contract. They call that the "Threshold" voltage. Finally, the PM multiplies the Threshold voltage by the safety factor & that is the voltage actually sent when the PM wants to pace a chamber. Typically, the Atria is about 1.5 Volts & the ventricular voltage is about 2.75 volts. Oh, yes - the sensitivities determine the lowest voltage the PM will sense (its sensitivity) for a given set of chambers. Since the Atria signal is much lower than the ventricular, it has a much lower sensitivity.

YOU: *changed mode from DDDR to DDD
No idea why this was changed, and how this will/will not
affect me.

ME: DDDR= Both chambers paced; Both chambers Sensed; Both chambers Inhibited; Rate Response ON.

DDD= same as above, but the RR turned OFF.


YOU: *lowered rate from 60bpm to 50
I would think lowering the bpm threshold would increase my odds of being fatigued. When I was at the initial clinic the tech and nurse discussed putting it at 70. So I'm confused as to why the EP would want to lower it.

ME: That is your BASE Rate. The rate below which the PM will NOT let your heart go. You say that now they are reporting SSS. That essentially means Bradycardia - slow heart beat. You did not tell us what your HR was at rest BEFORE the PM, so this number cannot be put in proper perspective. Yes, if you were an intrinsic resting HR of greater than 50, you could feel more fatigued. Conversely, if you were an intrinsic HR prior to the PM lower than 70, & they set the base rate at 70, you could feel hyper all the time. This is a parameter that can be easily changed & have effect on how you feel. The EP had a reason - call back & ask why!

This NEXT section must be from the second report since the two AV delays are different from above,

YOU: *lowered paced AV from 300ms to 200
*lowered sensed AV from 260ms to 180
I'm guessing this was done to make the pacemaker more sensitive to missed beats, and to react to said beats

ME: Recall my discussion of the two AV delays above. Here we see them in the same paragraph. The AV delay is the length of time that the PM waits after the Atria contract to send a pacing spike to the heart to make it function. It is measured from the P wave to the to the point that the PM has programmed into it when it releases a voltage spike to make the Ventricles contract. Remember that the Paced AV Delay is always LONGER than the Sensed AV Delay. That's because they measure from two different START points where the P Wave is (or should have been).

The old Paced AV Delay was set at 300 msec & that was allowing all sorts of stray Ventricular contractions. By decreasing this delay, the PM will cause ventricular contractions sooner. They lowered the Sensed AV Delay to 180 ms, meaning that if the Atria contracted on their own (No PM Spike) that now the Ventricles will contract a lot sooner when compared to the timing start point.

I am GUESSING that they set it this way because you have the "Winky Back" type heart block (Really Wenckebach). This means that the natural AV delay increases a little for each beat until the delay gets so stretched out that the beat is skipped altogether. This shorter delay SHOULD keep the actual AV delay constant & keep you from skipping a Ventricular contraction. Sounds like a poor man's approach to correcting for Wenckebach. You'll have to ask your EP why he did this.

Another Guess on my part - you are taking Atenolol, a Beta Blocker. One desired effect of BB's is that they SLOOOOOOOW the heart down. Guess what - that equals FATIGUE! Also means the natural AV delay will be longer - hence they reduced the PM's two AV delays to speed up your HR after slowing it down.

YOU: I know many of you will tell me I should have asked the nurse what changes were being made, and why. I did. The only thing she said was "He wants to turn off the rate response, and I don't know why". Only after I read the report did I see that other changes were made.

ME: YEP!!!!!


YOU: Sorry for the long post. I have a gazillion other questions, but feel these are the most important right now.
Thanks for any and all help!!

ME: Good Post! Lots of info.

I hope this helps. If there are any errors, I think they are minor.

Donr

@Inga

by Ck - 2014-03-01 07:03:25

Thanks for your explanation. Dont quite grasp it, but it's because thjis is so foreign to me.
Funny that answers just cause more questions....

@Tracey

by Ck - 2014-03-01 08:03:00

Question about the RR.

The nurse on the 14th said she was increasing my rate response from medium to medium-high. I started getting this intense bouts of being lightheaded that last just an instant. Sometimes get several in a row.

Because nothing else has changed, I'm blaming the pm change on these.

Ask the nurse yesterday to turn the setting back to medium. She says "no", because she has made several other changes.

But if she turned off the RR, then didn't she in effect take care of this? i.e., rather than turn the setting back, she turned it off

Or are there several rate response settings?

BTW, I'm still having the bouts of being lightheaded. And I don't feel any better- still feel like there's a fog in my brain.

Pacemaker Wenckebach

by golden_snitch - 2014-03-01 09:03:05

Hi!

A pacemaker Wenckebach behaviour is tied to the upper tracking rate. It happens whenever the atrial rate exceeds the programmed upper tracking rate. You then go into a 2:1 block because every second p-wave (atrial impulse) falls into the PVARP = time period after a ventricular event, either paced or sensed, when activity in the atrium does not inhibit an atrial stimulus nor trigger a ventricular stimulus. It has absolutely nothing to do with MVP. MVP needs no further explanation, because in someone with a complete heart block it is definitely switched off.

Rate response is not needed in most complete heart block patients whose sinus node is functioning well. On the contrary, if you active the RR in someone who doesn't need it, that person might feel really uncomfortable as the RR is competing with his natural rhythm. As long as the sinus node is healthy it will dictate the pace, and the pacemaker will just make sure that the ventricles are stimulated at the same pace.


Inga

Wenckeback vs Complete Heart Block

by Ck - 2014-03-01 09:03:20

Can a person have both?! And which one comes first?

I was told I have complete heart block, which is why I needed a pm. That was in 2012. Now I'm told I have Wenckebach.

I don't understand how I can have both. My heart can't possibly go from being great one day, to being crap the next!

@snitch

by Ck - 2014-03-01 09:03:27

The 14th the nurse says "your sinus is great" and yesterday the nurse (different one) says "you have sick sinus".

Now, I know I'm blonde, but don't those two statement contradict each other?

And.....if I have sick sinus, wouldn't they need to leave the RR on?

Way to edit comments

by donr - 2014-03-01 10:03:06

Cindy: Go to the Member Menu, top right corner of page. Click on "My Comments." a new page will open up w/ a list of all your comments. At far right, it says "Edit." Click on Edit beside the comment you want to edit. Then Go for it!

Donr

Wenckebach behaviour vs Wenckebach block

by golden_snitch - 2014-03-01 11:03:59

Ck,

the Wenckebach behaviour is a pacemaker thing in this case. It's a 2:1 block in which the pacemaker goes when the rate in your atria exceeds the upper tracking rate. The upper tracking rate is the rate at which the pacemaker stops to follow (track) the atrial rhythm. They did not tell you that you are now in Wenckebach, they said they want to activate the Wenckebach feature. Now, I don't think you can actually activate this, but you can definitely change the upper tracking rate.

A normal Wenckebach block (2nd degree heart block), also known as Mobitz type 1, is a heart block where the PQ-interval gets longer from beat to beat until one beat is completely blocked. This block rarely needs to be treated with a pacemaker. Mobitz type 2 is a block where very regularly every 2nd, 3rd, 4rd etc. atrial impulse is blocked. With Mobitz type 2 the prognosis is not as good as with type 1 as it often progresses to complete (3rd degree) heart block. Mobitz type 2 is more often treated with a pacemaker than Wenckebach/Mobitz type 1.

About the sick sinus: Well, I don't know what you have. If your sinus node was doing great on the 14th, it's very unlikely that all of a sudden it is going to slow. Also, sick sinus does not always only mean that you are having sinus bradycardia only, it can also be a tachy-brady phenomenon (the tachy part is usually not from the sinus node, but some other kind of atrial tachycardia). If you have the RR switched off now, but your heart rate increases more or less adaquately, you do NOT have a sinus bradycardia.

Inga

Ref confusing stuff

by Ck - 2014-03-06 11:03:03

Thanks simmsi! I think I'm gonna print out this post and highlight the questions I need to ask my pm.

Can you clarify some of your comments?

I had never heard I had sick sinus until this last visit- that's two years and about 6 face-to-face visits. So I'm not entirely sure the nurse was right.
The Medtronic tech (who was in the room) initially said my sinus was fine, but then after looking at the computer for about 5 minutes, she stated that yes I do have sick sinus.
Anyhow, I know I need to ask about this.

I was told I have complete heart block, and that was written on the hospital order when I got my pm. I never asked about the pm reports, or even really questioned the nurse or tech during my pm checks. I assumed they knew what they were doing. So I'm at a huge disadvantage by not having two years of data.

So back to clarification of your comments.....
You said if the bpm is at 50, the RR should be on. Is that irregardless if I have sick sinus?
Why would the bpm be set so low? If my chief complaint is fatigue, wouldn't it be better to have it set at 60?
And along the same lines, why would the nurse think med-high be a better setting than med? Seems to me that if I'm fatigued, it'd be better to LOWER that setting, rather than raise it!
The EP who determined I needed the PM was very reluctant to implant b/c of ventricle pacing problems. I've since learned he has researched it leading to heart failure. That may be why the ventrical pacing is so low.

Thanks again for your input, and for any additional help you can provide!

A Plan?

by simmsl - 2014-03-11 08:03:13

1. Ask for a copy of the implant procedure. This will clearly state what your rhythm was that required a pacemaker

So much more to say but too many unknowns.

This all solvable but will take a little time. Hang in there.

I am going to state what you should have set but it is all a guess as I don't have your diagnostic printouts in front of me. Ask for a complete printout next time, parameters and the diagnostic printouts. We can work through them. You will be an expert in no time.

DDDR:
- AAIR was a bit weird. I think it must have been AAIR-DDDR. This mode is designed to prevent unneccessary ventricular pacing. So only paces in the atrium , as you have SSS?? and doesn't pace the ventricular. It does watch the ventricule and if there are a beats which the ventricular doesn't behave then it will switch to the DDDR mode. It will then change back to AAIR mode once the ventricule behaves again. Your Cardiologist would have seen some Ventricular Pacing occurring which have made him supicious of Wenckeback. Hence change to DDDR.

Lower rate limit of 50 bpm: Would seriously consider this despite your fatigue. We need a baseline to work off so 50 bpm is best. This means that with sleep and rest periods your heart rate would be at a more restful state. Changing to 60 bpm should only occur after trialing the following. So everything is done in a logical order. Even with SSS 50 bpm is ok.

PAV and SAV: Paced AV delay to 300ms and Sensed AV delay to 280ms. Both you top and bottom chambers work together but there must be an appropriate pause between them to work correctly. Hence PAV and SAV. So when the atrial paces then the bottom chamber must wait 300ms before firing, If the atrium fires by itself then the bottom chanber must wait 280ms. Previously your Cardiologist extended to value from 250 to 260ms. That is ok but a bit too short. 300ms and 280ms is quite accceptable. Some companies woudl push to out to 400ms but I have never like that. 300ms and 280ms will mean less ventricular pacing and cover you for any wenckebach episodes. Can modify this later if still fatigued but would look at this a lot later on.

RR max heart rate. Always a difficult one to set. Have to go back to threatre so will quickly say the rest. ADL to 95 bpm. Max sensor rate = 220- age. Then find 80% of that and set that as you Max sensor rate. If you are fitter then try 85 or 90%. This will be wrong, usually too low, but need a start point. At this hospital we would then see them in a weeks time to review that data and start setting the rate better.

Your activity sensor should be Med and not med-high. They went the wrong way. So set to med as a start.

Have these set. Go away and stay busy. Go back in a week. Get all the printouts.possible. Then go back to this forum to discuss with everyone.

Good Luck

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