pacing ceases. med leads//BS generator

Hi
I am a new member and am an endurance athlete. My pacemaker ceases pacing (and i fall into my junctional rhythm) after 20-25 minutes of moderate exercise. I have medtronic MRI safe 5086 leads with a Boston Scientific Ingenio 173 generator.

Anyone else with a similar experience?
Anyone heard of a reasonable explanation for this occurence?

thanks, Aspen

18 Comments

Hi again aspen

by IAN MC - 2014-04-05 01:04:45

It sounds as though you know the answer and the Medtronic leads may be incompatible in some way with the Boston Ingenio PM

It also sounds as though you wanted the best of both worlds , the minute ventilation sensor from the Boston model combined with the MRI-safe features from Medtronic. Is there not another Boston model which could have given you both features ?

I was interested to read that you are just using the accelerometer feature ; because just yesterday I was talking to my PM guru and his experience has been that minute ventilation sensors seem to work very well with people with breathing difficulties, e.g. asthmatics but not so well with very fit people like yourself.

I am curious , has this been your experience , and why are you solely using the accelerometer feature ?

You may end up having to make the decision to keep either the existing box or the existing leads.

Best of luck

Ian

aspen response (no pun)

by aspen - 2014-04-05 01:04:55

Boston Sci and my doc have tweaked PM settings ad nauseum. I have done multiple stress tests on bike with docs present where they tried higher and lower rate response. but without fail (over 10-15 times) the PM ceases output after 20-30 minutes of 75% of max output. i have partiall block SA node and upon failure i usually fall back to a low junctional rhythm, causing me much distress if i try to keep going. Now the PM is solely on accelerometer mode and it works but i can't run or bike or hike up hills.
We believe it is the mixing of the 5086 medtronic leads (meant for mri safe and use with medtronic acceleromter) with the BS ingenio. Theknotdguy...how do you ramp up with only a rate response device...on, say, biking up a steep mountain.
I do lots of 2-5 hour runs, hikes, hard bike rides. I am 71. also have bradycardia (resting HR about 32) which was causing me dizziness and was a reason for PM

Have it checked out

by NiceNiecey - 2014-04-05 02:04:45

I am too new to be of much help, however, your pacemaker should NOT stop pacing unless your body doesn't need it, which is doubtful.

I feel like I'm almost constantly arrhythmic but it's apparently premature ventricular contractions and other occurrences that the cardiologist isn't concerned about; in other words, it's not a problem. I'm always surprised about that but it's my new reality!

You should call your physician's nurse or assistant and inquire about this. It really shouldn't happen and I'm not at all sure how you know that your PM "ceases pacing." Please keep us informed.

Niecey

What are your PM settings?

by IAN MC - 2014-04-05 08:04:37

Hi aspen Do you have Rate Response switched on and , if so, what is the maximum sensing rate ?

It is possible that you may need the max increasing . As an endurance athlete you probably need quite a high max.

It would help your Drs arrive at a diagnosis if you measure your HR at that moment in time when you go into some sort of block / junctional rhythm.

I hope it is a settings issue; let us know how you get on !

Ian

PM settings

by Theknotguy - 2014-04-05 11:04:32

Your bio doesn't give any info so that isn't a help. You've got the Medtronics PM. I've got the same. Medtronics may not react as quickly to increased activity so you get chronotropic incompetence. You may have to "ramp up" into your exercise. It took me half of my cardio rehab to learn how to start exercise with my PM and the medication I'm on.

As Ian said, you probably need your rate response tweaked. As an endurance athlete you'll probably need quite a high max rate. You don't say when you got your PM and that's a factor too.

Like Ian said, I hope it's a settings issue.

Theknotguy

back to ian

by aspen - 2014-04-06 04:04:57

you are right. we were trying to get mri safe leads and can and BS does not yet offer this in USA.

I have the accelerometer on because the ventilation mode crashes as i noted above. the accelerometer does not work for my hard biking or uphill running.

does your guru have suggestions for a PM that works well with endurance athletes like myself. or, what type of tweaking seems to help?

i am planning on taking the leads and can out -- they were put in only in late december -- and thus looking for best replacements for me as an athlete.

questions for inga an ian

by aspen - 2014-04-07 02:04:28

inga
do you do vigorous activity for lengthy periods with your PM? My BS works for 20-30 minutes at 75-80% capacity, as noted above, before failing

and Ian what does it mean specifically when your guru says 'he has been slighltly disappointed' visi-a-vis my situation.

thanks, aspen

Answers

by golden_snitch - 2014-04-07 04:04:00

Aspen, yes I have been able to exercise for lengthy periods with the MV + accelerometer sensor in my Sorin pacer. I have never had the problems you are describing. I'm sure there are others here with Medtronic leads and a Boston Scientific or Sorin device with this sensor combination. Maybe you could post another message searching for these people?

Ian, your pacer guru is the first one I have ever heard who does NOT like the sensor combination of MV + accelerometer. Now, this is important: You need the combination, not just one of the two sensors switched on. In my old Medtronic Kappa and in my Sorin Reply you had the choice of switching either both sensors on (they work with a cross-check, and one sensor usually leads) or just MV or accelerometer alone. I always had both activated. Don't understand what your Guru did. The combination is what makes this RR superior! If you switch the MV sensor on only, you get a slow but steady response; with accelerometer alone, you get a fast response, but it doesn't last when you exercise for lengthy periods.

Even my first pacer back in 1999 (an old Medtronic Kappa 401SR) had this dual-sensor rate response, and I had it also in my Sorin pacer until late 2010 when I was switched to epicardial leads. So, I have more than 10 years of experience with this sensor combination. I'm comparatively young and active, so I definitely put this RR to the test. I would recommend it to anyone with chronotopic incompetence. Of course, this is not as good as a well functioning sinus node, but it's a lot better than an accelerometer only. I'm really surprised by your guru's statements. My cardios/EPs and all the pacer techs I ever got to know preferred the MV + accelerometer combination to accelerometer only.

I'm now in the process of finding out how well my new CLS sensor works. Unfortunately, I had to have a revision surgery just two months after the Biotronik pacer with CLS had been put in (that was in January), so I'm still or again recovering from surgery, and not yet able to put it to the test. But I'll hopefully soon be. For now, I'm really happy with the CLS sensor. It has been doing a very good job so far, and the auto-optimization works great.

Inga

Medtronic leads

by golden_snitch - 2014-04-07 04:04:47

Hi!

Aspen, I have had Medtronic leads and a Sorin device with a minute ventilation + accelerometer sensor (like your BS), and there was no problem. Only when switched to epicardial pacing, the MV sensor failed. But as long as I had a transvenous Medtronic lead with that Sorin pacer, the MV sensor worked well. Have you given Medtronic a call and asked about compatibility? I'd do that before you have the leads replaced.

Ian, according to my knowledge, minute ventilation sensors do not work well in people who have increased breathing rates at rest due to asthma or due to being very young (children never get pacers with MV sensor because of that). They will simply overreact.
The combination of MV + accelerometer generally works well for everyone with chronotopic incompetence who wants to exercise regularly. That's what all of my EPs say. They always recommend either this sensor combination or a CLS sensor for active patients. I really liked the MV + accelerometer combination.

Inga

Accelerometer v Minute ventilation

by IAN MC - 2014-04-07 05:04:15

Hi Inga I'm glad that you, (our resident PM sensor expert) have joined in and I hope you're well !

I am particularly interested in this because I've been thinking of changing my Medtronic box to another make with MV sensors , but keeping my MRI - compatible leads as aspen has done.

I had always believed that you can use any leads with any make of PM so if aspen discovers otherwise I will be very interested.

You have first-hand experience of the MV / accelerometer combination and I'm glad that it worked well for you.

I was therefore surprised to get the comments from my PM guru.

He is involved with PM settings every day and has a couple of athletes in his care; His views are :-

i) Medtronic probably have the best accelerometers with the best range of algorithms to cater for varying symptoms of chronotropic incompetence.

ii) He has been slightly disappointed with MV sensors in very fit people , although those are just the people that they are supposed to help. I, too, had believed that they don't work so well in people with breathing difficulties but Mr Guru thought otherwise

iii) He tried switching from accelerometer only and on to MV only and back to accelerometer only on some of his fit patients and couldn't see much measurable difference in the handling of chronotropic incompetence

My view is that the combination of sensors has to be more "physiological " as the manufacturers claim but I doubt that it as good as the real thing and when tested to their limits, as athletes do, then the deficiencies become apparent. I hope I am wrong !!

Best wishes

Ian

aspen / Inga

by IAN MC - 2014-04-07 06:04:41

aspen : I can't give you much more info as to why my guru was not completely sold on MV sensors for his athlete-patients. I guess it was based on feedback from them . I cannot confirm though that their ventilation mode was "crashing" after intense exercise as yours seems to have done.

Inga ( my other guru ! ) : I am keen to get ANY feedback on the success of dual sensor PMs in vigorous exercisers as I am contemplating going down that route . I don't take lightly the decision to rip out a PM before the end of its battery life but you are convincing me that it is probably the way I should go.

One question :- could you explain why an accelerometer effect should not last when you exercise for length periods. ? If you have an adequate maximum setting, why does the sensor not carry on doing its job as long as the PM is physically moving ?

I have been using the accelerometer sensor since Friday, when it was switched on ( on a Medtronic Advisa ) and did an encouraging 4 mile run yesterday. I do hope that your CLS sensor continues to please.

Thanks

Ian

CLS sensor

by golden_snitch - 2014-04-08 02:04:37

Hi!

Well, first of all I do not do any multi-hour up and down riding or running. When fit enough, I exercise regularly for at least 30-60 minutes, and that can be anything: from cycling to running or hiking to playing table tennis with a friend to aqua fitness or swimming. And the info my EPs and I got from Biotronik and some pacer experts was that the CLS should be able to handle this. In addition, I have read, I guess, every study published on the CLS sensor, and even contacted one of the authors. From what I read and heard this sensor sounded very promising to me, especially since it also reacts to mental stress.

Keep in mind that I no longer have the choice between accelerometer only, accelerometer + MV sensor, and CLS. My choice is solely between accelerometer alone or the CLS sensor, because the MV sensor does not work with my epicardial pacer leads (ever since 2010 both my atrial and ventricular lead are epicardial). And being left with these two options only, the CLS is definitely the better option. So far it's working well. The auto optimization is doing a good job; the rates I get when I walk (pace 5-6km/h) are good; when climbing stairs I get an appropriate response; and the first little tour on my bike produced really appropriate rates, too (no shortness of breath, no tired legs like with accelerometer only).

Inga

to ian and inga

by aspen - 2014-04-08 02:04:55

Ian
Medtronics reps say their device doesn't work for bike riding. My BS accelerometer won't work well running up hill, hiking up hill, going fast down hill or biking on varied terrain. My heart rate is either too fast or too slow which i observe with my heart monitor i wear for training.

Inga
I talked to the tech people at biotroniks who said they were not confident their CLS would work well with strenuous exercise such as i do. What info has led you to conclude the biotronik will work well for multi-hour up and down riding/running?

aspen

Limitations of accelerometers

by golden_snitch - 2014-04-08 03:04:35

Hi Ian!

I'm going to copy and paste the answer to your question from an article:

"Activity sensors allow for instance to tailor the rate response to the individual patient with proper treadmill protocols [8]. Fast reaction to terminate short exercise represents further advantage of them.However, after longer exercise, an oxygen debt may require a sustained rate to increase, which is not provided by
activity sensors during recovery because these sensors are unable to acknowledge the oxygen debt.
Moreover, the fact that activity sensors do not respond to the activity not related to body movements (e.g., isometric exercise, mental stress, or metabolic inadequacy consequent to pathologic conditions), and the possible mismatch between exercise intensity and rate increase, represent the main limitations of activity sensors."
(http://www.uwstout.edu/faculty/shiw/upload/Recent-Advances-of-Sensors-for-Pacemakers-2.pdf)

There is another good article by the Sorin Group on why a combined sensor is of advantage:
http://www.sorin.com/sites/default/files/roles/3/files/Dual_Sensor_final_V2.pdf

When I was on accelerometer only, between Oct. 2010 - January 2014, I often had this problem of the sensor not providing an adequate rate when I exercised for longer periods of time. When I went running, and was pretty much worn out and getting shorter of breath after 20-30 minutes, I would have needed an increased heart rate, but the sensor just paced me up to a certain rate when I started exercising, and then left me there until I stopped exercising. No variations.

Now, I do know that with the Medtronic accelerometer you have a lot more options to optimize how it functions. My Sorin accelerometer didn't offer that many options. So, I might have done a little better with a Medtronic accelerometer. However, I really believe that for severely chronotopic incompetent patients an accelerometer alone just isn't enough. That's why I chose to have my Sorin replaced with a Biotronik Evia with CLS. My EPs said that with Medtronic I'd get the best accelerometer, and that this usually provided most of the "normal" (age 70+) pacer population with an adequate response. But they also said that, if the CLS sensor works well for me, it would outperform any other sensor, without all the limitations that an accelerometer has.

Before getting the Biotronik device, me and my EPs also did some research on whether the industry was going to come up with some new or better technologies for rate response in the near future. But no matter which manufacturer we asked, they all said, they were not planning on any improvements in this field. They said that many patients don't even need the rate response, and those who do, are doing quite well with what is offered at the moment. So, no reason to further optimize the rate response sensors.

Inga

Thanks Inga

by IAN MC - 2014-04-08 04:04:13

I do appreciate your reply !

Ian

Technology vs mother nature

by golden_snitch - 2014-04-09 04:04:59

I actually don't think any rate response sensor will be able to keep up with all your vigorous exercising. After all, it's technology, and in this case a technology that just isn't as good as what mother nature gave us, a fully functioning sinus node. If you rely on a rate response sensor, you've got to compromise, or otherwise you'll end up in deep frustration/depression. Sorry to say that. I had to learn this the hard way, too.

One often hears about pacemaker patients doing things like running marathons. However, as soon as you ask these people whether they need the rate response sensor, you learn that they don't (most of the AV block patients don't, and there are also people with sinus brady at rest only). To date, I haven't met anyone who totally depends on the rate response sensor, and who is nevertheless able to compete in marathons, bike races, swimming competitions.

So, even if you have the leads replaced or the pacer replaced, keep in mind that you'll most likely still need to compromise. Push the boundaries, put this technology to the test! But if you don't get to where you were, before your rhythm issues started, accept this, too, and compromise.

Inga

You must be psychic, Inga !

by IAN MC - 2014-04-09 05:04:10

I was about to write an identical sentiment to those expressed in your last post !

I hate being negative but I was an avid runner,( having done over 30 marathons,) until the heart problem came along , and It is the chronotropic incompetence element which is the real performance-changer !

So I now have different goals and aspirations AND LIFE IS VERY GOOD !!

Yesterday , incidentally, I was cycling on quite uneven footpaths with lots of bumps and potholes and the Medtronic accelerometer seemed to do everything that I require from it but as you say, Inga, it is not as good as mother nature !

Keep in touch, aspen, and let us know how you get on.

Ian

great info

by aspen - 2014-04-11 11:04:08

thanks, both of you, for really clear comments. I need to find out if i have chronotropic incompetence!
aspen

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