New settings and not feeling well

I would appreciate if someone could explain my new settings to me, so I can understand why I don't feel well. This is what it says: "Finally the decision was made to program her with more physiologic AV delays and a permanently prolonged PRVP. In the end her final program settings are DDR with a paced AV interval of 180ms. A sensed AV interval of 150 ms. PRVP of 500 ms. The upper tracking rate was lowered to 120 beats per minute as was the upper sensory. Rate responsive PRVP was turned off. The remainder of the device interrogation demonstrates 1.9% atrial pacing and 36% ventricular pacing. P waves were 2.6 mV, R waves were 5.7 mV atrial impendence 350 ohms, and RV impedance was 600 ohms."
I have difficulty walking a flight of stairs -- dizzy, cold perspiration, hard to take a breath... If I walk fast I have the same symptoms... also if I walk and carry my 15 lb. puppy. I am 74 years old, and I have had a pacemaker for 13 years. I have felt much better before this new setting -- 6 months ago I was walking 3 miles daily! A new doctor is in the office, there is no other specialist in town, and my trust level is not quite there. I take care of a dependent 81 year husband, and I can't quite afford to die at this time. My father died of sudden death syndrome. I am hoping and praying that someone can help me! I am so very grateful! Ariela

7 Comments

Ariela

by mtulau - 2013-02-17 10:02:34

My heart goes out to you. I have found my situation difficult but it is nothing compared with yours and many others on this site. I spoke to a senior person in charge of the pacemaker checkups with the manufacturers of my pm, because my cardiman will not tell me anything. I was told by them in reading the pm I am entitled to know 1. what has been going on, 2.what settings they are changing and why, and 3.what I should expect to happen then. You must surely make an urgent appointment and go back, preferably accompanied by someone who is prepared to insist you are listened to and action taken. I hope someone else has better advice. Regards MT

The Solution

by ElectricFrank - 2013-02-18 01:02:49

It's obvious that the new settings aren't appropriate. Do you know why they used the word "finally" in the description? It sounds like there was some problem that they were having difficulty trying to correct.

The best approach is to contact the doctors office and ask for an appt. Don't take no for an answer. Be prepared to get an intelligent description as to what is happening. If all seemed OK to you before the changes, you can ask (demand) that they be returned to the previous ones.

Does your report show the previous settings. From others posts it seems that the AV interval can lead to some uncomfortable symptoms if it is not set correctly.

In the meantime relax. You description is not one that would concern me as far as dying is concerned. It's just limiting and uncomfortable. That's no excuse for the doc to ignore it though.

best wishes,

frank

replacment Defib/PM

by Gailv - 2013-02-18 02:02:06

I had a St. Judes PM/DEFIB installed Dec. 2010, in the last few months my battery life has gone downt tremendous. I am now at 1.7 yrs. My voltage is at 2.56, St. Jude's sent out a notice of alert( not a recall) that some of the St. Jude's units are having some issues. Leads and Cans.
My doctor has been monitoring the unit and it seems that each month my voltage is decreasing. My battery life, just went from 3.2 yrs to 1.7 in the last month.
Getting nervous about this thing. Not feeling the love for possible new surgery since my shoulder still aches from the last one. My can has dropped so low that They will have to pull it up and make a new pocket for it. Will they put me to sleep again to replace it. I prefer that since I hate being awake during anything to do with surgery. I have also been diagnosed as a diabetic since June. so am worried about healing issues. Has anyone had similiar issues.

Gail

Frank is spot on!!!

by donr - 2013-02-18 02:02:33

But you really need some answers from the cardio. He owes you more than what he has told you.

I'll give you a starter lesson in reading the PM data, so you can sound intelligent when you talk to him.

1) AV Delay. That's the time between when the atria chambers contract & the ventricles contract. Actually, when you have a PM, there are two AV delays that concern you. AV Sensed & AV Paced. The AV Sensed is the time elapsed after the Atria contract and the PM EXPECTS to have the seen the Ventricles contract. That time for you is set at 150 Milliseconds (a millisecond is 1/1000th of a second - not very long!) If the ventricles do not contract on their own after 150 milliseconds, the PM waits an additional 30 milliseconds & then generates its own signal, causing the ventricles to contract. That's the 180 ms (milliseconds) (180 ms is the AV Paced delay).

Let me explain this a different way: Your PM sits there & monitors the heart's functioning. It does all its monitoring based on when the Atria (upper chambers) contract. If the ventricles don't contract 150 ms after the atria contracts, it waits 30 more ms then issues an order to make them do so.

2) PRVP makes no sense to me. I can find no abbreviation that is remotely close to it. That may be a personal note used by that Dr. I've searched a copy of the report from my own PM & could not find anything like it.

3) DDR. You sure that you did not copy it wrong? USUALLY it's DDDR, meaning Dual Pace, Dual Sensed, Dual Inhibited, Rate Response. This all means that the PM is set up to Pace both chambers (upper & lower); set up to Sense the activity of both chambers; set up to Inhibit both chambers from being paced IF the PM senses something being done by the heart naturally. Rarely do they turn off the Inhibit capability of the PM.

4) Upper Tracking & sensory Rates. These two numbers are read in conjunction w/ the Lower Rate Limit (the lowest rate the PM will let your heart drop to; if it senses that the heart is going to drop to that rate, it generates a signal to make the heart function.) The Upper tracking & Upper sensor rates are where the PM stops issuing commands to the Ventricles if it senses that they are not going to contract - it becomes a passive watcher then & lets the heart function as best it can. Getting beyond that discussion of the upper limits is confusing as all get out.

5) Rate Responsive PVRP being turned off is confusing - if it means what i think, there is a contradiction - DDR tells me that the Rate response is turned on You have to ask the Dr. on this one also.

6) the two pacing percentages tell how often the PM is functioning. Your Atria do not get paced very often - between 1 & 2 %. That's very good. Your Ventricles get paced about 36% of the time - again, good.This means that about 2/3 of the time, your heart functions correctly on its own! Congrats!

7) When he starts talking in the next section about "P Waves," he's talking about sizes of waves seen in your ECG. Nothing spectacular there. The Impedances are electrical characteristics of the heart/lead combinations. It tells the technogeeks how your PM battery is lasting.

8) sounds like you have a problem w/ functioning of the Rate Response functioning. If your heart depended on it, turning it off could well give you the symptoms you describe.


Hope I helped even a little bit.

Don

PVARP

by golden_snitch - 2013-02-18 04:02:40

Hi!

First of all, when you post settings here, it helps a great deal to get your diagnosis, too. Settings always depend on your diagnosis, for instance whether it's heart block or sinus bradycardia.

The PRVP is most likely the PVARP = post-ventricular atrial refractory period. Basically it means that a pacemaker will “close its eyes” for a prescribed interval after each QRS complex (ventricles beating), whether it’s a native QRS complex or a paced QRS complex. In other words, it will ignore P-waves (atrial activity) during that period of time.

When exercising this period usually shortens, the higher the heart rate is. Some pacers like mine define the PVARP automatically, in others you have to program it. If you switch the rate response PVARP off, it will always stay the same, not shorten, and this will reduce your max. heart rate.

To me it sounds like your doctor has lowered your max. rate quite a bit by lowering the upper tracking rate and switching off the rate responsive PVARP. Not sure why he did that. If you have difficulty to walk the stairs etc. that can very well be caused by your heart rate not being able to increase enough. So, if I were you, I'd tell the doctor about all your symptoms and ask him why he has lowered your upper rate limit. And I'd probably also ask him, if you the need rate response at all. Normally, only people who have sinus node issues and are paced a lot in the atria (not only 1.9%) need the rate response switched on. A switched on rate response that's not really needed can cause problems. There are quite a few members here who had the RR switched on when not really needing it, and who started to feel better when the RR was switched off.

Best

Inga

asfaf

by boxxed - 2013-02-18 09:02:05

"Finally the decision was made to program her with more physiologic AV delays and a permanently prolonged PRVP. In the end her final program settings are DDR with a paced AV interval of 180ms. A sensed AV interval of 150 ms. PRVP of 500 ms. The upper tracking rate was lowered to 120 beats per minute as was the upper sensory. Rate responsive PRVP was turned off. The remainder of the device interrogation demonstrates 1.9% atrial pacing and 36% ventricular pacing. P waves were 2.6 mV, R waves were 5.7 mV atrial impendence 350 ohms, and RV impedance was 600 ohms.

Let's break this down. And quite a bit of the above has been covered already.

PVARP is the post-atrial refractory period. Like snitch has mentioned, the device is closing its eyes in the atrial lead. There are two types of "closing your eyes". Blanking and Refractory. Blanking means it refuses to acknowledge it at all, it literally doesn't see it. Refractory means that it sees that it's there, but it won't do much with it. That may be a bit difficult to understand.

As for why it's prolonged, I have a guess, and its only a guess. Sometimes there is a fast rhythm that is created and maintain by the pacemaker itself. It is called Pacemaker Mediated Tachycardia. What happens is that it sees retrograde conduction, or an atrial event right after a ventricular event, and think it's a natural P-wave, and puts itself in a loop that's typically at the max track rate.

So instead of a steady heart rate like the below, where P is a natural atrial beat, R is a natural Ventricular beat, A is a paced atrial beat, and V is a paced ventricular beat:

P----R-------------P----R------------P----R--------------P-----R


You have something like:

P----R--P---V--A---V--A---V--A---V--A---V--A---V--A---V--A-V---A

The second P, or the retrograde atrial event that happened very quickly sets off a loop where it keeps on pacing itself @ a fast rate.


So the point of PVARP is that if you extend it long enough, it will "cover" that second P, or the retrograde event, so the device sees it and acknowledges it but does NOT do much with the event. That will keep you pacing in a rhythm that was intended.

Now there's a chance that you may not have been experiencing PMT, but I have not come across many reasons to extend a PVARP that long. But I am also not an electrophysiologist either.

Rate Responsive PVARP is the same thing as Rate Responsive AV Delay. As your rate goes up, the PVARP decreases. ASSUMING (AND PLEASE LET ME REITERATE THE WORD ASSUMING) that he is trying to program to alleviate PMT, there is always a chance that the "default" PVARP, which would normally cover the retrograde P, would inadvertently be shortened as your rate went up and "uncover" the event.

The rest of it are just interrogation diagnostics. Just looking at the numbers by itself don't mean too much. But keeping track of it and keeping an eye on trends of things increasing or decreasing over time is always helpful.

A possible reason why the Upper Track Rate went down is that PVARP and UTR are inversely related. If you extend the PVARP, you limit how high you can increase the UTR.

| AV Delay + PVARP | <---this is a simplified single beat. The longer this is, the slower the rate. Let's say that consecutive series of this specific cycle is 80 bpm.

| AV Delay + Really Long PVARP | <--- this entire single cycle is much larger. This means that it's physically and mathematically impossible for the device to pace @ a high UTR because it must count THAT long before it can reset another beat. Let's say that consecutive series of this specific cycle is 60 bpm.

| AV + PVARP | <-- very short beat. We can now fit in tons of these consecutively. Thus allowing us a much higher max track rate. Let's say that consecutive series of this specific cycle is 120 bpm.

Hope I helped.

I'm So Sorry

by Many Blessings - 2013-02-18 12:02:07

My heart goes out to you as well. I do know what you're going through right now. With me, Once my settings were all set correctly, I was doing great. Then, they made some changes to my settings that "should" have been good for me and my activity level (rate response, lower heart rate, turned on another caption.)

I, like you, felt just awful! I got back to work after my appointment and could barely make it across the parking lot. Then, I had to walk up two flights of stairs to my office which I could barely do, and I mean barely. I too, was out of breath, my legs were heavy and wouldn't respond when I tried to lift them. I also felt dizzy, weird, and tingly in my face, arms, hands, legs, and feet.

I called my cardio doc but couldn't get into my PM tech until a couple of nights later. As soon as I had my settings changed back, I felt normal again. It makes that big of a difference. Don't lose hope.

Like MT said above, it is SO important that you make another appointment and go back and beg or demand they change your settings back. You know how you feel! They don't. They will (hopefully) listen to you. They want you to feel well too. If they won't change them back, I wonder if you can call the help line on the back of your card or in your instruction manual to see what they suggest. But, I think your doc will fix things if you ask.

Please, please, please call the doctor's office tomorrow morning and get in there as soon as you can. Please explain to them how badly you feel after they changed your settings. I'm not sure what setting is wrong for you, but at least one of them is, possibly more.

My guess is it's your rate response setting, but maybe I'm wrong. That's what causes me the most problems when they're set wrong, so I always go there first when others have setting issues with those symptoms. I'm sure others have had just as bad of symptoms with other changes and they'll let you know those too. Go armed with as much information from here as you can so you can give them proof and ideas.

Do a search (above right hand corner of this site) for setting changes, settings, etc., and take a look at what others have been through and what advice was given to them. Don't give up and don't stop pushing them until you get your settings changed back to where they feel good for you, not what they think should make you feel good.

Please know a lot of us have been through exactly what your going through, and it can be fixed, and you will feel better soon. It's hard not to get scared when you all of the sudden feel just awful and you can't do a dang thing about it until they change those settings back.

Please keep us posted. Best of luck to you!

Thoughts & prayers to you

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