Biotronik Edora adjustments

Hi there…I had Biotronik Edora 8 DR-T implanted mid-June (chronotropic incompetence) and was not supposed to see the cardiologist until mid-September to do some adjustments to the PM.  Unfortunately, one of my internal stitches decided to try and exit my body the hard way – so I had to return for wound clean up etc.  During the meeting I found out a couple of things about my PM and asked them to make some adjustments.  First the discovery – my PM is dual chamber and apparently my PM is pacing me 100% but only my atria not my ventricle which I found interesting. The second was that the PM has CLS turned on but everything else is complete default settings.  I asked to raise the upper exercise limit that was set at 120 to 130 bpm and they will gradually move that up for me.  Next, I told them that the PM is trailing my activities or kicking in too late.  They adjusted some sensitivity setting …had me walk up and down the hallway briskly a few times and monitored my heart -- then said “try that”.    Now when I stand up and walk up the stairs or out into the garage the PM gets me to about 120-125 bpm right away.  I have low blood pressure so that rapid escalation and my low BP make me REALLY dizzy. It eventually balances out…but wow.  Anyway, back for a wound check on Tuesday…but any ideas what I should be asking for as an adjustment?  The one they made is not it! I get a sense this adjustment phase is some science and mainly art!!  Thanks!

5 Comments

I think you're right

by Aintgotrhythm - 2023-08-06 19:16:18

About the "some science and mainly art". I've got a different PM (Boston Scientific) but am experiencing the same "lag" you mentioned. Haven't been in for my initial adjustment yet (implant 9 days ago) but did go over settings with the BS rep post implant so I was hopeful they'd be in the ballpark.

In my case, for example, if I'm at 100 BPM and increase effort my HR goes up to 112 then stays there. Some time after (45-60 secs) it goes up more, to 125. Since I've only been cleared to ride a stationary bike indoors I haven't been pushing any harder than that but I definitely notice a delay where I'd be expecting a little smoother response.

Good luck, hope you get yours sorted!

Rate response

by AgentX86 - 2023-08-06 23:57:59

If I understand your "problem" correctly, well, that's the way they're designed. 

There is an "ADL" slope that starts at the normal resting rate and increases to the ADL rate.  These two parameters are programmable.

Then there is an "Exertion Response" that kicks in at another rate and has a slope to the maximum programmed rate. This "ER" rate and slope is also programmable. 

So, there is normally a plateau between the ADL rate and ER rate. The slope of the rate response device controls these rates.

In any case, the pacemaker can't "look ahead" or "predict" the heart rated for any given exercise.  Stairs become a big problem because you're off them before the PM detects the need for a higher rate. I find that carrying heavy objects or pushing a wheelbarow doesn't get my heart working nearly hard enough for the taks at hand.

You got it.

by PacedNRunning - 2023-08-07 02:35:24

I was told there are a million combos of settings. I have found in my short 5 years having a device the rate response is very finicky. It will definitely be a give and take. It won't act like a normal heart. Which I'm sure you know already. But I would ask myself,... is this tolerable or not? With each adjustment. I would give it at least a week to figure it out. Some were straight NO! But most were manageable until I could figure out if I liked it or not. The give and take is a faster HR than what you actually need but it helps in other situations. My friend says when she walks her PM paces her to 110-120. Mine goes to 80-90. But I don't have rate response. That's my own heart. I don't use the rate response feature. That feature made me very short of breath I could barely walk. My issue is heart block. So all my pacing is bottom with some on top. 
 

CLS can be tricky as well. Just take good notes and let them know how you feel. Go mainly by feel not HR. HR helps with guidance but symptoms tell us what we need and don't need. Also take notes on what they adjust. 

Thanks for the advice!

by xcanuck57 - 2023-08-07 12:26:04

So I read this morning about ADL & ER slope and rate.  Thanks AgentX86 for the primer and to you PacedNRunning for the "go by feel not HR" tip.  I see the cardiologist tomorrow...and he is the one who made the ADL change (I am assuming that's the one)...I got the sense that he helped me out because he felt bad about dragging me up there for a wound check.  I could tell he was not a regular user of the Biotronik computer - there were no techs around.  That being said I appreciated his efforts...you need to start somewhere!  So the focus on what I am feeling is - too fast of a response (high ADL slope?) when I start moving that takes my HR to a high ADL.  What I see is my heart rate going from about 65bpm to 125-130bpm many times when I stand and say walk across the house.  I can feel my HR beat behind my eyes sometimes but as I mentioned my BP at rest is about 98/50 so a lot of stuff is going on when I stand up!  I will hopefully try to have him reduce maybe both the slope(?) and the ADL(?)  some tomorrow and I will keep you folks posted on the progress!  I will also ask for a printout of the settings...Thanks again.

Update - Changes

by xcanuck57 - 2023-09-09 12:14:43

I saw the electrophysiologist twice in the past month.  I was pretty dizzy on standing, my HR would accelerate doing small tasks and my max HR was too low.  So over a couple of visit they increased my Max HR to 140 from 130...data from my Apple watch showed my HR being pinned at 130 during exercise which left me feeling a little gassed.  I think it is going to need to move up a bit more - my theoreticcal age max is 155.  They reduced the sensitivity of the CLS response to "medium" which seems to have helped with the rapid heart accelration and finally they adjusted the CLS resting rate control to +40 up from +20.  This last adjustment has certainly helped when I begin to stand up.  I will let these settings bake for a while - I have another follow up later in the month.

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