Pacemaker implant and follow-up

Hi folks, just thought I'd share some experiences I've had in the last 6 weeks of pain, diagnosis and recovery. I always had a ton of questions, so if any of this answers someone else's questions then it's done it's job.

Backgroud, I'm an otherwise healthy 36yo male, married 2 kids 2 dogs and a great job. This has probably been my healthiest year in at least the last decade. I had been swimming 3-4x/week and lost 20lbs from the swimming (I'm at 198lbs atm).

In August 2012 we took a road trip to a family reunion 1000miles away. We did the trip all in one shot, there and back and really only stopped for gas. After the trip I'd been swimming and thought I'd pulled a calf muscle. I stopped swimming and basically everything else hoping it'd resolve itself soon.

After about a month the pain subsided a little and I tried to get back to my routine, only to discover I thought I'd pulled a groin muscle! I rested a week then woke to discover I'd pulled a muscle behind my knee. Clearly something was amiss, my wife thought I should goto the clinic ASAP for blood clots. They were booked solid on that Saturday and told me to come back later. While we tried to goto lunch I nearly collapsed in front of our young kids and my wife took me the the ER.

I was diagnosed after blood work, an CT scan and an ultrasound with multiple bilateral pulmonary embolisms. Thus since just after Halloween 2012 I've been on a daily Coumadin therapy of 4mg daily. The rest of the PE story is for another forum.

The silver lining from the PE experience was that the hospital noticed my arrythmia during my sleep. I've known about my tachycardia since I was in high school and have always been able to manage it through rest and controlled breathing. This time though they noticed bradycardia during sleep, sometimes at 30bpm heart rate and other times missing a natural pacemaker pulse for 2-3 cycles.

I had not had any symptoms associated with the arrythmia so they told me to monitor w/ a home monitor kit for a month just to be sure. Little did I know that in the 2 weeks subsequent to leaving the hospital I was having a very difficult time with both tachy and bradycardia, which the doctors at first attributed to the PE. But now they have ECG readouts to show what was really going on.

After a near-miss episode walking my kids to school, I went back to the cardiologist from the hospital stay who informed me that I was suffering from sick sinus syndrome with stage 2, type 2 heart block and a primary candidate for immediate artificial pacemaker implant. They would've done the procedure the next morning if not for my Coumadin therapy and scheduled it 4 days later to wean me off the slow-metabolising Coumadin to prep for the implant.

Those 4 days were the most terrifying of my life. I was mentally exhausted from reading everything I could find on sick sinus syndrome and pacemakers, and just generally feeling terrible. I had zero energy that week, my wife told me I was ashen pale, and I could barely muster enough wind to make it through a 5 minute conversation.

But 4 days later I had my implant procedure done in local anesthesia. I have in me now Medtronics Revo MRI PM, and Medtronics MRI-approved dual leads for artrium and right ventricle. I believe the leads have pigtail screws to secure them to my heart. I also have my PM implanted on my right side as I'm left-handed. Note; if you are going into PM surgery ask about a implant-side preference, and options for which PM and leads you qualify for - I did and I'm thankful I just asked. My cardiologist said he'd never had anyone specify which component to use ahead of a procedure.

The procedure lasted about 75 minutes, and the OR played Carlos Santana. The comfort nurse used a combination of Versed and Fentanyl to induce a twilight state for me but it didn't work about 4 dosings. I was lucid but numb for the entire procedure. I asked too many questions and was just generally too chatty during critical moments of the operation that they asked me to try to settle down. :)

Post-op was decent. I had a major hangover from the pain medications from the procedure. They only gave me extra strength Tylenol for pain management in post-op and even at home. I was fortunate, and discharged the same day to recover at home.

The sutures I had are mostly subdural, and the external layer was sealed with Dermabond. The implant sight and incision were very tender for the first several days. My body also had a tough time adjusting to the new equipment. I had (and still have) weird spontaneous feelings in my chest that my medical team indicated were signs of the heart recovering from minor trauma from the lead insertion, as well as the chest implant. They noted that as long as the pain was local and specific and not widespread to my arms or my jaw I was probably ok.

The bruising and swelling began in earnest about 3 days post-op. It got so swollen I wondered if the dermabond would hold up. It looked like someone had inserted an oversized golfball just below my clavicle. Note; the PM I have is roughtly the size of an Oreo cookie. Eventually in the 2nd week of recovery the pain and the swelling subsided, but the bruising remained.

I learned the bruising was actually a subdural hematoma in my case (likely exacerbated by my coumadin treatments). Subsequently the dermabond finally wore out and a small breach in my incison leaked allowing a breach of the subdural hematoma. It took about 20 hours and several soaked gauze dressings to drain the hematoma, including a trip to the ER as the doctor on-call didn't want to risk further bleeding or infection. Luckily neither occurred and the ER team cleaned up the incision and redressed the wound with a compression dressing and sent me home.

This all just happened today in mid-December 2012. At this point I know I have a ways to go for recovery. I have very little activity tolerance (let alone excercise) and get fatigued and anxious very quickly. I try hard not to take any Tylenol or Xanax unless I'm totally crushed. I'm hopefully on the mend now. I've lost another 10lbs through this ordeal.

I've since completely quit alcohol, caffeine and the occaassional cigar. I'm allowed to drive again as I don't have any signs of syncope and have started getting back into my work. I know there are more details of the story so far that I've forgotten to include, but think this is enough to get started. This is a good way for me to cope and hopefully gives someone some idea what to expect.

Please feel free to ask any questions, at this point I'm not at all bashful about this experience and just want you and me to get better.

Cheers!


5 Comments

Chatty

by carissanv - 2012-12-16 01:12:56

Heh...that cracked me up. My EP said the same thing about me during my ablation. I couldn't help it. It was all so cool seeing the wires inside my body!

RE: Revo

by cuhead - 2012-12-17 02:12:19

Kbell - there aren't many combinations of PM/leads that are both FDA-approved for MRI, from what I've read.

I asked for MRI-ready kit because of the additional EMC shielding.

RE: PM implant depth. Mine is located just beneath the skin/fatty tissue layer, and above the muscle layers. The surgeon made a pouch for the PM to settle into over time. I have no clue yet what the level of discomfort would be with a backpack over time. You might look at a well padded shoulder strap or even a modified messenger bag for heavy loads.

6 week update

by cuhead - 2013-01-11 11:01:17

Just an update on where I'm at recovering as it's been 6 weeks since surgery.

My wound *finally* healed over last week, this is now my first full week without wearing a dressing over the incision. The anti-coagulants I'm on made the healing process very very slow.

I've only had one episode of either supra-ventricular tachycardia or inappropriate sinus tachycardia (I need to inform my doctor about this). From what I've read there is really not much they can do about it aside from beta blockers, which may not exactly be compatible with my lifestyle.

Since I'm no longer drinking, and my heart is operating normally (albeit it a higher pace) overnight, I'm feeling like a million-dollars every morning this week and have been super-productive.

I've also been able to get out and go sailing a couple of times this week too! Just steering though, my buddy rigs the running lines.

I'm going to check in with my cardiologist again early next week to see about physical therapy and lifting my arm over my shoulder height so I can start swimming again to regain some other shape besides Christmas-round. Note, the Medtronic rep had indicated that they recommend 3 months of limited range of arm motion on the side of the implant which is about 2 times as long as the cardiologist's discharge orders.

My pacemaker shows prominently beneath my skin though everything has healed well enough. I guess I just don't have enough fatty tissue to bury it.

Interestingly the next "regular checkup" is 3 months post-op with the pacemaker nurse, and 6 months post-op with the cardiologist!

6 month update

by cuhead - 2013-06-18 06:06:25

Hi, just checking in for those who want to know. Everything for me is much, much better. I walk my dogs ~ 1.5miles every day and was riding my bike until a wipeout last week (my own fault).

My energy level is good and my pacemaker seems to be doing its job. In my last checkup in April I was using my dual chamber pacemaker about 9-10% of the time on the atrial pacing and negligible on the ventricular pacing.

I'd been having some weird blood pressure spikes that went away after they disabled a feature called "atrial rate stabilization". I think my pacing was out of synch with my natural rythm and was pulsing on a closed valve which ramped up my BP. I also had my lower threshold lowered from 60bpm to 55bpm.

I'm ready to start swimming regularly again, just haven't done it yet. I still don't drink alcohol nor caffeine nor smoke my beloved cigars. But I think I'm ok with that.

I get palipations rather easily now from eating big meals or too many sweets and that is manageable. Life is good.

1 year update

by cuhead - 2013-11-18 08:11:57

Hi friends - some surprises at my 12 month checkup. I am doing exceptionally well compared to this time last year. I eat well, sleep well and get exercise daily. I quit drinking alcohol, caffeine and sugared drinks and stopped smoking cigars. As a result I feel great.

During the routine pacemake interrogation the Medtronic and cardiologist team noticed some abnormal sustained Fast A/V rhythms and more concerning a stretch of ventricular tachycardia. In a susbequent follow-up with a team of electrophysiologists they recommended an electrophysilogy study (EPS) and likely cardiac ablation of atrial nerve bundles, in this cases tricuspid and pulmonary vein isolation.

They initially had recommended an implantable cardioverter defibrillator (ICD) but decided that because of relatively young age (mid/late 30's) that I they just want me to avoid overexertion during activity and proceed with the ablations.

The EPS will also tell them if they think the procedure has a better chance of being successful.

The downside is no ICD protection for future VT's, but the tradeoff is that I will hopefully lead a better quality of life by not being inappropriately shocked during exercise.

The EPS and ablations are supposed to be outpatient procedures. I'll follow-up at a later time on the efficacy of these procedures and whether or not ICD treatment might be required.

Here's to our heart health!

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It is just over 10 years since a dual lead device was implanted for complete heart block. It has worked perfectly and I have traveled well near two million miles internationally since then.