Wait and see approach?

I had a pacemaker/icd implanted 11/29/12. I have IHSS/Cardiomyapathy (open heart in 2000 to filet the outflow track) I've recently developed an issue with frequent fainting due to rhythm issues. Thus the implant.

Unfortunately it took a few weeks for the device check folks to figure out why I was feeling such a strong "snap" in my torso. The "fix" was easy enough: turned down the voltage. After a number of other adjustments in my settings I'm feeling much better. (for that I'm thankful)

Here is my question/concern: I have a two lead pacer and my doctor had suggested replacing it with a three lead which will pace my left ventricle as well as the right. I have 100% heart block (was 60% paced when it was placed but now it's 100%) so the constant pacing in the right is DEF needed. My ejection fraction is currently 55. I am wondering if it would be a bad idea to take the "wait and see" approach to understand what if any effect pacing 100% on the right side will have on the EF??

Any thoughts, ole wise ones?

Thanks in advance for any thoughts you care to share
Kim

2 Comments

Wait and see

by golden_snitch - 2013-02-25 07:02:50

Hi!

In the first couple of weeks after the implant, they'll always program the voltage much higher than actually needed. They usually change that either 6 weeks or 3 months after the implant. This is because, while the area where the tip of the pacemaker leads is attached heals, the pacing threshold is usually a bit higher due to inflammation.

The 100% ventricular pacing depends on your settings, and does not automatically say that you definitely need this much. If the pacer is programmed in a way that does not give the AV-node much time to do the job on its own, you end up with a high pacing percentage. Also, if you are programmed in DDD mode, it will pace you out of every single heart block, even if it's just one skipped beat.

I'd certainly take the wait and see approach. Not every patient who's paced 100% in the right ventricle develops heart failure due to asychroneous beating of the ventricles. Also depends a bit on where exactly the ventricular lead is placed; if it's in the right ventricle's apex, the risk is higher than in other places. Why have another surgery now, if there is no evidence, yet, that the right ventricular pacing does any harm? If your EF should start dropping with every echo you have, you can still get the upgrade.

Best
Inga

My thoughts

by ElectricFrank - 2013-02-25 12:02:27

Taking a few weeks to figure out that turning the voltage down was needed doesn't inspire my confidence in the clinic. The pacing voltage should always be set to the lowest voltage that is needed for reliable pacing so why was it left high for weeks? An unnecessarily high setting not only can cause the symptoms you were experiencing, but it can also irritate the heart wall.

So before agreeing to a 3 lead pacer I would suggest getting a second opinion from a competent facility.

Ole wise? frank

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