2nd opinion

Hi All, thank for all your responses to my previous post, very helpful and re-assuring. I have a planned procedure date of this wednesday. I am 49 otherwise healthy male. Run minium of three times a week and generally very active, absolutely no symptoms. Went for a well man clinic in UK in December last year. Was originally diagnosed with complete heart block on the back of a 10 second ECG. Insisted on another ECG there and then and was told I had Wenkebach 2nd Degree heart block which is unlikley to progress. Had a holter monitor test and was advised that I had episodes of 2:1 during the night and a couple of pauses of less than 3 seconds. Also had MRI, treadmill and echo cardiogram which were all normal. Saw two Consultants, one said that I am likely to end up on Pacemaker, the other said 99% sure I wouldn't. Both agreed that I should have a follow up Holter monitor in 6 months time which I have just had. Results show and episode of nocturnal 3rd degree Heart block, heart rate didnt drop below 40 bpm at anytime. Consultant now says that its almost a certainty that I will need a Pacemaker at some point in the future as my condition has worsened so may as well have one now to reduce risk. I'm all for reducing risk but it does make you wonder when you keep getting conflicting information! Problem is that I have a slot to fit Pacemaker this Wednesday so I don't really have any time for a second opinion and given what the Consultant said about 2 minutes of 3rd degree, I'm not sure I want to leave it any longer. I guess this is just a bit of denial on my part but I would be interested in your thoughts. Have to say that this site is wonderful and its so good to be in touch with others who have been through a similair experience.

5 Comments

Not in favor...

by golden_snitch - 2014-06-23 02:06:32

Hi!

If I understood you correctly, you are absolutely asymptomatic and this heart block was just an incidental finding, right?

I know that the majority here will probably talk you into getting the pacemaker. Have been observing this here for quite a while, and as soon as someone posts who is undecided about whether to go for an implant or not, there usually is a majority in favor for the pacer. However, I do not believe in fear mongering, but in making decisions based on facts. From the info you have shared here, I'd say, yes, maybe one day you'll need a pacemaker. When that will be, I cannot tell and no one else can. Patients who have congenital third degree heart block often go for 20 or 30 years without needing a pacemaker. 2:1 heart blocks and pauses of less than 3 seconds at night are peanuts. Really, this can happen to anyone. Your last holter showed two minutes of third degree block at night, BUT your heart rate never dropped below 40, despite the block? Again, this is in my opinion nothing to worry about and nothing that would justify rushing into a pacemaker implant at the moment.

If I were you, I'd get a holter done every 6 months for a while, and see how things develop. A pacemaker implant is a minor surgery, however as every surgery it has it risks. Given that you are not symptomatic at all, and your current diagnosis is not a clear indication for a pacemaker, I'd put it off as long as possible. I mean, you are not even having these arrhythmias at daytime, only at nighttime. So, reducing the risk could also mean that as soon as episodes appear at daytime you go for the implant, but as long as it's a night only, you wait.

There are guidelines, for instance by the American Heart Association, regarding device-based therapy for cardiac rhythm abnormalties. You can find them at:
http://content.onlinejacc.org/article.aspx?articleid=1138927

Scroll down to the section on "Recommendations for Acquired Atrioventricular Block in Adults", and you'll find that you have no Class I indication, and but only Class II a, if at all. You don't have that "persistent" block that is being mentioned there. You only have it at night, and maybe not even every night.

Hope this helps a bit.

Best wishes

Inga


wait for now

by Tracey_E - 2014-06-23 04:06:33

You might want to postpone and take the time to get another opinion first. A few minutes of 3rd degree block is nothing. Your pauses are very minimal. You don't have symptoms. Definitely keep an eye on it, and yes one day it might get worse and you might need the pm, but for now it sounds like overkill to me.

I was diagnosed with congenital 3rd degree block in 1971. Not intermittent, I stayed in block all the time so my hr never went up and we knew it was a matter of when not if. I became symptomatic in my 20's and got my first pm in 1994. When the time comes, it is not a big deal and an easy fix, but imo you aren't there yet, not even close.

Wait and see

by gleesue - 2014-06-23 05:06:31

Rich,

I had the open hart maze procedure in 1991 and was told I may need a PM in the future. Even though the PM is great, it is still better if you can live without one. Finally, in 2012 I had to get cardioverted and my hart started going 6-10 seconds between hart beats. No option this time. Up till then I really didn't have many symptoms. I ran, biked, lifted weighs and was generally very active. Guess what, I still do the same things today with the PM.

If I were you and had no symptoms and were active, I think I would wait. golden_snitch/Inga knows what she is talking about ----listen.

Jerry

Very Similar

by PeteFindlay - 2014-06-23 05:06:40

My own experience is similar. I've had a low resting pulse rate (50 or below) for a while, and routine ECGs showed no problem until this year when heart block was spotted. Followed up with a 24hr Holter which showed significant episodes overnight, with pulse rates down to mid 20s.

I thought about whether or not I really needed a PM, or whether I should be waiting for symptoms to develop. My consultant said that it could develop into total heart block leading to black-out or worse... could be in 5 weeks, or 5 years.

However, the thing that persuaded me not to look at putting it off was the fact the my echocardiogram showed an enlarged atrium, which was likely due at least in part to the ventricular block. That and the low overnight rates, I was told, presented a much increased risk of stroke.

It's very, very hard to accept needing a PM when you're otherwise fit and healthy - I had literally never felt fitter - and have no symptoms. I'm still not sure I've come to terms with the need for one, as of course, I don't feel any better. I couldn't! At some point I had to trust the clinical judgement of the consultants - I had seen two.

Although time is short, I would try to get a serious talk with the consultant before the procedure to be as content as you can be that the potential risks of your condition warrant it - and if you do need one now, then also the benefits of placement sub-pectoral, as per the other discussion. If you're going to have one, it's for life as has been said above, so you might as well get it matched to your circumstances.

It's not something you'd rush into by choice, but on the other hand, if it's genuinely needed, you don't want to wait.

As and when you've got it, it isn't the end of the world. I flew away for a week's holiday at 10 days, and I was back running (with the clinic's approval) after 3 1/2 weeks, and I'm happy to say my pace over my typical 5 - 10k distances is much as it was.

Happy to share experiences and thoughts going forward (by private message if preferred) - sounds like you're in a very similar position to mine.

Pete

Reveal

by NiceNiecey - 2014-06-25 12:06:53

I'm big on this new Medtronic device called a Reveal. It's an "Insertable Cardiac Monitor." Here is a link to their website:
http://www.medtronic.com/patients/fainting/living-with/index.htm

Although there wasn't time for me to have one and they've just hit the market, it reminds me a microchip inserted in my dog! Sorry for the comparison but it seems so simple and much easier, less invasive, etc than a PM.

Hopefully with your medical coverage in the UK, they allow for this. Please ask your doctors; that way no one is rushing you into getting a PM if you don't need one.

Do keep in mind, however, that second degree heart block can quickly become complete heart block, in which case you WILL need a PM.

Please post an update to dilemma.

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