Children & young adults with PM

I'm wondering what type of PM Dr's have implanted in young children & young adults with complete heart block-but no heart failure & normal ejection fractions...dual chamber (2 leads) or bi-ventricular with 3 leads...and if it's a 2 lead PM -has there been any evidence of cardiomyopathy after long term pacing on one side of the heart? Thank you in advance for your time...

10 Comments

Already answered

by golden_snitch - 2014-12-31 04:12:30

Lisa,

we have answered that question already, and there is no difference with regards to children or young adults. There is no indication for a CRT device in patients with heart block only, a dual-chamber pacemaker is sufficient. Implanting a CRT in someone like you is not in accordance with any guidelines, neither AHA nor ESC.

And I have also explained that longterm pacing does not necessarily increase the risk of heart failure; there are patients who go into heart failure after a couple of months, and there are others having been paced for 30 years already and who are showing no signs of heart failure at all.


Inga

Children

by Pacemum - 2014-12-31 05:12:44

Babies normally start with a single lead which is attached to the outside of the heart as their hearts are too small to take any more. As the children get older they may move onto a 2 lead to gain a better heart function or to achieve a more normal heart function. It is extremely rare to insert 3 leads in a child and as stated above the 3 leads are not used for heart block patients only.

Long term pacing

by Selwyn - 2014-12-31 07:12:58

This is a very interesting question- one next to my heart!
Long term pacing ( as in children), as Lisabfit wonders is associated with structural changes in the heart muscle. We all have our impedance measured ( that is resistance) and this changes with time. Why? Muscle that is being paced changes with time, and moreover as the conducting system of the heart is not being used so does the muscle not actually under the pacing lead. This can lead to poor left ventricular function when the pacing lead is in the right ventricle, and in some the onset of heart failure. The heart failure can be treated with a lead into the left ventricle ( cardiac resync. therapy). Ventricular dyssynchrony may be present in up to 50% of the patients after long-term RV apical pacing. Importantly, it has been demonstrated that the presence of mechanical dyssynchrony after long-term RV apical pacing is associated with LV dilation and a deterioration of LV systolic function and functional capacity.

There is some luck as to who is OK and who is not as the tip of the right ventricular lead may be near to or far away from the normal conducting system of the heart.

At the moment there is ongoing medical work looking at the wisdom of a third lead in those not having any left ventricular dysfunction clinically. Perhaps in the future all long term pacing should have a third lead? I don't think we can answer this at present.

Thanks for the question and thought.

Ref:The Effects of Right Ventricular Apical Pacing on Ventricular Function and Dyssynchrony Implications for Therapy Authors:
Laurens F. Tops, MD; Martin J. Schalij, MD, PhD; Jeroen J. Bax, MD, PhD, published Aug 2009, J of American College of Cardiology

Impedance

by golden_snitch - 2014-12-31 08:12:28

The impedance that is being measured is lead impedance. It has nothing to do with the heart muscle, but with the shape the leads are in. Impedance increases when there is a lead fracture, it decreases when there is an insulation break.

In the normal heart, the impulse travels down into the ventricles (AV-node, His Bundle, Purkinje Fibers). However, left and right ventricle are never beating totally insync, but almost. The delay between the two chambers can get longer, if one chamber is paced and the other is not. In an ECG this typically looks like a left bundle branch block; the impulse travels from the pacing lead in the right chamber to the left chamber, from cell to cell, so, the left chamber contracts later than the right. This is not physiological, and it's this dyssychrony what can lead to heart failure. But it doesn't have to happen, not even if you are paced for 30 years or more. It has been found that right ventricular APICAL pacing seems to lead to heart failure more often than septal pacing or His Bundle pacing. So, cardios are testing different pacing sites at the moment to find out which location might be the best for the right ventricular lead.

In children you'll always make sure that you do not put more leads in than really really needed, because children for sure will need lead replacements, and the more leads are already in, the more complicated this will get (lead removals will be needed). Personally, I only know one child who got a bi-ventricular pacemaker, and that kid was already on the heart transplant waiting list. One had hoped that the bi-ventricular pacemaker would improve her EF a little, increasing her chances to survive until a heart was available. The device did not help, but fortunately the child still made it till transplant.

Inga

Impedance, changes in the heart structure with pacing

by Selwyn - 2015-01-01 07:01:03

Lead impedance is measured by the impedance of the wire and the fibrosis at the tip ( which is one of the reasons why impedance is measured at every check up). The fibrosis at the tip of the lead has a tendency to increase with time (... which is why impedance is measured at every check up). The threshold voltage can then be adjusted accordingly to overcome the resistance ( Ohm's Law states V=I x R, v=voltage, I = amps/current r = resistance. As resistance increases you need to increase the voltage to maintain the current). Steroid eluting tips help reduce the impedance associated with pacing.

I am concerned about the actual changes in the cardiac muscle with long term pacing. Perhaps my reply above is confusing. Impedance is one problem that is well understood as a consequence of pacing. What is not so well understood is the long term effect on the heart muscle, as lisabfit is inferring to. The question being asked is, "Has there been any evidence of cardiomyopathy after long term pacing on one side of the heart?". The answer is yes. A further reading reference is provided.

link to support group

by slarnerd - 2015-01-07 01:01:36

https://groups.yahoo.com/neo/groups/heartblockkids/info

Feel free to join us if you are a parent of an affected child. Please include specific details in your request - your name, child's name and condition, the hospital you use, device, etc.

variety of pacing options for infants/children

by slarnerd - 2015-01-07 01:01:41

The type of device used, number of leads, and placement depends on the preference & skill of the CT surgeon and/or electrophysiologist, as well as your child's size and anatomy. The most common placement for a child under age 6 is to place the device in the abdomen, epicardial leads. At least one electrophysiologist, in the Chicago area, implants transvenous in all children, even babies. Most others will place a permanent pacemaker once the baby is a minimum of 5 lbs or 2.7 kg. My own son's dual chamber Medtronic device was placed when he was 4 lbs - over 8 years ago. His surgeon has since paced a child as small as 3 lbs.

Most young children with heart block now have a dual chamber, rate responsive pacemaker - some have a single though. Most have a Medtronic brand pacemaker but some have a St. Jude.

I know of a handful of young children who have received a bi-vent device after their function decreased and they began to show signs of cardiomyopathy. I can think of 8 in particular, half of which were listed for transplant. Two ultimately needed a transplant and got it - the others improved. I don't know of a child to receive a bi-vent preventatively. However, some EPs prefer bipolar leads which I think stimulate more of the heart.

My comments are anecdotal - based on moderating a large online support community for parents of kids with heart block and/or pacemakers around the world. I've had contact with more than 400 families in almost 9 years. Feel free to join us if you are a parent of an affected child. Please include specific details in your request - your name, child's name and condition, the hospital you use, device, etc.

My daughter

by Jenniferlee48 - 2015-01-23 11:01:26

My 15 year old daughter just had hers implanted in July due to 3rd degree heart block. It was a dual chamber. She has one of the newer pacemakers inserted from my understanding. They used a Boston Scientific K174. We had it implanted under the pectoral muscle because she is thin and was worried about kids being able to see the box. The pacemaker she received is very nice because it has a remote box that sits in her room. It is set to run a quick check on her every night and runs a full scan every 2 months. Some of her check ups are done right over the phone. If a problem does occur the box has different lights and codes to let us know if there is a problem. She doesn't have to pull a wand out or anything. She just needs to be in the same room. If she feels like she is having symptom all we have to do is call the Dr and push a button on the box that will then send a full report to the Dr. For us this has been very easy. We are very new to this and the heart condition came as a big shock to us so I am not sure of others experiences.

ME

by Dobbyy - 2015-05-12 06:05:44

I am 16 in complete heart block. I have a dual lead pacer under my pectoral muscle. Started with a single lead, but we agreed it was better for a highly active lifestyle to stimulate both sides.

My son

by Shiva-Gupta - 2023-05-29 13:57:41

13 years with AV block due to which he was having syncope. He has dual chamber Medtronic leadless PM. Itscbeen 8 weeks and he is doing good and no syncope episode.

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