Masters swimmer-junctional rhythm

I’m a competitive Masters swimmer, age 62, who has been experiencing episodes of slow HR (low 30s) junctional rhythm over the past 15 months. On average I experience about 3-4 episodes/month with each episode lasting, on average about 12 hours. I’m conscious of a slow, unsynchronised HR (uncomfortable), slight breathlessness, fatigue, but no syncope (yet). Probable causes is sick sinus (?plus high vagal tone). Prior to these junctional rhythm problems I had occasional episodes of AF/atrial flutter which appears to have been rectified by a successful peri-mitral ablation performed 18 months ago. Both the AF episodes previously and now the junctional rhythm appear to be related to intense competition or hard training. (though curiously the junctional rhythm episodes usually don’t start until a day after competition). Have tried to train while in junctional rhythm but with HR maxing out at about 80 BPM the sessions are tiring and not very productive.
I’m struggling with the decision of whether to get a PM. My EP is ready to proceed at any time. Preference would be to go cephalic and perhaps sub-pectoral to allow greater arm movement (I’m a butterflyer). Although I am likely to require a PM at some point my choice now is between a PM and continuing to train and compete at a high level (am current Australian National record holder and World Top 10 ranked in several events in my age group) or to stop competing/hard training (difficult decision) and hope that the number of episodes decrease in time through “ de-conditioning”
Interested to hear from anyone who may have been faced with a similar problem/decision

5 Comments

swimming and pacemakers

by mikenall - 2015-04-19 09:04:37


while I don't compete at your level, I have a dual lead pacemaker for similar symptoms, am 64 years old, and will be competing in the triathlon at the National Senior Games this summer. When I got the pacemaker (August 2013) they told me to do whatever I wanted, that little kids go around and do all sorts of crazy things with the lead wires with no problem. I just started last month with noise in the ventricular lead. Is it caused by my lifestyle (swimming and other upper body exercise)? Who knows. If it is and they tell me to stop, don't know if I will.

conditioning

by Tracey_E - 2015-04-20 09:04:38

JMHO, but I would do what it takes to maintain your conditioning. If you will eventually need it anyway, I would do it sooner rather than later so you can maintain. It's so hard, if not impossible, to get it back once you lose it.

Did they talk to you about training while in junctional rhythm? It's not a good idea to push it when your heart rate isn't keeping up. 80 is probably half of what you normally train at, right? Your body is being deprived of oxygen and you're doing more harm than good by pushing it. When you're too tired to train, that's your body talking to you. Listen.

I highly recommend subpectoral placement. Healing takes a little longer but it's well worth it in the end. I've had one for 20 years. I'm very active, tho not at your level, and it never gets in my way with the deeper placement. Some people are more cautious than others about leads but I've never given mine a thought, and I haven't had a problem. I had one lead go bad but it was 15 years old, which is average life of a lead. I hike, kayak, ski, do Crossfit with no limitations.

If your rate is dangerously low, if you are at risk of passing out, then there is no reason to wait. The argument could be made that low 30's is dangerously low. It's certainly well under the definition of bradycardia (under 60). Don't wait until you pass out, that's too late, unless you happen to have a crystal ball to know when it will happen. We've had members pass out for the first time while driving, then have to recover from the accident as well as pm surgery. Others have had serious injuries from passing out. Your rate is low enough that you are at risk.

Even if your rate wasn't so low, my advice is always to get the pm when it's affecting your life. If you are tired at the end of the day,if you can't do what you want to do, then why put it off? There is a fix. Get it and get on with your life.

Just an observation

by IAN MC - 2015-04-20 12:04:04

i am very active (although nothing like to your level) and frequently play golf, tennis, cycle , run and swim.

I do not have a subpectoral implant and have never found the need for one. I realise that doing the butterfly stroke involves intensive repetitive stretching of the slack in the PM lead but so does a golf swing .

I can understand having sub pectoral for vanity / appearance reasons but my PM certainly never ever "gets in the way"

. Personally I would rather avoid having anyone slicing through my muscles with a scalpel because of the extended recovery period which follows and the prolonged post-implant pain. It must also add to the hassle of having a replacement PM fitted.

Ian

muscle

by Tracey_E - 2015-04-20 12:04:55

It's better to put it between the pectorals, not actually in or under.

Ian, burying it protects the leads more for activities like rowing, swimming, barbells. Some people can get that protection without going subpec, depends on your build and your surgeon. I was thin enough when I got my first one that it would have really poked out and been in the way if they hadn't buried it.

Thanks Mike, Tracey and Ian

by iany - 2015-04-22 05:04:51

Thanks Everyone, your feedback much appreciated.

Mike- very encouraged by your experience and hope that there is no issue with your ventricular lead

Tracey- Agree that deconditioning to limit the incidence of junctional rhythm may not work and is not the answer unless I wished to stop competing. Only wish I had some control during these episodes. Can go a month or so with no episodes and then have a number of consecutive days with the problem (often after a big meet). Only occasionally am I able to trick it back into a regular sinus rhythm with a burst of activity, otherwise I have to let it play its course. So, it’s a bit like a black cloud hanging over me and the sooner I make the decision to proceed probably the better in the long term. Admit I’m struggling a bit mentally with the decision. Also didn’t mention that I had a complication after my ablation in 2013, an embolism in my renal artery, so still, bit wary of any procedure, even a relatively simple one like a PM implant.

Have only tried to train a couple of times while in a junctional rhythm and unlikely to try again. EP says it not a risk as the reduced cardiac output will force me to slow down which is certainly the case. Perhaps similar to the effects of beta blockers? Given my fitness I can probably tolerate a junctional HR, at rest, in the 30s but appreciate your concern about the risk of accident.

Tracey and Ian: Appreciate your comments re sub vs pre pectoral placement. Hadn’t heard of placement between pectorals Tracey but perhaps that might be a good compromise? Was aware of the potential issues ie muscle damage, prolonged recovery, pain, etc. Glad to hear that you have not had any issues Ian. Golf is my other sport so that’s also good news. Do either of you know how much longer on average the recovery is for sub-pectoral?

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