Pace maker syndrome

Just wondering if anybody knows what the chances are of developing pace maker syndrome. My dual chamber St Jude PM has been in 3 1/2 years. Everything is fine says the EP. At 73 years old my ejection fraction is 50 to 54%  according to the echo. I asked about installing a lead to the left ventricle to prevent pacemaker syndrome. Cardiologist says " don't poke a skunk". What percent of users of a dual chamber PM develope this condition? I have read anywhere from 5% to 80%. I have third degree heart block, which means I pace 100% on the right ventricle. Atrium is pacing around 30% at last visit. Would appreciate any insight. 


8 Comments

I'm with your cardiologist

by Theknotguy - 2019-10-26 10:31:46

I did computer repair and network support for 35 years.  Used a saying from my Dad.  "If it ain't broke, don't fix it."  Same thing for pacemaker syndrome.  If you're getting along fine - leave it alone.  Don't borrow trouble by worrying about something that may never happen.  

Based upon comments on the forum, pacemaker syndrome isn't that common.  Besides, with the technology changes, problems with things like pacemaker syndrome have been decreasing as the technology gets better.  My pacemaker is six years old and I haven't had any problems with pacemaker syndrome. You have a newer pacemaker than mine which means you've got less of a chance for pacemaker syndrome than I do.  So if you're getting along fine with your pacemaker, I'd switch over to worrying about something else.  Plenty of stuff to worry about especially with the current state of government affairs.  

Hope everything else is going well for you.
 

poking a skunk

by Tracey_E - 2019-10-26 10:42:01

If it ain't broke don't fix it has always been my motto. I had one cardiologist offer me a 3 lead when I had my last replacement, I said no thanks. I switched to a different ep who also said no way would he consider it for me unless my EF dropped significantly. He further said that if we are paced 5 years without a drop in EF, he almost never sees it drop later. He's an adult congenital specialist, head of ep at a large research childrens hospital, so the bulk of his patients are paced long term. So I no longer worry about the day my EF drops. 

Pacemaker syndrome

by Stoudien - 2019-10-26 11:33:11

Thank you for the replies. To put this in propective I am the type of person that generally tries to head off a problem before it becomes a problem. 

. As an aircraft A&P mechanic with inspection authorization I have been trained to reduce the possibility of problems before they become problems..which makes sense, you don't want to be flying along and develope issues that could have been prevented by preventive measures. 

However I won't argue with the whole world...so ok..I will forget about it! Thank you for your replies.

odds

by Tracey_E - 2019-10-26 11:48:40

I think if the odds were very high of developing additional problems then you'd see a lot more preventative CRT's.  However, the odds are not high at all (under 5%?), and according to my ep there is also no evidence that having the CRT will prevent heart failure. He feels if we are prone to heart failure, we will get it with or without the CRT so he doesn't see a reason to treat for it before it happens. There are some doctors out there who are giving most new CHB patients 3 lead, but they are in the minority.  

I'm always going to choose less hardware. Less chance of infection, fewer parts to wear out.  I'm 53, have been paced 25 years and hope to get another 25 so I plan to outlive all of my current hardware. If I had reason to believe I was a higher risk for heart failure, my feelings on having the third lead would change. Just being paced ventricular is not a guarantee of heart failure. 

 

Third lead

by AgentX86 - 2019-10-26 11:59:32

Insurance is unlikely to pay for a CRT pacemaker unless it's needed.  In addition, the third lead takes space in the vein.  If a lead fails (and that's another one that may fail) it's space the new lead can't take, possibly requiring an extraction. An LVEF of 50-54% is very good, so there is absolutely no reason to go pissing off skunks.

It's a really *great* question

by crustyg - 2019-10-26 15:36:44

The evidence isn't yet strong enough for litigation or malpractice, but it's heading that way IMHO.

If I understand the literature correctly - and I'm still coming up to speed - RV apical pacing is associated with a 2-fold increase in 'heart failure' - commonly measured as reduced %LVEF compared with atrial pacing (MOST subgroup from DANPACE).  Subsequent studies have been evaluated comparing His-bundle with RV pacing, and it appears that this is valuable for patients with already reduced %EF.  I don't know of any large studies prospectively comparing His-bundle with RV apical pacing - something like another DANPACE.

Who gets the problems and why isn't known with any certainty.  I *suspect* that it will turn out to be a combination of heart muscle health (why you needed a PM in the first place) and your genetic makeup.  It certainly takes time - many months/year(s) to show reduced %EF and more time for that to show up in mortality figures in trials.

Adding a third lead is not without risk.  Replacing a RV apical lead with His-bundle may not be possible or available or affordable.

A fellow MD carefully chose His-bundle even though the data is not yet solid. 55% EF is considered the low end of 'normal' but that may still be a lot lower than your %EF 5yr ago.

Keep going with your reading and watching that %EF and explore your options. I *think* your EP doc's advice is inadequate.

Great question

by Stoudien - 2019-10-26 16:34:09

And you have just explained how I feel and why I have been looking into this..as I understand it, most insurance won't touch this until EF reaches 40% or less and as you say there is risk. It appears to me that the his bundle is the way to do this. In my area there is only one cardiologist that does the his bundle frequently, another does it occasionally. 
 

I will keep on trying to learn more about this subject.

PACEMAKER SYNDROME

by Gemita - 2019-10-27 05:49:56

Hello Stoudien,

Although I do not spend my day worrying about my dual chamber pacemaker and what could happen in the future, I do like to keep up with latest research, so that I may quickly make an "informed" decision on any new treatment if required.  I feel too doctors generally appreciate their patients taking the trouble to understand their condition and options for treatment.

I am new to the pacemaker world so cannot add anything more to the excellent advice given by members already.  From my discussions with my EP I understand that right ventricular pacing alone can lead to heart failure in some patients because of a loss of synchrony.  I also believe that heavy right ventricular pacing may trigger, or lead to a worsening of, Atrial Fibrillation which in itself is a strong reason to try to correct any dysynchrony as early as possible.  I too have read that His pacing preserves mechanical synchrony, so I would imagine if we can achieve a more natural physiological approach to pacing it has to be to our advantage.

I wish you well for the future

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