Upgrade

In November, 2019, before surgery I had an echocardiogram. I had a St. Jude Pacemaker inplanted. It had two leads, one to the lower right chamber and the second to communicate to the upper chamber. I was placed on blood thinner. Upon return to the hospital in December, I was echocardiogramed again and cardioverted. In late Feburary I had one of my follow up medical appointments. I was removed from meds. I don't know why the doctor did not say anything before but during this visit he said the second echocardiogram revealed there was cardio myopathy. The left ventrical enlarged. Chances are doctors will have to remove the existing implant and install a new one with 3 leads. The cardiologist said I will probably be placed on medications again. I will have a 3rd echocardiogram tomorrow morning.  Is it common to go from a 2 lead pacemaker to a 3 lead pace maker? All of this will take place in the shadow of covid 19 spreading. 


10 Comments

Pacemaker Upgrade

by Gemita - 2020-03-19 08:09:48

You ask whether it is common to go from a 2 lead pacemaker to a 3 lead pacemaker.  

My understanding, as a pacemaker patient, is that it would depend on our heart condition, how well it responds to being paced with your current two lead system, whether pacing is primarily in the right ventricle (RV) since heavy RV pacing alone could lead to dyssynchrony between the two ventricles.  This is more likely to occur with a single lead pacemaker but with heavy RV pacing it could also occur with a dual lead pacemaker.  Some of us just do not like being paced in the right ventricle alone (I certainly don't) and may develop heart failure symptoms which could be helped by a third lead to the left ventricle.

I have had a quick peep at your history.  I see you suffer (have suffered) from Atrial Flutter.  Is this well controlled?  An arrhythmia can make it harder for your heart to pump blood effectively to the rest of your body.  

I hope your situation improves quickly and safely and that you get the best treatment possible for your heart condition

You need cardiac resynchronisation therapy...

by crustyg - 2020-03-19 08:24:27

..which is a recognised complication from Right ventricle apical pacing.  The electrical stimulation to the Left ventricle is delayed from the normal pattern and in some patients this causes significant problems - reduced percentage LV ejection fraction (%LVEF), muscle remodelling etc.

The usual way to address this is to add a third lead which stimulates the LV directly, and for this to work your PM box has to be replaced with one that can provide a stimulus to this additional lead.  Your existing two leads will stay in place.

The lead for the LV is usually placed by getting it into the coronary sinus (where the venous return from the heart muscle's own blood supply arrives in the R atrium a little above the top of the tricuspid valve).  From here it's usually possible to guide the lead into a venous branch that comes from the main part of the LV, so can be sure to stimulate the LV muscle.  It's skilled work but is usually successful.

CRT is usually effective at improving LV function (%LVEF increases), for some patients it's quite quick but for others it takes weeks to months.

There is still debate as to who gets this complication from long-term RV apical pacing, but it seems fairly clear that it's much commoner in patients with existing heart muscle damage (ischaemic heart disease, perhaps tachycardia-induced cardiomyopathy).  Not everyone gets it, no matter how long they've been paced.  Some series suggest 25% of long-term RV apical paced patients develop this problem.

If you need CRT it's not wise to put it off whilst worrying yourself about SARS-CoV-2.  You (and I) are still relatively young, but we both have a cardiac risk factor.  Right now your LV needs to work better, so get on with that.  Your personal contribution to avoiding this virus - and the Covid-19 disease - is hand washing, lots of it, and avoiding prolonged close contact with strangers (work colleagues, customers, Gov officials).

Best wishes.

PM replacement with CRT

by AgentX86 - 2020-03-19 14:07:31

Yes, as Crusty said, you really do need to get this taken care of.  If they want to upgrade you to a CRT, your LVEF has probably fallen below 35%.  You don't want it to go lower or a CRT may not be as effective in reversing the cardiomyopathy.  In these circumstances, they'll probably do the precedure as an outpatient and you'll be there maybe three hours.  I'd make sure they don't lose you in a room with a hundred other patients and make sure they can get you in and out.  Make sure everything is set the day of your procedure.  I went the cath lab once and they said, "___ who?" "We don't have any record that you're sheduled today".  SWMBO went on the warpath on the hospital admins.  But it took time.  Something you never want to do but particularly not in this climate. 

 

I just returned...

by runpacer - 2020-03-19 16:56:58

Thank you AgentX86, crustyg and Gemita!

Each of you were helpful and sound as if you are sophisticated professors of cardiology. I just returned home from UCLA medical. I did the echocardiogram. Next week I will meet with docs and find out if the echo confirmed surgery is needed or not.  Gemita, the atrial flutter seems to have been resolved when they performed an cardioversion on me. Once in a while I experience arrhythmias but nothing like the month leading up to surgery. I went from episodic to constant with my upper chamber beating at 300 to 500 beats a minute. My pulse maintained about 40 to 44 (I run distance). However, it dropped considerably when at the time I was admitted. On the day of surgery it dropped to 25. I run through most of the recovery and this morning. The cardiologist a month or two gave me a choice from lowering the pacemaker from 60 to 40. I requested to have it done in increments and left it at 55. 

One physician said the leads remain, like you wrote crustyg and may add the third lead onto the existing device. He was not a cardiologist nor my doc. Someone I know from the running community. 

Thanks again. I will post an update after the consult next week.

Flutter

by AgentX86 - 2020-03-19 23:01:17

Flutter can be a RPITA.  I had a full Maze that just traded Afib for a bad case of permanent Aflutter (240-300bpm).  Interestingly, if you want to call it that, my AV node was so slow that my heart rate was only 80ish, with random 2:1, 3:1, 4:1, 5:1 conduction. It felt like Afib because it was irregular.  Aflutter is normally a regular, fast, beat.

It was taken care of with drugs, in particular ameoderone, but that was only for the short term.  I had three ablations with ameoderone between procedures to try to stop it . Only to end up with SSS and thyroid damage (temporary, fortunately). Since I was left with SSS, it was a PM for me.

Hang in there.  Your story sounds vaguely familliar.

Follow-up

by runpacer - 2020-03-24 18:28:42

Spoke to two doctors in so many days. The first doc, my cardiologist, said there was no progression or difference between the second echocardiogram and the third. Therefore I do not need surgery or change of pacemaker. However, he said, the next cardiologist will probably place me on medication. That second cardiologist called about 45 minutes ago. We talked. I describe how even though I run everyday, including 6.4 miles this morning, I can feel a heaviness in my chest and get out of breath easily. I also I think I am experiencing some arrythmias. He is placing me on a beta blocker - a half tablet at night. I thought it strange. I don't have chest pain... so I researched the literature. It seemed that the medication is contrary to what a person should receive if they have total blockage and bradycardia. I believe I have both... So.. I sent an email to my first doc to see what he thinks. The second doc is not on my email list so I can't contact him. I am supposed to talk on the phone in one week. Should I take a medication that seems to be the wrong prescription? Is my heart weak if I am still running everyday? 

Follow up

by Gemita - 2020-03-24 21:14:34

Thank you for posting the update.  You might get more responses (and more people will see your post) if you post again as a new item.  In the meantime I will try to give you my thoughts.

I think I understand your question and your concern that a beta blocker may not be appropriate to treat your condition.  I will answer your questions as follows:

Heaviness, out of breath, those symptoms could well be caused by an arrhythmia and if this is the case, a beta blocker will quieten all this down. What is the dose and name of the beta blocker?  Although a beta blocker will reduce both blood pressure and heart rate, your pacemaker will not let your heart rate fall below the set minimum so you will be perfectly safe taking it.  A good beta blocker will help to treat an arrhythmia and help your heart to stay in normal sinus rhythm and pump blood more effectively around your body.  This would then help with your cardiomyopathy.  I would not be concerned about taking a low dose beta blocker like Bisoprolol for a trial period to see if you feel better.

I would ask your cardiologist why he has prescribed half a beta blocker. It sounds as though this might be to treat an arrhythmia. A beta blocker isnt necessarily prescribed for a weak heart.  It can have a very relaxing affect on our entire body and stop any adrenaline surge which can trigger palpitations.  What medication were you on previously?  

Meds

by runpacer - 2020-03-24 23:00:18

Here are the meds I just picked up from the pharmacy:

Metoprolol Succ ER 25 MG Tab

Generic for Toprol XL

Take 1/2 tab once daily.

I will take this med for one week to see how I feel. 

In addition I was prescribed Asprin once daily. 

One month before and after surgery I was on Eliquis. 

One doctor repeated something to the effect of this will help with heart healthiness. I think the second doctor mentioned arrhythmia. I don't mind taking the meds. I worry about side effects. My blood pressure is usually on the low side. My healthy  pulse before surgery was usually 40-44. Low from running. When things went sour my pulse on the day of surgery dropped to 25. It is now set at 55 and I have the option to lower it to 40. I won't drop it that far... I did drop it from 60 to have it at 55. With added milage as the weather warms I will probably drop it down to 50 in a month or so. 

Meds

by Gemita - 2020-03-25 01:41:26

The Metoprolol ER (extended release) 25 mg (half that dosage) will be a starter dose I would think.  I have never tried it but it is widely used by a lot of people.  Some love it, some hate it.  Many switch to taking it at night to prevent fatigue and to help them to sleep better.  I have a friend who is really helped by it.  She has cardiomyopathy.  Hopefully it won't prevent you from enjoying your running, especially if you take it at night.  No harm in trying such a low dose for a week.  Your pacemaker will safely maintain your heart rate at the set minimum of 55 bpm and hopefully the low dose, extended release Metoprolol will help calm any arrhythmia without lowering  your blood pressure too much. 

Did you have any side effects from the Eliquis ?  It is a very good anticoagulant, one of the best in terms of safety, although expensive if you have to pay for health care.  If you have a confirmed arrhythmia like atrial flutter and you have several risk factors for a related stroke, a daily anticoagulant like Eliquis may be necessary to protect you.  Aspirin is an antiplatelet med.  I have both atrial flutter and fibrillation and was told that Aspirin will not effectively provide this protection and may in fact long term increase the risk for a bleed,  I would definitely question your doctors as to why they stopped the Eliquis.  Perhaps you do not need a daily anticoagulant due to low risk?  If this is the case, do you really need a daily Aspirin?  These are the questions I would be asking.

I do hope for the very best for you.  I would be inclined to leave your heart rate where it is and not reduce it further since your breathlessness, particularly during running or exertion, will not be helped by a lower heart rate (in my opinion). 

Thank you...

by runpacer - 2020-03-25 02:09:24

I started the beta blocker. I am sleepy from it. I think I will be ok in the morning and ready to run. I was removed from eliquis at my request a couple of months ago. My numbers were low for certain risks but needed to be on the meds for surgery and the cardioversion. This new doctor who prescribed the beta blocker and asprin sounded surprised when I talked to him earlier that I was not on eliquis or anytype of blood thinner. I think because of that he placed me on asprin. It looks as if I have only a weeks worth of both meds. It seems this doctor is expecting me to revisit the pharmacy next week with a new prescription. 

Thank you for the insights and advice. 

Phillip

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