What is the procedure like? What questions do you suggest?

Tomorrow I'm having the pacemaker conversation with my EP.  I have a list of questions, but I'm wondering what you wish you had thought to ask up front.  (I have lots of PACs/PVCs and now intermittent bradycardia - HR 40s, hx of A-Fib, and "a very ectopic atria." EP doesn't think I have sinus node dysfunction).  

Also, what is the procedure like?  I've seen conflicting stories elsewhere re: anesthesia, no anesthesia, general vs. propofol, day surgery vs. overnight.

Also, I haven't had an Echo for 3 years since the ablation, and I feel like I need to push for that before the PM placement.  Afterall, how do I know if breathlessness, fatigue, etc. is due to more than my arrhythmia?  Right?  

Thank you  =)


6 Comments

Good questions for your EP

by AgentX86 - 2020-06-22 23:39:38

Only your EP can answer most of your questions because the answers will be all over the place.  We're all different and our EPs have different priorities.

I would have asked more about the pacemaker I was about to get.  I'd have preferred to have one with "Minute Respiration" rather than a Medtronic that only has an accelerometer for rate response. Since you say that don't have SSS.  It sounds like you have a second degree heart block?

A pacemaker, alone, won't fix your ectopics, Afib, PACs, PVCs, or any of that stuff.  As we often say here, a pacemaker is a gas petal, not a brake.  It can only make the heart go faster.  It can't stop what's already there.  It can fix Bradycardia, though.  That's what they do.  Some can try to pace you out of arrhythmias but don't count on it working.

The procedure is simple, IMO.  I liken it to dental work.  I had only local anesthetic (much less than the gas I had for dental work).  My EP would rather have his patients consious and less of an anesthetic hangover. The more anesthetic, the longer the recovery time and the higher chance of a bad reaction.  It was still a piece of cake.  I was chatting with the EP who did the implant the whole time (my EP was doing his thing with the catheters doing the AV ablation).  I was held overnight but only because I was then pacemaker dependent.  If I weren't, I'd have gone home that day.  They wanted to watch me for another eighteen hours or so. 

As far as pain goes, this is all over the place too.  I had very little, more like a sunburn than having been sliced open.  My EP gave me a prescription for Vicodin, which I filled but didn't need. Others have  a lot more problem with pain.

Echo?  Well, a pacemaker isn't going to do anything for your arrhythmia anyway.  You have Bradycardia, which will explain your symptoms.  If it's, as I suspect from what you've said, a second degree heart block can become third degree pretty easily.  It needs to be fixed, no matter what a echo would show.  You can ask about an echo but I wouldn't bother getting one unless my EP thought I needed it.  If there is something else, he'll know it soon enough and you need the PM in any case. An echo is fairly simple and if needed can be done after.

 

questions

by Tracey_E - 2020-06-23 09:27:32

A pacer can't cure afib, but some of them can help with it so I'd ask about that.

They vary on anesthesia but most no longer do general unless there are extenuating circumstances. They either do local or local with versed. If you have a preference, speak up. In the US they tend to do conscious sedation.

Expect to stay overnight. They like to do a quick xray and pacer check the next morning to make sure everything is in place before they send us home. 

Talk about placement. Some put them right under the collarbone, just under the skin because it's the fastest way to the heart and heals the fastest. You might prefer it lower and/or deeper, or possibly under the pectoral. It takes a little longer to heal and is more sore, but I found it well worth the extra trouble to have it out of my way. 

Echos find structural problems, our problems are electrical. Nothing they find on an echo is going to change the need for pacing if your heart rate is too low, but it's good to have a baseline and rule out anything else going on, and to know what your heart function (EF) is now. I have an echo once a year to keep an eye on function. 

Your EP's personal preference may be a factor

by crustyg - 2020-06-23 09:52:02

I asked my EP about local/conscious sedation and day-case/overnight, and his response was revealing.  He prefers conscious sedation (much better pain relief), but he does all of his PM/lead implants as day-cases, NHS and private.  Overnight only if complications.

By contrast he'd discovered that *all* of his other EP colleagues in the area only use local (+/-adrenaline to prolong the action) and always keep their patients in for the first night.  Odd.

FWIW mine was done with local only (at my specific request), no adrenaline, and as the leads took ages to get into the big vein all the local had worn off by the anchor suture and skin closure.  No amount of local will really make the PM pocket creation painless and that really hurt, but the sutures were uncomfortable but not agony.  In for 07:30, down to EP suite at 08:45, home by 14:30 (driven by son).  There's nothing to see (sterile drapes were pinned up to allow me to look to my right), and little conversation (EP doc concentrating too much).  The smell of my flesh frying with the coag diathermy doesn't bother me but it was interesting to watch my BP rise during the painful parts.

Conscious sedation is great because not only do you get some nice pain relief (usually fentanyl) but because over here they use midazolam and this specifically prevents you from forming any memories - so if it *does* hurt, you won't recall it!

Risk Information

by Terry - 2020-06-23 12:15:21

Be sure you take a look the latest. Google "His bundle pacing" or visit www.His-pacing.org for paced patient morbidity reduction.

Terry

Mine was fast-- it's probably up to your EP

by Protimenow - 2020-06-28 04:48:44

I was having Bradycardia for quite a while. Heart rate was usually around 50. When it dropped to high 30s, I called my EP and mentioned it. 

EKGs didn't show the drop, so I think the EP had problems believing me. 

Fingers to wrist, counting pulses for 60 seconds, confirmed the low heart rate. 

I called my EP on a Saturday afternoon and told him about my low heart rate. He said 'let's get this fixed, man.' He told me to go to the hospital and have them call him. 

I got there about 4 PM. They gave me the choice of having the surgery right away (and they MEANT right away) or waiting a few days until they had a free O.R. 

I chose 'right away.' I was admitted at around 4 PM. At 4:30, I was in Pre-op, met with the anesthesiologist, and was moved into O.R. I moved form gurney to operating table. The surgeon arrived a few minutes later. I breathed into a mask that they said was Oxygen, I was given Propofol and some kind of tranquilizer. About 45 minutes after the start of surgery, I was awake and rolled into post-op area.

The surgeon said that he did the PM placement in about 30 minutes. 

I was moved to a room at around 7 PM and discharged at 9:30. Total time from check in to discharge - about 5 1/2 hours. 

Doing it this quickly had some benefits: I didn't have any time to worry about (although I don't think I would have worried, anyway). The choice of pacemaker and leads was made by my surgeon (I wasn't given any choices). I was able to get in and out quickly. I took Uber to and from the hospital. 

I didn't have a lot of pain post-op - I'm on coumadin, and I don't like pain medications anyway. I didn't require anything for pain. I had a lot of bruising because the blood drained slowly.

Aside from some itching around the wound, I haven't had many problems - although my heart rate still drops to low 50s. 

For me, not having time to wait, do a lot of research, and even more worrying about the relatively simple procedure was a good thing. 

Thanks for the responses re: PM appointment

by twodrifters - 2020-07-02 19:33:30

Your responses were so helpful  I went in to the appointment feeling well prepared and ready to ask my questions which were all typed up.  I asked for an echo due to there being a confusing picture as to symptoms I've had of late, and he agreed that it is a good idea.  Thanks!

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