the 5th week after implantation

Try and get that static bike tuning session

by crustyg - 2020-07-04 07:44:55

Hi Moussa: There's no medical reason why you can't have a tuning session on a static bike - it's no different to a Bruce Protocol treadmill test (although kinder and more fun for cyclists).

As I mentioned in my earlier comment, *either* your SA node isn't responding to your need for greater cardiac output in a timely manner (this is called Chronotropic Incompetence), or your PM isn't correctly set to allow your dual-chamber mode to faithfully replicate atrial electrical activations (from your SA node) down into your RV.  This might be that someone has left a tachy threshold too low so it triggers a protection mechanism and your PM reduces the pacing rate.

6-weeks/2months: there's a lot of caution about returning to major physical activity amongst non-athletic doctors, *much* of it unncessary.  *IF* your heart muscle is healthy (and it sounds as though yours is) then the real issues are a) anchoring of the leads into your heart muscle with fibrous tissue, which takes some weeks, b) letting the skin wound over your PM pocket really heal - if infection gets in here it's a major problem.  Your skin wound should be well healed by now, and your new leads well bedded in - hence why they were happy to increase your maximum HR.  Why a limit? There has to be something that the PM can be told is normal and what is an abnormal rate.  175bpm at your age is pretty good, and I seriously doubt that you were managing much more than that before.  The athletic heart tends to enlarge and deliver more blood per minute by higher-volume contractions than by simply increasing HR, which isn't actually good for your heart.

Does putting in leads damage your heart? - not at a level that any patient would notice (unless something has gone seriously wrong).  If you'd damaged your heart during the 2 weeks with unpaced CHB then they would have told you - effectively you'd have had a heart attack, but actually it's usually the brain or kidneys that suffer if this period isn't well managed.

Only about 10% of PM patients are seriously athletic (ok, don't all shout at me), so most EP docs will only have a few athlete PM patients, so you are outside of their experience.  My EP doc (relatively recently appointed to a Consultant post) said that he had 1 other.  But he's smart enough to get the PM rep and his EP tech to give me the static bike tuning session that I asked for, and it works really well for me - *BUT* my major issue is SA-node failure=>CI.  Without a PM I survive on a junctional rhythm which really drops my cardiac output - no A=>V synchrony and limited maxHR.

See if you can charm your EP doc into giving you that static bike tuning session - WITH the Biotronic rep to assist the EP tech.  I think this will transform your experience of cycling with your new PM.  There's no reason (other than increasing age) that you won't be able to pace 40kph rides again.  If your EP don't won't organise this for you, I suggest you change EP doc.  You've got this CHB and PM for the rest of your life, so you might as well get the most out of it now.

There are folk here who dance and they need their PM's tuned for the fastest possible response, swimmers need high sensitivity accelerometer settings, etc.  Being athletic doesn't have to mean putting on skintight Lycra!

my thoughts

by Gemita - 2020-07-04 08:17:18

Moussa,

It sounds as though you need to find a new team to take care of you, since from your post you have clearly lost all respect and trust in your cardiologist.  This is not going to help you move forward at all.

At the same time, I think you need to be kinder to your body and accept that it will take longer than 5 weeks before you are able to resume anything like a normal life.  Perhaps too it might be helpful to accept that “normal” for you may never be quite the same again.  If you can accept this and gradually build up strength, you may be surprised to find that you will be able to achieve a great deal more than you could have hoped for.

Moussa, I am not a cyclist but at 71 I am still fairly active in my daily life.  When I first got my pacemaker I struggled too with palpitations and dizziness, especially in the weeks after pacemaker implant when my body was clearly getting used to being paced.  I had all sorts of pains and I started getting new arrhythmias which were not seen before pacemaker implant.   I was beginning to wonder whether I had made the right decision to have a pacemaker even though I needed one.  My team decided to do nothing, advising me that making adjustments in the early weeks was fruitless.  We needed to wait for my heart to settle down before anything meaningful could be done.  With time (after around 3 months) my palpitations eased and I was able to reduce/stop some of my meds and now my heart is so much quieter and performing its tasks better.  

So in answer to your questions: 

yes I feel the pacemaker needs to settle in and your heart needs to get used to being paced.  This settling in period will vary from person to person depending on our other health conditions and why we had the pacemaker implant in the first place.  It could be that your cardiologist might suggest in the meantime a small dose of a beta blocker to help quieten your palpitations if they are really troublesome.

Two leads will be a more invasive procedure than one lead and two leads will require more complex tuning to get the settings right for you than would a basic one right ventricular lead.  The fatigue you feel I think will be due to your palpitations and the fact that you are still recovering from your implant procedure and may I also courteously suggest, trying to push yourself too early.  I know this because it happened to me.  I tried to exert myself a few weeks after implant and I was fighting for air and having awful palpitations.

I see Crustyg has now covered your questions better than I could, so no need for me to go on.   I do hope your symptoms improve quickly Moussa.  Good luck

Patience needed

by Moussa - 2020-07-04 09:04:45

Thanks Crusty & Germita.

Will try & make an appointment for a treadmill session and see how responsive the reaction will be.Its funny the state of mind one gets into after implantation e.g. of course the thankfullness,gratitude to all concerned but at the same time as you allso mentioned Germita the distance I seem to feel now that the ' project ' has ended as it were and me asking (demanding?) isn't I feel, being appreciated - I'm the one that has to go on with his life with a gadget in his body! Will post back asap the continuing story of my activities.- greetings M

Fifth Week

by AgentX86 - 2020-07-04 11:34:43

Hi Moussa.  Welcome to the club.  Sorry you had to be here.

Lots of things here but the most important advice I can give you is to understand pacemakers and your specific problems.  It's usually not hard to know more than your doctors.  They're specialists but within that specialty, they're generalists.  They have to treat people with all sorts of issues.  You only have to be concerned with one.  Your doctor probably knows next to nothing about pacemakers.  They have a technician who is supposed to know them, or at least the subset the doctor uses, like the back of his hand. That's what I mean about knowing more. 

Lets dive into your complaints but first let me state that if, for any reason, you're not happy or don't trust your cardiologist (or any doctor) find another.  Immediatel.  You're not doing yourself any good taking potentially life and death recommendatoins from someone you don't trust.

You say that you have "sick Sinus ' e.g. 3rd degree AV block (Bradycardie)".  These are three separate things.  Sick Sinus Syndrome (SSS) means that the sinus node, or the heart''s natural pacemaker is't doing its job and needs help.

3rd degree AV heart block means that regargless of any other condition, the signal from the sinus node isn't being repeated on to the ventricles. This is a completely different issue than SSS but there is no reason they couldn't coexist.

SSS and 3rd degree heart block are very different things and either can lead to "Bradycardia", which means a slow heart rate.  Technically, any heart rate below 50bpm is "Bradycardia" (any resting rate above 100bpm is "tachycardia").

If you have SSS, I don't understand the low rate set to 45bpm but I'm not a doctor.  I do understand the upper rate at 175.  There is possible issue called Pacemaker Induce Tachycardia (PIT) where the pacemaker and heart get into a fast loop.  The the pacemaker starts a heartbeat in the atrium, then after a time coppies it to the ventricals to complete the heartbeat the signal then uses the AV node to go backwarts (retrograde conduction) into the atrium and it starts all over, causing a fast loop.  If the rate goes over 200bpm (give or take) the heart can go into Vtach or Vfib.  Both are express highways to the morgue.  The pacemaker is set so this is unlikely to happen.  It may be increased later if there is no indication that this is going to affect you but they don't know that now.

It's not unusual to get strange arrhythimas right after pacemaker surgery. Your heart has been assaulted and it's pissed off for a while and will act up. It'll likely get over it and things will calm down.  I had terrible PVCs after my implant but they've greatly neen reducedl  Talk  to your doctors about this.  There are things that they can do.

 Unfortunately the pacemaker they gave you isn't the best option for cyclists.  Since you have SSS, there is a good chance that your chronotropically incompetent, though perhaps not since they set your bottom rate to 45bp,