Complete heart block to now having a ventricular escape rhythm

I have a damaged heart resulting from radiation therapy directed on my chest for Non Hodgkin Lymphoma in 1995. In December 2018, I passed out a few times and they discovered a complete heart block because sometimes there was no signal going to my AV node. 

At first I was paced perhaps 70-80% of the time but then over time it was 100% ventricular pacing. However, I have been continually going to the EP to get my PM adjusted so that I can get back to my running/cycling, etc. and during the last visit, the Medtronic tech did an ECG as well. To our surprise, he found that there was a ventricular escape rhythm at 40 bpm. However, my cardio had told earlier something like this cannot happen.

I was wondering if someone has had experience like this or knows of someone that has recovered. 

6 Comments

Escape rhythm

by AgentX86 - 2020-10-24 00:09:29

Sure, you can have an escape rhythm without an AV node.  It's the same mechanism as PVCs.  There are many places in the heart that can be a pacing source.  Actually, pretty much any nervous cell in the heart can be the source of a heartbeat.  Some common examples, besides the SI or AV nodes cause PACs, Afib, Aflutter, PVCs.  Essentially the fastest pacer wins.  That said, what's usually relied upon in the case of an SI node failure is the AV node ("junctional rhythm").  The others are usually slower so are hidden.

I had my AV node ablated (intentonal complete block) and have no RA lead but have RV and LV  leads.  Because of this, I don't have any AV schymcrony and am dependent. I also have no known escape rhythm.  I have had PVCs but not regular enough to rely on for pacing.

Escape rhythm

by PacedNRunning - 2020-10-24 04:24:43

This ventricular escape rhythm is not one that can sustain you. It's possible to have an escape rhythm with complete heart block if the main one fails. If the AV node fails and the ventricles take over it will be 20-40 Bpm  When the AV block is above the av node it will be 40-60 called junctional escape. A ventricular escape is dangerous. A junctional escape isn't as dangerous. Not surprised you have one. Most do have some sort of escape rhythm. I have an escape rhythm too. Pace 100%. But mine is junctional. This is totally possible. What is the issue with running?  I've had my pacemaker tweaked for about 4 mos to get it right for exercise. So I'm pretty familiar with settings. I'd be happy to help make suggestions to try. 

escape rhythm is not a cure

by Tracey_E - 2020-10-24 10:39:15

My escape rhythm is all over the place. When tested, it's been anywhere from 20 to 60 over the years. Developing an escape rhythm is great, but it's not a substitute for the pacer. It's the ventricles beating on their own, not beating because they got a signal from the sinus node. It's a back up plan, not something we can depend on. 

Thx

by SNORTINGDONKEY - 2020-10-24 16:00:41

@ar_vin - Yes, we of course did want to put in the atrial lead too at the time the PM was put in but couldn't because my veins/arteries are damaged due to radiation therapy.

@AgentX86 - this was the info I was looking for...appreciate it!

@PacedNRunning - Good info about the junctional rhythm. BTW, I am not thinking about the escape rhythm from a sustaining perspective...I was just curious to know if it's possible to develop one later because I did not have any after the PM was put in...the ventricles stopped beating by themselves sometime between December 2018 and Jan 2020 or so.  Thank you for trying to help me...that goes for everyone. Frankmcw2's settings helped a little bit but ultimately I will have to go in for open heart surgery because the radiation therapy damaged two of my heart valves and they need to be replaced. They intend to put in the atrial lead at that time. The doctors are not willing to take on the risk because I am still active.

@Tracey_E - I was not suggesting getting rid of the pacer...I was simply curious about getting back the rhythm.

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A little more context about condition and medical history:

The docs gave me a very strong CHOP therapy for 6 months followed by 30 cycles of radiation therapy to treat Non Hodgkin Lymphoma in 1994-95. They also had to cut off a part of my left lung because they thought the cancer had spread. So I have half the lung capacity of a "normal" person based on PFT tests...there's also a lot of scar tissue. My heart was also affected  - other than the AV block that popped up in December 2018, the therapy destroyed two of my heart values, which need to be replaced. I also don't have a thyroid and am on replacement therapy for hypothyroidism and hypogonadism. There's also a host of other issues...

So I know I have a lot of reasons to not be able to stand on a podium... However, I have done many century rides around Lake Tahoe, Olympic distance triathlons in FL, still run 5 - 6 miles, play tennis, etc. My VO2max was above average for my age group until I had to get a pacer. My EP told me that they have never seen anyone do what I do given the conditions. He spoke last year to the CEO of Medtronic who was supposedly following my case. Have been to Mayo, etc...they told me that when they were reviewing my file prior to me coming to see them, they expected me to be in a wheelchair. I will continue to fight and argue with the docs until they give me an answer based on proven causal relationships backed by credible data.

Thx

by AgentX86 - 2020-10-24 18:46:29

That's all pretty amazing.  Since you have a comlete block and no atrial lead, you're essentially in the same situation as I'm in - AV dyssynchrony.

The atria are responsible for about a 20% kick to the heart's output.  Dyssynchrony knocks that out plus some because the valves don't operate at the right time so there may be some back-flow.  The heart has a lot of excess capacity so there is no problem for most people.  Athletes use everything they can get out of the heart (and lungs) so it makes sense that losing this 20% will cause problems.

The good news is that once you get that atrial lead and valves replaced, you will probably get that capacity back and be pedaling like a madman soon after.

Thx

by SNORTINGDONKEY - 2020-10-25 13:23:00

AgentX86 - yes, same as your situation. The cardiac imaging showed moderate to severe backflow. 

 

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