Ejection Fraction

I am 53 years old and 5 years ago I had a Medtronic  two lead pacemaker installed for complete  heart  block that came out of nowhere. I am paced 100% of the time.The only meds I take is 100mg of Cozaar for blood pressure. My doctor  does an echo on me about every year or so. My last echo two years ago my EF was 50-55% which is where it normally is. This past May my EF was 45-50%. My doctor suggested that I get a third lead added to help keep my EF from continuing  to lower. I asked for a second test to confirm that my EF had gone down. So we did a nuclear stress test in June which  showed my EF was 65% but that I may have a blockage. So I had a catheterization done and thankfully I didn't have any blockages. My doctor wanted to do a follow-up echo in six months to recheck my EF. I had that done last week and it showed my EF between 45-50%. He again suggested that I have a third lead added to help my EF. Keep in mind that the echo didn't show anything remarkable other then the EF. I really don't want a third lead added if I can avoid it but I am not sure at this point what to do. I am fairly active hiking  and mountain biking. lately I have been feeling  really  tired but not out of breath after riding moderate trails for about an hour. 



Tough decision

by jds66 - 2020-12-20 21:02:06

Boy, I am glad I came back here to this site after my initial pacer in 2012 to see if I could help anyone with advice. Since I just had a Bi Ventricular pacer installed on 12-9-20 to replace my 2 wire device, I can offer you some insight that may help. 

I was not paced 100 percent, but was getting pretty close. My Vent pacing number had steadily gone up, from the 30 percent range in 2013 to about 90 percent in 2020. Something was obviously getting worse. 

I keep a spreadsheet of all my pacer readings, all the time. My EP and the Medtronic reps are actually impressed by that, they have never seen a patient have that much data with them when they come in. It is easy, just Excel spreadsheet to record all your readings over the years and a notes column to document what changes were made each visit. 

You would be shocked that info is not kept to the level of organization by your owe EP, but really they have so many patients, you are your best advocate, and data collector. 

Now, back to you. 

I have had almost a yearly echo since I pointed out to my EP that the vent pacing numbers were becoming unacceptable and could put me at risk for possible pacemaker syndrome, aka cardiomyopathy at some point in the future. 

My Ejection fraction readings since 2012 have not changed all that much, basically anywhere between 50-60 percent in every test.

I never have had shortness of breath or swelling, a direct sign of cardiomyopathy, so as a younger patient, 54 yrs old currently, had to decide what to do. 

My EP would have been fine to let my V pacing numbers just continue to go unchecked, and have me getting yearly echos, just to check my ejection fraction numbers. 

But, that to me was not the prevent the problem in the first place thinking I was looking for. He referred me to a high end EP and he suggested an ablation and a Bi V, the Bi V pacer being the key to help prevent the cardiomyopathy in the future, becaue I am youngish, active, close to over 90 percent paced already. 

I decided to have the Bi V pacer installed, really in a bet to hedge my longevity. They did not end up doing the ablation, thankfully, just the new pacer. They had to put a third lead into my left bundle branch, to fire off the left ventricle in additon to the RV lead that has been in since 2012. 

Now, I could have waited I guess, and let symptoms come on me. But, my data collection, and honestly, something about the slight dimishment of the way that I was feeling led me to take the leap to get the Bi V pacer. 

Time will tell, I guess. But, the answer is within you. How you feel. Any swelling of the extremeties. Out of breath where you never used to be, stuff like that. 

And, after that, you are still taking a chance. I have read in years past, plenty of people pace for years without cardiomyopathy and effects and have fine ejection fractions. 

Since I am pacing alot more than I have ever, I figured this insurance policy of a third lead will hopefully ensure that my ejection fraction echo results never get worse than what they are now, which is not so bad in my case either, very similiar to yours. 

Is your recent being tired because of what is going on in your body? Only you have the gut feeling. But, know this, you already have a pacemaker, so it isnt like they are introducing something too dramatic if they do a third lead into the equation. It will just help the ventricles beat in better synchonicty and make the heart stronger, keeping that ejection fraction high and you feelign ok. 

Hope that helps, but I get it, ALOT to think about. 

I would wait

by Tracey_E - 2020-12-20 22:20:20

Your insurance may not even cover it until your EF gets lower. 50% is considered normal so you are just the tiniest bit  under.

I was offered one at my last replacement. My EF hasn't gone down, it would have been preventative. My leads were in good shape and I felt great so I said no thanks. If I'd needed new leads, if I felt bad, I would have been more open to discussing it. I switched to a different EP who said no way, that they can be helpful once EF drops but he hasn't seen any evidence that it helps prevent it. 

I'm no doctor and don't know your full history, but I would be more likely to continue to keep an eye on it. When the current battery goes, or if I suddenly couldn't do what I wanted to do, then I would have the discussion. But I'd have to be feeling pretty bad to do it when I still had lots of battery life left and was just barely under normal. 

Two excellent opinions already

by Gemita - 2020-12-21 02:52:20

What would I do?  If you have confidence in your doctor, I would tend to listen to/follow his advice.  If not, I would consider getting another opinion on something so important. 

I agree that your EF seems only just below the normal range and that an upgrade to a CRT device (cardiac resynchronization therapy) may not yet be indicated but clearly an eye needs to be kept on this in case your EF continues to consistently fall.

To implant a new pacing system and additional lead would not be without some trauma/risk and I too would probably prefer to wait until I was closer to needing a device/battery change in any event. 

Just keep an eye on your EF and keep notes of any symptoms you might be getting like exercise intolerance, breathlessness, swelling of lower extremities, fatigue, arrhythmias.  I am glad your echo has not shown any major problems.  A changing EF can be due to other health conditions, so make sure if say you have other conditions like diabetes, high blood pressure, high cholesterol these are kept firmly in check.

Finally I do have concerns about the potential for heart failure to develop over time with a high percentage of right ventricular pacing.  It clearly doesn't happen to everyone but it can be a risk factor leading to heart failure.  Loss of synchrony between our two ventricles needs to be closely monitored and this is why if you are in any doubt about what to do for the best, I would get a second opinion

Very true Gemita

by jds66 - 2020-12-21 10:25:59

Gemita, your comments in regards to my sitaution  were right on target. I was due for a generator change in about 6 months. Because of that, I decided to have that third lead added, and the new pacer at the same time.

My hearts synchronicity between the AV and ventricles WITH the 2 wire pacer were so out of whack, they considered ablating. My junctionals were causing really bad chest pain alot of the time, basically outrunning the pacer. Strangely enough, my EP who did my surgery this time noticed that on the Medtronic the MVP mode was on. Now, that is supposed to HELP reduce vent pacing, to some extent. 

Once he turned that MVP mode OFF, a good portion of my chest pain went away, and hence we choose not to ablate that day, just put a new pacer in instead. 

All our situations have so many other variables, that in the end, it really is a huge decision based on factors that none of us here are exactly alike. We like to read each others stories, and hope to glean a little comfort, like I do, but each individuals decsion has to be made with their own special unique to them taken into account. 

I am a big fan of go with the gut, and prayer!

I just made the jump to CRT-P.

by asully - 2021-01-23 03:23:59

So far the only difference I have noticed is the device size, which I will probably get used to, fingers crossed.  Other than that I can't even tell it's different, at least not yet.  I am hoping to actually get some reverse remodeling improvement over the next year, as my problem was similar to yours over pacing in the left ventricle (I am 100% with CHB). So far my QRS duration is still really long, but I am still in the setting adjustment phase so praying for improvement.


by asully - 2021-01-23 03:25:42

I meant overpacing in right ventricle I think, sorry it's super late and I am sleepy.  I think you know what I am talking about.

New medtronic Percepta Quad CRT-P

by JSTANAWAY - 2021-01-23 10:43:17

On 1-21-20 after talking to a couple different  medical professionals I had crt device upgrade done.  So far I feel fine just a little  sore  at the surgery site.  I have been having  some PVCs and my doctor added 50 mg of metoprolo to take with 100mg  of losartan that I was already  taking  for HBP. Thanks for everyone's input on this.

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Yesterday was my first day mountain biking after my implant. I wiped out several times and everything is fine. There are sports after pacemakers!