Crt

There are several posts about this if you search for epicardial

by crustyg - 2020-12-26 11:54:15

There are two challenges for the EP-doc to set a patient up for CRT-<x>.  1st, getting a third lead into the right atrium, the second, getting this new pacing lead into the coronary sinus (to provide access to the LV muscle), as the anatomy of the angles can make getting a lead in there very difficult in some patients.

For you, Number 1 is the issue, but it's not a show-stopper.  An LV-pacing lead can be placed on the *outside* of the heart muscle (epicardial) and it's no longer the case that this need be done via an open thoracotomy.  There's a nice paper from Marini et.al. (Clin Cardiol 2020;43:284-90 describing a video-assisted approach that is much less damaging to your chest, and safe and relatively quick.  PM - the CRT-<x> device stays in the usual pocket, but the LV lead is tunneled up from the pericardial sac to the PM pocket.

A couple of the contributors here who've had this done have actually had SVC-syndrome (due to lead-produced clot in the vein) and have had a good outcome.

Pacemaker upgrade to CRT

by Gemita - 2020-12-26 12:38:22

Hello Stoudien,

May I ask what your actual ejection fraction was?  Have you tried any meds or lifestyle changes to try to improve your ejection fraction (EF)?  I do appreciate with 100 per cent right ventricular pacing the risk always exists to develop loss of synchrony between your two ventricles and that this might best be treated with a pacemaker upgrade as you have been recommended.  I am wondering though whether there is anything else going on to cause your steady fall in EF as well that might need treating, since an EF of around or just below 50 percent wouldn’t necessarily trigger an immediate referral for an upgrade from a dual chamber pacemaker to a CRT. 

I believe a normal ejection fraction is anything above 50-70 %.  Anything in the range 40-50 per cent would be regarded as borderline abnormal and anything below 40 per cent could indicate that a person might be developing heart failure, but this is not always the case.  I attach a link below which gives a simple explanation of Heart Failure and Ejection Fraction.

https://www.heart.org/-/media/files/health-topics/heart-failure/hf-and-your-ejection-fraction-explained-481884.pdf?la=en

There are many potential causes of heart failure and many possible treatments, from cardiac resynchronisation therapy - an upgrade of your present dual chamber pacemaker as you have been offered to include a third lead to your left ventricle to restore synchronisation between your two ventricles - to medication, to surgical intervention, to lifestyle changes.  There is a lot that can be done to help reverse the situation, providing we are prepared to make changes to our lifestyle and we can successfully treat any other health conditions present that may be contributing to heart failure, like e.g. high blood pressure, diabetes, anaemia, thyroid disease, arrhythmias, cardiomyopathy, coronary/ischaemic heart disease, heart valve disease. 

If you need an upgrade of your present system, I do hope your veins will be found to be healthy to accommodate another lead without causing any future damage which is always a risk when adding leads. If you have confidence in your doctors treating you and in their ability to safely and successfully carry out this upgrade, then I would try not to worry.  There are a number of contributors who have had complete success with their CRT upgrade and who have reported an increase in EF.  For others, it may take some time to show any improvement, maybe as long as one year, or their EF may not improve at all, and they may still need lifestyle improvements and other treatments in the future.  I would recommend having a meaningful conversation with your doctors, if you haven’t already done so.  Remember too that healing may take longer with a CRT device since it will be larger, to accommodate a bigger battery and additional lead.

I hope for the very best.

CRT pacemaker

by Aberdeen - 2020-12-26 18:30:15

Hi Stoudien, I had a dual chamber pacemaker implanted in January 2020 which had to be replaced in May 2020 with a CRT pacemaker as I developed LVSD ( left ventricular systolic dysfunction) . My Ejection fraction was low 35- 40% . It is now 63%. I had no problems with having the third lead but as you can see from my dates I had the first pacemaker for 4 months only.  

Gemita and Crusty G have given you very comprehensive answers- I hope my reply gives you some reassurance.( I am 65)

CRT upgrade

by Stoudien - 2020-12-27 08:03:05

So Thank you for your replies. My EF is just under 50%. I started asking my EP about upgrading to the third lead 2 years ago. At the time my EF was 50 to 54 %. This was down from +55%. My EP reply at the time was "Don't poke a skunk". He has since changed his mind due to declining EF & mitral valve regurgitation. He thinks with this procedure the valve will stop   Leaking. We are convinced the declining EF is from pacing the right ventricle only and they are out of sync. Life style changes are not going to help , although I don't know I what could do. My weight is ok, BP is controlled, lipid panel is good, eat healthy, exercise regularly, don't smoke , moderate alcohol consumption. So the idea of this upgrade now is to prevent further degradation, maybe even reverse the EF. 

Personal Choice

by jds66 - 2020-12-27 19:12:55

I choose the Bi-V pacer upgrade from my 2 lead device as a younger(54) year old person just a few weeks ago. My vent pacing with my 2 lead the past nine years had been going through the roof the past few years. My EF however, was still over 50 percent. 

My concern over cardiomyopathy was great enough, that I choose a preventative measure, which I hope serves me well in my later years. Why wait for cardiomyopathy to develop, if they have a device that can pretty much assure that your ventricles will now beat in harmony for a long time. 

My artery for the third lead was 80 percent open, so that was good. The implant, as far as I can tell of the Left Bundle Branch lead was successful, so I am hoping I am good for a long time now.

Of course, some errant extrasystoles have reared their ugly head the last week and I am getting junctionals again, causing chest pain, but that is not related to what I just decided to do, the BiV pacer. 

It is a personal choice. Are you a, "leave good enough alone" person? Are you a "lets nip this in the bud before I end up with something that may not be reverisble, cardiomyopathy?"

I am a realtively healthy, active 54 year old, who doesnt smoke,  heals very quickly and has had pacemaker experience. So, for me, the decision is easier because surgery is less of a risk to add a third lead. If I was older, maybe I make a different decision. 

For me, and my piece of mind, I didnt like the way I was feeling, in spite of what tests were telling me and I was concerned about my long term prognosis. 

BV upgrade

by Stoudien - 2020-12-28 10:33:21

And this is what I am doing, trying to be pro active to head off a problem, since I am pacing 100% . LV is changing due to out of sync rhythm. EF has fallen about 5% in the last two years. EP says no amount of exercise will change the condition, BV pacing is the answer. 

Extrasystoles

by AgentX86 - 2020-12-28 18:14:49

JDS, I'm surprised they gave you a choice.  The word around here has been "no CRT for you!" if your LVEF is above 30 or 35.  Insurance companies frowned on the extra cost for measures that haven't proven to be beneficial.  It's good to know that things are changing. 

I note they're also getting the message about the Watchman device, as well.  They were only allowed if, for some reason, you couldn't take anticoagulants.  Now it's a lot easier to get the procedure approved.  It saves them money (over a lifetime of anticoagulants) in the long run.  Perhaps the CRT devices do as well?

I was sort of surprised also that I was given a choice

by jds66 - 2020-12-28 21:39:49

Thank you AgentX86 for your feedback. I was actually supposed to have an ablation on 12/9/20, for the issue of the Extrasystoles that were coming from somewhere around the Bundle of HIS, causing my chest pain for years, usually under stress. 

I was telling the nurse who was prepping me for the ablation of my story why I really was dreading the ablation, and sure enough, the condition happned, the extrasystoles started and I went into bad junctionals. 

The EP came in, saw that and got the Medtronic rep in to check some settings that my local EP never thought to change, the MVP mode. They turned that off, and my junctionals went away, at least for the first ten days. 

I think the EP was fooled that that was the fix long term, as now they are back with a vengance just three weeks later. The EP then gave me 3 options there on the surgery prep table in the hospital where I thought I was going to have an ablation that morning:

1.Keep my nearly end of life (had about six months battery life left on my Revo pacer), with the MVP mode turned off, see how things went. 

2.Since I was there and was very concerned about my increasing V Pacing, I could right there and then get a BiV pacer, since it would be covered by insurance, because my other one was end of life. And, I actually asked the EP to first check with the hosp, that insurance would cover it, he said no one ever asked that, haha. Well, I dont want to be paying for that, so lets hope they are accurate that insurance is covering it. 

3.Have an ablation- but even the EP was fooled at the time that the junctional were fixed, as the MVP mode being turned off seemed, for that period of time, to make them go away. 

Looking back now, 3 weeks later, I honestly think the EP should have guided me a bit better and told me to basicially go home with the MVP mode turned off on my 2 lead Revo pacer with six months of battery life left and see how I felt. I think because I was all prepped for surgery and ready to act, that sort of made the decision rushed. 

Now, I think I would have ended up at the same resultant place, a BI V pacer in the spring anyhow, but now the EP has put himself in a tougher sitatuion. Now, if we can isolate the exstoyles that are causing my junctionals and pain, we now have a third pacer lead to work around, which makes his job to do an ablation much harder now. 

How do I know that? He told me that in Sept, that the ablation would be harder if they put in the third lead into my Left Bundle Branch for a Bi V pacer first then ablated. 

Honestly, I am surprised that he acted that quickly, but I trusted his knowledge, as my local EP had not been able to figure out for years beyond the extrstoyle guess what was causing my constant chest pain under stress. 

So, my upcoming visits the next two weeks are going to be very intersting, when I tell him that he did not at all fix my main issue of pain, but we did fix the V Pacing issues for the future. 

A mixed bag, as they say. 

Let my tale be a caution to you all, and I will say, bad on my EP sort of, for having me make that big of a decision while on the prep table for an ablation that I was dreading, and I guess, avoided, for now.....