Diaphragmatic stimulation and GERD

I did a little search on this forum about GERD and found some old posts, but I am wondering if someone has more current information or experience. 

I am having more episodes of what I think is diaphramatic stimulation, as evidenced my twitching of my abdomen. It has been mainly positional, such as when sit with my knees drawn up whilst watching TV. But this last week, it is happening more often, usually when seated. It is not painful, per se, but it is uncomfortable and distracting. For the last 2 days I have been burping a lot, and my reflux is flairing up. 

Is this all in my head? I hate to contact the office if I am imagining this, plus if there is little to be done, I don't want to go through the bother of an office visit. I found a scholarly article about it, but of course I can't find it again, but it said this is more common in a LV lead in a lateral vein, which mine is. 

Any words of wisdom, or experience? 


Any dietary changes?

by Persephone - 2021-03-31 15:48:15

This probably goes without saying, Julros, given the level of research that you've done and knowledge gained  -  but have you perhaps had any change in diet?

A few questions to ask

by Gemita - 2021-03-31 16:19:04


No it is definitely not all in your head!  Perhaps these are two separate issues, or caused by pacing.  

1. phrenic nerve irritation caused by a lead touching the nerve can result in symptoms you describe. This is very much a question for your pacing team.  Check whether your pacing is Bipolar (not Unipolar which can stimulate muscle).  They may be able to adjust power to a lead and reduce your symptoms?   But take the problem back to them! 

2. gastric reflux is horrible I know.  Have you tried a short course of a PPI (proton pump inhibitor).  If this doesn't help I would go back to your GP for further advice.  Gastric reflux is a frequent cause of arrhythmias for me and it is well known that there is a clear link between gastric related issues and arrhythmias.  While you are having acute systems, watch your diet carefully.  Caffeine, chocolate, acid foods, rich foods can make reflux worse so go bland for a while.

Have a read of the attached links.  Anything from oesophageal to stomach emptying problems, to a large hiatal hernia as well as ulcer disease, gut inflammation, irritable bowel syndrome and many autoimmune conditions can quickly lead to worsening reflux.  The first link, Roemheld syndrome is becoming more known today;  the second article is extremely useful too on GERD/Afib.  So if your reflux doesn't settle with a PPI, further investigation may be warranted.  

I also attach an old PM Club post on acid reflux being triggered by incorrect Sense Polarity setting, that is the use of Unipolar instead of Bipolar pacing as I mentioned above.  Please do ask about this, unless you have access to your data settings, then you can check which setting you have.




I wish you freedom from your symptoms quickly.


by AgentX86 - 2021-03-31 16:23:42

Is the twitching synchronized with your hearbeat?  If so, you can likely blame it on your diaphragm being paced.  Talk to your EP/cardiologist about it.  They may be able to adjust the pacing level, while still maintaing capture margins to fix this.

The LV lead, obiously, needs to get to the left side of the heart.  The pacing leads go (usually) from the subclavian vein, to the venacava, and eventually to the right atrium.  From there, the RV lead goes down through the tricuspid valve and the LV lead goes into the coronary sinus vein, which is a collection of veins that service the LV. Remember, all veins, except the pulmonary, end up in the RA.  So, from the RA, the lead is snaked into the coronary sinus vein around to the LV. 

Edit:  I knew "pulmonary" sinus was wrong.  Pulmonary = lungs.  Coronary = heard. Duh!

Thank you

by Julros - 2021-04-01 00:23:14

Thank you for taking the time to reply. I have had a complete GI work-up, and I was not looking for treatment for GERD, as I am well familiar with that. 

I was seeking experience with the sucess of treating phrenic nerve stimulation with pacemaker reprograming. It does not appear that anyone has recent experience with this. The link that Gemita posted is from 16 years ago, and discusses unipolar vs. bipolar, and mine are set to bipolar. 

Thank you again for posting. 

Phrenic Nerve stimulation - or injury?

by Gemita - 2021-04-01 03:07:00


May I ask whether you have raised the issue again with your clinic, since electrical reprogramming may still help with some of your symptoms and avoid the necessity of more invasive treatment to try to fix the problem.  Also as you know, nerves can and often do heal over time although no consolation for you at the moment, I do understand.

I had a Nissen Fundoplication wrap for GERD 20 years ago which is slowly breaking down but it has been a very very good treatment for GERD caused by my oesophageal high pressure contractions.  My gastroenterologist/cardiologist has confirmed my heart rhythm disturbances are frequently being triggered by oesophageal spasms leading to GERD.  Maintenance dose 30 mg Lansoprazole is helping but I need dilatation of my oesophagus from time to time to treat my now overtight Nissen wrap.

In your shoes I would go back to see whether any pacemaker adjustments can help with your immediate symptoms of nerve stimulation and GERD.  They may be connected.  Treat one and the other may well improve.  Many of the scholarly papers out there all seem to point to a considerable benefit to be gained from electrical reprogramming rather than having invasive lead repositioning. It is worth a try.  Good luck 


by Julros - 2021-04-01 04:34:20

Gemita, I am not even sure at this point that I what I am experiencing is related to my pacemaker, as the abdominal twitching that I experience is not constant and I doubt that I will be believed unless they do not witness it.  Each visit to the clinic involves a signigicant financial charge, so I was looking examples of others experiences with this condition. I am sorry that you have needed such extensive intervention, but I don't think it is at all similiar to my situation. I have a routine interogation scheduled soon and will mention it at that time. 

Diaphragmatic Stimulation

by Selwyn - 2021-04-02 15:52:05

Whilst I had unipolar muscle twitching of my chest wall after pacemaker insertion ( changing to bipolar was like throwing a switch to stop the twitch), I have not heard of the abdominal muscles being stimulated from this.

With hiccups, which is due to diaphragmatic stimulation, when prolonged this tends to produce gastro-oesophageal  reflux as the sudden increase in pressure from the diaphragm forces acid up out of the stomach and overcomes the lower oesophageal  'valve'.

So, I think Gemita is correct - go back and see the pacing people and explain your symptoms. They sound like diaphragmatic intermittent pacing stimulation which may vary with your body position. 

I delayed, thinking my chest wall twitching was due to my  'nerves'. I wished I had taken advice sooner.

I think it’s GI related

by PacedNRunning - 2021-04-04 23:31:32

I know this is going to sound weird. Even my doctor looked at me like I was crazy. But I had minimal GI issues prior to my PM.  After Implant I started getting bad reflux.  Took Prilosec off and on for a year with flare ups.  Finally I had to see a GI doctor and get a endoscopy and Colonscopy.  They found I have a moderate size hiatal hernia. Obviously the HH isn't new but I think my heart irritates my diagphram which in turn irritates my esophagus causing reflux. I use to burp a lot and feeling like something is in my chest all day. I do watch what I eat but that didn't seem to correlate.  My theory is when we are paced, our paced heart beats are very strong. Our hearts are basically sitting on our diaphragm, so super close. I feel the strong heart beats irritate my diaphragm and in turn cause the reflux and crazy burping. 

What's the solution? Well mine was to turn down the voltage as low at it could go. I had fixed voltage with the daily threshold checks off because I did not like the daily checks. They freaked me out in the beginning so they set a fixed voltage and turned it off. When you set a fixed voltage, it's higher than it would be set with the daily tests.  So basically I was at 2.0V fixed but with turning my daily checks back on, my voltage got lowered to 1.2Vto 1.3V depending on the daily results.  That helped tremendously!!!  I still had GI issues off and on.  Instead of daily, it's once a week.  Even though I still don't 'like the daily checks, it's definitely worth it.  I have a Boston Scienfitic and they check every 21 hours. So most checks I sleep right through. Most people never feel the checks.  


Again, Not sure if this is scientifically proven. I'm a nurse so I do understand the anatomy and how the body works. Doesn't hurt to ask if you have daily checks on and if not, ask to have it on so that the lowest voltage may be used.  My background is high grade AV block. I have 2 leads and I am pacer dependent. 

One more comment.

by PacedNRunning - 2021-04-04 23:33:23

When we adjusted the voltage, it took a good month to feel the difference with my GI symptoms. 



Pacer checks

by Julros - 2021-04-05 23:53:59

Thank you, PacedNRunning. This gives me another option to inquire about. My checks are not daily, only scheduled quarterly. 

My leads are already set to bipolar. From my understanding, there are multiple points along the LV lead that may deliver the impulse, so I am guessing they will try that. 

For the time being, the abdominal "jumping" has subsided, but the burping and burning continue. As I posted before, I have an interrogation coming up. 

Checks should be daily.

by PacedNRunning - 2021-04-06 02:11:08

So for checks. They are daily or off. The quarterly checks are different. The daily checks are auto performed by the pacemaker daily. The pacemaker auto adjusts output based on the results of the test. The quartely check is just a collection of data.  You may not have this featured turned on. You either feel it or you would ask if it's on. Most don't feel the daily checks. So they have no idea it's going on. 

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