Single Lead for Intermittent AV Block

Hi again, high-anxiety soon-to-be-implanted pacemaker patient here.

I had a cardiac MRI done last week that confirmed mild LV noncompaction, QRS ~ 140ms. My doctor saw 3 long pauses on my Zio monitor over two weeks: 10s, 8s, and 7s. "High grade AV block". During waking hours I have 1st degree AV block with no pauses, been that way for 5 years. Asymptomatic but he wants to give me a PM to reduce my risk...

I talked with this doctor yesterday, and he recommended a single lead (VVI) pacemaker for these nighttime pauses. This seems counterintuitive considering the EKG shows symptoms of AV block. But, he wants to give me "the simplest system possible" so it can be useful for the longest amount of time.

He also said I could get a leadless pacemaker (he didn't mention if he meant the AV Micra or VR Micra) but he would rather fit me with a single-chamber in the RV.

I did not expect him to even suggest leadless given the cardiomyopathy and AV block, and was shocked that he said he wanted to "start with one lead and see if we need more". I am kind of scared of the stability of a 1-lead PM even if I'm only being paced like 5% of time time.

I need another opinion, I don't know what to do. I desperately am seeking a second opinion from another EP, but don't have one yet (Kaiser Insurance).

Thoughts?

 


13 Comments

I'm no doctor...

by AgentX86 - 2021-09-01 19:40:51

...but it sounds weird to me.  VVI buys you dyssynchrony which really defeats the purpose of a pacemaker unless there is no other choice.  Since you're havnig sinus pauses it would seem to be a good idea to attack that angle first with an atrial lead.  Sine you also have a low-grade block, go for that one too with a lead in the RV (DDI mode).  Other than the obvious problems with VVI, I don't see anything to gain from putting off the second lead.

It'll most likely be needed at some point.  Fix everything now while they have the hood open.  It's a no-brainer for me but they don't pay me the big bucks for my opinion.  I strongly suggest that you get another opinion from an EP (I sure hope you're dealing with an EP).

get another opinion

by Tracey_E - 2021-09-01 21:56:55

While I respect wanting to do minimal hardware, you also want to fix the problem. Why set yourself up for problems down the road when you can fix them all now? I would get another opinion from an ep not associated with the practice you are in now. If you see a second in the same practice/network, they will automatically back each other up.

It's rare to do a single lead. Most of us end up using the second lead, for imformation if not for pacing. You already know you have some av block, and av block is known to progress, so IMO it's a no brainer to treat that as well with the second lead. 

With Kaiser you might be stuck.....

by ar_vin - 2021-09-01 22:07:08

AFAIK no way to go "outside the practice".

Maybe there's a way to file an appeal with the system and see what you get.

 

Thanks

by Runner86 - 2021-09-01 23:18:22

Tracey, Agent, ar_vin - thanks for chiming in. Very stressful being confined to Kaiser, they are good when the treatment/path is clear, and as I'm finding out, less of a sure thing when it comes to more unique circumstances.

This particular doctor is very highly rated with "top doctor" the past several years, I just don't know about this take at all. It might not be VVI, ignore that. I just know he said "start simple and minimize risk". I feel like the diff between a generator and one leads vs a generator and two leads is similar recovery/risk. Maybe over many many years, God willing, more leads need to happen.

He also said he didn't wanna do subpec and it was more pain (I mentioned this in an earlier post for those playing along at home). I asked him how many he did this year and he said 5 subpec and 90 subcutaneous, because it's easier to replace. I think he's just used to older folks, I don't know. 5 out of 100 subpec speaks to inexperience, he also said there's less to anchor it to and it's going to get pinched by my muscle and migrate etc. Really tried to talk me out of it.

Kaiser should get back to me tomorrow with my options, I probably have to stay within Kaiser docs...

Grateful I can vent to this group. Thanks so much for replying.

 

opinions

by Tracey_E - 2021-09-02 09:24:22

Just for peace of mind, it might be worth paying out of pocket to get an opinion from someone in another network. You may or may not get anywhere with Kaiser, but it can help you feel better about what the current doctor is telling you, or give you more succinct arguments to push for subpec and/or two lead.

"Outside" opinion

by ar_vin - 2021-09-02 12:43:42

I second Tracey_E'e suggestion. In your shoes I'd consider it a small price to pay IF the EP that does your implant could be persuaded to: go with a two lead PM AND do it sub-pec.

I wonder where you are located - being close to major medical centers would give you more options. But what we're talking about are some very basic issues that *any* competent EP should be able to handle. The level of resistance you're seeing tells me you ought to stay away from this EP.

Please do keep us posted on progress.

 

VVI

by AgentX86 - 2021-09-02 21:19:47

I've been thinking about this some more and VVI may not be so weird for a very infrequent type-1 block.  Synchrony would only be lost for the few beats during the block.  It would solve the pause problem.  Type-1s don't always progress so maybe it's not horrible.  A dual lead DDD would still be much better, IMO.  There is a good chance it'll be needed at some point.  I the pauses start happening during the day I don't think you'd want to lose AV synchrony at random times.

VVI

by Runner86 - 2021-09-02 23:05:56

Thanks, Agent. I am working to get a second opinion still.

I was also offered leadless (even though I'm betting it's the Micra VR and not the one with synchrony, I don't know) and that seems appealing given that they're only recommending occasional pacing.

My 1st degree AV block on EKGs has stayed stable for 5+ years (I'm 34 FWIW, hoping the worst isn't yet to come but who knows). I just worry about being paced abruptly in my sleep and losing synchrony, waking up with pacemaker tach, etc. I just don't know enough, I don't like that he seems to not wanna do subpec and asked me nothing about lifestyle.

Thoughts on leadless? This is a very early finding and a precautionary measure, but I guess I can't just wait it out when it comes to long pauses in my sleep. Maybe apnea treatment would help but they did a sleep study and AHI was 2-3.

Grateful for comments. I'm a WIP.

Sleep, synchrony, and leadlessv

by AgentX86 - 2021-09-03 23:58:19

1st degree heart block usually doesn't require a pacemaker at all. However, long pauses aren't acceptable. I guess with the patch, they know they're AV related and not SI related.

Dyssynchrony while sleeping, particularly for a few seconds, wouldn't likely be a problem.  There is no danger of pacemmaker mediated tachycardia with a single lead pacemaker.  There can be no retrograde conduction so no feedback path. 

At your age, I wouldn't go near a leadless PM.  You have too many years left.  Only (I think it's) three Micras will fit in the RV.  After that they have to be pulled out.  I wouldn't go into the deal knowing that they would have to be retrieved.  This hasn't been proven over a long period.

 

WIP, Sleep

by Runner86 - 2021-09-04 09:55:38

I am getting a second opinion from another electrophysiologist w/Kaiser and going to pay out of pocket for an outside electrophysiologist. Need more takes. I don't know if a loop monitor would influence the decision if they could see the blocks getting worse or something over time.

My current doctor (recommend single lead or leadless) says I should get an implant in about 4-5 weeks, he "wouldn't wait longer to reduce your risk".... This is hard, I did not expect so many decisions to be made directly by me.

Since the pauses happen during sleep, and I wake up somewhat confused and short of breath... every morning (not overweight, no immediate apnea findings), I wonder if a CPAP would help to at least try. I have bradypnea (like 5-8 breaths per minute) when I sleep. Maybe the PM would fix that, maybe it's the wrong treatment.

As for leadless, I am leaning towards it because 1) it is being offered by an admittedly very conservative doctor, though he says the same thing everyone else does, "they can only fit 2-3 of them, they can't get them out" etc. 2) I am very active and am dealing with mental health issues. Even if a Micra only bought me like 3 years (worst case for some with Micras), this would allow me to attack that problem without worrying about PM recovery and revisions. I do not know what the future holds, and I hear stories like "your PM will fix you right up, you will live a normal life" vs "I just got my 2nd lead revision in a year and my PM is now in my armpit" etc... I feel like attempting to go leadless would at least try and keep those problems away so I could focus on what I was dealing with (I just started therapy in June) before all this came up.

I could always get a traditional PM, but once that happens I'm committed to wires. With the cardiomyopathy (mild LVNC) I may just want to kick the can down the road with a leadless that is doing < 10% of the work. If I can get several years out of it, it might let me live normally, and would reduce the risk of a botched implant or bad placement.

Thanks so much for responding, I am so grateful to have feedback on this from people who live with PMs. It is hard to continue to be strong with all this; it helps to have this forum to sound off.

Kaiser

by jfbuffy - 2021-09-05 23:33:19

Just want to say my experience with Kaiser Doctors was excellent. They were extremely accommodating and excellent Doctors. I always felt whatever I asked for they were pretty much willing to accommodate . I have seen more than one electrophysiologist and more than one cardiologist . Just ask I'm sure they are willing to give you more opinions . 

Kaiser Medial

by Stache - 2021-09-06 22:43:37

I have Kaiser, however, 6-months ago I had a complete 3rd-degree heart block and died in the ER a Mery General in Sacramento, CA No 1 heart hospital rated in CA.  They revived me 6 times a few cracked ribs and a dual-chamber PM with two stents and a burned chest.

 

My follow-up was with Kaiser and I went through three Kaiser heart doctors before I pick one I could trust and is upfront with me.  My original heart doctor has been releived.  Kaiser has been very helpful with me in my situation now.  I read all the time and have self-educated myself on my condition which greatly helps when discussing my heard with my current doctor.  

 

Kaiser is just like government the squeaky wheel gets oiled and I squeak a lot as I am the retirement plan for the family.  Don't be afraid to ask to be evaluated by another doctor. I had three of them in my room discussing what to do to fix me.  It was obvious which doctors I did not want working on me.  Don't take no for an answer, we do have options even with Kaiser.

 

My 2 cents

by PacedNRunning - 2021-09-21 02:41:00

I'm not sure how old you are but doctors are concerned about putting a lot of hardware into the heart and veins.  Especially when you are young. You will need lots of replacement devices and possible new leads at some point.  You only have so many veins to place them and only so much space in your heart to place them. If your older say 80's then this is not an issue becasue of less replacements.  

The minimal amount is best if it's all you need. If you just have night time pauses a single lead will work just fine.  You probably wont' pace much at all which is just enough to keep you safe.  I mean they could put in 2 leads and only turn on one. But the second one is there if it's ever needed.   The only time AV synchrony comes into play is if you need a good amount of pacing. Otherwise the short amount of times you will need pacing, your body will compensate for the brief amount dysnychonry you will have.  So I wouldn't worry about that.  If you could qualify for the micra get that! You are a perfect candidate with someone with intermittent pauses. 

 

Under the muscle vs under the skin.  Such a debate.  Mine is under the skin. It's buried very deep and similar to under the muscle expect not.  My EP prefers under the skin and stated he could put it under the muscle for cosmetic purposes but if he could find a good spot with enough tissue, he would place it under the skin. The reason, because of future replacements.  If you are young you will have scar tissue develop and that could make future replacements more difficult.  Under the muscle puts more stress on the leads also because it's under the muscle.  So if your active, which I"m guessing you are based on your name "runner" they you will want it under the skin.  I have no issues with it. Nothing bothers.  No purses, bra's, bags etc.  Just because your doctor does 3 subpectoral implants and 90 subcutaneous does not mean he's inexperienced. It means it's the best way to implant it and if they need to go under the muscle they will. Your going to have to trust your doctor on this like i did.  Everyone told me under the muscle is Best but they aren't active or lift weights or play golf. But if you do, and it's under the muscle you have a higher risk of fractures and stress on the leads.  It's more secure under the skin if they bury it deep enough. Just don't have them place it shallow.  

I have 2 leads for high grade block but I have to pace 24/7 so I needed the 2 leads to coordinate.  The top lead unnecessarily paces me if I go below 50bpm when in fact before my PM I tolerated 30-40's fine.  But do to settings I have to be at 50bpm.  Not a big deal.  

 

Let me know if you have any more questions.  

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