Echo Question/thoughts

Body habitus

by Gemita - 2022-05-26 02:31:33

Dave - I attach a simple link of the four types of body habitus (that is, our shape, size, weight, organ position, density and things like this).  I have read (although I am not suggesting that you have a large body habitus!) that a large, heavy body habitus could technically be difficult to image, due poor visualization, which might lead to inconclusive imaging results.  This could ultimately lead to a misdiagnosis or a failure to make a diagnosis.  Ultrasound is the modality most impacted by say obesity, because thick layers of fat are barriers to beam penetration and this could result in poor image quality.

https://sites.google.com/site/odettessonographyportfolio/dms-101-physics/body

Personally I would ask for another echo, perhaps a transoesophageal echo to get a closer view of your heart, or a cardiac MRI, to try to get a more accurate assessment of your EF so that your doctor will know how best to proceed when you see him in September.  You might wish to email your new consultant again pointing out your concerns about your echocardiogram results due to technical imaging difficulties and asking whether you could have another assessment of your ejection fraction?  My EP requested another echocardiogram for me when he saw what was written on my results: "technically difficult due to body habitus - low parasternal window".  I haven't had an echo for 4+ years but this is not unusual here in the UK, especially if there is no indication of a problem.  I will be getting another echocardiogram soon, body habitus permitting!

I really hope your EF percentages turn out to be better than those quoted Dave. I would tend to be guided by how you are feeling rather than worrying about those numbers which can fluctuate depending on other health conditions, on your meds, on blood pressure, heart rate, lifestyle, echo operator experience and dare I say it, on body habitus for some of us and things like this.  

Gemita - Thanks!

by Good Dog - 2022-05-26 07:06:31

First off; no offense taken. Actually, I very much appreciate your response. I am 6 ft and weighed-in yesterday about 209 lbs fully dressed. I probably weighed about 7-9 pounds more when I had the last echo. My recent weight loss was intentional and I plan to get down below 200. So I certainly cannot argue about being over-weight, but I don't think too excessively. At my prime I was about 185 - 195 lbs. Although I was then doing 300 or more pushups and other exercises regularly and in great shape in my 40's through early 60's. Not so much anymore. I needed  a shoulder replacement at 61 due to arthritis and all the pushups. As I have gotten older, I am getting the proverbial man-boobs which are embarassing for someone that has always cared about their appearance. That could be the issue? It is interesting how my priorities shifted with age from caring about how I look, to caring about how long I can live.

As far as how I am feeling: I don't have the energy in my 70's that I had in my early to mid 60's, but I am functioning just fine. I have been mowing my perfectly manicured 1/4+ acre yard every two days. Up north here it grows like crazy in the springtime. Of course, I have to fertilize it to make it grow faster. I am always washing and waxing my cars and stay very busy around the house and I even do all the shopping. Just got a new puppy that really is keeping me busy now. So I can do everything I've always done without exception, but I just get a little more tired upon completion. I have no shortness of breath and so I think I am pretty much asymptomatic. I don't take any med's except a low dose xanax to help me sleep. I also quit smoking and drinking many, many years ago. 

I don't know what a transoesophageal echo is, but I will ask. I think an MRI is out due to my old clunky leads. I truly appreciate your suggestion to get another echo. That seems to make perfect sense. I just didn't know what, if any, my alternatives are. I am going to try that!

Again, thanks so much for your response! It was certainly helpful!

Dave

trans oesophageal echocardiogram (ToE)

by Gemita - 2022-05-26 08:21:42

Dave, although body habitus (shape) will obviously change with obesity, it could just as commonly be affected by being too small or too slender.  Having too small a rib space for example to adequately get between the ribs to clearly image the heart, may result in sub optimal views.  The non invasive transthoracic echocardiogram is an adequate test, but we are limited by not being able to see through bone (ribs and sternum) or air (lungs) – both are affected by our body size and shape.

The ToE can view the heart directly from the oesophagus and may get clearer views, especially if body habitus gets in the way.  I attach a link on ToE in case this helps:-

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/transesophageal-echocardiogram

Variation in EF

by SeenBetterDays - 2022-05-26 08:59:40

Hi Dave

I have real sympathy with your situation.  It must have been a shock to discover this change in your ejection fraction, especially if you haven't noticed any limitations to your normal activities.  I was told last time I had a check up that EF readings were not absolute and that ideally you should have them measured by the same person each time for consistency (that is clearly out of our control in many cases).  I have had two echo readings in the past twelve months, one showing 49% and subsequently 45%.  As you say, if there's a potential for a variation in these figures of 5, then whichever way you go can put a completely different perspective on things.

Gemita's advice seems absolutely sensible to try and get another EF measurement.  It would seem logical that the more readings you have in the same ballpark you can be more confident that the reading is accurate.  I have also been told by my EP that some people feel absolutely fine with a low EF whilst others are symptomatic.  

The really positive thing is that you are still feeling good.  Also, this new information has coincided with your forthcoming battery change so if interventions are needed it can all be done at the same time rather than having to go through several surgeries.  I think it would be helpful if pacemaker patients had some kind of regular monitoring of their EF from implantation onwards.  I know I have only discovered my drop in EF because I haven't been functioning normally and they have measured it in response to my symptoms otherwise I would be none the wiser.  I really hope you get some good news before your surgery and that they are able to determine an accurate reading for you which might put your mind at rest or at least allow you to plan with your cardiology team what the next best steps might be for you.  Let us know how you get on and good luck with the puppy!

SeenBetterDays & Gemita

by Good Dog - 2022-05-26 10:39:35

Gemita-Thank you for all the great info and your input.

SeenBetterDays - Thanks for your input as well. You really seem to be able to identify with my situation and vice versa. I am very grateful that I'm feeling O.K., but staring down a potential lead extraction of these old rusty wires and this issue with heart failure is stressful. I keep thinking that leads this old will present greater risk for extraction than those that are not as old, but I don't know if that is the case. I should have asked the doc when I saw him, but didn't. He had already told me that although he has extracted hundreds of leads, he is not as agressive as he had been due to some that presented complications. He told me that they have done thousands at the Clinic. He also said that anyone that tells you that it is a safe and simple procedure never ruptured a vena cava. He emphasized that there can be complications that shouldn't be taken for granted. That was not what I wanted to hear, but I believe it is the truth. It also gives me confidence that he views extraction as a last resort and does not have a cavalier attitude about it. 

Thanks again to both of you!

Dave

LVEF

by AgentX86 - 2022-05-26 12:29:00

The +/- 5% error in an echo isn't abnormal.  A lot depends on the cardiologist interpreting the echos. I'm really surprised that the went so long (15 years!!) between echos.  That makes no sense for a pacemaker patient. I have one every year and it's not unusual.

BTW, was it his "nurse" or "nurse practitioner".  There is a huge difference. Since she was discussiong possible treatments, I assume a nurse practitioner.

As far as extraction, after 35 years and, no space, and an already capped lead, I'd go for the extraction.  It's not an easy procedure but you're going to one of the best places in the world to have this done.

My first echo wasn't useful so they just wheeled me down to the MRI machine.  With a PM and capped lead(s) this will be unlikely but they could replace the leads first, then worry about a more precise LVEF. 

You're in good hands now with the Clevland Clinic - one of the best. I still lived in Kent, I'd have started out there. 40% isn't anything to panic over. Rest easy. They'll figure out what's going on and what to do about it.  Since you're almost due for a PM change, it's an excellent time to fix things.

AgentX86

by Good Dog - 2022-05-26 15:01:05

AgentX86, Thank you for your input. I think that you are probably correct about her being a nurse practitioner. I have not met her since I saw the Doc at the Clinic Main Campus. She works in his office in the burbs (Twinsburg). 

As far as the 15 years, you are also correct about that. There is no way I should have gone that long without an echo. I know that now. I guess that I never gave it a thought, because I had not had any issues at all, and I just didn't know any better. So I left it to the doctor. However, this is the same Doc that made the incision to remove my old generator before they anesthetised me. I was yelling that it hurt (I almost came off the table) and he apologized. On one visit, I had to remind him that I had two leads through the valve. Not one. I can only guess that he was thinking about his vacation. I know doctors are human too, but I suppose that I should have taken a hint from those occasions. There were others.

Human?

by AgentX86 - 2022-05-26 21:49:57

Going 15 years is nuts.  You should have had at least a few echos in those years. Of course, it's not your job to know that.

However, cutting you without some sort of anesthetic isn't excusable.  That's worth at least a report to the licensing authorities. I'm sure this wasn't an isolated case. If it was, no harm in the report.

Yeah, you should have bailed some time back but you didn't know better. 

To err may be human but so are inattentive and incompetent.

ditto

by dwelch - 2022-05-27 22:04:47

In some respects you are telling my story.  First I have had pacers same number of years.  they should have started doing an annual echo like 15 years ago.  And whomever you get should be giving at least annual if not twice a year right now.

I think mine started low and has always been low, I think at/above 50 is normal, mine was mid 40s and over a decade or so dropped closer to mid 30s, and that was the trigger to for the biventrical.   And that not only stopped it but brought it back up nicely.

Granted there can be other reasons than the pacer that cause a drop in EF so I had to sit there for it turned out a year instead of 6 months to see if it had fixed it.  Up to then I was getting an echo and pacer check the same day, but that visit they had moved and didnt have someone to do the echo, so get one between now and next visit and we will look then.

I had, like you a couple of 30+ year old leads, one was broken and capped.  A 20 something year old lead.  There turned out to be room for a fourth lead so all four are on the left side and I am using 3 of them. We have not discussed removal.   I had opted for tunelling to the other side if it didnt fit, but that did not have to happen.

Biventrical is fine, jumped back a bit in size of the pacer because in my case it needs to drive every beat (complete heart block), but compared to most of the other pacers it is still small.  Just bigger than the wee bitty one I had just before.

Now they are not doing echos every six months, we are doing them every year, and that is more of a why no rather than have to or need to.

if you are just cresting under 40 then they should be doing echos every 6 months and keeping an eye on it, if not more often depending on your condition.

Sorry to meet under these conditions, but you are one of the rare ones of this community with that long of a run. 

dwelch - THANKS!

by Good Dog - 2022-05-28 08:14:58

dwelch; I truly appreciate knowing your sentiments and the info you provided! Our stories are similar! It is great (and valuable) to hear from someone that has the experience you have had. Frankly, I consider you very fortunate that you were able to get that 4th lead. The reason I say that is, because I really worry about the risks of extracting my old leads.I would like to avoid it if possible. The Clinic brags about their 2 1/2% complication rate (compared to the average 5% elsewhere) which is good. However, if they remove a lot of newer leads from younger and relatively healthy patients, that could very well contribute significantly to that low complication rate. A previous doc of mine had told me that complications mostly occur in older less healthy people. Don't know if I fit into that category or not, but I have resigned myself to the fact that I really have little choice in the matter anyway. I trust my doc to be as conservative as possible on that matter. BTW: I asked my doc about the possibility of moving my PM to the opposite side in an effort to avoid extraction and he really discouraged me from considering that. He said there is a much greater chance of fracturing a lead, because of the minimal amount of tissue in the center of the breast bone. He also said; what would we do if you got an infection? So I concurred. He did agree that if I get a new (3rd) lead and CRT, that he would place it in the left ventricular HIS Bundle which should help to improve my EF. I have read stories from others that went from a dual chanber to a CRT and their EF jumped-up dramatically. So I am hoping for that outcome too. 

And yes; I wholeheartedly agree with your opinion on getting an echo as frequently as possible. 

It was great to hear from you and hopefully we can stay in-touch!

Sincerely,

Dave

Confused

by AgentX86 - 2022-05-28 14:53:19

I think there is a miscommunication problem here (could be me). A CRT pacemaker has a third lead placed into the right atrium, snaked into the corronary sinus and around to the back of the left ventricle.

Alternatively, His pacing has a lead placed into the bundle of His from the right ventrical.  There is no need for the third lead to the left side because the bundle of His is the natural conduction path. There is no left or right bundle of His.  It splits into the left bundle branch (LBB) and right bundle branch (RBB). Pacemaker leads don't get placed directly into the left atrium or ventricle.

Left Bundle Branch

by Good Dog - 2022-05-28 17:20:17

You are correct about the three leads. Bare with me here, because I am not great with the terminology. My doc said that in my case, the standard (right) HIS Bundle pacing is not an option. I assume he believes I would have a suboptimal clinical response, but I am unsure of the exact rational. I plan to ask him at my next visit. So I will have one atrial lead and one RV apex lead (unless it is replaced with a new lead that would be high septal) and then one burrowed (instead of non-specific in the epicardium) into the LBB to pace the left ventricle. It is a "relatively" new approach that has shown the same benefits as the standard right HIS Bundle Pacing. 

Left bundle branch pacing is a novel pacing modality that can bypass the pathological or disease-vulnerable region in the cardiac conduction system, to provide physiological pacing modality for patients. LBBP guarantees a narrow paced QRS complex and fast LVAT, with a low pacing capture threshold.