What kind of pacemaker for a Pace & Ablate (AV Node Ablation due to Afib)

100% Pacing Implications

by SeenBetterDays - 2022-06-17 11:20:19

Hi JOHNJO569

There are many knowledgeable people on this site who have had AV node ablations and can probably guide you on the technical aspects of pacemaker makes and models.  That's not me sorry but I can give you some things to be aware of before having your discussion with your EP.

I was 49 when I had my dual chamber pacemaker fitted at the beginning of 2021 for 2:1 AV block.  My heart block progressed and I am now 100% paced in my right ventricle.  I think there are parallels between complete heart block and AV node ablation, they just occur in a different way but you end up at the same point i.e. requiring 100% ventricular pacing.  There is no communication between the atria and the ventricles.  In my dual chamber pacemaker a lead is attached to my right atrium and right ventricle.  The atrial lead senses an intrinsic contraction of the heart muscle and then feeds that information to the ventricular lead so that the block is effectively circumvented.

In some people  a heavy pacing burden can create problems and my cardiologist suspects that I may have pacemaker induced cardiomyopathy as a result of the high level of pacing in the right ventricle.  My ejection fraction has dropped significantly and I am still symptomatic.  I am now looking into physiological pacing (His or left bundle branch) or a biventricular  device to hopefully reverse some of the issues that have developed.  What I am saying is make sure you go into this with your eyes open.  My concern for you would be the potential for problems further down the line if you go for the single chamber option.  As I said, for some people their hearts seem to tolerate the high level of pacing but, from my own perspective, I would have liked to have known the potential risks earlier on.  You are absolutely right to do your research and ask questions.  This is an important decision for you and you need to be fully informed before you make it.  Good louck with the appointment and I hope all goes well for you.

Rebecca

Pace & Ablate

by AgentX86 - 2022-06-17 12:06:56

I had an AV/His ablation for permanent flutter (long story)  four years ago. Your EP may have different ideas but mine is a CRT-P.  This is normally a three-lead pacemakeer but since the atria are disconnected, the atrial lead isn't used, as you probably know because your EP is talking about a single lead in the RV. His pacing isn't appropriate because the bundle of His has been ablated along with the AV node (belt and suspenders).

Cardiomyopathy and heart failure aren't sudden events rather a slow process that can take years.  There will be ample time to find and treat it if it occurs.  However, I would be pushing for the CRT over a single lead. Not only do you avoid PIC mentioned above but it adds a backup in case of a lead failure. The AV/His ablation removes another source of an escape rhythm so the ventricular ectopic is all that's left and it's not reliable (I don't have  one at all). A failure like this could cause SCA/D (sudden cardiac arrest/death). Perhaps this is what you've been reading about.

Exercise isn't a problem, particularly something like running where the torso is moving. You won't become a competative runner but more normal levels of exercise will be just fine. I walk ten miles a day.  I normally walk the neighborhood, three laps a day (neighbors have called me "Forrest").  Recently, I've been doing a treadmill at the gym for three hours a day because it's been in the mid-90s.

If you were cycling or swimming for exercise, some pacemakers are better than others but for running/walking the specific make/model doesn't matter much and, really, you may not have a choice. Some EPs/hospitals have an exclusive deal with one manufacturer.  This isn't a dirty deal, though.  Pacemakers take a *lot* of support. In fact, larger hospitals may have a manufacturer's rep on site.  This is a huge gain but it can only be justified with a lot of patients.  Even for smaller facilities, the equipment and training can be significant. Supporting multiple manufacturers may be overwhelming. I have a Medtronic W4TR01 (I never remember the silly marketing names).

The question is how many leads do we need?

by Gemita - 2022-06-17 14:33:02

Hi John, welcome.  I don’t want to dampen your spirits to find the perfect pacemaker but looking for CRT therapy at this stage may be a little premature unless you are already suffering from heart failure?  I would have a conversation with your doctors first about what can be offered under the NHS in your particular circumstances following an AV Node ablation.  I suppose the question would then be:  how many leads do you need and where should they be best placed to give you as “natural” a pacing experience as possible?  

I have AF and when I was considering an AV Node ablation following my dual chamber pacemaker in 2018, I was told I would be offered an upgrade to CRT if I were ever to develop signs of heart failure, since let us be clear, not everyone goes on to develop heart failure from right ventricular pacing.  

My husband who suffers from “persistent AF” and severe bradycardia, received his pacemaker 4 years ago too, and although he already had signs of right sided heart failure at the time, he was only given a single lead pacemaker;  he wasn’t given a choice.  Neither of us were too happy about this but it was an emergency procedure with little initial discussion.  His current percentage of right ventricular pacing is more than 80% and this doesn’t seem to have caused a worsening of his symptoms which are being reasonably well managed with frequent pulmonary rehabilitation.  He suffers from COPD and pulmonary hypertension as well as ischaemic heart disease.

So it will largely depend on your heart condition and other health conditions John and whether you are in heart failure as to what your doctors will offer you under the NHS?  Yes after an AV Node ablation, we would become pacemaker dependent and in need of 100% pacing support in the ventricles, leaving the atria in AF.   CRT might be recommended at that time depending on whether or not we were showing signs of heart failure with an ejection fraction say below 35%. 

There are many here who have heart block and who have been 100% paced in their right ventricles for years and have never gone on to develop heart failure.  I would discuss your concerns carefully with your doctors and ask what all your options are following an AV Node ablation.  Explain to them your concerns and see what they and the NHS can offer, but I suspect if you are not in heart failure now, CRT may not immediately be offered. 

While I can see the benefits of pacing our ventricles as “physiologically” close as nature intended to avoid dyssnychrony between the left and right ventricles, placing the left ventricle lead in the most effective position to achieve this, even in experienced hands, is still not without technical difficulty.  There are many anatomical and technical challenges which can hinder LV lead placement which is why unless we suffer from serious pacing problems following an AV Node ablation or are already in heart failure from AF at the time of the AV Node ablation, my doctors rightly or wrongly tend to keep CRT in reserve should it ever be needed in the future.  Good luck John and I hope you get the answers you seek.

Pacing after AV node ablation

by Julros - 2022-06-17 14:44:26

You may not have a choice about a single lead versus a bi-ventricular system depending on protocols. In the US with private health insurance you likely wouldn't be covered unless your ejection fraction is already low. I've been reading about left bundle-branch pacing with creates a more natural electric pattern, but I don't think it's in wide use as yet. 

You may already have significant damage to your heart muscle

by crustyg - 2022-06-17 18:49:39

Allowing the ventricles to be driven at high rates for a long time (perhaps 6-12months) can produce tachycardia-induced cardiomyopathy, and I don't think the heart muscle recovers from that.

So while I understand your desire to really consider the implications of AV-ablation + PM, you may not have as much time as you would like to think.  Yes, prolonged RV-apical pacing (alone) can produce LV remodelling, which results in reduced %LVEF which is bad news, so EP-docs try to pace the LV directly (CRT) or via His-bundle pacing (more physiological).  However you may already have some heart muscle damage, which you need to be aware of.

A big thanks a few more questions!!

by johnjo569 - 2022-06-18 17:23:13

Thanks everybody for taking the time to reply to my queries I really appreciate it, these have been very useful indeed!

Crustyg, sorry for my ignorance on this, I am not sure what you mean by 'EP-docs try to pace the LV directly (CRT) or via His-bundle pacing (more physiological)'?

So based on most of the responses I will most likely not get offered a CRT until my heart worsens again from a single chamber pacemaker and/or I start to get heart failure. I find that quite worrying and would have thought they would prefer to PREVENT rather than again have to treat new problems. Surely that would work out cheaper for the NHS in the long run.

If I was to be able to choose, are there any downsides to having a CRT over a single chamber pacemaker? 

I also like to go out on bike rides with my partner, do they all have the ability to pick up my heartbeat even if it looks like I am not exerting myself, like while riding aa bike?

Finally, like when buying a better quality car or a lighter weight bike is there the option to 'upgrade' to a better, more advanced model of pacemaker even if that means you have to pay for it yourself? ...(That may be a completely stupid question to ask as I have absolutely no idea how much they cost but to my mind technology advances all the time and I would imagine that would be the case with pacemakers as well and if a newer version is superior to an older model currently in use then paying for that one if you have too may be the better option... or not, I'm just speculating i guess).

Thanks again everybody i really appreciate it. 

A few thoughts

by Gemita - 2022-06-19 04:58:48

John, my doctors would say “if it ain’t broke, don’t fix it”.  All procedures carry a risk, including CRT which is technically more difficult to perform than placing a single right ventricle lead or right atrium, right ventricle (dual lead pacemaker).  I know we all want the best, a more natural means of pacing as nature intended, but what is the best in these circumstances?  If you don’t have an indication (need) for resynchronised pacing, then why do it? 

But of course you need to be speaking to your doctors.  They may be recommending CRT pacing in any event for your particular medical condition?  You don’t tell us whether you are in heart failure or have cardiomyopathy after so many years in AF?

Yes of course prevention is always better than cure but the majority of patients do not go on to develop HF with RV pacing, so why treat a condition that doesn’t exist and may never develop?  Using CRT to treat the "fear" of developing heart failure would not be without considerable risks either John.

"If I was to be able to choose, are there any downsides to having a CRT over a single chamber pacemaker" you ask?   The downside is that CRT is a more invasive surgery than a single lead pacemaker, it is also technically more difficult to perform and potentially riskier than a single lead to the right ventricle for example.  There is more that can go wrong afterwards too mechanically, even in the most experienced hands.  Lead dislodgement and the technical difficulties of placement in the optimum position for adequate lead capture come to mind. The main procedural complications include lead dislodgement, coronary sinus dissection, and phrenic nerve stimulation. 

Importantly, perhaps up to 30+% of CRT patients do not show clinical improvement with CRT “when it is indicated for heart failure”.  CRT works best when you have heart failure, and a need for synchronised pacing support, not before I was told.  The higher the need for CRT pacing, the higher the benefit apparently.

You ask “Finally, like when buying a better quality car or a lighter weight bike is there the option to 'upgrade' to a better, more advanced model of pacemaker even if that means you have to pay for it yourself?” 

If you can afford private treatment and pay a willing EP, anything might be possible but is it practicable and safe to change your pacemaker just because you are bored with its features or you want the latest upgrade?  With technology moving so fast, you would always be getting a device change.  There is considerable risk of infection with each successive device change and this cannot be underestimated.  So the answer to your question would probably be "no" with a responsible and caring NHS doctor.

You ask:  "I also like to go out on bike rides with my partner, do they all have the ability to pick up my heartbeat even if it looks like I am not exerting myself, like while riding a bike?"  All pacemakers are capable of capturing heart beats whether you are at rest or active.  My doctors tell me that my pacemaker can differentiate between a high heart rate caused by one of my arrhythmias like AF and a high heart rate caused by exercise.