Micra Install Fail

I went in today for an implantation of a Medtronic Micra. This would've been my first PM. Unfortunately, after about 5-6 attempts to place it, my EP said it was unsuccessful and decided to stop attempting to implant. 
 

Has anyone experienced a failure during the procedure like this? My EP said I was the first in his "many, many" Micra procedures. 
 

This PM is to act as a safety net for occasional sinus node pause. 
 

I am now up for a Medtronic Azure to be implanted in the next week or two. Any experience with this device? Any limitations not initially disclosed?


9 Comments

Why failed? No preference for leadless or leaded?

by brady - 2022-11-02 23:42:27

Sorry to hear about your unsuccessful implantation of the Micra.

Do you know the reason for the failure, without which is hard to appreciate why. Also was it supposed to be implanted in the atrium or ventricle? (My guess it was the ventricle.)

I have an Abbott’s leadless dual chamber pm pair. According to a EP, during implant the main failure was dislodgement and the rate was about 2%. The dislodged PMs were retrieved. 

A detailed failure mechanisms and rates for the Abbott’s leadless ventricle LP PM are given in(if you are interested):

https://www.jacc.org/cms/asset/34c2cf0c-f4de-4ce0-85c1-95f6a46fb9ae/gr1.jpg?download

As you can see the during implantation, the total failure rate is only 4 %. The major failure is  cardiac perforation and is only 1.5%. In my memory, leadless seems to have less failure than leaded, but I could be wrong

My understanding is that the micra is leadless whereas asure is a leaded pm. And You don’t mind which type you get? Or no choice?

Medtronic Azure pacemaker

by Gemita - 2022-11-03 08:15:19

Mattin, firstly I am very sorry to hear of your difficulties during implantation of a Medtronic Micra.  We do have some members with leadless pacemakers, specifically the Micra, but they are in the minority.  Most members here have conventional pacemakers with leads and yes many members have a Medtronic Azure pacemaker and I hope they will see your post and respond.

I attach a Medtronic link on the Azure pacing system in case it helps answer a few of your questions.  

I have a Medtronic dual lead Ensura pacemaker, implanted in 2018.   All manufacturer devices will have similar features and benefits, although some will be better for athletes than others.  It is important that your doctor knows about your lifestyle and what activities you want to continue, since this could affect the choice of your pacemaker.

Limitations?  There may be a few initially during the first six weeks of healing until the leads are firmly embedded in.  Wound care is also important to prevent an infection.  Limitations with the Azure pacing system itself however is more difficult to predict, but with my older Ensura pacemaker, I have few limitations.  Any limitations are mainly due to my arrhythmias which can cause many unwanted symptoms like breathlessness, dizziness, chest pain, weakness, but when my arrhythmia stops, my pacemaker does an excellent job of helping me to live a good quality of life.

I wish you a better experience next time.

https://www.medtronic.com/us-en/healthcare-professionals/products/cardiac-rhythm/pacemakers/azure.html

Dual or ventricle pacing?

by brady - 2022-11-03 10:27:47

Gemita, good post and information filled reply!

"Any limitations are mainly due to my arrhythmias which can cause many unwanted symptoms like breathlessness, dizziness, chest pain, weakness, but when my arrhythmia stops, my pacemaker does an excellent job of helping me to live a good quality of life.". ----- nay I ask, this happens when the person has ventricle pacing or dual chamber  pacing?

Dual or Ventricle pacing?

by Gemita - 2022-11-03 13:06:54

Brady, electrical disturbances (arrhythmias) of the heart are complex.  Sometimes no cause can be found for their initiation which is why they can be so difficult to treat.  You say, may I ask, does this happen when the person has ventricle pacing or dual chamber pacing?  If I understand the meaning of your question correctly, I would answer, anyone who suffers from a symptomatic arrhythmia, irrespective of whether they are paced in the right atrium, right ventricle, have either single lead pacing or dual chamber pacing or even third lead to left ventricle as seen in CRT (cardiac resynchronisation therapy) pacing may experience severe symptoms during an irregular heart rhythm such as those I have described (breathlessness etc.) 

There is no doubt that some of us may not like being paced in the right ventricle alone since it is not “physiologic” and they may feel better with atrial or dual chamber pacing.  I certainly do.  While there is some evidence that an arrhythmia (like Atrial Fibrillation) may be triggered with a high percentage of right ventricular pacing, it certainly doesn’t happen to everyone but of course if we can get our pacing to closely match what nature intended, the better for us all.

My arrhythmias and symptoms started occurring well before my pacemaker was ever implanted.  Atrial arrhythmias are more common and less serious than a ventricular arrhythmia.  With a ventricular arrhythmia like ventricular tachycardia especially if sustained, this would need treating immediately, and a permanent defibrillator implanted which can shock the heart and stop the dangerous arrhythmia if it occurred again.  

Brady an arrhythmia cannot be controlled or treated with a simple pacemaker.  Only a defibrillator can shock a heart and stop a dangerous ventricular arrhythmia.  An arrhythmia starting in the atrium is usually treated with medication, cardioversion or an ablation.  

I have tachy/brady syndrome, part of the Sick Sinus syndrome. I have experienced syncope at the start of a fast irregular arrhythmia and also get long pauses at the end of an arrhythmia before I go back into normal sinus rhythm.  The starting and stopping of my arrhythmias, sometimes multiple times a day can be difficult to tolerate and cause instability.  Although my arrhythmias are still occurring, the pacemaker is really helping to steady my heart rate at the start of a tachy arrhythmia.  There is a pacemaker program which prevents the tracking of a fast atrial arrhythmia, switching me to a non atrial tracking mode until the arrhythmia stops and this really helps. There are several different anti tachycardia programs that are available on newer models apparently.  I also have both intermittent left and right bundle branch blocks which is probably why my EP decided to implant a dual lead pacemaker in case these blocks worsen, although clearly I do not have a complete atrioventricular block.

I am mainly atrial paced, but I clearly need ventricular support occasionally too.  I am happiest (have fewer symptoms) when I am atrial paced.  When I experience pausing or when they automatically switch my pacing mode away from the atrium, I become highly symptomatic but this is often caused by the irregular arrhythmia itself rather than from being paced in the right ventricle.

ventricle pacing question

by brady - 2022-11-03 14:43:44

Hi Gemita, thank you for your reply which is very educational. I read it several times to fully understand its contents and also thank you for sharing your pacemaker information.

I am ignorant on heart issues so have learned a lot from your previous and current answers. 

My understanding is that a pacemaker can only do one thing: when the heart is beating too slow, it could send out an electrical pulse and stimulate the heart to beat faster. Thus it can treat slow heart rate and also offer rate response by quickening the heart beats when exercising or doing demanding chores. (And obviously, for dual chambers PMs, between the two there could be coordination of responses.)  So only when the arrhythmia (irregular heart beats) is slow heart beats, can the pacemaker intervene. For other arrhythmias, the pacemaker is helpless. Is this correct?

I still don’t understand ventricle pacing and want to ask an elementary question. Let’s assume there is only one lead placed in the ventricle and no lead in the atrium (this is the situation for leadless pm placed in the ventricle and no pm in the atrium), without knowing when the atrium has received a p-wave and start to contract,  how does the ventricle knows when to pace?

Ventricular pacing question

by Gemita - 2022-11-03 20:38:23

Brady, so as not to hijack Mattin's thread on Micra implant failure I have sent you a private message with answers to your questions.

Thank you

by brady - 2022-11-04 12:13:25

Gemita, thank you for spending time to explain to me. I am digesting your answer and trying to absorb it.

Some More Info

by MattinMSP - 2022-11-04 15:57:06

The Micra was to be placed in my right ventricle to resolve very occasional sinus pause, which has caused approx 5 second pauses in my rythym. I also have WPW and Ebstein's. My EP specifically cited the Ebstein's as a potential cause for the implantation failure. They were not able to secure the unit in my heart tissue. The one or two times it was secured it was firing at around 4v, which is too high for the unit which usually should only require 1.5v.

I'm partly happy this didn't work since I'm 40 and I wasn't crazy about stacking 3-4 of these things in my heart when I live another 30+ years. On the other hand, I'm very active with 4 younf kids and am now concerned about the complications of having a PM with leads, even a sinlge lead to my ventricle.

I'm also not sure how to go about a second opinion since there is a level or urgency to get this device implanted. Any insight is appreciated.  

 

2nd opinion recommendation

by brady - 2022-11-04 23:54:42

Sorry about my ignorance. I don't know what is WPW and Ebstein.

Just wondering where do you live. If close to NYC, I would recommend Dr. Larry Chinitz of NYC. Dr. C (EP and professor of NYU) didn't do my leadless implant. However, before my implant, I did a lot of research and he stands out. He is one of the pioneers in using leadless pm and an expert in ablation. I could also tell you whom my EP is. He is a very personal guy, easy to talk to.

I share your pain. I was diagnosed low heart rate (34 bpm day and sometimes dip to 27 at sleep), both my cardiologist and EP strongly recommended me to have a leaded dual PMs. But I resisted, I didn't want 2 wires in the heart, one had to go thru a valve, neither did I want the pocket. I was told my heart might stop. I read the literature and I knew the failure rate of the lead pms. I endured this pain for  2 years until Abbott came up with leadless dual chamber PMs and I was lucky to be given a pair. So far they are working great.

I am not promoting leadless. Just personal opinion.

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