Bad lead

Just when I thought all was going along great, I had a pacer checkup and they found one of my leads has an "increase in RV threshold and RV lead impedance." So they want to replace it. I had 1.5 years left on this device so they said they would replace that too. They also claimed that I had progressed from Mobitz 2 to CHB. It wasn't fun when the tech tested that! 

Anyway, my questions are: Is it a big surgery to remove the bad lead? I'm guessing it will be an overnight stay? Also, if I'm a CHB, do they use a temporary pacer during the change? Sorry, one more ?.. I currently have the Medtronic Adapta implanted in 2012, are the new ones the same? Are there better ones to consider? I asked about the Micra and was told the DR. probably wouldn't want to remove the good lead., but they will ask.. .Also, I would love to get this deeper into the "pocket" or under the muscle. Since last implant, I've lost a bit of weight and I can see the pacer. Not very happy about that.. Thanks all!

 


12 Comments

No fun.

by AgentX86 - 2023-01-16 01:12:50

Indeed.  I call it the "elevator test". The bottom just falls out.

If you're truly dependent, they'll attach a temporary pacer as they disconnect one and switch in the new. It's done all the time, so my cardiologist says anyway. If you can get away with a low pulse rate for the minute or so, they'll do that.

I wouldn't go for a Micra.  Not with CHB, anyway. If your Medtronic is working for you now, I wouldn't switch horses. You know the devil you have.

Burying it sub-pec isn't a horrible idea but the recovery isn't as easy.  I've lost a little weight (25#) since my PM surgery and it does show fairly prominently. Mine is a CRT (larger) but I don't mind the bulge. It's inconsequential next to the sternotomy railroad tracks. 😐 It's a personal thing, obviously.  Burying it under the pecs protects is a bit more so if you're into mild contact sports or hiking (backpack straps) it will probably help. Personal descision.  Be sure to tell your surgeon what you want well before the procedure.  He may want to bring in another surgeon.

Thanks for your reply..

by USMC-Pacer - 2023-01-16 01:48:29

Yeah, if they can't go under the pec, I'll just ask them if they can make the pocket deeper. They have asked me a couple of times if I bumped it. I think they don't understand why the lead is failing. It's scary to wonder what would happen if the lead failed completely..yikes!

leads

by Tracey_E - 2023-01-16 07:59:07

Leads don't last forever. 15 years is average-nsome make it more, dome don't make it that long. The insulation can rupture, scar tissue can grow on it making it ineffective, or sometimes we don't really know what happened. 

If they are going to keep the good lead, they may not remove the old one just yet. If there is room in the vein, they can simply cap off the bad one and add the new one. This is what I did. That was in 2010. My other original lead is still going strong. 

This is the perfect time to have it repositioned if you aren't happy with where it is. Sometimes depending on your build they can go lower and deeper without actually putting it subpec. When mine was repositioned, my ep brought in a plastic surgeon to do that part. 

Progressing to CHB is very normal. The good news is, you never felt the difference because the pacer automatically stepped up and took care of it. We can pace every beat but still have an underlying rhythm that will be sufficient for the duration of the surgery. I'm on my 5th now. Before each replacement, they do the fun test you just had to see where my underlying rate is. It's been anywhere from 20 to 60. They will use either an external or temporary pacer for the surgery so you stay safe. 

CHB is not generally considered for a Micra. The technology isn't there for us yet. 

If you do a search for extraction, you can get more information on the surgery to remove the old leads. But first make sure that's the direction they are going! It's not a given. 

Hi there Jarhead!

by Lavender - 2023-01-16 09:11:22

I'm personally acquainted with complete heart block and the feeling of "no detectable escape rhythm" testing. Ugh

Sounds like you are headed for an equipment upgrade. I have a Boston Scientific CRT-P. You might be getting a three lead device at this point. 
 

You won't be their first rodeo. They're aware to keep you pumping while they tool out your parts change. You leathernecks are a tough breed-and thank you for your service!!  🫡.  It's going to be just fine!

Not to worry

by Good Dog - 2023-01-16 10:43:58

If I were you I would not be overly concerned about the CHB. Almost all of us have an underlying escape rhythm that will keep you alive. Most of us have a CHB which is why we have these devices. I laid in the ICU all night long (back in 1987) before my PM was inserted watching my rate on the monitor bounce around from 35 bpm to as low as 12 bpm. The nurse came in my room with eyes as big as saucers when my rate dropped down to 12 bpm. I asked her what was wrong and she said, "most people are not consious with such a low rate". Well, I was! Since that time, many of my cardiologists have told me that it was negligent to allow me to suffer with such a low rate and not use a temp PM. My point is; not to worry. Worst case scenario is that it is very likely that you'll be fine. Additionally, they will certainly verify your escape rhythm before they put you under anyway. That should ease your worries about what would happen if your lead broke entirely. Yeah, it isn't good, but it is highly unlikely that you would die.

Also, if they are going to extract a lead, which they should do while it is relatively new (11 years is fairly new). There is a new philosophy emerging in cardiology that says; they should not kick the can down the road. In-other-words; depending upon your age, they should not wait until the lead is much, much older and there is a need to extract under emergency circumstances. Just be sure that whoever is doing the extraction has a lot of experience. The general school of thought had always been; someone that has performed at least 100 extractions, but in reality, just insure the Doc does have a considerable amount of experience.

I wish you the very best! Please stop back here and let us know how it all went.

Sincerely,

Dave

WOW! Thanks all!!!

by USMC-Pacer - 2023-01-16 12:02:52

At this point, I've only seen the "tech" and a NP. It was the tech that kept asking if I bumped the device. I figured it should take more than that.. 

Tracey, I would love it if they would go that far to reposistion the device. It's a great hospital and great staff (Beth Israel Lahey Health) and the same place I had my AVR and previous device implanted. Hopefully they will work with me..

The tech only gave my test 3 seconds, or so he said. It seemed longer. I was extremely dizzy and faded. I heard some type of noise in my head.. lol, not pleasant and I hope that is not a frequent test. I'm relieved to know there is most likely and escape beat. I know malfunctions are rare. I don't want what my dad (bless his soul) would have called a "coronary conclusion." 

I'll certainly report back. I meet an "advanced NP" on the 26th to discuss and have an xray.

Thanks again for ALL the responses! What a great group!!!

 

repositioning

by Tracey_E - 2023-01-17 09:20:50

The plastic surgeon was my ep's idea. He didn't want to mess with it, and it was the easiest job of the day for the plastic surgeon. Insurance covered it. 

Tracey

by USMC-Pacer - 2023-01-17 09:41:39

I'm hoping they will work with me. I doubt they will put it under the muscle as they refused the first time and it's still the same EP (insurance issue?? I dunno)

. I can't find any info, but I wonder if the new Adapta is smaller than the one from 2012?? Might assist them in burying it more.. 

size

by Tracey_E - 2023-01-17 12:13:30

I'm not sure if they size has changed. Mine have all been about the same size. 

I suspect not wanting to put it under muscle was more the ep not wanting to mess with it than size of the box. Some only want to keep it where it's easier for them. There are people with icd's- which are considerably larger than even the biggest pacer- under the muscle. I would bring it up again and ask if a plastic surgeon is an option. Push if you need to, tell them where it is is not working for you. 

Temporary PM and CHB

by Dixie Chick 65 - 2023-01-21 18:20:27

Just wanted to let you know that I also had CHB and when my doc told me I'd need a pacemaker, he mentioned he'd do a temporary pm first. I just nodded - I had just had a catherization and was still a little groggy. Of course I didn't know or feel anything. I got along great with no complications and that was 2 1/2 years ago. I've since learned that a temporary pacemaker is considered best practice in complete heart block cases. Mostly because the "pads" are quite painful if needed and with the temporary in place there's no worry.

No experience with lead changes though. All the best to you !

 

Thanks Dixie

by USMC-Pacer - 2023-01-22 19:42:16

I was just curoius as to how they unplug the leads. CHB is a new development for me since my implant in 2012 as my HB only affected me during exercise. I don't want to feel that feeling again when they cut off the juice, lol.. maybe if I'm on the coocoo juice I won't care.. 

Thanks for your reply. I see them this Thursday to see what they have planned. I'll have lots of questions for them, and I'll report back here.

Update...

by USMC-Pacer - 2023-01-26 18:38:12

I saw the NP at the clinic today. They are removing and replacing the lead that is in my right ventricle using some type of laser. They are going to replace the lead higher in the ventricle at the LBB. She showed me on a model and it looks like it's near the AV node closer to the top of the ventricle. My current lead is at the very bottom of my ventricle. She said it results in better contracton. They still don't know what went wrong with the lead. I also had a surprise echocardiogram and after reading my after visit summary, they are looking at pacer-induced cardiomyopathy. Sounds great!!! I've read up on it quite a bit. Thankfully, I don't have any HF symptoms at all. Looks like I'll be heading for the CRT pacer route.. Anyone have any experience with this?

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