biventricular pacemaker lead 3rd surgery

Hello wanted to post and get people's thoughts.  First some background  / context I am currently 40 yr in good health (besides my heart) weight lift and do Brazilian Jiu Jitsu 4-5 days a week. 

I have had a history of both irregular / slow heartbeat + low EF rate (around 30%)
In Oct 2019 they decided to put in a Dual Chamber Pacemaker. Literally while I was going into surgery the Dr asked if I wanted to switch to a Bi Ventricular pacemaker. I really didn't know what to say so I decided just to get the Dual Pacemaker.

Well shortly after I ended up having some issues with the dual chamber PM - Afib and some erratic heartbeats etc. Plus my EF rate did not improve.

So in Feb 2020 they went back in and switched out my Dual Chamber PM to a Bi Ventricular three lead PM. Well a couple of days after that the third lead fell out. They turned it off and let me know that my heart structure made it challenging getting the third lead in place. But I live in an area where there is a super renowned specialist that works on cases where the third lead is hard to get into place that I was able to connect with.. So I had surgery scheduled again to get it reinserted for May 2020 but then Covid hit and everything got postponed, so then it got pushed back to July 2020. At that point I was feeling a lot better and I spoke with my doctors that I wanted to hold off as I felt like I was feeling better and a third surgery in such a short window was just something I did not feel right about. 

Anyway since then I have been generally pretty good. My current PM is only working as a Dual Chamber but my heartbeat numbers have been pretty good any no more Afib at all. However, my EF rate is still low about 30% and has been checked every 6 months.

Last week my Cardiologist was pretty adamant that I try to get the third lead put in correctly so I am currently getting it scheduled. His main concern was even though now I am doing ok what is going to happen 10 years from now etc. And the third lead should really improve my EF rate or help keep what I have.

I guess what I am looking for is some thoughts around
1. I think this is the right course of action but welcome any thoughts etc.
2. How much more complex / worse / better will the surgery be than a normal PM install? - 2 leads they are not doing anything with. 1 Lead is turned off and out of place. The PM may or not be replaced - It has been 3 years so they may want to replace it with the same one to get a little more battery life. My main concern is since the third lead has been in place for like 3 years what will that be like scar tissue etc. I do not believe there is an extraction happening but they need to place it back into the correct spot.  I have heard lead extractions  / replacements are a little challegning. 

Thanks everyone

4 Comments

EF of 30%

by Penguin - 2023-01-31 08:08:23

Hi, 

This is a quick reply, because I can't answer your questions.

What a shame they didn't put the bi-ventricular lead in first time round and what a long wait you've had! I'm glad you've had a reduction in your AF whilst waiting for this procedure and time to research a suitable expert surgeon. 

Take good care of yourself.  

 

CRT (cardiac resynchronisation therapy) to treat a poor ejection fraction

by Gemita - 2023-01-31 09:51:14

 SK288702, your current state of fitness, despite your heart condition, is certainly impressive.  However as an arrhythmia sufferer with both a slow and a fast heart beat, sometimes occurring simultaneously, I know just how bad we can feel when these disturbances hit us, turning our perfectly normal hearts into a quivering mess, barely able to pump blood around our bodies.  I am not surprised that a low ejection fraction (EF) can sometimes be the result, together with other acute heart failure symptoms.

I have read your comments and I am surprised at some of the things you say about your experience with first the dual chamber pacemaker and then the third lead.  I have heard the third lead can be really difficult to place in a position that can effectively pace the left ventricle and I am glad that you sought the opinion of a specialist in your area who might be able to help.

With AF and a dual chamber pacemaker, I would not have expected any improvement in EF, only CRT (biventricular pacemaker) can possibly help with your EF, but cannot do anything to help with AF unfortunately.  Only medication, cardioversion or an ablation can help treat AF.

Although I understand your reasoning for holding back, an EF of 30% ideally needs treating if not with a CRT device, at least with medication perhaps to see whether it can be improved without going down the surgical route?  I am reassured though by the fact that your Afib has settled and that will certainly help you to feel better and may even help your EF to recover.  

Unfortunately although CRT “should” help improve your EF, this is by no means guaranteed for all patients with a low EF.  In any event there are other conservative treatments, like medication and lifestyle changes that can help.  My sister, for example had an EF of only 16% just over a year ago and without ICD or pacermaker support, her condition was successfully managed with medication alone and now her EF is over 40%.

There is no doubt that an upgrade if carried out by an expert surgeon who has experience managing complex cases such as yours, should be safe and successful.  I note no lead extraction is expected, although no doubt this will be assessed fully during initial investigations prior to any upgrade.  Yes lead extractions can be challenging but again, in expert hands, you should be okay.  Replacing a lead by feeding a new lead into the same vein is also possible for some of us and may be an alternative, safer option to any lead extraction.

There is no doubt that the more leads that are required, the more complex the procedure will be.  For example a single lead pacemaker is more straightforward than a dual or triple lead pacemaker and procedure time and complications for a single lead pacemaker will be lower too of course.

But it seems to me as though there are still so many questions that remain unanswered, whether leads will be abandoned (left in place and capped) or removed, whether your veins are healthy to take more than one lead if a new lead has to be fed into the same vein?  I would therefore ask to see the specialist as soon as possible to discuss this while you are still well enough to make an “informed decision”.

Appalled

by Lavender - 2023-01-31 10:27:44

Your doctor asking you what kind of pacemaker you want just makes my jaw drop! The EP and cardiologist chose my CRT-P for me. I would not be in the position to professionally decide which device I needed!

Your cardiologist is adamant about this surgery. I would go with what the experts say. Perhaps asking the surgeon who will be doing the lead replacement is best. 

I agree!

by Aberdeen - 2023-02-01 14:50:43

I agree with Lavender that she was appalled that you were asked which type of pacemaker you wanted! 
I had to have a dual lead pacemaker replaced by a CRT pacemaker after 4 months. My EF was around 35-40. 5 months later it was 63! 
I also have experience of leads being replaced. My RA and RV leads failed in April last year ( actually I think they had been failing since October 21) They were easily replaced as they had only been in place for 2 years. Perhaps since your third lead wasn't in place for long I hope it would be easy to replace?                                         
I wish you well and let us know what happens.

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