PVC's

PVC's

by KHammond - 2024-04-07 09:11:05

Evaluated by a nurse at my appointment on 4/4.  ECG did not show anything of interest, a short interrogation indicating dual paced heart rhythm with some atria and ventricular inhibition.  Bloodwork results showed eveything in normal range except magnesium a touch high (2.4).  Pacemaker data only shows 16 PVC's /hr, did not get a a good answer as to why I feel a heart flutter or missed beat about every three heartbeats.  Scheduled for an echocardiogram on 4/12, maybe that will reveal some clues or at least check my heart efficiency. 

Prescribed Metoprolol 25mg/1/day (beta blocker).  No side effects with the first dose taken yesterday.

I have a scheduled consult with my cardiologist in May.  Nurse says PVC's are benign but the symptoms are irritating and I would like to rule out cardiomyopathy and dyssynchrony.

KH       

100 per cent right ventricular pacing?

by Gemita - 2024-04-07 11:35:06

KHammond, just a few observations.  I see you have Sick Sinus Syndrome/Bradycardia and some right bundle branch block and that you are pacing 100% in the Right Ventricle in VVI mode, with only 38% right atrial pacing.  Your diagnosis sounds rather like mine except I am pacing 100% in the right atrium, with only 1-2% in the right ventricle.  However my base rate is set at 70 bpm which helps to overdrive pace slow, pausing ectopics and keep them under better control.  You could ask about raising your lower limit to see if it helps?  It helps some of us, but not all of us.

I would not be surprised with 100% ventricular pacing that you could be symptomatic with PVCs and perhaps experiencing some co-ordination difficulties between the upper and lower chambers of your heart.  In other words, the timing might be off.  Any loss of synchrony can lead to symptomatic abnormal heart rhythms which can decrease cardiac functioning and output.  Perhaps this is a cause of your PVCs?

Doctors usually like to keep right ventricular pacing to a minimum unless you have an absolute need for it, for example if you had heart block and required a high degree of pacing in the right ventricle.

If your magnesium is on the high side or electrolytes are abnormal that could cause PVCs too.  I would ask for an external holter monitor for 7 days or longer to better capture all your abnormal heart rhythms, like atrial ectopic beats also which may not be picked up or stored by the pacemaker.  It may disappoint you to know that even with a pacemaker, we sometimes still need external monitoring to ensure that nothing is missed because the pacemaker has limited storage and will only report on events like an arrhythmia that the doctor has asked to see and events that meet the criteria set up for their storage and recording.

I am glad you have been prescribed Metoprolol.  That will calm your PVCs.  As an arrhythmia sufferer I know how awful it is to be out of rhythm.  There is no such thing as a benign heart rhythm.  If the heart rhythm is adversely affecting your quality of life, it won’t be a benign event for you and the sooner you get your PVCs under control, the safer in all respects.  Good luck

PVCs

by piglet22 - 2024-04-07 19:24:51

PVCs can be benign or not.

A few don't matter much, but if they become "significant" - consultant term - then they can start to interfere with the normal operation of your pacemaker.

PVCs can be sensed and "fool" the PM into not firing. The net result is to get symptoms similar to those you had the PM fitted for in the first place.

Low palpable heart rate, low blood pressure, leading to pre-syncope and possibly loss of consciousness.

Persistent PVCs need treatment urgently and beta blockers at a high dose is the initial treatment of choice.

This comes with it's own collection of problems like low exercise tolerance.

As far as I'm aware, no current PM manufacturer is able to provide a software solution.

I find this extraordinary as ectopy or out of place signals in a a normal rhythm can be detected and filtered out.

But I'm just a tinkerer, not Medtronic.

PVC's

by KHammond - 2024-04-08 09:17:54

We did adjust my lower HR limit from 60 to 70 BPM and turned off mode switching, not sure that has helped..  My PM does sense the PVC or abnormal beat and pauses my ventricle firing making for a lumpy heartbeat.  So far my tolerance for exercise is pretty good.  Hopefully my echocardiogram on 4/12 will shed some more light and I am meeting with my cardiologist next month.  In the meantime I will see how the beta blocker does.  How long before it takes effect? 

And I will ask about a Holter monitor to capture better data. 

KH

My beta blocker was fast acting causing volatility of blood pressure/heart rate initially

by Gemita - 2024-04-08 11:01:24

KH, they can be fast acting for some of us, but it may take more than a beta blocker to stop some rhythm disturbances, depending on the cause.  You should notice a benefit in a few days.  Hopefully your electrolytes have stabilised.  Many of us are deficient in magnesium and take magnesium supplements, but I see your levels were slightly elevated.  Keep well hydrated.  Dehydration can trigger heart rhythm irregularities, as can lack of sleep and too much caffeine.  Hope you find the cause and will feel better soon

VVI

by AgentX86 - 2024-04-08 11:42:26

VVI mode and "atrial pacing" are mutually exclusive.  VVI means pacing in the ventrical(s) only (the first 'V') and sensed (the 'I') in the right ventrical, only. There would be no atrial pacing at all.

I would guess that your pacemaker is set in DDI  or DDD mode. That is, paced in the RA, if atrial beat is not sensed (inhibited if sensed, 'I' mode), then paced in the LV if natural LV isn't sensed ('T' mode). 'I' + 'T' = 'D'

I am paced VVI because I've had an AV ablation, so have no atrial function at all.  Pacing in the atrium would be superflous, so I don't even have an atrial lead. My pacing mode is actually VVIRV. ('V') paced ventrically only, ('V') sensed ventrically only, ('I') sensed only, ('R') rate response on, ('V') biventricular pacing.

PVCs

by AgentX86 - 2024-04-08 11:48:27

Yeah, PVCs suck eggs. I've been having a lot recently.  An event monitor showed a 10% PVC burdon. It's substantially better now, but it still sucks. I'm sure they'll be back.

VVI

by KHammond - 2024-04-09 08:20:38

You are correct, I misstated my pacemaker mode.  It was originally set to AAI<>DDD with mode switching.  Since I require 100% ventricle pacing the mode switching is not required so it was turned off last week.  My atrium is only paced when my heartrate tries to drop below 70BPM originally set at 60 BPM) which happened about 38% of the time since my resting heartrate used to be in the low 50's.  An interesting feature of my pacemaker is a sleep mode, you can set a lower paced heart rate during the hours of normal sleep.

KH   

PVC's

by KHammond - 2024-04-14 09:32:14

An update to my current PVC situation.  Fortunately my PVC's seem to be reduced in frequency so either the beta blocker or pacemaker adjustments, or both are helping.  I did receive my echocardiogram results and am posting the narrative summary here:

Narrative
•  The left ventricular systolic function is low normal (50-54%). •  Normal left ventricle cavity size. •  There is mild concentric left ventricular hypertrophy present. •  Unable to assess left ventricular diastolic function  (paced rhythm). •  The right ventricular systolic function is normal. •  The left atrium is mildly dilated. •  The sinuses of Valsalva are mildly dilated. •  Moderate mitral valve regurgitation.

Changes from my echo done on 22 Aug (just prior to PM implant) show ejection fraction reduced from 65% and mitral valve regurgitation worsened from mild to moderate.  Are these changes to be expected after getting a dual chamber PM ?  I may not see either my cardiologist or a Nurse Practitioner for at least a month and would appreciate any input before then.

KH 

Thank you for the update

by Gemita - 2024-04-14 13:32:08

I am glad your PVCs are better controlled.  That will help you to feel better.  To try to answer your question, I note your ejection fraction has reduced from 65% to 50-54%.  This percentage reduction could be due to several factors, including technician ability and visual quality, so I wouldn’t worry too much especially as 50-54% is still within normal limits. 

As I think I mentioned previously, my main concern in your shoes would be the 100% Right Ventricular pacing which could lead to dyssynchronous left ventricular contraction.  A high burden of right ventricular pacing affects some patients more than others.  Mitral regurgitation can worsen with such a high burden of right ventricular pacing.  Some patients do not tolerate Right Ventricular pacing and may develop pacing induced cardiomyopathy or other difficulties too.  I would question whether a high burden of ventricular pacing is really necessary for you unless you have developed a total heart block.  Like you, I have Sick Sinus Syndrome and right bundle branch block, but am paced almost exclusively in the right atrium in AAI mode.

I see there is mild concentric left ventricular hypertrophy present and the left atrium and sinuses of Valsalva are mildly dilated, otherwise a fairly normal echocardiogram.  Mild leakage of heart valves would not be significant, but valves with "moderate" leakage may need watching in case they progress to "severe", causing symptoms

PVC's

by KHammond - 2024-04-16 09:52:26

I require 100% rt ventricle pacing since it will not beat on it's own.  My original diagnosis included 2:1 a/v block so I had them test my intrinsic heart function in the clinic a few months ago to see if I still had that partial block. (They were quite sure I had a total block from my EKG) As they turned down pacemaker support I very peacefully passed out.  Really, a very pleasant feeling and now I know how it will quietly end for me if my pacemaker were to quit for some reason. 

I sure the same concerns about 100% ventricle pacing and the dysynchrony issue.  Also would like to keep an eye on my heart efficiency with periodic testing to make sure it is not continually deteriorating.

As a side note I watched some of my echocardiogram and I had no idea how wildly the ventricle lead moves around in the heart while it is beating.

KH