Conduction system pacing

Experience with crt pacemaker and his bundle pacemaker

by JaneJ - 2024-08-10 02:35:02

Hi!  Wow, 4 leads is a lot!  Did you have several leads that have fractured or failed?  I have a bit of experience with conduction system pacing.   I also have complete heart block and am 100% paced in the atria and ventricles.  My ventricular lead fractured several years ago and I had to have an extraction.  My dr also strongly pushed conduction system pacing and sent me to a large university hospital that did his bundle pacing, thinking this was the way to go.  Unfortunately my his bundle pacemaker was placed and ended up needing removed about 3 months after they put it in because of extremely high thresholds and even occasional loss of capture (which is bad if your pacemaker dependent).  Because of all the energy required for the his bundle pacemaker to work correctly, the battery would only last about 1 year.  So end result was that they ended up placing a crt pacemaker.  I've been doing fine with the crt and will be getting a generator change in the next 6 months.  It's lasted almost 7 years.  Hopefully your conduction system pacemake will work out for you.  They are not sure why the his bundle did not work for me.  They mentioned it may have been because of scar tissue.  They were just unable to find a place to put the his bundle lead that resulted in a decent threshold reading.  I wish you well with your procedure.  Take care!

Left Bundle Branch pacing

by Gemita - 2024-08-10 03:37:32

Amy, thank you for the update.  You have quite a challenge ahead and I hope it goes safely for you and will be a success.

There are a few members with left bundle branch (LBB) pacing and I  hope they will read your message and respond.  I attach a Pacemaker Club link from a member with LBB pacing in case it is of help.  The link should be copied and pasted into your main general browser to open.  I also attach a link about LBB pacing in general as well as a useful diagram of conduction system pacing "positions", third link.  They should keep you busy and well informed Amy!

For patients who require long-term right ventricular pacing, alternative pacing sites should perhaps always be considered.  Traditional right ventricular pacing can lead to dyssynchrony of the left and right ventricles and to increased risk for arrhythmias and heart failure in some susceptible patients.   LBB pacing uses the heart’s natural conduction system and helps to provide synchronised contraction of our ventricles. 

Although His bundle pacing has been widely used as a physiological pacing system, it can be limited, for example by challenging implantation techniques, high pacing capture thresholds, and early battery depletion.   LBB pacing has emerged as perhaps a better physiological pacing approach.  Results from early clinical studies have been encouraging, with rare complications and high success rates.  Overall, this approach has been found to provide physiological pacing that guarantees electrical synchrony of the left ventricle with low pacing threshold. 

Amy, as always though, further clinical trials to learn more about the benefits of the LBB approach are needed.  Of course, make sure you go to an experienced surgeon for your lead extractions and with experience in LBB placement for the best results. 

Me?  I have a dual lead pacemaker, without any sophisticated physiologic positioning of my lead tips but I rarely pace in my ventricles.  I am mostly 100% atrial paced with less than 5% ventricular pacing but of course these pacing percentages can frequently change.  I have the right atrial lead placed in the right atrium - endocardial area, and the right ventricular lead positioned in the right ventricle - septal area. The right ventricle “septal” area is supposed to be slightly better than the conventional area in the right ventricular - apex area. 

https://www.pacemakerclub.com/message/42193/left-bundle-branch-area-pacing

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021709/

https://www.radcliffecardiology.com/image-gallery/12837/9611/conduction-system-pacing

Very interesting

by piglet22 - 2024-08-10 05:54:41

Thanks to all for posting this useful item.

Really brings it home just how complicated things can get and how lucky we are to have the skilled clinicians to deal with problems when they arrive.

It does underline the fragility of our leads and the need to look after them.

So, 16 years old leads are old technology. As long as they work is the main thing.

Can someone explain why extraction is so difficult?

Of course removing an old 50 cm lead is going to be tricky to say the least.

Is it the tines that cause the problems?

Good luck with your procedure.

Lead extraction

by Gemita - 2024-08-10 06:37:47

Piglet, I haven’t needed a lead extraction, so hopefully we will hear from those who have, but I can imagine the potential difficulties in taking one out and this would require a skilled surgeon.  

Although extraction in experienced hands is usually successful, there would be a risk of puncturing the heart or tearing the delicate heart and blood vessel tissue and causing a dangerous bleed, possibly requiring a further invasive procedure (open heart surgery) and a blood transfusion.  Other risks might include a pulmonary embolism, stroke, damage to the heart valve on the right side causing it to leak, fluid accumulation around the heart or lung, infection and fragments of the lead being dislodged, so not insignificant risks;  hence the need for an experienced surgeon.

Also leads that are older or hardened (calcified) will be more difficult to remove, or a patient needing more than one lead removed, might  increase the risk for potential complications.  I believe the surgeon uses special tools now ? Laser/mechanical sheaths are placed over the leads to free them from the scar tissue and heart muscle. This allows the leads to be removed safely from the body ?

That's my system.....

by Andiek11 - 2024-08-10 12:28:11

My EP installed a CAP system this past May when because of my cardiac anatomy they were not able to successly implant all of the leads for bi-ventricular system to achieve cardiac resynchronization for my LBBB.  I don't know how similar our situations are, but my only issue was a LBBB that was caused by a chemo drug I received 34 years ago.  I have no arryhthmias or other cardiac issues of any type.

CAP is the next "golden child" in the wings for LBB pacing, but as my cardiologist and 
EP both said, while CAP shows a tremendous amount of promise, the amount of data is still minimal to make it a first choice (for either of them) just yet.   In my case at my 12 week check-up 2 weeks ago we decided to get an Echo to see if any changes were happening.  My cardiologist's goal (and mine) was to get my EF back into the normal range and to bring the internal diameter of my LV back to normal.   I'm excited to report that in the first 12 weeks I saw a 25% improvement in my EF (from 40%-50%) and LV size is back to normal.  To quote my cardiologist, the improvement are "...very encouraging..."  I'm not yet into the normal range for EF and it may take up to a year but at least Im heading in the right direction and hope that progress continues.

If for some reason I don't achieve the goals we're aiming for my cardiologist has already said that we might need to discuss the current gold standard of bi-ventricular (3-lead) pacing, only this time going about it using a different surgical approach given what we now know abut my anatomy. I'm keeping my fingers and toes crossed we never need to have this conversation.  

Good luck with your procedure and I hope you get the results you're after!

old lead placement

by Tracey_E - 2024-08-10 12:30:02

I, too, have leads placed the old way and have been 100% paced for 30 years. I see an adult congenital ep. I also asked of CRT was in my future, he said he highly doubted it, that if EF remains consistent for 5+ years of pacing, he almost never sees it drop after that. 

Piglet22

by USMC-Pacer - 2024-08-10 14:13:38

In my case with 12 year old leads, my EP said they were tangled and covered in scar tissue and attached to the super vena cava vein. It's a risk of punctering or tearing that vein and bleeding out on the table. They have become more techincally advanced with lasers that are threaded through the vein to dislodge the leads. In my case there was the EP team along with a cardiothorasic surgical team on standby just in case. My EP said it wasn't easy but went as expected. I was nervous just like others to say the least. Hope that helps explain it a little :)

LBB Paced

by karensoftball - 2024-08-10 19:51:28

Hi, 

I am on my first PM so no comparison to make. Just wanted to chime in quick. 

The conduction system pacing is something my team was strongly hoping would be able to be done and they were successful. They said it would be the best thing for me. I feel so much better after the PM.

Best of luck to you, and happy that you have a team working to make things better for you.

Thank you all!

by Amyelynn - 2024-08-11 00:40:21

Thanks so much for all your input and well wishes.

to help answer a few questions/clarify a few things.

i was told the placement for my current leads that are 16 years old are considered old technology. As my current EP highly prefers the LBB approach/placement.

i believe she may be concerned as I have been paced since I was 12 (so 26 years now)  I have always been 💯 ventricle paced. My atrial used to be minimally paced even last year it was around 40% it is currently 85% paced. 

my ventricle lead has also been requiring more power than usual to appropriately pace me (which does decrease the battery more quickly) she does not know why this is happening 

my atrial lead has some damage on the insulation that was fixed with a silicone sleeve during my last generator change in 10/2023.

reason for all four leads to be removed they have caused SVC syndrome (90% stenosis at my SVC and 80% stenosis at left bracaphaliac (sp?) vein) I got angioplasty last year but that is only temporary fix.

both the doctors I have seen regarding my case think it's just a matter of time before the SVC comes back and that my body will not grow enough collateral veins to stop that from happening....

my abandoned leads have caused a lot of scaring and calcification (seen during my venogram) which makes lead extraction more difficult.

The longer I wait the higher risk (as the abanadoned leads on left side have already been in 26 years) and due to the damage on the 16 year old leads my surgeon thinks best to take all four leads out and start fresh. I agree with this especially seeing as my ventricle lead has been acting up now.

he wanted to put in the aveir leadless pacemaker but I do not want that for many reasons.

i am having a cardiothoriac surgeon perform the procedure (Dr Raymond Schaerf) he works at the number 2 cardiac hospital in the country Cedar Sinai (after Cleveland clinic) number one in California (where I live) he performs 125 lead extractions a year. It's rare to find a cardiac surgeon who performs lead extractions from my knowledge it's usually an EP.

i am going to ask and make sure he or someone at cedars is experienced at LBB placement beforehand (as it sounds like from what I've read it could really make a difference for my present and future.

my surgery is on Election Day!

I plan to tell the surgeon not to wake me depending on the results 🤣🤪

cheers!

Amy

Explanation

by piglet22 - 2024-08-11 05:43:30

Thanks Gemita and Pacer.

Amy, let's hope their aren't too many distractions for for your team with an election on the go.