Pacemaker!

[Seeker]

So, I went to my GP for a check-up. I told my doctor about my occasional dizziness so he had an in office EKG done on me. He looked at the results of the EKG and asked how I was feeling? I said, except for the occasional dizziness and a little fatigue I've been getting around just fine. I told him about the yards of rock I've been shoveling into wheel barrows and the plants and irrigation work on my back yard. My doctor gave me this puzzled look. He said my EKG indicated I had a Third Degree heart block and your heart rate is in the 30's. He said my heart chamber's have lost communication and are beating independent of each other. 5 minutes later I was in an ambulance for a ride to the ER. Had a my new pacemaker installed and now I'm back at home convalescing.

So my question to you all is has anyone had a heart block many years after your valve replacement? My surgeon suspects scar tissue from my valve surgery may have been the culprit. My vitals have been great up to about 2 months ago when I stated having symptoms.

 

[Lynn]

Seeker, my heart block occurred as an immediate result of my surgery so I can’t offer any insight on your situation, except to say that I hope your pacer resolves your issues and you recover quickly. I can say though, that I have complete heart block, however as my atria have a nice steady rhythm, the ventricles are simply paced to that. This feels very natural and seems to work really well. I hope this is also the case for you. The only setting I need to have adjusted is the upper limit of 140 bpm to allow my to exercise harder. Best of luck

 

[Seeker]

Seeker, my heart block occurred as an immediate result of my surgery so I can’t offer any insight on your situation, except to say that I hope your pacer resolves your issues and you recover quickly. I can say though, that I have complete heart block, however as my atria have a nice steady rhythm, the ventricles are simply paced to that. This feels very natural and seems to work really well. I hope this is also the case for you. The only setting I need to have adjusted is the upper limit of 140 bpm to allow my to exercise harder. Best of luck

Thanks Lynn. I had no idea there is an upper bpm limit built into the pacer. I'll need to ask what mine is set to.

 

[Lynn]

Yes, usually and upper and a lower beats per minute. And there can be many other settings for folks with different requirements,

My minimum is 50 (which I don’t get to) my max is 140 which I push up against all the time exercising. When this happens, my atria (top chambers that have their own rhythm) will go higher but my large ventricles on the bottom that move all the blood will only beat at 140. This isn’t optimal and if I go to long like this my legs get tired and I feel light headed. The solution is simply to increase the limit to say 150 or even higher if need be. My cardiac rehab kinesiologist recommended this as did my surgeon. I will need to go to the pacemaker clinic for this which I plan to do shortly. You will probably have a pacemaker check up by about the 6 week mark, and they should be able to tell you the settings for your pacer and why they are set that way. Good luck.

I will say, I was pretty bummed about the pacemaker initially, but so far it has worked better and been much less of an issue than I thought. Fingers crossed it stays that way for me and for you. Cheers.

 

[pellicle]

I will say, I was pretty bummed about the pacemaker initially, but so far it has worked better and been much less of an issue than I thought. Fingers crossed it stays that way for me and for you

I can't offer much more than say its bad to get dealt a bum hand, best you can do is to try to win a few tricks with what you have. Even misere is better than throwing in your hand (I think mostly)

 

[Lynn]

pellicle

 

[JWalters]

I understand now a significant % of mechanical aortic valve replacement recipients experience heart block. I'm still at 100% block after 4 years, and so have been paced 100% of beats since then with my Boston Latitude L331. I'm 46 and very active. I hit my 180BPM upper limit often (which cuts me back to 80BPM for a few minutes). I imagine you will have an incredible improvement in endurance after your ventricles are paced correctly.

My background is in electro-mechanical engineering. I've asked and researched until I'm content that these devices are reliable and robust. It's a great backup system in any case!

 

[Lynn]

It’s good to hear that 4 years in with the pacemaker things are still working great and fitness is not a problem. Given you background, I also appreciate your comments on reliability. I’m only 4 months in, and being so pacemaker dependent is scary at first. But as my Father use to say “consider the alternative”.

 

[gerrychuck]

I needed a pacer about 5 years after my mitral replacement. I had a left bundle branch block, and with occasional gaps of up to 3 seconds between beats. Currently I'm around 70% paced,mostly at rest. To clarify regarding an upper beat limit, a pacemaker can only control maximum heart rate if you are 100% pacemaker dependent, or very close to it. If your heart wants to beat faster,the pacer has no control over that. That is the case for me, as I tend to be Brady/tachy. The pacer fixes the bradycardia, and beta blockers control the tachycardia. Good luck with your new addition, and welcome to the fraternity of the chest lump.

 

[Lynn]

Good point on the maximum heart rate gerry, I should have clarified that the upper limit doesn’t apply to many folks that are paced. Primarily just those with a high pacing demand, the kind of thing you see in 3rd degree or complete heart block.

 

[vitdoc]

There are interesting things that can occur with pacemakers and 3rd degree heart block.
I had a pacer placed after my aneurysm surgery when I developed complete block (3rd degree). It was a standard R ventricle lead pacer that had a max pacing rate of 150. On my bike at that time I would exceed that heart rate at times and my rate would suddenly drop to 100. So I would go from 160 to 100 suddenly. Not fun. There is a phenomenon called pacemaker Wankebach which causes this. Basically if the heart rate exceeds the max pacemaker rate the pacer suddenly drops some of the beats. Since the pacer was electronically constrained to 150 max I had it removed for a new pacer that would go to 180. Problem solved.

Problem two. Most pacers are set up with a lead in the right atrium to pick up the normal atrial signal and then there is a lead to the right ventricle to cause the ventricle to contract. The ventricular contraction goes from the right to left ventricle. This is not physiological. Normally there are two pathways that go to the right and left ventricles so that they contract very close together. With right ventricular pacing there is a delay for the left to contract.

A number of years ago pacers were placed with leads in both the right and left ventricles in people who had heart failure. The ventricular contractions could be altered and the heart could be made more efficient. This was named Cardiac Resynchronization treatment.
https://www.medtronic.com/us-en/healthcare-professionals/products/cardiac-rhythm/crt-systems.htmlAnyway to make a long story shorter just pacing the right ventricle is not optimal in the long run. I had the usual right ventricular pacing for about six years when I realized that my cardiac output was slowly declining. I looked into it and found that in patients that were not in failure that there was evidence that biventricular pacing was superior to right ventricular pacing. One of the first studies came out of Hong Kong on this topic.
I spoke with my electrophysiologist and he agreed to place a new biventricular pacer with a lead added to the left ventricle.
My ejection fraction improved from 45% (it had started 6 years earlier at around 55%+) back to 55-60%.
I have never gotten a straight answer why biventricular pacers are not used routinely with complete block. It may be that at least right now primarily electrophysiologists are more comfortable in placing the left lead which is a bit tricky since it is placed in the coronary sinus which is a giant vein. Other leads are screwed into the heart muscle. Non electrophysiologist cardiologists are not generally comfortable placing this type of lead. It may be the cost is more. It has not hit prime type yet. Or other reasons that I am not aware of.
So those of you who have or will have long standing need for pacing due to complete heart block you may want to discuss this issue with your physicians to see what they have to say.

 

[Lynn]

Thankfully I haven’t experienced the pacemaker Wankebach...interesting term lol.

But I have been reading about the possible long term damage left ventricular pacing can Do. It is a bit of a concern for sure, though I know it doesn’t happen to everyone. Those of us with standard two lead pacing obviously need to take any signs of decreased cardiac output seriously. I have a date for follow up echo next April and if there is any signs of decreased ejection fraction I plan to push for a change to biventricular pacing.

Any other signs to watch for Vitdoc?

 

[JWalters]

Great info here from Vitdoc and others.

I also do not understand why the EPs are reluctant to propose bi-ventricular pacing. I've been discussing this with my EP as well, and we decided to consider it seriously when my battery dies in 10 years.

My Ejection fraction is normal/good, but I'm definitely down in athletic capability vs pre-surgery, despite now having a good AV. Oh well, definitely better than the alternative !

 

[LondonAndy]

This isn't directly relevant to the question asked, but in case useful to mention: I had a pacemaker inserted within a week of my OHS as my heart did not recover its electrical function properly - ie complete heart block, and I am 100% dependent, but did not have any issues with pacing prior to surgery.

The pacemaker operation is a piece of cake compared to OHS - I gather often done as day surgery under local anaesthetic. IE maybe no need for an overnight stay. (I was asleep through 90% of this procedure, but started to wake as the surgeon was pushing the area of the chest where the pacemaker goes. I am not sure if this was to create the pocket or to push the device to seat within it, but it wasn't painful and I think they were slowly bringing me round as they were close to completion).

It was some 4 months after all this that I even began to think 'what do I need to know about pacemakers'!

 

[Seeker]

There are interesting things that can occur with pacemakers and 3rd degree heart block.
I had a pacer placed after my aneurysm surgery when I developed complete block (3rd degree). It was a standard R ventricle lead pacer that had a max pacing rate of 150. On my bike at that time I would exceed that heart rate at times and my rate would suddenly drop to 100. So I would go from 160 to 100 suddenly. Not fun. There is a phenomenon called pacemaker Wankebach which causes this. Basically if the heart rate exceeds the max pacemaker rate the pacer suddenly drops some of the beats. Since the pacer was electronically constrained to 150 max I had it removed for a new pacer that would go to 180. Problem solved.

Problem two. Most pacers are set up with a lead in the right atrium to pick up the normal atrial signal and then there is a lead to the right ventricle to cause the ventricle to contract. The ventricular contraction goes from the right to left ventricle. This is not physiological. Normally there are two pathways that go to the right and left ventricles so that they contract very close together. With right ventricular pacing there is a delay for the left to contract.

A number of years ago pacers were placed with leads in both the right and left ventricles in people who had heart failure. The ventricular contractions could be altered and the heart could be made more efficient. This was named Cardiac Resynchronization treatment.
https://www.medtronic.com/us-en/healthcare-professionals/products/cardiac-rhythm/crt-systems.htmlAnyway to make a long story shorter just pacing the right ventricle is not optimal in the long run. I had the usual right ventricular pacing for about six years when I realized that my cardiac output was slowly declining. I looked into it and found that in patients that were not in failure that there was evidence that biventricular pacing was superior to right ventricular pacing. One of the first studies came out of Hong Kong on this topic.
I spoke with my electrophysiologist and he agreed to place a new biventricular pacer with a lead added to the left ventricle.
My ejection fraction improved from 45% (it had started 6 years earlier at around 55%+) back to 55-60%.
I have never gotten a straight answer why biventricular pacers are not used routinely with complete block. It may be that at least right now primarily electrophysiologists are more comfortable in placing the left lead which is a bit tricky since it is placed in the coronary sinus which is a giant vein. Other leads are screwed into the heart muscle. Non electrophysiologist cardiologists are not generally comfortable placing this type of lead. It may be the cost is more. It has not hit prime type yet. Or other reasons that I am not aware of.
So those of you who have or will have long standing need for pacing due to complete heart block you may want to discuss this issue with your physicians to see what they have to say.

You mentioned your max pacing at 150 bpm. I have the Biotronik Edora 8 SR-T pacer. I asked about the upper HR threshold and tech said there isn't one with this manufacturer. Apparently these pacers all seem to have their own "features".

 

[gerrychuck]

There are interesting things that can occur with pacemakers and 3rd degree heart block.
I had a pacer placed after my aneurysm surgery when I developed complete block (3rd degree). It was a standard R ventricle lead pacer that had a max pacing rate of 150. On my bike at that time I would exceed that heart rate at times and my rate would suddenly drop to 100. So I would go from 160 to 100 suddenly. Not fun. There is a phenomenon called pacemaker Wankebach which causes this. Basically if the heart rate exceeds the max pacemaker rate the pacer suddenly drops some of the beats. Since the pacer was electronically constrained to 150 max I had it removed for a new pacer that would go to 180. Problem solved.

Problem two. Most pacers are set up with a lead in the right atrium to pick up the normal atrial signal and then there is a lead to the right ventricle to cause the ventricle to contract. The ventricular contraction goes from the right to left ventricle. This is not physiological. Normally there are two pathways that go to the right and left ventricles so that they contract very close together. With right ventricular pacing there is a delay for the left to contract.

A number of years ago pacers were placed with leads in both the right and left ventricles in people who had heart failure. The ventricular contractions could be altered and the heart could be made more efficient. This was named Cardiac Resynchronization treatment.
https://www.medtronic.com/us-en/healthcare-professionals/products/cardiac-rhythm/crt-systems.htmlAnyway to make a long story shorter just pacing the right ventricle is not optimal in the long run. I had the usual right ventricular pacing for about six years when I realized that my cardiac output was slowly declining. I looked into it and found that in patients that were not in failure that there was evidence that biventricular pacing was superior to right ventricular pacing. One of the first studies came out of Hong Kong on this topic.
I spoke with my electrophysiologist and he agreed to place a new biventricular pacer with a lead added to the left ventricle.
My ejection fraction improved from 45% (it had started 6 years earlier at around 55%+) back to 55-60%.
I have never gotten a straight answer why biventricular pacers are not used routinely with complete block. It may be that at least right now primarily electrophysiologists are more comfortable in placing the left lead which is a bit tricky since it is placed in the coronary sinus which is a giant vein. Other leads are screwed into the heart muscle. Non electrophysiologist cardiologists are not generally comfortable placing this type of lead. It may be the cost is more. It has not hit prime type yet. Or other reasons that I am not aware of.
So those of you who have or will have long standing need for pacing due to complete heart block you may want to discuss this issue with your physicians to see what they have to say.

Excellent summary. I discussed biventricular pacing with the surgeon who put my pacer in; he acknowledged that right ventricular pacing could affect function for the reasons you describe when I asked directly about it, and said that they would look at that option were my EF to drop. He also confirmed that the left ventricular lead was indeed much trickier to place. I was later told that in these parts the normal criteria for going to biventricular is when EF goes below 30%(!). The cardiologist I work with currently assured me that she would be much more aggressive in going to biventricular if my EF we're dropping much. Ultimately my EF did decline from around 50% to low 40's. On the cocktail of beta blocker, ACE inhibitor and Spironolactone, my EF is now back into the high 40's, so I doubt resynchronization is in my immediate future. I may push for it at some point though. Even my initial drop in EF after my mitral valve replacement was likely due to the left bundle branch block I developed after; just like with right ventricular pacing, the left ventricle is fired by the right in that circumstance. Either way, resynchronization would likely make a big difference.