Adding the third lead

I am scheduled for an AV node ablation with the addition of the third lead and a change of the PM. The insurance has refused to pay for the third lead. They don't have a problem with all the surgery, new PM etc. Their thinking is I must be in congestive heart failure before they will sanction the third lead. I have seen a few studies that indicate the addition of the second ventricular lead gives the patient more strength and prevents heart failure down the road. Can anyone make a suggestion as to how to get insurance to cover this? Also would love to here from any 100% PM dependent people. Not sure what to expect after the surgery as far as lifestyle changes.

5 Comments

dependence

by Tracey_E - 2013-03-25 09:03:11

I have congenital av block so I more or less was born with what you'll have after the ablation. I've been 99.9% paced since 1994 and feel great. It won't be any different than being paced now, really. The pm kicks in when needed, now it'll just be kicking in more often. The net effect is the same- it keeps our hr normal.

No suggestions on the insurance, what a pain. Have you discussed it with your dr? In my experience, most of them won't budge if they have a way to get out of paying an extra bill. There are no long term studies conclusive either way, mostly because the 3rd lead is fairly new and hasn't been around long enough to accumulate long term evidence.

My personal plan is to avoid anything more invasive until it's necessary. When I start to lose strength, when my EF drops, then I'll think about adding the 3rd lead. Until then I feel terrific with the 2 I have. I hike, ski, kayak, skate, do Crossfit... there's nothing I want to do that I can't do and I'm in the best shape of my life. My EF is exactly the same now as it was the day I got my first pm almost 20 yrs ago, so I'm going to leave well enough alone and continue to watch the studies.

Hopefully Inga will chime in. She is very up to date on the studies and a lot better at the technical aspects than I am.

also 99% paced

by dad4dds - 2013-03-26 02:03:31

I have had a pacemaker since 2009. My EF has gotten worse each year till no I am 99% paced. Was updated to a BiVentricular ICD(with pacer) in Dec. 2012. Life is good I can do almost eveything I did before. As far as insurance goes maybe they would save money having it added now rather then another surgury. You know preventive. Hope it goes well.

Brian

PS:

by Many Blessings - 2013-03-26 09:03:37

I forgot to mention:

I recently spoke to a gal at my cardio doc who said things are starting to change, and they are doing the 100% paced/dependent procedures sooner than later now, due to the current patients doing so well. Maybe there is hope your insurance will lighten up on their criteria if that's what you really want to do.

Also, I made an error above in stating my A-fib is "not" at a contrlled rate now. I meant to say it is "now" at a controlled rate now, so that did improve, it just didn't "cure" it.

There are some pros and a lot of cons to having the procedure done, so please, please, please make sure you have all of the information you need to make the right decision. Do your research. Ask every question you can think of.

To me, the biggest con of all is, you are no longer a candidate for other procedures, meds, or other "cures" that might come up down the road since they've damaged and ablated your nodes, etc. Once that's done, it's done. There is absolutely no turning back. That's my one "regret" if I have to name one. But, I really didn't have a choice.

Non-regret: I went hiking a few weeks ago for the first time in 2 or 3 years, and I'm going to do it again next week at the coast! To me, that's amazing, as it is something I've loved to do all of my life and wasn't able to do for the last few years due to declining heart health issues.

100% Paced/Dependent

by Many Blessings - 2013-03-26 09:03:39

Hi Ty,

I'm 100% Paced/Dependent as well. There are a lot of others out here as well. You can see that from those who answered above and there will be many more that will answer your post.

My history is mitral valve issues, holes in the heart, enlarged heart, etc. at birth (I'm 52 now). Due to 2 open heart surgeries in my teens and late 20's (mechanical valve & replacement, hole closures, etc.) it damaged my heart in other ways that didn't show up until my 20's. At that point, the uncontrolled high rate A-fib and other new issues started and lasted until last year (CRT-P helped but didn't cure) which eventually damaged my heart "beyond repair" as they say. A few years ago, I was diagnosed with cardiomyopathy with heart failure, and a year ago, with highest level of each.

I had to take test after test to prove no medications or other procedures would work, my EF had to be below 30 for a period of time, my heart failure & cardiomyopathy had to be in the highest stages, and my physicians had to agree I had less than a year to live (they waited until one felt only 3 months). One actually wanted to go for a heart transplant instead.

I bring this up only because all of my cardio docs, surgeon, EP doc, etc. would not do the procedure/surgery to make me 100% paced/dependent, until it was ABSOLUTELY necessary. Period. Others may disagree with me on this, but I feel if that many of my own physicians and surgeons feel it is important to wait until "almost" the last minute, you should wait until there are no other options.

For me, insurance wasn't a problem, since I already fell under all of their criteria.

As for lifestyle changes, there are some, but really not too many. At first, there are setting issues. Until they get your settings right, you might not feel real well. When making setting changes as time goes on, there might be a bad one here or there (which I hate), but can be fixed or changed back.

There are some interferences that you'll want to watch out for, but those are explained to you in the booklet you'll get after your surgery/procedure. Some things affect others worse than others, and some people aren't affected at all by things that bother others. Bottom line, if all of the sudden you don't feel well, step away from where you're at and try to figure out what it could be.

While traveling by air, you'll want to show your PM card and get the pat-down vs going through the detector. If it's an X-ray, you can do that. Some still go through the metal detector. I don't because mine does set it off.

Please know with me, things couldn't be, and weren't "fixed" with my surgery/procedure and CRT-P. The efficiency of the heart was improved, and my symptoms improved, but the problems and heart damage are still there. So is the A-fib, but it is not at a controlled rate. It was explained to me that this is a "band-aid" only to make things "not as bad" and to make me feel better. I do, so to me it is worth it.

Feel free to private message me if you have any questions at all. I will answer any of your questions as honestly as I can.

Best of luck with your decision. I know it's a big one!







Third lead

by golden_snitch - 2013-03-26 12:03:07

Hi Ty!

You did not say why you are having an AV-node ablation. Is it because you have AF that's been resistant to several drugs and catheter ablations?

Regarding the third lead, I'm with Tracey: If your EF is perfectly normal at the moment, you're probably safe to take the wait-and-see approach. Yes, many studies indicate that the more you pace in the right ventricle, the higher your risk of developing heart failure. However, not everyone who's paced 100% ends up with heart failure, and even if someone does, it often happens after many years, and not straight away. So, in that case the third lead could still be added during the next regular replacement surgery.

The HRS recommendations at the moment do not indicate a CRT implant in anyone whose EF is greater than 35%. If you had a lower EF and were going in for AV-node ablation, you'd be a candidate for a CRT according to the guidelines, but as long as your EF is normal (and you don't have left bundle branch block), you're not. So, I guess with the guidelines being that clear, it will be difficult to convince the insurance of paying for the third lead.

Best wishes
Inga

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