Doctor Selection

Hi! I'm super-grateful for this forum.

I'm male, 45, 6'6", 210, athletic with diagnosis of Bradycardia, Av Block, 1st Degree, Second Degree Av Bloc, Right Bundle Branch Block.

My question is regarding the possibility of finding a doctor who will support an active lifestyle (surfing, swimming, nordic skiing, rowing, triathlons.) My original referral for an EP seems to be the most accomplished and experienced in the area, but not super-athletic. In mentioning any kind of activity that involved extending my arm, he was not super supportive. (Like I should not plan on doing push-ups or pull-ups?!?)

Should I be shopping around for possibly traveling to another EP who would support my lifestyle better? Or, should I continue with the experienced guy and plan to do what I want with pain as my guide?
Also, with the intention of having a full range of motion after implantation, should I be requesting a certain placement?

It's been about a month since my diagnosis and I'd like to get this procedure scheduled before it's mandatory.

Thank you!

Eric

9 Comments

choosing a doctor

by Tracey_E - 2016-03-29 01:03:41

I would at least shop around and see who else is available. Highly qualified is great but a good fit is important, also. I've always had a doctor who is active and fully supports me being active, and it has made a difference in my treatment. It's not just his thoughts on exercise that matter, but how far he's willing to go to get your settings fine tuned to support that exercise. Most paced patients are not very active and often doctors don't have many (if any) other patients like us which means things may come up they haven't seen before. How committed they are to us staying active can make a difference between them going the extra mile to find an answer vs telling us to live with it.

You will most definitely want the surgeon to take your lifestyle into consideration when doing your placement. Many do it just under the collarbone, just under the skin, which can get in the way when you are active. My first 4 were submammary (not a choice for you, obviously, lol), and my newest one is now subpectoral so it's higher and not as deep as before but still lower and deeper than most. I do Crossfit, was back at the gym 4 weeks after. That was 3 weeks ago. I'm still a little wary of the pull up bar and haven't gone heavy on overhead lifts yet, but I've been doing everything else. I fully expect to be doing everything in a few more weeks.

An option for placement is having a plastic surgeon assist. My ep doesn't like to mess with alternate placements but he gets that it's important to me, so he brought in a plastic surgeon to do that part. Easiest job of the day for the plastics guy, ep could concentrate on what he does best, and I got a comfortable placement that lets me be active. Everyone's happy :)

Don't let the long list of diagnoses scare you, most of that is redundant. Bradycardia is a symptom more than a diagnosis, it just means your heart rate gets below 60. RBBB is a type of av block, that's where the signal is getting dropped. First and Second degree is how often you are in av block so sometimes you are in first (occasional dropped signal) and sometimes in second (either half the signals are getting through all of the time or no signal getting through some of the time). It's not uncommon to have periods of both. Are you struggling to exercise? First degree is rarely treated, second degree only if symptomatic. I have congenital 3rd degree, which means I'm always in block (no signal gets through) and was born that way, and I went without until I was 27. Unless you are extremely symptomatic, you are a long way from mandatory so you can take your time to find the right doctor and discuss placement.

choosing a doctor

by emuell - 2016-03-29 03:03:15

Thanks Tracey!

I'll definitely take a look and see if there may be a better fit.

My original symptom was low HR during exercise. I had a stress test with max 76 BPM in late February. Since then I haven't been doing much of anything strenuous and have not measured my HR over 60. It's usually in the 30s-40s.

As far as placement goes, I'm not too concerned about where it is, as long as I have full range of motion. Do most PM users doing crossfit, swimming, or other repetitive upper body motions have their doctors arrange specific placement? Or is this a case by case basis?

Thanks again!
Eric

Eric

by IAN MC - 2016-03-29 04:03:09

With your lifestyle I would strongly recommend that you establish whether you are " chronotropically incompetent " or not before choosing which PM to have. If you are, this means that your HR doesn't increase with exercise the way it should.

If so, then you will definitely need the Rate Response function of the PM turning on . This means that a sensor in the PM detects when you are exercising and generates extra heart beats. But there are sensors and sensors,none of them are totally physiological but some are much better for athletic people like yourself than others.

Most people with AV block seem to not need Rate Response; if that applies to you then it would be good news but if you do need it , then PM selection is all-important. There is always the possibility that you may need RR eventually.


I was a keen marathon runner prior to having a PM; no longer unfortunately because I was fitted with a Medtronic PM with an accelerometer sensor which only responds to upper body movement.

There are other better sensors for active people.

Before you ever let them near to that personal space next to your collarbone , stress to them that you are a triathlete and an Olympic rower !! The wrong RR sensor could make the cycling part of the triathlon very very difficult and running a struggle.

Rowing probably puts more consistent stress on the PM / leads than any other activity so you need an experienced PM implanter . I happily play frequent fairly strenuous golf without problems. I have the conventional PM placing under the clavicle and can only assume that I have adequate slack built into the PM leads.

Best of luck

Ian

placement

by Tracey_E - 2016-03-29 05:03:48

If your rate isn't going up and you can't exercise, then yep, you need it. You aren't in danger so there's no rush, but it's frustrating when you can't do what you want to!

It's case by case, but for sure have a discussion with the surgeon about your lifestyle. The usual placement will work for most activities, it depends on your build and exactly where they put it. What you don't want is it to be so close to the collarbone that it gets pinched with overhead movements or repetitive moves. That can damage the leads. If you lift, you want it low enough so that the bar isn't near the device in front rack.

Theoretically if you only have av block, you will not need rate response. RR is for sinus dysfunction, when the atrial rate does not go up on exertion. With av block, the sinus rate goes up like it should, but the signal doesn't make it to the ventricles so the pulse doesn't go up. When we are paced with av block, our heart is setting the pace and the pacer is only completing the broken circuit. If there are no signs of sinus issues, then you don't need to worry much about the RR.

I almost agree with Tracey

by IAN MC - 2016-03-29 06:03:04

If you look at the most recent published data you will see that :-

42 % of all new PM patients need Rate Response

Breaking it down by reasons for having the PM ;-

49 % of Sick Sinus patients need RR
30 % of AV block patients need RR

But the most important data of all is that Chronotropic Incompetence is a progressive disease , only 53 % of people who have had a PM for 2 years or less need RR but this rises to 70 % for people who have had a PM for 4 years or longer.

So I don't agree with Tracey's last sentence. I think we should all work on the assumption that we may need RR eventually and therefore choose a PM with the best RR sensor to fit our lifestyle from Day 1 . Chances are that we will need it eventually.

I only needed RR switching on after 2 years.

Ian

What causes need for RR after 4 yrs of having a PM?

by WillieG - 2016-03-29 07:03:05

Hi Ian! I found your above comment to be interesting and think I have read about developing Chronotropic Incompetence. I have had my PM for almost 2 years now for Mobitz II block and am wondering how and why things might change soon. Is it just something that happens or is there an explanation of why having a PM causes IC.

Thanks! Wilma

I enjoy your sense if humor!

Hi Wilma

by IAN MC - 2016-03-29 07:03:11

As far as I know having a PM does not cause Chronotropic Incompetence to develop , it is your underlying heart condition which changes with time. This could happen whether you have a PM or not.

If instead of saying CI we call it "exercise intolerance " then we can clearly see that many other factors may contribute to the above figures. For example getting older leads to exercise intolerance . A 70 yr old cannot run as fast as a 50 yr old ( dammit , there is an attractive 50 yr old blonde in my running club, I can never catch her )

Also starting betablockers may reduce your exercise tolerance as can atrial fibrillation so there may be several factors which contribute to the above figures.

You may be one of the lucky ones, Wilma, who doesn't develop CI and you may never need RR . I hope so.

Ian

Thanks Ian!

by WillieG - 2016-03-29 09:03:33

Appreciate your response. Stills seems like with such a large % increase that maybe having a PM affects developing CI (or exercise intolerance) but good to know that it is just aging. Or not...as I just had a birthday, ha! I have noticed that I seem out of breath often with going up a flight of stairs but maybe I have always been that way, just never paid attention.

I see my EP in the morning and have so many great questions for him. To reduce my pacing, they have the AV search+ turned on (Boston Scientific's same as Medtronic's MVP). I have to skip beats for pacing to begin and I feel that uncomfortable "squeeze" or "thud" every eight minutes while spinning or biking (searches every 1024sec). I want to learn if more pacing is all that bad as I'm only at 9% ventricular now. So many on this site have complete block and are paced at 100% at a much younger age than I was when I first got my PM at 61. So am curious to hear the pros and cons of more pacing for comfort. Also, my Holter study says I still have Mobitz I blocks and I thought the PM was supposed to prevent those. So far I don't have AFib and don't take beta blockers or any meds. Yea! For that!

Until then, keep chasing that cute blonde...sure you can catch her with RR! :)

Choosing a doctor reply

by boberic - 2016-04-22 04:04:16

The choosing a doctor reply ha several incorrect statements as regards types of heart block. First degree block has nothing to do with dropped beats of any kind, It is a lengthening of the PR interval to over 200 milliseconds. The PR interval is the time between the start of the Atrial bat and the start of the Ventricular beat. Sometimes the AV delay (the time between the pacemaker atrial spike(beat) and the pacemaker ventricular spike. Is set longer than 200ms so as to preserve native rythym. (that's how mine is set). Right bundle block is a somewhat lengthening of the R-wave (ventricular beat) or a little slowing of the conductive pathway. It is, as long as there are no other problems, harmless. But it does need to be followed. Rate Response is atrial tracking or allowing the pacemaker respond to the rate of the atrial beat. It is set at a limit so as to prevent the pacemaker from beating to fast. Hope this info helps

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