“Lead placed High”

LEAD PLACED HIGH

by Gemita - 2020-01-18 05:05:59

Yes, my right ventricle lead has been placed in the "high right ventricle septum" and so has my husband's single lead PM, so it must be a well tried area.  Of course now I know the benefits of HIS pacing, I wish I had asked whether HIS positioning would have been possible, but I guess my team did the best they could for me at the time (at least I hope so).

You were obviously told (truthfully) that they have not had good results with HIS pacing, so I would imagine they either did not have the expertise to perform HIS pacing successfully, or the patients had conduction problems (like for example bundle branch block) which may have adversely affected signals getting through to their ventricles, or they had particularly difficult anatomies(!) where positioning of the HIS lead was sub optimal.  I don't know what else to think Johnny?  You should ask your team.

As far as not wishing to wait for a decline in EF is concerned before asking for a CRT device or a HIS bundle placement, I believe the thinking is why change anything if what you have now is working for you . . . and you have such a good EF anyway and would anyone really be prepared (certainly not the insurance company) to carry out an upgrade on your present system? To add additional leads and go through another procedure is not entirely risk free either.

According to one well respected member of this forum, EF decline from RV pacing alone is not a certainty and even without RV pacing, some of us will develop heart failure symptoms in any event.  If you are really worried and feel you would be better with HIS pacing, then I would find another EP and practice that specialises in HIS pacing and has had a good success rate from their procedures.  Personally I would wait and watch and if your EF "noticeably" declines over time, then act swiftly or seek another opinion.  As we age, no doubt we can all look forward to a steady decline of all our vital organs but in the meantime, we need to try to live our lives without fear.  You are doing really well at the moment, so why change anything just now ?

Haven't re-read your medical history, but if you have a dual chamber PM, presumably your doctors will want to keep right ventricle pacing to a minimum.  I have dual chamber pacing and my ventricular pacing is very low, so I am reassured.  Do you know what your % ventricular pacing is, or are you 100 % paced ??  If 100% paced, your doctors will keep a close eye on your EF and step in quickly when needed.

His or CRT

by AgentX86 - 2020-01-18 12:43:32

Neither makes any sense now.  Gemita is right on - no insurance company, or doctor for that matter, is going to touch changing anything with a "perfect" EF.  You wouldn't be eligable for a CRT even if you didn't have a PM now.  Since your EP hasn't done well with His pacing, and you're already where you are, there is no sense in worrying about water over the dam. Your chances of pacemaker induced cardiomyopathy are minimal anyway.  If you can't trust your EP/PA, find a new practice but it sounds like they're doing you right.

I agree with both of you

by Johnny63 - 2020-01-18 13:26:18

  Thank you, you both give great information, advice and perspective. 

  Everything happened so quickly when I initially got the Pacemaker and things seemed pretty bleak those first 48 hours before I understood the situation. There is a real learning curve in this crucial area. 

  You're both right. I am doing really well and when I started swimming again, my schedule and life returned to normal. 

  My business is great, nothing has changed at all there. My relationship with my Spouse, children and extended family is great, I am on a trip with friends and I feel great. I am eating healthily, swimming, going to shows, movies etc and feeling very fortunate. 

  I will just monitor my situation and continue to pray for myself and everyone here. 👍 Have a great weekend. 

Seeing a PA

by Mallya - 2020-01-18 21:26:40

I have a coment on something I actually just logged on for. You had an appointment with a PA to make adjustments? You’re EP had 4 years of medical school 3 years internal medicine 3 years cardiology and then (2-4 yrs) electrophysiology and then passed the electrophysiology boards and you trust your heart to someone with 2 years of schooling no residency no board certification and maybe a few years working in the department suddenly makes her an expert? The previous posts here talked in all the jargon as well and you all sound like experts but I wouldn’t make you my doctor unless you actually are one. I speak from experience I actually am a physician who plowed through 4 years of medical school 3 years of residency passed my boards every 7 years and now I’m in a position where I do chart review on PAs and trust me there’s a lot of knowledge missing 

Mallya

by AgentX86 - 2020-01-18 23:10:03

Not only are you wrong but you're nuts.

Mallya

by Johnny63 - 2020-01-19 00:03:13

  Hi Mallya, my appointment with a PA was as a follow-up. She works for the Cardiologist who implanted my Pacemaker who is an EP. I have an appointment with him in a few weeks.

  I also have an appointment with another EP on Tuesday who is a family friend that was out of the country when I was initially seen.

  Lastly, I have a appointment for a third opinion at the Cleveland Clinic in March. 
 

Let's avoid being directly rude to each other

by crustyg - 2020-01-19 04:45:22

AgentX86: no-one here objects to criticism of other folk's opinions, but please don't be rude to the person.  However much you may disagree with Mallya's PoV, it doesn' justify ad hominem attacks.

In the relatively minor amount of healthcare that I'm involved in (as I no longer practice), I see evidence of mistakes, omissions and lack of knowledge.  At my most recent PM interrogation the EP tech remarked on the lack of auto-adjustment of my pacing voltage.  When we chatted about it later, I pointed out that this feature is not available for my PM in my current pacing mode - it's in the manual.  Tech was surprised, but not as much as I was, as my EP centre are supposed to be big users of BostonSci.

There's at least one contributor here who has seen the effects of pacing wires being put in whilst anti-coagulated.  Not best practice!

There's a reason why doctors and nurses make terrible patients: when we read on the consent forms that one of the complications of <x> procedure is death, we actually believe it - we've seen it happen.

“High placement”

by Johnny63 - 2020-01-19 04:57:15

My lead wasn't placed in the HIS Bundle; yet it was placed "high" as I was told. I am concerned about the possibility of LV remodeling, not worried, not anxious, just logically interested at this point. Does anyone have any opinions regarding this placement? Can it be changed? I do not know what that would even involve. I agree that as long as my heart echos are good, no problem. However, if my EF goes from 65 to 50 I am not going to wait until it hits 35. How challenging is it to change lead placements? 

Swangirl

by Johnny63 - 2020-01-20 00:40:58

  Hi, I agree with all points of view that were expressed to varying extents.

  My Pacemaker was implanted in close to an emergency situation. The entire experience was completely unexpected and came out of the blue. I swam 5 days in a row the previous week roughly a mile, or 2 each of those days and felt great. I had no time to consult with anyone, I was in a daze.

  After the implant, I start walking to just see how I could expect to function in the future the next day, then Christmas came with family and extended family, so I compartmentalized and decided to deal with concerns like LV remodeling in January.

  I saw a PA who is employed by a EP last week simply to adjust my Pacemaker high range from 130 to 160 for exercise. That was the only purpose of my appointment with her. I am meeting with the EP who installed my PM in a few weeks to ask the harder questions. I did tell the PA, I am not interested in waiting until my EF declines to take actions that might prevent that.

  Besides meeting with the EP who installed the device in a few weeks, I am meeting with another EP from another hospital (a family friend) on Tuesday to discuss the lead placement and other criteria related to LV remodeling issues. I also am going to the Cleveland Clinic in March to discuss the same issues.

  I am 100% paced with a current EF of 65%. If a change is prudent and I have to do it without  insurance I will.

  LV remodeling is an important issue for many of us with AV failure, so it's great that we are all discussing it. 

Placement of ventricular lead

by Gemita - 2020-01-20 04:05:45

Hi Johnny,

We all want the very best, that is natural. I will be following this thread with interest and please report back after you have received further guidance from your EP.

At this stage just a word of caution.  Removal of a lead, or addition of a lead, will come at some risk to you, so I would ask your EP all about the possible % risk of further surgery.  Then ask what the % risk of developing heart failure symptoms from RV pacing alone would be for you and then maybe decide on balance your best course.  The position of your RV lead is working well for you at the moment since you are reporting good symptom control..  I hope it will be the same, or better for you after a HIS bundle lead placement but there is no guarantee so this is a risk in itself.

Ideally we would all wish for optimum placement of RV lead (and change what we may have at present) but factors like age, other health conditions, infection risk, complication risk of further surgery really all have to be taken into account, especially if you are not showing any signs of needing further intervention.  I will be asking the same questions when we see my husband's cardiologist but I know in my heart that it is really just too risky for my husband to go through further intervention even though he is clearly showing signs of difficulty.  You on the other hand are still young and in good health, so hopefully the benefits of optimum placement will exceed any potential risks. You have a busy week ahead, good luck