Total Heart Block - 5 years

Sure

by AgentX86 - 2020-01-26 23:26:26

There is a danger of LV remodeling/cardiomyopathy in those with LV pacing.  Think about holding a water baloon in your hand. This is your heart.  Squeeze one side and the other bulges out.  The side that bulges out is your left ventricle.  This happens because both sides don't contract together (supporting each other).  This is known as ventricular dyssynchrony.  If this happens, it's rarely permanent, particularly if it's caught early.

One solution His bundle pacing.  As the name suggests places the RV lead into the bundle of His, which is right under the AV node in the heart's electricql system.  The bundle of His then transmits the signal to the RBB (Right Bundle Branch) and LBB (Left Bundle Branch) as it would with a healthy AV node.   This only works if the problem is in the AV node itself and there isn't a problem with the bundle of His, the RBB, or the LBB.  This can be done (if possible) during the initial pacemaker implant.  It doesn't take a special pacemaker and isuance usually covers it. It's a more difficult lead placement and your EP may not offer it, or you may not be a candidate.  In any case, you should ask about it.

The other solution is a CRT pacemaker.  This alternative places a lead in both the RV and LV.  The PM then paces both ventricles and is tuned to get them to contract together. This replaces the bundle of His, RBB, and LBB.

The other alternative is a CRT pacer and is somewhat more complicated The CRT pacemaker requires a second (or third, in the case of AV block) lead, placed in the left ventricle.  This is also a difficult lead placement due to the fact that the pacinf wires go into the right ventricle.   The placement is in an artery supplying blood to the LV and is sometimes difficult to get to. CRT pacing generally not done unless the problem occurs and the LVEF (Left Ventrical Ejection Fraction) falls below 35 or 40% or there is a high probability of Sudden Cardiac Arrest (SCA). Cardiomyopathy and a low LVEF is usually revoverable by implanting a CRT pacer at a later time (hence the "therapy" in the name), if required..

Both of these solutions will cause a more normal ventricular response and lower the probability of cardiomyopathy even more (it's already a low probability complication).  This is certainly not a reason to avoid a pacemaker for third degree AV block.  Doing so would really be dumb and is a risk to your life.

Ask about both but you'll likely not get CRT pacing out of the gate. This is another reason to have the best EP that you can find.  Your chances of a good lead placement go up with someone who does this stuff all the time.

Me too

by AgentX86 - 2020-01-27 00:37:31

TSJ, you already have a CRT pacemaker.  No need to worry.

Thank you AgentX86

by Joe Newbie - 2020-01-27 02:19:56

2nd best thing I read all day. THANK YOU...really

Seems to depend on the health of your heart muscle

by crustyg - 2020-01-27 03:53:37

One study that I have found suggests up to 26% of patients who are RV paced at the apex go on to develop heart failure.  Risk factors include ischaemic heart disease (==furred up arteries) and prolonged paced QRS-complexes, which is what has lead to the attempts to put the RV pacing wire higher up and closer to the RV outflow tract.  The first study reporting His-bundle pacing seemed quite good - good success at placement, reasonable lead survival (*have* to use active fixation), but it requires a lot more time using fluoroscopy to find and attach to the His-bundle (and everyone is terrified of the X-ray dose - silly really, it's actually quite small) and it's not possible in a lot of patients due to various factors.

If you look at the congenital CHB patients they don't *seem* to be affected - not that I've yet found any studies actually supporting that claim - which would tend to support the idea that heart health really matters here.

I'm still working my way through the literature, but in general, for those with acquired CHB, long-term RV apical pacing (1-2years +) definitely carries a risk of heart failure - which is why there are so many patients who have now been converted to Cardiac Resynchronisation Therapy.  It's a *lot* bigger risk than 'slight'.  Add in the separate increased risk of AFib in SSS patients with functioning AV-nodes who are paced in the RV and it's clear (to me) that RV apical pacing is far from ideal.  But a lot better than nothing.

Not reassuring, but I HTH.  I shall try to post with the references soon.

Heart failure, pacing, and sick sinus disease.

by Selwyn - 2020-01-27 09:16:19

In those that are paced, the lack of coordination  between atrial and ventricles tends towards heart failure in some unfortunates, the risk increasing with age.

Of course the risk is greater if there is complete heart block ( if there is some signal getting to the ventricles naturally that is ideal ie. the 'normal' 'person). I am paced less than 1% of the time in the ventricle, however it is a life saving 1%! Dual chamber PMs  are designed to keep ventricular pacing to a minimum so as to lessen the risk of heart failure. [ Younger people may have less problems with single leads]

Personally, I would not want to have a single pacing lead  for the above reason. However, if the normal heart conducting system is sound, and there is infrequent use of the single  pacing  lead, I expect there is some justification.  Leads do have problems associated with them. The cost of a dual lead device is much more. Heart failure risk is very similar in both single and dual lead groups, though in the older person, dual has a better outcome. 

I think the guidelines in the UK for pacing are for upper and lower chamber leads unless there are exceptional circumstances. This is because of the small, but known risk of heart failure associated with long term single lead pacing, especially in older people.  A Swedish study, DANPACE concluded that there was little reason for single lead pacing ( of the atria) for sick sinus syndrome. Also, a proportion of single lead folk end up needing dual lead pacing and a redo op. is not without problems.

( see https://www.nice.org.uk/guidance/ta324/chapter/2-Clinical-need-and-practice)

HIS Bundle Pacing

by Good Dog - 2020-01-27 15:12:32

The right ventricular (RV) apex has been considered to be the primary site for ventricular lead implantation as the norm as I understand it. It has also been known for many years that a negative side-effect can be eventual heart failure. I initially read a little about HIS Bundle Pacing some time ago, and gained an interest, because of the positive claims that the danger present with RVA pacing is much less likely with HIS Bundle type of pacing. It essentially mimics more normal conduction and thus less potential for negative impacts.

I have my own motives beyond just that benefit. That is due to the fact that I already have two leads through the tricuspid valve. Should I have a ventricular lead failure, it will likely be detrimental to have a third lead through the valve. So HIS Bundle Pacing would allow an additional lead placement in the atrium instead of the ventricle and without the need for undergoing the risks of lead extraction.

The problem I have experienced is that there are only a limited number of EP's that perform Bundle Pacing. The closest to my location and the best for cardiac issues is the Cleveland Clinic. I spoke to the head EP a few years ago and he informed me that they prefer CRT instead of Bundle Pacing. It was his view that Bundle Pacing insn't always as reliable as they would like. So the bottom line for me is that I'd have to find a different hospital and EP if I wanted to consider Bundle Pacing. The next closest place I could find (closest to my home) is Geisinger Health System in Pennsylvania. So I will be consulting wiith a doctor (EP) there that specializes in Bundle Pacing. 

I have read quite a bit on HIS Bundle Pacing in recent years and it seems to me to be the best alternative to traditional RVA pacing. I am just really dissapointed that the Cleveland Clinic does not perform that procedure. In any case, my opinion is that for 3rd degree AV Block (full heart block), HIS Bundle Pacing is obviously the best alternative. Of course, that is just my opinion, which doesn't mean much!

Biventricular pacing

by vitdoc - 2020-01-27 22:25:58

I developed 3rd degree block after aortic aneurysm / valve surgery.  I initially had the standard RV pacing.   My cardiac output started to gradually decrease from 55% to 45%.  I found papers on biventricular pacing in hearts that  were not in failure.   So I convinced my electrophysiologist to have a biventricular pacer placed with a left ventricular lead.  My cardiac output came back to around 55%.    There is definitely the potential of increasing failure with chronic right ventricular pacing.   I am not sure why everyone doesn't get biventricular pacing with complete heart block. It may be that only electrophysiologists place the left ventricular lead while most cardiologists can place a right ventricular lead but not a left lead due to their training.  Also the cost is somewhat more.

Confusion

by AgentX86 - 2020-01-27 23:42:45

There is some confusion here.  We're talking about conventional RA/RV pacing vs. CRT or His pacing.  With either, there is no AV dyssynchrony.  The issue is a "slight" right/left ventrical dyssynchrony with conventional pacing.  I say "slight" because the delay is the difference in the electrical impulse traveling across the heart.  They're not completely out of sequence (really random beating) like the atria an verntricals are with heart block or AV node ablation, without an atrial lead.

Confusion

by Good Dog - 2020-01-28 08:39:14

I don't think that I am confused. Your explanation of the differences is correct. The point being that while the  dyssynchrony with full AV block and AV node ablation is extreme compared to that of RA/RV pacing, they all may result in heart failure (very low EF) over time. It is just more likely that it will occur and occur much quicker with uncorrected full AV block and AV node Ablation than with conventional RA/RV pacing. It is my understanding that some patients with conventional RA/RV pacing never end-up with heart failure.   

I think that the issue of alternative lead placement with conventional pacing was controversial for a time, but is not so much any longer. Makes me wonder why they are still doing conventional RA/RV pacing (lead placement) in young patients. It seems that the philosophy seems to be to wait until heart failure (very low EF) occurs and then go to CRT. At least that is/was so at the Cleveland Clinic. It doesn't seem to be a very proactive approach.

The same?

by AgentX86 - 2020-01-28 10:39:05

AV block is different than an AV ablation in that the intention of the pacemaker in the first case is to replace the AV node, bringing the heart back to AV synchrony. The latter case the ablation it designed to obliterate the AVnode, intentionally causing  AV dyssynchrony. The latter risks dyssynchrony in three sections of the heart (LA+RA, LV, and RV). There is quite a difference.

Also note that apparently CRT pacing isn't universal even in AV node ablation patients. I understand why it's not in AV block patients, particularly in the young. Only so many leads can be put into the veins and through the valves. Leads don't last forever. It's good to keep options open.

Single ventricle pacing, bi-ventricle pacing, or His bundle.

by Selwyn - 2020-01-28 11:50:00

Have been to see my cardiologist today. He says they are waiting for a new generation of PMs that result in even less right ventricular pacing. ( A good thing given the risk of heart failure with pacing.) He also mentioned a new type of PM ( not yet produced) that monitors the Q-T interval of the ECG( EKG) and can anticipate the need for a rise in heart rate!.  I mentioned the problem of climbing stairs and lifting weights producing breathlessness. 

In spite of my poorly performing ventricle lead, we think this should stay in place as it is not often needed and is not a significant drain on the battery. Lead removal of having an extra lead placed all have increased risk.

The placement of a lead in the left ventricle is a more complex procedure, the lead having to be placed through the coronary sinus ( that vein that connects the left side of the heart to the right) as such there are more complications. Clever stuff!  That is why it tends to be only offered for improvign ejection fraction in heart failure ( which has a poor prognosis).  His bundle pacing is, as noted, something of a speciality.

A recent paper ( August 2019) looked at the outcome of all the choices presently available as pacing areas and found  'outcome improvement' appeared to be limited primarily to patients who have chronic atrial fibrillation with rapid ventricular response rates and have undergone atrioventricular node ablation. ( see the full paper ref. below).

His bundle pacing may not offer an ejection fraction advantage except in very selected cases. 

There is no doubt that ejection fraction can be improved with left ventricular pacing. 

(http://www.onlinejacc.org/content/74/7/988)

Here is a paper on pacing site options

by Good Dog - 2020-01-28 15:32:37

This is really interesting relative to various lead placements:

http://www.innovationsincrm.com/cardiac-rhythm-management/articles-2018/may/1229-right-ventricular-septal-pacing

Ms M - No Choice and Trust

by Good Dog - 2020-01-29 08:56:27

With the hope of giving you a little comfort, I just want you to know that I have the traditional RVA lead placement and in DDD mode for 33 years. I was in 3rd degree AV block (complete block) when I had the original implant in 1987. So far, so good. I am not running any marathons, but I have no physical shortcomings. 

AgentX86 - The same:

by Good Dog - 2020-01-29 09:11:13

I understand the difference with AV node ablation and 3rd degree AV block and concur with your assessment of the reasons for not using a CRT in young folks. However, my point was that I question why the Cleveland Clinic isn't doing HIS Bundle Pacing as a proactive means to address full heart block in young patients. After all, they are the preeminent cardiac hospital in the world?

Cleveland Clinic

by AgentX86 - 2020-01-29 23:10:18

Cleveland Clinic is the preeminent hospital for cardiac problems, like CABG and transplants but not elecrophysiology.  From what I understand, that honor goes to Texas Cardiac Arrhythmia Institute in Austin.

by AgentX86 - 2020-01-29 23:10:18

by Good Dog - 2020-01-30 09:54:21

Do you have a source for that? I'd like to see it. The Cleveland Clinic, the Mayo Clinic, etc. cardiology rankings can be accessed on-line, but I haven't been able to find anything specifically for elecrophysiology.

Rankings

by AgentX86 - 2020-01-30 10:48:42

I don't have a citation handy but TCAI is at the forefront of electrophysiology, at least arrhythmia treatment. The reluctance of Cleveland to do His placement is a good hint that it isn't a place I'd put at the top of the list. It's not a rare procedure. OTOH,if the problem was CHF, transplant, or even a simple CABG, sure, it would be at or near the top of the list.

RANKINGS - Cleveland Clinic

by Good Dog - 2020-01-30 13:46:33

I have to acknowledge that I agree with you. Frankly, I was very surprised that they woulld not even consiider HIS placement. 

It really put me in a bad place since I felt like; who am I to be arguing with the Clinic doc's that I think a HIS placement is better than a CRT.

im fine

by dwelch - 2020-01-31 01:29:02

Not going to battle the technical terms here. I have CCHB congenital complete heart block, as in from birth.  First pacer at 19 about 30 years of pacing with two leads, EF finally got low enough, now I have a biventrical not only did the EF stop dropping it went up.  Not implying EF is remotely related to what is being debated here.  I made it well well past 4-6 years with 100% RV pacing, with CHB.  I made it more than 4-6 after being diagnosed but before my first pacer and was doing very risky things every single day not knowing how stupid that was.  Still here.

Im a single data point, one out of one is not interesting.  Add Tracey_E and you get two out of two, still not interesting.

Not going to talk about water balloons although that is a good way to describe it.  If you have complete heart block and dont treat it we know what will happen in short order.  It is trivial to treat with a pacemaker single or biventrical, well or not so perfectly placed leads.  There are odds related to the surgery itself, there are odds related to complications, there are odds related to infection, odds related to device failure.  There are odds of getting hit by a bus with or without a pacemaker as are there odds of space trash crushing you.  

Find a doc you trust, trust the doc you found and go with what they say. 

One of the most dangerous thing you do is take a bath/shower.  Tile and water and skin and mass pressing them together do not mix well.  Far less worse but very dangerous is be in a motor vehicle of any kind.  Airplanes far far far far less dangerous.  And this thing far less than that.  If this worries you then I assume you have stopped bathing and dont leave your house, if you still do those things then how is this something to worry about?

Words like "study" and "reputable medical journal" really dont mean much.  I can find studies in reputable jounals about how easy it was to fake studies in reputable journals.  Dont get worked up about this, and the original poster might not have been worried, this could have just been flame bait.  Either way it definitely worked, be calm, it is not worth getting this worked up.

HIS bundle pacing may be what we think is best today in 2020, but just like my 1985 RV lead, all we have is two lead pacers and this is what we think is best.  We wont know for another decade or few if that is actually the case.  HIS bundle pacing could be the worst disaster in cardilogy history when this all plays out.  

Finding a doc that actually cares for you is a higher priority than one that conforms to some papers/journals you read online this week/year.  That is the opinion I have on CHB treatment with RV pacing.

Almost 10 years later

by heartu - 2020-02-05 15:06:41

I received my PM for complete heartblock in late February 2010. No problems until last year when during my in office checkup in November 2019 revealed a few short lived episodes (less than 5 seconds each tine) of vtach prompted testing which revealed I have CHF. Just had my CRT-d implanted on Jan 28, 2020.

What comes to mind is that we have these devices which have saved, improved, and prolonged our lives. Other people have heart rhythm problems and don't know what is going on. But we have a tiny computer which keeps track of everything.