CRT pacemaker

LV remodelling with RV-apical pacing

by crustyg - 2020-07-08 17:21:38

Hi: In your bio section you suggest that reduced %LVEF only happens in 1/100 cases.  I'm afraid it's a lot more than that - perhaps 30% within a year or so, depending on the health of your heart muscle and the percentage RV pacing.

IMHO, it's already close to malpractice to deliver RV-apical pacing for non-CCHB patients who are going to be heavily RV-paced.  I fully accept that it's not always possible to provide His-bundle pacing, but it's already best practice in some of the biggest centres to provide RV pacing as high up towards the triscupid as possible.

Cardiac-resynchronisation therapy is often effective and can do a lot to repair the impact of LV-remodelling, as measured by %LVEF. It doesn't always work, and can take some time for the beneficial effects to be realised.

CRT pacemaker

by Aberdeen - 2020-07-08 18:04:05

Thank you very much- your comments are very helpful. Before I had my first pacemaker( January this year) I hadn’t heard of this risk. 30% is higher than I had been informed. With this pacemaker I am now also on beta blockers, ace inhibitor and aspirin. With the first pacemaker I didn’t require any medication. I am in my 60s and hadn’t taken any medication for 25 years prior to this so the whole thing is a shock.

CRT Pacemaker

by Gemita - 2020-07-08 19:43:18

Hello Aberdeen,

That sounds as though you have been very unfortunate to need a third lead so quickly although i had read that some patients can develop heart failure symptoms within a very short time with a high percentage of right ventricular pacing, although clearly not everyone goes on to develop this problem.    Do you by chance know how often you were paced in the right ventricle compared with the right atrium ?  That would be very interesting to know.

My husband has a single lead to his right ventricle and is now being paced a high percentage of the time.  His Medtronic single lead pacemaker was implanted in early 2018.    He seems to be tolerating this fairly well so far although I am concerned that he could develop symptoms of dyssynchrony between the two ventricles over time leading to worsening symptoms.  Certainly his arrhythmias have increased, especially Atrial Fibrillation and right ventricular pacing is a well known risk factor.

Aberdeen,  I know it is still early days with your third lead, but are you able to share with us how you feel now compared with how you felt when you first received your dual lead pacemaker ?  Can you feel a difference, any specific improvement in symptoms for example with the third lead ? 

I hope you make lots of progress quickly so that you can enjoy your activities.

CRT

by AgentX86 - 2020-07-08 20:22:17

Yes, as Crusty points out, it's not that uncommon for RV pacing to cause RV/LV synchronization problems. I'm surprised they don't, as a matter of course, either use CRT or His pacing for anyone who has a high V-pacing percentage. As you're finding out,  it's a lot easier to do it from day one than to go back in a few months and do it all over. There's a good chance the original pacer can't be used, requiring a new box, too.

Gemita, your husband is paced RV-only?  No atrial pacing? I've never heard of that before, at least in the modern age. I'm paced VVI but have a CRT-P (both ventricles only or VVIRD, in PMese).

CRT

by Julros - 2020-07-08 21:06:05

I received a pacer last year for a slow heart rate. I was in atrial flutter, underwent ablation, but my underlying rhythm was still arount 40 bpm. My EF is 50%, the low end of normal, so they implanted a BiV. The only draw back is that is seems huge on my small frame and remained painful for months. 

Yes AgentX86

by Gemita - 2020-07-08 21:09:58

that is correct, My husband was only given a single lead pacemaker to the right ventricle because I believe they suggested he was in permanent AF at the time of placement and decided not to track what was going on in his atria.   His AF was "persistent" during hospitalisation but I do not believe it was or is permanent.  I am pretty certain he has periods of NSR (as an AF sufferer myself) although how long this will last with right ventricular pacing is the big question? He has AF with a very slow ventricular response which frequently led to bradycardia,  He also has intermittent blocks (Mobitz II) and bundle branch blocks too.  He has a history of loss of consciousness which were frightening while we were away in Italy.

I tried to ask doctors why they didnt consider dual chamber pacing when I learned he only had one lead but I never really got a satisfactory answer.  I believe this in part was due to the fact that he had had a massive bleed during the procedure because they failed to stop his triple therapy Clopidogrel, Aspirin, Edoxaban beforehand.  Michael heard the cardiologist tell his team to "stitch him up quickly" as he was fighting to stop the blood flow.  Not a good experience AgentX86.  Needless to say we have now transferred to another hospital under a very caring and able EP/cardiologist in whom we have complete confidence but I will be asking more questions when we next see him because I do worry that this could all turn nasty quickly particularly in view of Aberdeen's experience

Wow!

by AgentX86 - 2020-07-08 22:05:03

That sounds like borderline malpractice, Gemita.  No wonder you found another hospital/doctor.  Did he have an AV ablation or is his RV pacer just inhibiting on a normal beat, then limiting the rate?  This seems to be a really weird setup.  I understand the issue with AF (BTDT) but I don't think I've heard of that solution.  I can't see how it is any sort of solution but I'd like to learn more.

Julros:  I'm not a small guy (5' 10" 195 but getting smaller - slowly ;-) and have a BiV (CRT, really) with no atrial lead just because I was (still am, actually) in permanent Aflutter. I gave up AV synchrony for a life without AFL.  My paemaker and leads are clearly visible, so I know what you mean.  I don't much care about the looks but I understand why one would.  I don't like that it's so close to the surface, though.  It gets quite sensitive at times.

AgentX86

by Gemita - 2020-07-09 07:19:09

Hello again, I have just looked at Michael's last PM check summary (dated 16.4.19).  It states he is in VVIR mode and that he is 100% of time in AF.

They told me that ventricular pacing had increased from around 40% (in 2018 at implant) to around 70% (in 2019).  He was due for another check this past April but it was cancelled due to the virus.  His next appointment is due next April which would be two years and I am not happy about this and may try to bring it forward.  We have since transferred his pacing records over to his present EP at another hospital. 

No Michael has never had an ablation of any kind.  I think they are concerned to intervene since hubby has many health problems and at 81 they probably think he should be left in peace.  I had to push hard for them to unblock his LAD/RCA artery two years ago because of his history of previous strokes.  They were going to try medication alone.  When they looked closer he was almost 100% blocked (LAD) so it could have been fatal.

CRT pacemaker

by Aberdeen - 2020-07-09 10:11:39

Thank you for your helpful comments. Gemita, I don’t know how often I was paced in the right ventricle compared to the right atrium. I know I was paced to be above 70 bpm and now above 50 bpm.     The dual pacemaker caused LVSD and has caused damage to the left side of my heart which was healthy only 4 months before. I feel well with the CRT pacemaker but it feels bigger and you can see the shape on my chest particularly if I move my arm. I don’t mind that if it helps the LVSD. If I wasn’t on medication I would feel a lot better.I am due to get an echocardiogram at the end of the month to see if there is an improvement. I am not sure if it will go ahead as I live in the UK and many appointments even cancer treatments have been suspended due to Coronavirus. Where I live there have been few cases of Coronavirus. I wish that an echocardiogram had been carried out earlier as I wasn’t aware anything was wrong until I collapsed. I hope that this doesn’t happen to anyone else as the left side of my heart was healthy before.

Aberdeen

by Gemita - 2020-07-09 11:32:53

Try not to worry, even if you dont get your echocardiogram, you are still receiving treatment for your LVSD and that is what is important.  The longer you wait too, hopefully the bigger the improvement they will see.

I know what you mean about the medication, sometimes the treatment can be worse than the disease itself but hopefully your body will adjust and you will feel fewer side effects as time passes.  Beta blockers and Ace Inhibitors can be difficult to tolerate especially if the dose is too high initially, so our doctors generally start us off really low to see how we go.  My husband and I both take Bisoprolol as a beta blocker.  Hubby tried Ramipril, Ace Inhibitor which triggered a very irritating cough and whole body rash but doctors can try other combinations to find something that suits.

We live near London, UK and I have just been called for my dual chamber pacemaker check which I thought they would cancel until the New Year.  I felt I had the whole of the pacing clinic to myself and even the technicians had loads more time.  They admitted that patients do not want to attend hospital because of the virus and they had plenty of time to spend with me. Although my arrhythmias are still present and there were lots of events recorded, the good news was that my pacing is almost exclusively in the right atrium now with very little right ventricular pacing seen (certainly an improvement from a year ago).

I do hope for the very best for you Aberdeen 

CRT pacemaker

by Aberdeen - 2020-07-09 14:43:35

Thank you very much for your support Gemita! I am on the lowest dose of Bisoloprol and 2.5mg of Ramipril. My blood pressure varies from 100/55 to 127/74 so I am hoping I won’t have these doses increased.                                                        

Hoping to get back to the gym soon when they open!