Biventricular Pacemaker

I'll do the easy ones

by crustyg - 2021-12-08 12:56:01

1 No, a different model will be required.  Existing RA/RV leads should stay in place.

2 Not predictable.  Anywhere between recovery to normal (>55%), some and none.  And while, for a few lucky folk, improvement in %LVEF has been nearly instant, more usually it takes weeks to months.  And a few unlucky folk get no benefit at all.  It depends on the underlying cause of the reduced %LVEF and the extent of LV-remodelling *IF* that has been caused by prolonged RV-apical pacing.

3 You're on your own with that one.

4 USA-based folk will probably know the answer.

Being less frivolous for a moment: you need to have had a proper conversation with your EP-doc about the likely causes of you feeling tired and needing to rest.  Not being on any heart meds *suggests* that your medical team don't think you need anything, so no salt/water overload, no raised BP, no ischaemic heart disease etc.  But you say that you had swollen ankles at PM implantation and since.  Diagnosis informs treatment and prognosis.  It doesn't sound as though you have a proper diagnosis yet....

Ejection Fraction (EF)

by Gemita - 2021-12-08 13:50:52

Hello Al,

You could also ask your EP/Cardiologist:  

5.  "Should I proceed to a biventricular pacemaker immediately or would I perhaps be better off trying heart medication first to see whether I could improve my EF and overall general health with medication alone"?

6. Am I still getting arrhythmias, in particular, PVCs and could these be causing my lowered EF?  Would these be helped by CRT?

What stands out for me, is that you are not on any heart meds.  I would have thought your doctors would want to try meds first before moving on to CRT.  I am in the UK and I wouldn’t expect to be offered CRT unless my EF went below 35% and certainly not before trying medication.

I am all for pacing to be as natural as possible, but with any procedure there are some risks and these must be weighed against the potential benefits of CRT.   There are no guarantees that you will be better off although I realise that you will not want your EF to fall too low before taking action, but I feel at 40-45% you are not in the danger zone just yet so take your time is my best advice.  Having said this, there are some members who have had enormous, immediate success with CRT and I hope they will see your post and contribute.

Good luck with your discussions and I hope you come to the best decision for you.  By the way, did you succeed in eliminating your ankle/foot edema?  Sorry, I see you still have this problem.  Are you on diuretics or any other meds for this?   I see too that you had an ablation for PVCs.  I wonder whether they have returned and are causing problems?  Also are you 100% paced in the Right Atrium or Right Ventricle?  I am assuming RV

Ejection fraction

by Aberdeen - 2021-12-08 14:35:28

Hello Al,

           If you are not on any heart medication so far I agree that perhaps medication should be tried first. 

I had a dual lead pacemaker which had to be changed to a CRT pacemaker in just over 4 months. I was warned that it has a 70% success rate. Fortunately for me my ejection fraction went from > 40%  to 63% in 5 months. 

Good luck!

Insurance (Medicare)

by AgentX86 - 2021-12-08 19:36:53

#4) It's a 50:50 whether Medicare will pay for it.  I'm just trying to get the government to recognize that my wife exists (they processed my applicatoin within weeks (!) but completely lost her application.  They were faxed in on the same fax (yes, Virginia, the US government still works by Fax).

Anyway, most insurance won't cover a CRT pacemaker until the EF gets down to 30-35%.  I don't know what the rules are for Medicare but, like private insurance, your EP can fight it claiming need. BTW, supplimental insurance doesn't figure into it.  Supplimental insurance only covers what Medicare covers. If Medicare doesn't pay, they don't either (for all you right-pondians, it's the law).

have one

by dwelch - 2021-12-08 23:56:24

after about 3.5 years on device number 4 we went into this same deal of my ef dropping into the 30s, time for a biventrical.   you need a new device.  can reuse the existing leads and you get a new one.  the surgeon is the surgeon, cant help there.   mine was covered by my insurance (in the usa) but you just have to find out.  I would assume, but you just have to make the calls yourself.  

Another question is, is there room for another lead, do they need to tunnel across, etc.  In my case I have a broken lead. Im a big guy, maybe that doesnt matter, but I ended up having room for all four in there.  We decided that if there was not room then would tunnel across to the other side , that lead on the right side could be used later (I started at 19, I am about 34 years in with pacers, on device number five, if I live long enough we will "wear out the left side" and have to move over to the right).  

Do I need to spend the night.  My first docs rule was if you get a new lead you spend the night.  for some insane reason on this last one they left it up to me to decide. I chose to, but seriously who is in charge here.  I do very much like and trust my surgeon (EP and surgeon are not the same person in this particular practice, former docs did both).

can I keep the device.  lol, I got to keep my first three, but number four and beyond I dont think so.  too many lawyers.  why not the thing costs as much as a car, it has been part of your body/life for a while.

In my case my ef did improve.  due to the doc moving offices instead of it being a 6 month check to see if it had improved (she had told me it would take 6 months anyway), the echo didnt happen that day so I did the echo between that first and second 6 month appt, I probably could have done it sooner and just called, in as it was actually a long around two year plus ordeal of trying to deal with family issues and getting the stress test done (something bad would happen in my life that day/week, got to where I was afraid of scheduling anything).  replacement was delayed at least a year, and then the additional 6 month wait to see if it made a difference.   I dont remember my numbers, doc had indicated it might not go up, but hopefully it stops going down, I think I moved from the 30s back into the 40s, was always in the 40s so dont really have any expectation of moving into the normal range.   YMMV

It really is just like any other replacement, just that the time from the last one to this one is shorter...

Follow-up on Biventricular Pacemaker

by Al_495 - 2021-12-10 18:02:19

I met with my EP. Thank you for the responses as I was much better informed and had a good understanding of what he was discussing.

First, I want to respond to a couple questions that were asked in the responses.

1. My swollen ankles and feet have decreased over time. Possibly or not, being caused by a result found on a recent ultrasound of chronic non-occluding thrombus noted in the left short sapherous vein.

2. My last two pacemaker device checks showed no PVC's.

3. My most recent pacemaker device check recored a RA=97.14 and RV=99.92. Thus I'm considered 100% paced.

My EP is putting me on a low dosage 2.5mg of Lisinopril (Prinivil). A week after I've started the medication, I'm to have a Basic Metabolic blood test at the lab and I'm also scheduled for a Nucleur Medicine Stress Test in about 2 weeks. After a period of time and a possble increase of the dosage Lisinopril (Prinivil), another ehcocardiogram will be scheduled to evaluate the EF.

Al

Thank you for the update

by Gemita - 2021-12-10 19:50:25

Al, thank you for your helpful feedback.  I am glad you had a useful meeting with your EP and that you have worked out a plan to follow before you commit to having a third lead.

It is the first time I have actually read here of a member being paced almost 100% in each right upper/right lower chamber although you won’t be the only member I suspect.

On the subject of PVCs you may need additional external monitoring to pick these up and to record/store the total number of PVCs you are experiencing since isolated runs are often not stored unless your EP has specifically set parameters to record frequent PVCs.  My EP has set my device to aggressively reject/ignore all ectopic beats like PVCs and PACs since there is only so much storage space on a pacemaker and I have more than my fair share of other, perhaps more serious arrhythmias like Atrial Fibrillation and Non sustained VT to record and to store.

I hope your new measures work well for you and that your ejection fraction and other symptoms will quickly improve.

Follow-up

by AgentX86 - 2021-12-12 11:35:09

Hi Al,

A few short comments:

1) Left short sapherous vein: I would think that this would perhaps explain a swollen left foot/ankle but I can't imagine that it would affect the right ankle.

2) PVCs: It's not at all unusual for a pacemaker to ignore PVCs.  PVCs are just too common to bother recording and would memory that is better used to record more important issues.  Unless they come in strings, there is no point in recording them.  The lowest setting on mine is a string of 5 PVCs.  I had bigeminy (every other beat) shortly after iI got my PM and there was no way of recording it.

3) 100% paced:  Sounds like it to me too. Many here are 100% paced with no ill affects.

Lisinopril really brought my blood pressure down, and  very quickly, from plumbing bursting levels to almost normal within 15 minutes.  Unfortunately some rare side-effects showed up some months later and I had to get off it. I can't use any ACE inhibitors because of the reactions.

Keeping your old pacemaker

by Griddlebone - 2021-12-14 05:40:36

This came up in the comments. I was able to keep mine; I am sending it to the University of Illinois School of Veterinary Medicine for use in a dog. 

ACE inhibitor reactions: my ex had a severe reaction to an ACE inhibitor, somewhat like anaphylaxis. We're still trying to figure out what the charge for "speech therapy" on his bill covered. Maybe they came in, asked how he was feeling, he said "Better" in a clear voice and they rang up the charge. He is also off ACE inhibitors now. 

Update to Ejection Fraction

by Al_495 - 2021-12-22 21:14:38

Today I had a nuclear stress test and have to admit I was worried going into it, mainly based on the name of the test and really not wanting to walk on an elevated treadmill. But when I arrived the technician indicate the part of the test to raise the heart rate would be medically induced. That was a relief.

I had read on the forums regarding the Nuclear Stress Test and had an understanding of this process. The first step was an IV to insert a radioactive material, then I drank a bottle of water and waited for 45 minutes. The next step, imagining of the heart for 8 minutes. After imagining, the tech insearted a medication, I think Lexiscan, to raise my heart level. An EKG was running and my blood pressure was monitored several times. I defiantly felt tightening of the chest and slight dizziness. After the stressing, I drank a Coke they provided and waited for another 45 minutes until they redid the imaging for 5 minutes. Test completed.

The results showed normalcy and what was surprising the Ejection Factor was 59%. A recent echocardiogram show an EF of 40-45%. I've been on Lisinopril 2.5 mg for 10 days.

Just wanted to provide an update and explain my experience with a Nuclear Stress Test.

Biventricular pacemaker

by Dh13 - 2022-01-10 19:38:14

I've had my pacemaker to a little over two year.   Did a stress echo and my ef is 35.  So it has dropped since I had the PM.   I can still exercise but I could tell things were going in the wrong direction.   The dr did mention that if my ef does not improve with medicine that I might need a new pacemaker.   It does require another lead.   I get the feeling that your Ef must be below 35 even on medication before they move to the biventricular pacemaker.   I'm 59 and stay active.   I'd let you know how things work out for me.   I would love to get my ef closer to something higher.   

Home

by Dh13 - 2022-02-23 14:06:26

Home from the hospital.  No isssues with the surgery.  Lead added and CRT-P implanted to replace my 2 lead pm. Hoping my EF improves.