2 months Post Pacemaker/ICD and AV Node Ablation

It will be 2 months tomorrow that I had a Medtronic Claria MRI Quad CRT Defibrillator implanted and an AV Node ablation.  I thought I would be feeling happier about the decision to have this done by now, but I would say overall my arrhythmia is no better and frequently worse.  I was in 2 weeks ago and they did the final settings on my device.  They set the low rate at 70 and the high at 130.  I would say I am rarely at 70 resting.  I had to stop Jardiance for 2 weeks due to yeast infections and, despite that my cardio says stopping it doesn't cause arrhythmia, my arrhythmia got worse.  I'm back on the Jardiance and waiting to see a better rhythm return.  In the last week I've had a handfull of NSVT (the device previously recorded 1 episode of NSVT with the last interrogation time 0f 9/14-10/19) and lots of PVCs.  The last device interrogation also showed 99% was paced and everything solidly where it should be.  I'm pretty sure if they did an interrogation now, it would not be nearly as good.

My understanding was that the AV Node ablation would prevent me from feeling most of the arrhythmia, thinking it was due to a-fib.  But I have to say that the PVC's I'm having are just as bad, if not worse.  Should this be recorded on the automatic nightly download, if I called the EP and asked them to look at the data?

Is an adjustment in order?  Not sure who to contact on this first - my primary cardio, who controls my meds (metoprolol, jardiance and losarten), or the EP cardio who did the implant.

Thanks for any thoughts on this,



I am hopeful it will get better

by Gemita - 2023-11-06 06:55:16

Karlynn, I am so sorry to hear your news.  Firstly the AFib is being firmly held in your atria by the AV Node ablation, have no fear about that, but the rhythm disturbances that you are feeling now are coming from your lower chambers, the ventricles, the main pumping chambers of your heart and this will be causing you a great deal of distress.  This was always my fear about having an AV Node ablation.  What would happen if the ventricles got irritable afterwards?  What could be done to help?

Usually they leave the lower rate setting (Base Rate) at 80-90 bpm while your heart is settling down and to prevent worsening symptoms such as those you describe.  This can work and be very effective.  70 bpm may not help with your PVCs.  It may need to go higher until things settle, so I would respectfully ask your doctors about this.

Patients with high-risk factors for arrhythmias, such as congestive heart failure or impaired LV function (and I see you have a CRT-D), may require pacing at higher rates, for example at 90 bpm for up to 3 months.  Adjustment of the pacing rate, although rarely to less than 70 bpm, is usually undertaken during this period, preferably after an ECG evaluation for repolarization abnormalities at the lower rate.

Another adverse effect following an AV Node ablation is ventricular dyssynchrony induced by RV pacing, which may result in impairment of LV systolic function but because you have cardiac resynchronization therapy (CRT), this is obviously taken care of.

What would I do?  Perhaps ask whether a higher base rate, say up to 80 bpm-90 bpm would help, as well as get electrolytes checked and have some other blood checks to look for other causes?  Do you have structural heart disease (blocked arteries)/ischaemia?  Both may trigger PVCs/NSVT and be a cause for your rhythm disturbances.

You are still in the healing period (up to 3 months or longer), so I would try to stay calm and positive. There is still time for healing to take place and for things to improve. Keep hydrated, rest, relax (I know difficult but it will help).   I hope things improve for you quickly

PS  Yes PVC counts are recorded/stored on your pacemaker as of course are non sustained VT episodes and other important events, especially with a defibrillator.  If you ring your team they will be able to see how many PVCs you are getting over a period which will help them to decide on a treatment plan.  I would ring your cardiac team in the first instance to have a look at your nightly downloads, but also ask your general doctor to see you for some general blood checks too.  Dehydration can quickly cause electrolyte disturbances.  Some meds, other health problems (like an infection) may also cause worsening symptoms.  Perhaps your yeast infection has not resolved for example?



Such good information

by Gramzo - 2023-11-06 12:33:55


Thank you SO much for your wise perspect.  I think you are on to something.  I was thinking it was going off the Jardiance that caused the increase arrythmia, but your reply got me to thinking that was also at the same time my rate was lowered to 70.  Plus, the more I thought about it, the increased arrythmia seems to happen at times of rest or low activity.  Which makes sense, my rate will go below 70 and my ventricals use it as an excuse to misbehave because they can "work faster" than the pacemaker.  I have sent messages to both my IV Cardiologist and EP Cardiologist.

Again, thank you for the time you took to reply.  I appreciate all the information you offered.

Rate raised to 80

by Gramzo - 2023-11-07 19:06:52

I went in today and had an interrogation and my rate raised from 70 to 80.  I'm probably just not understanding how the pacemaker works, but they said my pacing was 100%, which I found surprising given the amount of PVCs I was having.  They said it was interesting that I would get a PVC on top of a paced contraction frequently.  They seemed thrilled with the interrogation. So I guess that's good news.  

I came home, had a protein shake for lunch and proceeded to feel awful.  A lot gas, lots of PVCs and SOB.  I'm suspecting the protein shake.  Feeling better now. Hoping the rate change will decrease the PVCs.

Hope it helps

by Gemita - 2023-11-07 19:17:55

Karlynn, thank you for the update.  I am glad about the increase in heart rate.  That should slowly help.  Eat little and often and watch out for foods that might cause stomach distress - a sure way to increase those PVCs!  I am not surprised you are pacing 100%.  You have had an AV Node ablation, so you are 100% dependent on your CRT pacemaker.  We can chat more tomorrow if you wish, goodnight


I'm not understanding some thing, obviously!

by Gramzo - 2023-11-09 09:35:55

At my first in-office interrogation after the ICD implant (a week after procedure because of PVCs), they said it was doing 96% of the pacing. The Medtronic tech seemed happy with that, the EP's NP wasn't as happy.  A month later, at the regular interrogation, it showed 99% and this was when they lowered the rate to 70.  A few days ago, when they raised the rate back to 80, they said it was doing 100%.  To the uneducated (me!) that would tell me that my heart should be regular and right as rain,  I'm sure the ICD isn't set to pace irregularly, so how can it be pacing 100% if I'm having so many PVCs.

The tech was so happy with the interrogation this week, it has taken away some of my concern and I just put up with the periods of PVCs, but it still is confusing.  32 years with a St. Jude Mitral Valve, I feel so knowledgable about heart valve replacements.  2 months with an ICD, I feel clueless about them.  The reason for the ICD was to hopefully stahl and, more hopefully, improve the Grade B heart failure I'm in.  Ideally my cardiologist wants the rate at 70 because he felt my resting rate prior to the ICD was mid 80's and he felt it was wearing my heart out.

Patience and with a little understanding

by Gemita - 2023-11-09 11:47:51

Karlynn, I feel there has been some misunderstanding about what a CRT-D pacemaker system can and cannot do for you.  A CRT-D pacemaker cannot cure an arrhythmia, not even the Defibrillator part, although the Defibrillator part can shock the heart back into rhythm . . . until the next time.   You are pacing 100% because you are pacemaker dependent, after having had an AV Node ablation.  I can understand they don’t want to keep your resting heart rate at 80 bpm indefinitely because of the potential for your heart to be weakened, but they need to get your PVCs under control too, because PVCs also have the potential to weaken your heart, particularly if you are symptomatic and PVCs are frequent/prolonged.

The defibrillator part of your CRT, the -D part of the device, will only step in and provide pacing support/pacing therapies, even a shock, if it encounters a dangerously, fast arrhythmia, for example sustained Ventricular Tachycardia or Ventricular Fibrillation.  Since you have had an AV Node ablation and the fast, irregular Atrial Fibrillation signals are confined to the atria, your defibrillator won’t need to do anything more about your AF and will only need to take care of your ventricles and control any dangerous rhythm disturbances when they occur.   An arrhythmia like a PVC will not be regarded as a dangerous disturbance of rhythm, or needing pacing support/therapies, so PVCs may just be watched and left to their own devices, since unless there are many PVCs at any one time, they usually have a benign course.

Your statement  “A few days ago, when they raised the rate back to 80 bpm, they said it was doing 100%.  To the uneducated (me!) that would tell me that my heart should be regular and right as rain”, made me chuckle.  Not true.  100% pacing doesn’t mean you will be 100% symptom free or arrhythmia (PVC) free.   No pacing system in the world can cure (indefinitely) an arrhythmia.  A pacemaker with a defibrillator will only stop a dangerous arrhythmia, or shock your heart back into rhythm.  It won't permanently cure the arrhythmia.  Only a combination of treatments like medication, ablation, pacemaker adjustments, CRT + Defibrillator pacing therapies can help with an arrhythmia. You can also look at lifestyle as well as looking for other causes for rhythm disturbances (like abnormal electrolytes, anaemia, infection, inflammation and so on).

Although the AV Node ablation has taken care of the AF by confining it to the atria, you are now facing a ventricular arrhythmia (PVCs) which can be difficult to control.  Now we need to build you up and hope to see improvements in your ejection fraction.  Hopefully your mitral valve is working adequately after your replacement?  You could ask your doctors for another echocardiogram at some stage to see how well your heart is pumping and to see how well your mitral valve is functioning?

Your statement “I'm sure the ICD isn't set to pace irregularly, so how can it be pacing 100% if I'm having so many PVCs” made me chuckle too.  Let us talk about the CRT-D.  The defibrillator part is not pacing you 100%.  Pacing therapies will only be given by the Defibrillator when it sees a dangerous arrhythmia as I stated above. Your two ventricular leads (the CRT part) is what is pacing you 100% and will have many built in algorithms to overdrive pace some of these irregular beats.  There are some specific settings that may help with PVCs and I will have a look at your model of pacemaker and see what else we can ask your technicians/doctors about but I would take your time.  They don’t like to go rushing in and change too many settings at once.  Our hearts need time to adjust and settle after an AV Node ablation and after a new pacing system and with respect, so do you.

So to conclude the defibrillator part of the CRT-D pacemaker system will only go after a dangerously fast rhythm disturbance like sustained VT or VF.   Your CRT-D device will be focussing on pacing you in a synchronised manner in both your left and right ventricle.  With time - up to 6 months or longer in some cases - CRT pacing should help to improve your heart failure (ejection fraction) and with an improvement in heart failure symptoms, your PVCs should also hopefully settle.  You are only around two months into CRT-D pacing and following an AV Node ablation too and I don’t think we can expect much more for the moment.  Patience, belief that things will improve will help you now, as can appropriate medication, lifestyle changes (good diet, good hydration, avoidance of high amounts of caffeine, avoidance high levels of stress, avoidance too much alcohol (I avoid last three altogether with PVCs);   getting plenty of rest, gentle exercise) - and then how can PVCs ever survive in such a healthy environment?

Thank you so much again!

by Gramzo - 2023-11-09 13:01:34

It's great to see this all in one place.  I had thought I'd get this info from the EP staff, but I only get brief responses when I ask a question.  It's a large practice and I've only seen the EP's NP twice sine my ICD was scheduled and I've only seen the actual EP once, right before the procedure.  My IV cardiologist has assured me he's had lengthy talks with the EP about me, and I trust him a lot... so far.  I've been a "heart patient" for 38 years and my St Jude mitral is 32 years old and "looking amazing", so I was told. The tech that did my last echo in April couldn't believe it's as old as it is. So my "fake" valve is fabulous.  I found from a cath in July that I have "beautiful coronary arteries".  The rest of the heart - not so much.  I have my next echo in January.

Again, thank you for taking so much time to answer my questions. It has helped a lot, eased my concerns and I truly appreciate all the information very much.

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