Pacemaker wires + heart valves + light headed.

Since my pacemaker 18 mths ago I have experienced constant light headedness + frequent mild nausea. Nothing has been found. I noticed on my oximeter that O2 levels have dropped from fairly constant 98/99% to 94/96%. The only thing left that I could think of was valve leakage in the paced side of my heart. Looking at my heart X rays I was surprised how thick the pacemaker wires were going thru the heart valves. Heart valves calcify as we age + any foreign object going thru them must cause leakage. Question-how significant is this leakage under pressure? What are the common wire diameters? What are the long term effects on the heart valves themselves with a wire shoved thru them?


9 Comments

Wires and valves

by AgentX86 - 2020-06-08 23:06:56

There is a possibility of the leads causing damage to the tricuspid valve (between the RA and RV).  This can be serious but I'd think your doctors would be on top of it.  As always, for important questions, your cardiologist is the one you should be asking.

A web search finds a lot of information but here is a relevant example, I think:

<https://pubmed.ncbi.nlm.nih.gov/15893186/>

Reduced Oxygen saturation implies shunting, not valve leakage

by crustyg - 2020-06-09 04:57:00

For your O2sat% to go down it implies that some blood is failing to pick up O2 in the lungs - by-passing the oxygen-rich environment of the capillaries of the terminal alveoli, where gas exchange actually happens in the lungs.  If blood manages to bypass these areas it won't pick up O2 and then mixes with oxygenated blood and reduces the overal O2sat% - it bypasses, or shunts.  Causes: lots of alveoli that don't have oxygen (mucus plugs, poor ventilation (lack of deep sighs from time to time)), alveoli that have a thickened basement membrane (fibrosis), R=>L shunt in the heart (PFO), pulmonary emboli (undeclared cancer somewhere).

Simple home pulse-oximeters don't cope well with abnormal haemoglobins, so sometimes (rarely) the reduced O2sat% value actually reflects a process such as oxidative damage to the red blood cells (weird, huh? Oxygen not a good thing!) or some other abnormal process affecting the haemoglobin.

As the Right heart is a low pressure system, the valves aren't great thick strong structures, and you can almost always show a *little* leakage in the tricuspid, leads or not, you just have to look carefully on the echo.  Putting a pacing lead through the tricuspid is very unlikely to affect this or make any leakage worse.  Valves usually only calcify after damage - think rheumatic fever, but still, valve leakage doesn't reduce your O2sat%, it produces heart failure - in this case RHF - ankle oedema, raised JVP.  On its own, RHF doesn't reduce your cardiac output enough to make you dizzy or nauseous unless it's really severe and the Left heart isn't receiving enough blood to maintain your BP.

It's an interesting paper, but a series of 41 patients out of the MILLIONS of paced patients is a drop in the ocean.  Doesn't say much for the quality of the echocardiograms if only 12% had noticed SEVERE tricuspid regurg during a routine echo!

Time to consider stopping the SCUBA I suspect: there's been a *lot* of academic discussion of PFO in recreational divers, the very high incidence of venous bubbles in sport divers keeping within dive guideliness and the (thankfully) low incidence of paradoxical embolus given the very high incidence of demonstrable PFO in post-mortem series (27% IIRC).

Reduced 02

by Tem - 2020-06-09 09:40:11

Thanks for the info. I really miss my deep diving because of the depth limitations of my Biotronic ie 1.5atm. Had I known at the time I would have asked for a diver 'friendly' model. The Cardiologist + technicians had no idea about pressure limitations on pacemakers. I was told last week that the Germans make the best batteries + that mine has 12yrs charge left. I can have another brand if prepared to pay + go thru the pain again. After 50yrs of diving maybe it is time to stick to snorkelling! Being lightheaded + nauseous at 60m is not pleasant.

Check your O2sat% before and after deep breathing

by crustyg - 2020-06-09 10:48:32

If I pop my pulseox on it sometimes reads 97%, and if I then perform some deep/sighing breathing it moves up to 99%.  One of the things that Yoga/Pilates teach is deep breathing (not *over* breathing and all of the reduced CO2 issues *that* produces), as it tends to open up terminal bronchioles that have become plugged with mucus (and hence shunting).

If you observe that then I wouldn't worry about your O2Sat% - but I would still worry about lightheadedness and nausea.  Sounds as though your cardiac output isn't always enough to provide decent brain oxygenation.  Have a search for other posts here about postural tachycardia and tilt-table investigations - only relevant if your HR increases sharply when you stand after sitting for a while.  And depending on why you have a PM your box may need tweaking to help adjust this.  I find that squatting down for gardening and then standing on a hot day is most unpleasant, while my PM thinks about increasing my HR, but there's no easy fix for that for me (CI).  You *may* be the same.

Light Headed

by Tem - 2020-06-10 07:03:45

Biotronic was for slow heart beat + RBB following episode of syncopy. Dual chamber pacing, but lower chamber never paced + 33% currently for upper. Light headedness + nausea worse when lying down + at night time, not when suddenly standing. Exercise tolerance is very high. In top 5% for age group on stress tests. No history of tachycardia. Had hypercalicemia [Parathyroid ademoma] + thyroid nodule, both recently surgically removed. Heart structure appears normal on Doppler,except for some moderate calcification of aortic valve. Pacemaker set to 50bpm for sleep + 60bpm for daytime. I notice some members prefer higher settings to feel better. Maybe a higher rate would supply more 02 + help moderate these symtoms. I wake frequently + feel absolutely dreadful, enough to make me reach for the phone + think of an Ambulance ride. However when ever I have nothing is ever found, so I am reluctant to waste ambo's time.

Nausea is a common symptom of hypercalcaemia

by crustyg - 2020-06-10 09:19:21

Hi Tem: you don't need a higher lower-rate limit if your symptoms aren't BP-related: if the nausea/lightheadedness is worst when lying down it's not BP.  Had your calcium level rechecked recently?  It's easy to miss part of a parathyroid adenoma.

When lying down, does the position of your head/neck affect your symptoms?

Do you snore?

It doesn't sound cardiac to me.

Calcium

by Tem - 2020-06-10 11:24:16

Hi crustyg. Calcium is back within the norml range, but my PTH is moving up again. Endo thinks its secondary hypercal. + wants blood test for Vit D which is on the lower end of normal. Aware of positional vertigo + have had an episode in the past where I felt the whole bed was spinning. Occassionally do the exercises to get the calcium balls back into their pouch! Its the low level nausea which is annoying + the light headedness is different to vertigo. I do snore occassionally. Have had symptoms of GERD. Purchased electronic bed that allows me to raise head + feet when necessary. This all began after my syncope episode + subsequent pacemaker implant. It may just be a coincidence + I agree there is probably something else going on. Unfortunately there are so many things that may contribute. I take a statin + ace inhibitor + low dose aspirin. These meds can all have adverse side effects, but my Cardio wants me to continue with them. If I can rule out pacemaker + heart that would be a major step forward + I appreciate your input. Cardio + GP are not that interested in how I actually feel. If the scans + numbers are ok just keep going appears to be the prevailing attitude.

Sounds rough

by crustyg - 2020-06-11 12:30:54

I emphathise - sounds like a real PITA.  I can tell you from personal experience on the other side of the table that appearing to do nothing is sometimes actually waiting for the patient's symptoms to become clearer / any underlying process to become more obvious!  Not great for the patient, but that's where we are.  There's no doubt that the best physicians, who know you and have time, can sometimes spot something before anyone else.

In young patients one always tries to fit everything into a single unifying diagnosis (application of Occam's Razor), but as we get older it's increasingly common to have two or more things that contribute to the symptomatology - we're both old enough to have more than one thing wrong.  But if your O2sat% doesn't increase to normal after breathing exercises it does suggest that there's something wrong.  I'd try to get my PCP to request a CRP/ESR, FBC, d-dimer or FDP.  Prostate OK? (assuming that's appropriate)  A couple of years ago my own PCP and I debated what to do after a lowerlimb DVT - they wanted to play hunt-the-tumour as it's such a classic presentation.  We compromised.

Down 60m - not Sport Diving then!  Respect.

Down 60m

by Tem - 2020-06-12 08:48:48

Thanks crustyg. My last deep dive was 15min at 70m on the wreck of the US destroyer  Aron Ward in the Solomon Islands. These dives were on air only not Helium mixes. Had 4 tanks with different Nitrox mixes to  reduce time spent at decompression spots. Now will just use my 'Hookah' dive compressor  with 100m hose + stick to very shallow wrecks. Loved the warm tropical waters+ regular visits to Truk lagoon + its 75+ wrecks,- back to dry suits + heavy neoprene here in the Southern Ocean! My boat has been sitting there patiently waiting until I sort out my health issues. Wasn't expecting to collapse on my daily beach walk + stair climb! OK with pacemaker now, just annoyed about my lack of knowledge about their pressure limitations. At least being attached to a Hookah hose it will be easier to find the body should something go wrong! Would have loved to dive the German wrecks scuttled after WW1 at Scapa Flow. Also we had planned diving the wrecks at Bikini Atoll in the middle of the Pacific which are difficult to get to. If I had the means I would purchase a new generation bubble submersible like Putin used in the Black Sea!

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