Pacing-induced Cardiomyopathy

Pacemaker Induced Cardiomyopathy

by AgentX86 - 2023-01-29 19:45:02

Yes, PIC is a complication of Right Atrial pacing.  You've been around here for a while and the subject ot cardiomyopathy has come up a number of times.

Something like 5% of people who are RA paced develop PIC. The good news is that 40% isn't really all that bad.  A LVEF of 50-55% is considered normal and above 60% is unusual and above that may point to other problems. You likely wouldn't have symptoms until it got a lot lower.  We've had people, here, who have been surprised, with an LVEF  in the teens or twenties.

Normally, they wouldn't be discussing CRT until you got down to 30-35%.  Insurance often won't cover it until then.  I see you're a veteran so this changes things in that regard.

CRT isn't a 100% cure for PIC but often reverses it completely.  No guarantees. There are also other pacing schemes that may offer help.

See what your cardiologist recommends. It's not something to get all excited about, at least at this point. He'll probably recommend more closely tracking your LVEF with regular echo-cardiograms, perhaps every six months. A lot of us get them once a year, just because. Since you've had your PM for ten years, it's likely due for replacement any minute so now is the time for the upgrade.  Or, all of the above.

AgentX86

by USMC-Pacer - 2023-01-29 19:53:23

Thanks for the reply. They are replacing the lead and unit at the same time in a few weeks. My battery has just over a year left. I'm still waiting for the surgery date. In another post I mentioned that they were going to place the lead higher in the ventrical, but I think that was the plan before the echo. Maybe it is still the plan. I'll update after my EP appt. with what they come up with. Thanks again for the reply..

CRT

by Julros - 2023-01-29 20:34:57

I have a CRT-D. It was inserted when my EF was 50%, but per my echo I was thought to have cardiomyopathy. I was in atrial flutter with a slow ventricular response of 40. Since placement, my EF has come up to 55%. Pacer-maker induced cardiomyopathy can occur in 10-20% of people with right ventricular pacing. CRT is achieved by threading a wire to the left ventricle and pacing in concurrently with the right ventricle. 

It seems like if you have to replace the pulse generator anyway, that upgrading to a CRT is the way to go. It is slightly bigger, because it has a larger battery. They may even install a unit that includes a defibrillator, which is bigger still. 

Julros

by USMC-Pacer - 2023-01-29 20:40:18

Thanks for the reply. Yeah, the NP told me 20%+ of right ventricular paced peeps have  this condition.. aren't I lucky :) 

We'll see what happens.. thanks for the reply

Ejection fraction

by Lavender - 2023-01-29 21:27:30

Like Julros, I got my CRT-P when my EF was still in the 50's. It has raised my EF and I am normal.  I'm thinking you may be getting one since you're due for a change soon anyway. 

Lavender

by USMC-Pacer - 2023-01-29 21:30:41

I hope so. From what I've been reading it can return me back to normal again. I've also read that EF can keep getting worse. So, hopefully they just do it now when they are changing it out anyway. Thanks, I'll update soon :)

EF of 40

by Good Dog - 2023-01-30 09:15:37

I have had the exact same experieince you are going through. I can tell you that I completely understand how you are feeling! My Doc sent me for an echo and I had not had one for about 20 years. At that time, I had my PM for 30+ years and always previously had an EF in the 50's. So when the result of the EF after about 20 years dropped to 40, like you, I was really concerned. Maybe a bit shocked is more accurate. I too have a lead that needs replaced sometime in the near future, It is a 36 year old atrial lead that doesn't sense properly, however it has not negatively impacted my battery life. I am currently approaching 8 years on my current battery and have about a year remaining.  

The first thing I will tell you about your EF by echo is that it has a +/- accuracy of 5%. The results depends to a large exntent on the technician performing it. After discovering my EF was 40, I found a new doc (btw: he has since left the practice) and he sent me for another echo about 8 months later. That result was 39% with the caveat that the technician had noted difficulty making the determination. I freaked out with the 39% result, because I figured it could be as low as 34 considering the accuracy of +/- 5%. I also figured it must be getting worse. So about approx 8 mo after that, I ended up in the hospital with a minor stroke and they performed another echo. That result was 44%. I was thrilled with that result, because now I am thinking it could be as high as 49% if I look more optimistically at it. These were all performed at the Cleveland Clinic with the exception of the fist one. So my point is, don't panic! 40% is not panic worthy anyway unless you are seriously symptomatic. You likely are not. Besides, your EF can stabilize and remain constant for a very long period of time. Do you know what your EF had been previously and how long ago that was?

It seems that you may be a candidate for a CRT and that can return your EF back to normal. It is very, very likely that it will with PM induced cardiomyopathy as opposed to HF resulting from other causes. Especially those cause by lifestyle. I remember reading a post here from someone like us that had their EF return to 60% after getting a CRT. So there are no guarantees, but they would not perform the procedure if they didn't think it would make a big difference (benefit). 

So on your next generator change your doc may replace you lead and decide to wait to convert you to a CRT or he/she may decide to do it then. A part of that decision may be made based upon if your veins are open and can accomodate additional leads easily. If not, there are always other options. In any case, simply adding leads and converting to a CRT is not a risky surgery. Not much different than your original PM implant. Should you need a lead extracted, that adds a little more risk, but it is becoming very routine. The important thing is to discuss it all with you doc. You need to be confident that he has experience performing these procedures if he is doing it. Should you need a lead extracted, that is the most important to insure the doc performing that has a lot of experience with lead extractions. There has always been a rule-of-thumb that he should have done at least 100, but I don't think that is a hard number. Though, you should ask. You simply need to have a high level of confidence in him! 

I think that for many of us, what you are experiencing is a common issue. So do not feel alone. There are lots of smart, compassionate and experienced folks here that are always glad to help with answers to questions and suggestions. You should try to remember that if you do need a CRT, it should be a very gratifying experience. You'll likely feel better than you have in a long while.

I wish you the best!

Sincerely,

Dave

Confused by the Variation in Impact of EF

by SeenBetterDays - 2023-01-30 10:44:24

Hi

I have also had a similar experience with falling ejection fraction.  I had a cardiac MRI prior to my first pacemaker insertion which showed an ejection fraction of between 60 and 65%.  Within twelve months of 100% right ventricular pacing my echo showed a reduction in my ejection fraction to 45%.  This really worried me as I was not feeling well and, after doing some research, suspected I might have pacemaker induced cardiomyopathy. This can arise as a result of the ventricular dyssynchrony which may occur with a high burden of right ventricular pacing.  My cardiologist was taking a "watch and wait" approach (the NHS won't generally intervene until EF drops to 35%) but I wasn't comfortable with waiting for my condition to potentially worsen.  I may have felt differently if I had been feeling good but I was struggling with chest pain and shortness of breath.

I decided to get a second opinion from a private cardiologist who agreed that, although he couldn't make a definitive diagnosis, pacemaker induced cardiomyopathy was a real probability.  After lots of soul searching, I decided to pay for private His bundle surgery - this is a form of conduction system pacing where the pacing lead is implanted in the His bundle with the aim of reducing ventricular dyssynchrony and mimicking a more natural activation of the heart muscle.  In the first few weeks following surgery (July 2022) I felt so much better, other than the discomfort of the pacemaker site, the chest pain and shortness of breath seemed to have been relieved.  Unfortunately, this did not last and I am now still struggling with my day to day function - the chest heaviness, pain and shortness of breath have returned.  My last echo showed no increase in my ejection fraction since the surgery.

I suppose what I have learnt is that we are all very different physiologically and that, what works for some, is not always the case for all.  I can see that some members have had fantastic results from CRT and some who have had 100% RV pacing for years with no ill effects.  There also seems to be huge variations in the impact of changes in ejection fraction.  One person may operate just fine at 40% whereas, for me, the fall to 45% seems to have had a drastic effect.  

Sorry that I can't be more helpful.  My only advice would be to fully explore all your options and listen to your body.  It may well be that your ejection fraction will stablise and, potentially, if you decided to go for CRT, could well increase to its former level.  These decisions are really tricky when the outcomes are unpredictable.  I hope your forthcoming surgery goes well and that you have a positive outcome.  Please let us know how things go and I send you all my best wishes.

Rebecca 

EF (Ejection Fraction)

by Gemita - 2023-01-30 11:17:15

USMC-Pacer,

I wouldn’t feel downhearted with the prospect of getting a CRT, if indeed your EP feels it is needed, since I note this is currently to be discussed. 

I have no experience personally with a low EF, but a family member was diagnosed with an EF of around 16% just over a year ago.  Of course she and the rest of the family were very concerned for her safety/survival without a pacemaker/defibrillator as backup.  Instead however, her doctors managed her EF with medication alone and other conservative measures despite our concerns and today she is looking at an EF of well over 40%, so please don’t assume that CRT is the only way to improve your situation.  Medication and lifestyle changes can really help.

I would question your EP whether RV pacing has been the likely cause for your reducing EF or whether other factors could be at play here too?  Clearly RV pacing doesn't adversely affect the majority who need a high percentage of pacing in their ventricles.  My EP told me that if it was going to happen it would happen quickly, within the first couple of years and if it didn't within this time frame, it probably never would.

I agree with Good Dog, that results from an echo can be different depending on the experience and technique used by the technician performing the test (and of course on our body habitus).   Also they usually like to follow up on any echo results some 3 months later to see whether conservative measures are helping before going down the CRT or device route.  

I hope all goes well for you during your appointment.  Please come back and let us know how things went

Thanks everyone!

by USMC-Pacer - 2023-01-30 11:34:30

Thanks for the great pointers and for always making me feel better. A few have asked about my previous echocargram / EF values. I found this one from 2016:

SUMMARY: Status post tissue aortic valve implant with normal valve
function. Normal left ventricular systolic function with ejection
fraction 65%. Normal pulmonary artery systolic pressure. No significant
change compared with prior echo from 8/27/12.

I think I should have another echo record in between now and back then, but I can't find it. Either that, or I was way overdue. 

Thanks again everyone. I'll update as soon as I have a sit down with the EP Dr.

Some final comments

by Good Dog - 2023-01-30 14:11:27

SeenBetterDays: I just wanted to comment that I have been researching HIS Bundle Pacing as a means to correct HF and it seems to be the absolute best and renders positive results even in patients where a CRT failed. So it sure seems like you made the best decision. Also, from what I've learned, improvement in your LVEF does not happen immediately, It is marginally improved at 6 months and a much more significant improvement at 1 year. Of course, that certainly depends upon the reason/cause of the low EF. 

Gemita: My understanding of PM induced cardiomyopathy is a little different than characterized by your EP. Please correct me if I am wrong. A previous EP of mine and a lot of literature I've read indicates that patients that are dual chamber paced for long periods of time may/are likely to develop PM syndrome upon remodeling of the LV as a result of dyssynchrony caused by less than optimal (unnatural physiological) pacing. That seems to be the case with me as my left ventricle has become somewhat mis-shaped (oblong shaped) which reduces its ability to pump efficiently. As I understand it; that can take many, many years to occur. In my case, I wonder if that could be that early-on I did not depend on my PM. That is, at least to the extent that I did as I got much older. In my younger years my PM tracked more than it paced. It has only been in the last few years that I have become fully PM dependent. 

Sincerely,

Dave

EKG Results

by USMC-Pacer - 2023-01-30 15:55:47

I just found my recent EKG results on the portal. I don't know how to read these, but I think the QRS number looks bad and I'm sure will be a topic of discussion with the EP:

Test Reason : cardiac arrh
Blood Pressure : ---/--- mmHG
Vent. Rate : 077 BPM Atrial Rate : 077 BPM
P-R Int : 272 ms QRS Dur : 202 ms
QT Int : 436 ms P-R-T Axes : 082 -79 097 degrees
QTc Int : 493 ms

Atrial-sensed ventricular-paced rhythm with prolonged AV conduction
Abnormal ECG
When compared with ECG of 25-JUN-2021 11:45,
Electronic ventricular pacemaker has replaced Sinus rhythm
Vent. rate has increased BY 29 BPM
 

Good Dog - Pacing Induced Cardiomyopathy from RV pacing

by Gemita - 2023-01-30 15:58:01

Hello Dave, I was referring to pacing induced cardiomyopathy as a complication of RV pacing only, say when we are totally pacemaker dependent or when we receive a high burden of pacing in the RV (more than 40%).

The context in which my EP gave me this information was during my discussions with him about having an AV Node ablation as a treatment for my Atrial Fibrillation.  He was giving me the pros and cons of having this procedure and what could happen. 

Having an AV Node ablation would immediately lead to pacemaker dependency and would result in 100% pacing in the RV alone (the atrial signals would be blocked).  He tried to reassure me that the majority of patients do very well with only RV pacing and only in a minority of patients does he see heart failure symptoms develop.  He said that should I go ahead with an AV Node ablation and develop heart failure symptoms, he would immediately upgrade my device to CRT to restore synchrony between the two ventricles.  I found myself thinking “why don’t you do it at the outset” but the NHS wouldn’t do this without an indication for CRT, especially since heart failure may never occur.  Our National Health Service is not in the business of prevention, unfortunately, it doesn’t have the means.

He further said that in all his years of practising, if it was going to happen, it would happen quickly and if it didn’t happen within a certain time frame (he actually quoted 1- 3 years), in his experience pacing induced cardiomyopathy from RV pacing would be unlikely to happen.  I have heard this reported by other members also.  In other words, heart failure would reveal itself quite quickly for those susceptible to having problems.

I see from this thread however that AgentX86 started the conversation with Pacing Induced Cardiomyopathy from right atrial pacing?  As far as I can see USMC-Pacer is paced almost 100% in the right ventricle now?  Does that answer your question?

Gemita

by USMC-Pacer - 2023-01-30 16:26:57

Good info, thanks.. I've only been 100%  paced within the last year. Prior the percentage has gotten higher year after year. In the beginning, 10 years ago, I was only paced during exercise when my HR went about 125+- beats per minute. CHB was just diagnosed in my last EP visit when all this fun started. When I speak to the EP, I'll certainly ask him about other causes like I dunno.. exercising too hard, not hard enough, drinking too much through covid lockdowns :) ? I doubt that is the issue - just my lame attempt at humor. Anyway, I'll definitely ask him and report back. 

Two for one

by Good Dog - 2023-01-30 16:34:48

Yes Gemita, you did answer my question, I think......Thank you! And your answer is pretty consistent logically with the last post from USMC-Pacer (his RV rate increased by 29 bpm to 100% since Jun-21). I guess that the timer starts (on the 1 to 3 years) when we are nearly or become 100% RV paced. Although I know that there is no hard and fast rule. However, that would seem to be the case with me since I have only become 100% PM dependent in the last few years. I don't know exactly when, because my previous doc never provided me with my interrogation results. I didn't really care until I found-out that I had a low EF.

I only prefaced my response with "I think", because logically, it would seem that the dyssynchrony between the RV and LV has been there all along to some degree. Obviously, it would seem that there would be a greater impact the more you are RV paced. I am still a little confused, but that is nothing new for me. Some things are just over my head.

It is a shame that the NHS would not pay for a CRT, but the rational is understandable.

As always, thanks for your efforts!

Sincerely,

Dave

CRT pacemaker

by Aberdeen - 2023-02-01 15:06:49

My dual lead pacemaker caused LVSD and dyssynchrony between the rv and lv in less than 5 months. It was replaced by a CRT-P pacemaker. My EF was between 35-40. 5 months later it was around 63! 
Nearly 3 years later I would certainly recommend a CRT-P pacemaker.

Good luck with your decision!

Thanks for that.

by Good Dog - 2023-02-01 15:29:37

I don't think that it gets any better than what you experienced! That is some really positive testimony!

Thank you!

Dave

Aberdeen

by USMC-Pacer - 2023-02-01 16:03:20

"My dual lead pacemaker caused LVSD and dyssynchrony between the rv and lv in less than 5 months. It was replaced by a CRT-P pacemaker. My EF was between 35-40. 5 months later it was around 63! 
Nearly 3 years later I would certainly recommend a CRT-P pacemaker.

Good luck with your decision!"

That would be great! My cardiologist has said the EP hasn't decided, or hasn't said what's up for me yet. The NP told me they are deciding between putting the lead higher in my vetrical near the ?his bundle with a regular two lead pacer like I have which can improve contraction or going with the CRT which sounds better to me... My cardiolist doesn't think I need a defibrillator which I was worried about. 

Makes sense

by Good Dog - 2023-02-01 16:40:44

USMC-Pacer: What you are saying makes good sense to me. If you don't have tachycardia (i.e. V-Tach) or any dangerous rhythm disorder, a defib wouldn't make any sense. So it sounds like he is advocating for HIS Bundle Pacing. That may be even better than a CRT. It is a more natural physiological form of pacing. It often corrects low EF even when a CRT could not. So either a CRT or HIS Byndle Pacing sounds like a great plan! Seems like you are on a good track!

Wishing you the best,

Dave

Another update..

by USMC-Pacer - 2023-02-11 16:14:46

Sorry for the late update.. busy, busy :)

My cardiologist also advised me that they "think" I have a paravalvular leak (aorta). They aren't sure of the extent bacause they can't see it via the regular echo. So, I am scheduled for a TEE (transesophogeal echo) on Monday to see how bad the leak is and to check the rest of the valve, leaflets, etc. The valve was implanted in 2007...hoping it hangs on, lol.. Still NO symptoms. Also, my recent bloodwork had some strange changes: Low blood platelet count @112 and High RDW @15.1. I wonder if it's possible that red blood cells are being damaged by the leak?

Update..

by USMC-Pacer - 2023-02-22 21:53:40

I had my meeting with the EP today. Accoring to him, my results based on what they saw with the TEE are not near bad enough for a CRT device. He feels that moving the lead up to the LBB area will fix my EF and QRS issues nicely with the same device I have now, but a new one. I haven't researched if these (Medtronic Adapta) come with upgrades.

The other thing they saw: I don't have a paravalvular leak @ my aorta. It is a transvalvular leak due to a thickened leaflet. I'm not sure what they will do about that. I see my cardiologist on 3/22 and will discuss that then. The EP doesn't think it is that bad and may warrant watching it... but, we'll see what tmy cardiologist thinks.