100% ventricular pacing

My tech has told my pacemaker is pacing 100%, and that this is not good as it can lead to heart atrophy. Anyone know more about this?

14 Comments

100% Pacing

by SMITTY - 2009-08-26 10:08:57

I'll not try to comment on what that technician was talking about other than to say that person needs another profession. Take a look at the definition of atrophy.

"Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply to the target organ, disuse or lack of exercise or disease intrinsic to the tissue itself."

I can assure you that your heart muscle is not wasting away because you have a pacemaker that is pacing at 100%. If anything your heart muscle may become stronger because of your pacemaker causing it to contract more often. Just like your arm or leg muscles will get stronger if you use them more often. In the distant past I have read something about a pacemaker having some adverse effect on part of the heart under very specific conditions, but that did not include anything about causing the heart to atrophy.

I wish I could remember it or know where to find it right now but it was something to the effect that a pacemaker, if doing something, could cause one of the ventricle chambers(I think) to get what I will describe as lazy. If or when this happens the solution is to implant a pacemaker with an additional lead that will put the lazy chamber to work full time.

I'm afraid you have a tech that is trying to impress you with their knowledge of the heart and pacemakers when they must not be very smart about either. Unfortunately, many of us have, or have had techs like that.

My suggestion is to take anything that tech tells you with a grain of salt and check it out with people that have knowledge about pacemakers and their effect on the heart. A good place to start sometimes is the doctor, the pacemaker manufacturer or as a last resort come to the Pacemaker Club, like you did this time. There are some people here that do know about these things, or know how and the time to do research and find answers.

Good luck,

Smitty

also paced in the ventricle

by Ashregan - 2009-08-26 11:08:35

I'm by no means an expert about all this. I do have a pretty good doctor and trust his guidance on technical matters--- in addition, by luck I have some scientific education as well access to the internet and certain medical sites---like to think that this keeps this doc and me communicating adequately.

As to my own health situation, I have 90-some percent ventricular pacing due to complete heart block, I got a pacemaker in June of this year, really out of the blue, but without a lot of excitement or problems related to the whole thing,--at least not yet. Of course, I'd like to keep it that way!

The doctor I had for the pacemaker was very aware of Michael Sweeney's work concerning the fact that long-term ventricular pacing can be bad for the heart. I mean, some (even most patients in certain studies) do fine, but long-term ventricular pacing has been associated with an increase in heart failure when you look at the situation epidemiologically.

The idea appears to be that somehow the ventricular pacing is not exactly replicating the natural pattern of the heart's rhythm and this puts an extra strain on the heart's functioning--at least that's what the literature seems to be saying, from what I understand .

But there are things to be done that seem to mitigate this risk, for example in my case, they used screw-in leads, one of which was placed in the Bundle of His which is a little technically awkward unless the doc is trained to do this---but believed to be helpful in avoiding the reported complicatons.

Of course, I was a little out of it during the implant, but I do remember that after this doctor had screwed the leads in and taken some soundings as the the conduction pattern he was getting, he thought that he might be able to make it more optimal--so he removed the thing and slightly altered the position to get the ideal conduction he was looking for. For which I'm very grateful to him---no reason to do less than you actually can when somebody's life--and quality of life--is involved.

I think (but am not sure) that Sweeney in one of his papers talked about altering the AV delay to help with limiting the heart failure risk as well. If it wasn't Sweeney, somebody or other in the literature suggested this, I'm pretty sure--sorry I didn't keep that info.

I think you ought to be able to find some articles on the subject by googling such phrases as 'Michael Sweeney and Ventricular Pacing", or "Permanent, Direct HIs-Bundle Pacing"---or an interesting article by C. C. de Cock entitled "Fifty years of cardiac pacing: the dark side of the moon?"

It's annoying that what they put in your body to help can cause problems, but if your AV node isn't working, what are you going to do? So in my case at least, I've got to have the ventricular pacing to live as I wish to. The challenge may be to find a way to deal with, ideally eliminate, any side-effect that arise.



Bottom Line

by bobad - 2009-08-27 01:08:18


It used to be true that 100% ventricular pacing lead to long term problems. It's still true, but lead placement and pacer technology have reduced the problems substantially.

heart failure

by golden_snitch - 2009-08-27 01:08:48

Hi!

Just google "unneccessary right ventricular pacing" and you'll get some info. Studies have shown that too much right ventricular pacing - when it's not really needed - can lead to hear failure. However, if you have a permanent third degree heart block, then it doesn't help worrying because there's simply no choice, you need 100% pacing. But if you don't have a permanent heart block, the percentage should be watched. Every pacer has as feature to reduce the unnccessary pacing - some are better than other. Prolonging the AV delay is in most pacers the only thing that can be done.

Hope this helps a bit.
Inga

Side effects

by ElectricFrank - 2009-08-27 01:08:49

If there are any problems due to the pacer they only occur over a long period of time. By the the time they develop there will likely be new developments in pacers to handle them.

All of us with complete AV Block have our ventricles paced 100%. There are people on this forum who have had a pacer for many years for this condition who are doing quit well. I wouldn't be concerned about it for now.

frank

IM PACED 100% AS WELL

by pete - 2009-08-27 02:08:22

Pigs might fly and I might keel over tomorrow. And I might get sat on by a ten ton parrot. So what have we got to worry about, maybe only worry itself. ElectricFrank gives some sound advice as usual. Im 100% paced so why is it after 2 1/2 years of it I go from strength to strength?
ust be the 100% ventricular pacing of both ventricles dispite permanent atrial fibrillation a leaking mitral valve and cardiomyopathy. I can jump over the moon if I want to. Think positive and dont worry youll soon be right as rain. Happy pacing Cheers Peter

information

by Ashregan - 2009-08-27 03:08:38

To me, and I do have this high rate of right ventricular pacing, there's just no way around the literature: right ventricular pacing is associated with problems in a substantial (ie statistically significant) number of people.

The degree varies. In the DAVID trail, for example, ventricular pacing "....more than 40% of time is associated with a higher risk of hospitalization for heart failure or death". In the MOST study, they found that "every 10% increase in cumulative percent ventricular pacing (Cum%VP) (up to 40%) was associated with a 54% relative increase in risk of hospitalization for heart failure". These are just a couple of many research reports I looked at as I decided whether nor not to get a PM.

Maybe someone else has studies that showed no risk or effect of ventricular pacing on heart health---I don't have access to all the literature and I'd love to hear about any studies that do show a different finding. Based on what I've seen though, it's sort of a a decided issue: ventricular pacing is shown to be a problem for the heart in a measurable percentage of cases.

It's also true that these problems don't happen to all PM patients and I don't think they completely understand why. Or why some people get these problems in the first 6 months and others not for years. Baseline left ventricular function may play some role but it doesn't appear to in at least some of the studies I've read. There seems to be reason to believe that placement of the lead in the His Bundle or other non-traditional sites or biventricular or left ventricular pacing may be helpful at least according to Michael Sweeney. But the jury is still out on the whole story.

My own view is that it's helpful to face the facts of a situation and do what you can to reduce harm. Certainly I'm glad that I stumbled onto some info about using a alternative site for my device and that I was able to find a doctor skilled in accessing that site because apparently not all docs can. Do I know that this will make a difference? Obviously not. But life is about being informed as well as you can, doing the best you can and maybe hopefully having a little bit of luck at times. I hope that by posting discussions like this one, others who are in the position of deciding about a pacemaker can be informed about their choices and risks, perhaps more clearly than they might be through reading the sometimes ponderous scientific literature.

as opposed to not pacing?

by Tracey_E - 2009-08-27 07:08:48

I'm with Smitty, that tech needs to find another job. I've been ventricular paced 100% for 15 yrs now, my EF hasn't changed. Others here have been paced longer than me and are still fine.

I'd be dead if I wasn't paced so even if there are long term side effects to the gizmo that's kept me feeling great all these years, I am not going to lose any sleep over it. Study results have been mixed. There is some evidence to indicate that some people will have problems long term. As Frank said, technology gets better all the time so by the time you have an issue, odds are good they'll have a solution. Every prescription you take has long term effects. Every preserved food, fatty food, high sodium food, cocktail you consume has long term effects. Aging has a lot of side effects, too ;o)

Ashregan

by Tracey_E - 2009-08-27 09:08:26

I'm no scientist and half the terminology in the studies goes over my head, but if you took an informal survey of the members here, many of whom have been paced long term already, I don't think you'd find anything close to enough to support the numbers in those studies.

different ways of seeking knowledge

by Ashregan - 2009-08-27 10:08:05

To the previous poster,

Obviously the scientific method is just one way to seek knowledge. In other cultures and in other times within our own culture, more intuitive, spiritual and/or experiential models of knowledge have existed and still exist.

But for those of us who believe in concrete positivism to any great extent, the quantification of outcomes, if done with adequate control of confounding/contaminating factors, has to have a certain level of importance.

I mean, from what philosophical tradition do you think all this cardiac research (which ultimately produced PM's and ICD's) arose?

When this philosophical approach is taken, an "informal survey of the members here" doesn't carry much weight.

That's just part of the story though. At the same time, because scientific knowledge is (in almost all circumstances that I can imagine) incomplete, one has to be a little bit humble about thinking that everything can be explained with current studies and statistics. I mean---take something like pancreatic cancer, in general, statistically speaking, something like 95% of people die in X number of months, whatever treatment they get. Still, one has to ask, "what about the other 5%?".

The answer to this conflict/conundrum? I feel---and this is a personal approach---that one cannot really look away from the statistical evidence, unless one can find a way to invalidate what is being reported. These population numbers DO mean something--we just may not at the current time be able to say completely what they do mean.

For that reason, I personally think that it doesn't make sense not to investigate what is known in an epidemiological sense, weigh its importance, and do what is possible to apply what seems valid to one's own situation.

In addition, I'm all good with applying what seems intuitive, folk-wisdom based, experiential and anecdotal knowledge. Keeping in mind of course that while the research model may not be the full story, I can't see any rationale to assume that the self-report of a group of individuals on a web site can be taken as "proof" for or against the studies in question. The persons reporting are self-selected, not randomly chosen and this makes a considerable difference in a statistical sense.

I do continue to note that there are many studies that are somewhat statistically controlled---which suggest the existence of this negative effect of ventricular pacing in many (presently unclearly defined) individuals.

Just my opinion, certainly anyone else is entitled to a different one!

Anne

Sorry

by golden_snitch - 2009-08-28 01:08:59

Hi,

I'm sorry that I seemed to have tread on your toe, Anne. I know very well that for some patients the 100% ventricular pacing are necessary, and I know that this does not mean that heart failure or atrial fibrillation is not an issue for them. It's just that those cases are, like you said, in the eye of the storm - as unfair as it is. The discussion is for those who don't need ventricular pacing that much. And especially for those who have a very high pacing percentage although their diagnosis is not a permanent, complete heart block.

Regarding solutions: CRT devices are doing a pretty good job in restoring synchrony between right and left ventricle. A friend of mine had an EF of 27% before she got the CRT, now she's back to 45%, sometimes even 50%. So that's something that can already be done.

Inga

"unnecessary" is the point

by golden_snitch - 2009-08-28 02:08:41

Hi again!

I agree with Ashregan, there's lot of evidence. I have been to several international EP conferences, and unnecessary right ventricular pacing WAS a big issue there. However, I think many of you miss the point, and I might not have explained that well in my first post: it's called "unnecessary" right ventricular pacing. For those with permanent 3rd degree heart block this is no issue. It's a problem that occured with the rising percentage of dual-lead pacer implantation. A recent study by the European Society of Cardiology shows that the number one reason why people get a pacer is sinus node dysfunction. And most of them get a dual-chamber pacer although there is no indication for ventricular pacing. Believe it or not, many of those patients end up being paced 30-40% in the ventricles (with the so-called av-delay programmes) although their heart could do the work on its own. Now, these are the patients that might develop heart failure somehow in the future. Ages also plays a role. Young patients like me who'll at the end have had a pacer for about 50-60 years of their life are of course more at risk of developing heart failure.

I'm not pessimistic, only realistic. So when I had to get an upgrade to a dual-chamber pacer last year, I knew about these problems with right ventricular pacing, and so I really looked into the different pacer models and their features to reduce this unnecessary pacing.
It's important for all those who have no heart blocks or only occasionally. Not for those who have a permanent 3rd degree heart block.

Best
Inga

no offense taken!

by Ashregan - 2009-08-28 10:08:34

Thanks for your response to my post, Inga, and sorry if I somehow gave you the impression that your comments were "treading".

My main interest was---and is---to have this conversation posted and available on the internet---don't know if you're aware but when somebody out there searches these kinds of topics on google, this site comes up just like medical articles. I'd like to think that our comments and exchange will help others who have to make decisions or further investigate what to do.

Yes, I'm aware of CRT devices, but as you might imagine, I'd much rather that my heart not be wrecked by a device in the first place than that it should have to be "remodeled" after the damage is done.

In my own case, by all appearances (MRI and CT and I can't even remember what else at the moment-echo-this or that?) my heart is just about perfect in its functioning except for this outage of the AV node. Why this outage should have happened (and believe me, we did all the appropriate tests) we don't know. What happens next perhaps we don't know, largely because of these ventricular-related potential problems.

Looking forward to the time at which medical science can offer a more immediate and permanent solution to this possible complication.

permanent 3rd degree av block is the issue

by Ashregan - 2009-08-28 10:08:40

To Inga:

Yes, those of us with this condition are in the "eye of the storm" vis a vis this issue.

100% pacing may well be "necessary" for quality of life or life itself. But does the fact that ventricular pacing is "necessary" for life mean that it may not still be deleterious to the heart? I don't think that's what the studies show. Often therapies that are "necessary" for treatment of something will still have deleterious side-effects. Not fair but that's how it is sometimes.

The study by Milasinovic et al in Europace (2008) 10, 151-155 (which may the the European Society of Cardiology study you refer to since Europace is one of their journals) looks at managing pacing in patients with a variety of conditions in order to cut down on ventricular pacing for the reasons discussed earlier.

If you look at their Table 3, using alternate pacing algorithms it was possible to reduce ventricular pacing even in patients with first and second degree heart block. But for those patients with third degree heart block, the Median Cum% VP was 99.4%. That's a whole lot of ventricular pacing!

Again it's completely unfair, but that's just the nature of third degree heart block of the permanent type: there's going to be constant ventricular pacing.

And so, given that it's "necessary" for the patient, I don't think this means that it can't still cause the problems we've been discussing.

I think what the articles are saying is: "Because of these potential problems, you should not pace in the ventricle when it's "unnecessary".

I don't think that they're saying that just because it's "medically" necessary that it is free of potential harm: it's just that you have to do it and risk the harm because you have no other choice. (well that's not completely true---you always have the choice to die but most of us aren't considering that choice at the moment, I don't think).

I've had the opportunity to discuss this subject with some pretty expert people, but if you think I've got it wrong, I expect everyone here has knowledgable people that they can ask if they think this is way off-base.

It makes me feel a little better and hopefully is comforting to others that some very well-known people in the field are even now working on completely new types of pace maker technologies that will get around this problem. I know for a fact that one such application is far enough along to be in the sale-of-techology negotiation phase---though that is surely still far from being available as a medical device. So until then, I put my faith in doing what I can to minimize risk (ie the alternative placement of the lead and anything else they come up with). And of course, hope that I'm not among the recepients who gets to have the side-effects, something that as of now, is unknowable.

Anne

You know you're wired when...

Your favorite poem is “Ode to a Cardiac Node”.

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