Need for pacemaker post-AVR?

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Yankeeman2

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Oct 17, 2019
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I had a St. Jude's valve implanted in 2007 (aortic) and have had no real problems with the heart since then. But yesterday my cardiologist said that I need a pacemaker because my heartbeat is too slow when I sleep (more than three-second pause between beats on two occasions.) I think this is called bradycardia. (He's been monitoring it recently with an implanted monitor since I developed an irregular heartbeat although he says it is not atrial fibrillation.) Looked online and there seems to be a connection between need for a pacemaker in about 15 to 20 percent of people who had valve replacement. Anybody heard about this?
 

epstns

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Maybe so, but most of us who needed pacemakers after aortic valve replacement found out right away -- not 13 years later. The most common driver for pacemaker implants after aortic valve replacement is damage to the nerve bundle that connects the atria to the ventricles. This nerve bundle runs right alongside the aortic valve, and in some cases (like mine) the surgeon needs to cut wide around the native valve to remove a badly calcified valve, and in doing so, damages the nerves.

I did have brady/tachycardia prior to surgery. In my case, my resting heart rate was down around 48-50 BPM, but under exercise load my heart would go up to the 170's. Immediately after surgery, while still in ICU, my heart would go slow, it would go fast, it would skip beats, it would add beats. . . OR it might just stop! I would experience stoppages of 20-30 seconds at a time. Of course, this would set off all the alarms. Let me tell you, it is no fun to watch your own cardiac monitor go "flat line." I would see it go flat, feel funny, and the lights would go out. When I awoke, it would be to see a circle of very concerned looking faces looking down at me. Within days of valve surgery, I received my first pacemaker, and the problem was solved.

Don't fear the pacemaker. I am now just about 10 years into this saga, on pacemaker number 2, and I still say "The only time I am reminded that I have a pacemaker is when I look into the mirror with my shirt off."
 

Protimenow

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It took 28 years, post AVR surgery, for me to need a pacemaker. It's possible that I may have needed it before that, but I wasn't watching my heart rate.

I had a serious bout with multiple, simultaneous, arrhythmias. Ultimately, i needed ablation of the source of two arrhythmias.

My resting rate was around 50 or so. My doctor seemed to have trouble believing that it went too low. When it ran down to the 30s, I called him (on a Saturday afternoon -- he takes all his calls after hours), one hour later, I was at E.R. at the hospital, and because it was Saturday, they had no conflicting surgeries scheduled - about 30 minutes later, I was in the O.R., prepped and ready - the cardiologist arrived shortly later, and I got my pacemaker implanted.

Total time from phone call to doctor to discharge from hospital - maybe 7 hours - and from arrival at the hospital to discharge - maybe 6 hours. I think this is pretty amazing.

Needless to say, it's my first pacemaker. I got a monitoring device with it - it supposedly queries the pacemaker and records any bad stuff that the pacemaker may have encountered.

A pacemaker can make life easier - and more secure - than having a heart with bad timing issues.

As epstns said, the only time I know I have a pacemaker is when I look in the mirror.
 

vitdoc

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Apr 16, 2017
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Basically two primary reasons for a pacemaker. The first and most common is when the normal pacer in the right atrium starts to punk out and the rate slows. A pacer is placed that signals the right atrium to contract and the signal is sent to the ventricles to contract when the normal rhythm drops below a preset number.

The second reason is when there is a disruption in the signal getting to the ventricles from the atrium. Some beats may get through (second degree block) or no beats get through ( third degree block).

Sugery around the aortic valve even TAVR can cause 3rd degree block.

Sometimes the ventricles will beat on their own without any signal at a very low rate say 20 beats/min. Other times they don’t beat at all without a signal.

I developed 3rd degree block after my third surgery which was replacing the aortic valve and repairing a aortic aneurysm. I had no intrinsic ventricular beat. Been paced for 14 years . And I am considered pacemaker dependent.
No pacer no life . Those with slow atrial rates are not pacemaker dependent.

To make matters a bit more complicated the usual routine is to pace the right ventricle and have the signal spread to the left. But having wires in both the right and left ventricles makes the heart more efficient. Generally biventricular
pacing is done for people in failure. It probably should be done for everyone who needs 100% pacing. I was not in failure but I convinced my electrophysiologist to add a left ventricular lead and place a biventricular pacer. Improved my cardiac output 20%.
 

Yankeeman2

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Joined
Oct 17, 2019
Messages
10
Thank you all for your prompt replies and very professional advice....some of you are MDs????...You have reassured me about pacemakers and now I can meet with the cardiologist/surgeon and have some idea of what he is talking about. I have learned the hard way that you really have to trust doctors when they recommend something; they're not on commission as far as I know! The cardiologist who suggested it said it might happen in a couple of months, but with the coronavirus surging, Cape Cod Hospital is swamped, like most hospitals, and I suspect it will be later unless there is an urgent need to do it faster. And that will probably show up on the monitor implant they put in a month of so ago. It is a fascinating device....takes only minutes to insert using local anesthesia, the cut is shallow and only a few inches long. (a specially-trained physician's assistant actually did the cutting) and every night it sends a record of that day's heartbeats to the cardiologist through a wireless device next to my bed.
 
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