Need for pacemaker post-AVR?

[Yankeeman2]

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]

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]

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]

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]

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.

 

[Yankeeman2]

Thank you all for your replies concerning the heart rate monitor whose usefulness I questioned. You have provided information that makes it clear that I'm not alone and my cardiologist may actually know what he's doing. Obviously the loop monitor will help everyone know when or if I need a pacemaker.

 

[Chuck C]

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?

I don't think it is that high for valve surgery, but it does depend on the type of valve surgery. Please see the figures from the New York state figures from 1996 to 2014 below.

"The prevalence of pacemaker implantation was lowest after MVr (4.5%) and highest after AVR plus MVR (13.3%). The prevalence was 6.6% after AVR by itself, 9.3% after AVR plus MVr, and 10.5% after MVR"

Pacemaker Implantation After Valve Surgery - American College of Cardiology

Fred Morady, MD, FACC

www.acc.org

.

However, the findings of this meta-analysis for low risk patients found that pacemaker after TAVR is about 3x as likely as compared to aortic valve surgery, coming in at 17.4% in the study below.

" Patients receiving TAVR had lower rates of new/worsening atrial fibrillation, life-threatening/disabling bleeding, and acute kidney injury stage 2/3, but were more likely to need permanent pacemaker implantation (17.4% vs. 5.5%; "

Meta-Analysis of TAVR vs. SAVR in Low-Risk Patients - American College of Cardiology

Bina Ahmed, MD, FACC

www.acc.org

.

When I was evaluated at Scripps, my cardiologist told me that they did all their TAVRs on Tuesday, which had come to be known as TAVR Tuesdays. However, the need for pacemakers following TAVR was so high that the cardiologists would joke, "TAVR Tuesdays, followed by pacemaker Thursdays."

 

[bizinsider]

I like that TAVR Tuesday, Chuck!

When I had my AVR, I had no aFib, thankfully. Was immediately put on metoprolol and 75mg, now take 25mg and my cardiologist (at Scripps) pretty much says if it ain't broken, don't fix it - so on metoprolol, I stay. (Largely b/c it has helped my bp.)

However, as I've known for the past 50 years, I have a right bundle-branch block. If nothing else, the docs have said that I'm almost guaranteed to need a pacemaker if my next one is via TAVR, because of the way the procedure cuts across that part of my heart. So, if I outlive this valve, and this valve lasts at least 15 years (I'd be 82, and I'm currently 70) that would beg the question at that point and time... which will be worse, OHS or TAVR? I dunno, and obviously I have no idea where TAVR technology will be by then, but it'll be something to ponder if TAVR is a possibility.

That said, I know people who have lived great lives for decades with pacemakers (including replacements when he batteries wore out)... no worse for wear and happy to be alive.

The best news of all is that with pacemakers, TAVR, SAVR etc technology exists, without which most of us wouldn't be posting here or would be living with a ticking time bomb that we might not know about.

Cheers,
Herb

 

[Chuck C]

So, if I outlive this valve, and this valve lasts at least 15 years (I'd be 82, and I'm currently 70) that would beg the question at that point and time... which will be worse, OHS or TAVR?

Given how well the Carpentier-Edwards has shown to do in those 65+, I think you have an excellent chance of getting 15+ years and even 20+. In my view, 82+ is probably when TAVR starts to make a lot of sense, in order to avoid the risks of OHS at that age. Of course, if it makes it 20 years, at 87 I think that the scales get even more heavily tilted towards TAVR.

And I agree with you that a lot of people live decades with pacemakers. It does not seem to impact quality of life, so I don't know how much weight I would give that concern.

The good news is that you have plenty of time to think about your future options, and to see what future technology brings.

 

[Lynn]

I unfortunately drew the pacemaker card after AVR. My AV node which sends the impulses between upper and lower chambers of the heart was damaged. I am 100% pacemaker dependant and ya, it was a shock and scary at the time.

After 15 months, the most important part of this, Yankeeman2, is that Sparky works great! Sparky simply tracks the beats of my upper chambers and causes the large lower ventricles to beat. I had a routine pacemaker follow up last week, and the tech said he saw no record of any problems or irregular beats in the data which tracks with the way I feel. Yes, I was disappointed and anxious that I needed a pacemaker, but it works so well, I seldom think about it. So if you need one, go for it. It’s a minor procedure compared to valve surgery and it can not only improve your quality if life but save your life as well.

 

[Debster]

My mom got a biventricular pacemaker a year after her mitral valve replacement. Her heart was not beating in synch. That was in 2005. Like Lynn said my mom never thinks about hers-and hers has greatly improved her life and longevity a great deal. She was 65 at her replacement and she is 81 now

 

[pellicle]

Hi Debster, hope you're well

my mom never thinks about hers-and hers has greatly improved her life and longevity a great deal. She was 65 at her replacement and she is 81

I guess the thing I have about pacemakers is how I would have felt at 45 getting one, even at 55 I would have been an interference to my outdoor activity and to my lifestyle (different countries, moving around ... ).

I expect to someone who's 61 (not far off for me now) its not as onerous (let alone 81). I feel so often that the opinions here are often couched in the expectation that "the asker is as old as the answerer". They may not be.

Best Wishes

 

[Debster]

Hi Debster, hope you're well



I guess the thing I have about pacemakers is how I would have felt at 45 getting one, even at 55 I would have been an interference to my outdoor activity and to my lifestyle (different countries, moving around ... ).

I expect to someone who's 61 (not far off for me now) its not as onerous (let alone 81). I feel so often that the opinions here are often couched in the expectation that "the asker is as old as the answerer". They may not be.

Best Wishes

Hi Pellicle!

You are right..it probably is different for a younger patient to consider a pacer rather than an older individual like my mom. I guess I am so used to her situation that was truly life and death that I didn't consider a younger persons point of view. For my mom there was no choice really-and the fact that she just did what she needed to do to extend her life there was no question. Thanks for that clarification.

 

[TomM]

I had a mechanical valve installed in November 2020. Surgery went well but a week later while in hospital recovering my pulse dropped to 23 BPM. I spent a night trying not to sleep for fear of the worst until I was moved to a cardiac critical care ward. The surgeon told me I would need a pacemaker and within a few hours I had one installed. I was apprehensive about getting one installed but when I asked my cardiologist if there was any other option for me he said no. I was 38 then and I am grateful to this technology to be alive. I work as an electrical engineer in substation design. I now don't go to visit substation sites as a precaution. I found that during cardiac rehabilitation that there is an upper limit of 140 BPM set on my pacemaker. Exerting myself above this limit makes me fell fatigued as the pacemaker I am told acts to reduce my BPM. It does have an impact on my life but I like to think I've a different perspective on life now and am enjoying it more I must say

 

[Lynn]

I was 58 when I had valve surgery and ended up with a pacemaker, and I am not saying I wasn’t bummed and worried or disappointed. I was. And I agree with you Pellicle, needing a pacemaker at a younger age is like needing a valve replacement at a younger age; there are different considerations for sure. Getting a pacemaker is like valve replacement in another way, if you want to live, you usually don’t have a choice.

Is there limitations, inconvenience and possible complications? Yup. But like valve surgery and taking warfarin, I have found the pacemaker to have much less impact on my life than I had expected. I hike, I jog, I lift weights and do planks. I travel. Did I pass on the Iphone 13 and go for an 11 to avoid the large charging magnets. Yup. Minor inconvenience for me.

Everyone leads their own lifestyle, and the reasons for needing a pacemaker very greatly. My tech spent most of her career putting pacemakers in new borns that will need them for life. I know a couple of people who have needed a pacemaker at a very young age, and while I am sure they wish they didn’t, they have made lemonade so to speak.

They often don’t mimic normal heart function for some conditions as well as they work for complete heart block like I have. And yes, they are not benign and can cause issues over time. However they save lives and they allow for a terrific quality of life for for many, many people.

It’s tough to hear you need a pacemaker to keep your heart beating, but I want to encourage anyone struggling with this that it very likely will not be the big deal you think it is. Life after a pacemaker is like after valve surgery, it will be what you make it.

 

[Lynn]

Tom M, my PM was initially set at 140, and I also continuously bumped into the max when exercising. It’s a very simple fix. Have the pacemaker tech up the limit. I had mine upper limit bumped to 160 last Sept. Now when the upper chambers of my heart beat over 140, the ventricles follow. It has made a world of difference and allowed to reach my fitness goals. Both the pacemaker tech and the cardiologist said I could go higher if need be. I should note, that I have not had any Afib or racing heart so to high a heart rate is not a concern for me.

This really is a very simple fix Tom, the pacemaker should be programmed to fit your lifestyle as much as possible.

 

[pellicle]

For my mom there was no choice really-and the fact that she just did what she needed to do to extend her life there was no question

If it's dead or alive I'd pick remaining alive too, it's just that many hope to have life return to normal (is at least better than pre surgery levels). There are quite a few posters here under 60 (indeed under 40), who would be pretty bummed by that outcome.

I know that Eps was nonchalant about his, but IIRC he was an active 70yo.

Glad your mum is doing well

Best Wishes

 

[TomM]

Tom M, my PM was initially set at 140, and I also continuously bumped into the max when exercising. It’s a very simple fix. Have the pacemaker tech up the limit. I had mine upper limit bumped to 160 last Sept. Now when the upper chambers of my heart beat over 140, the ventricles follow. It has made a world of difference and allowed to reach my fitness goals. Both the pacemaker tech and the cardiologist said I could go higher if need be. I should note, that I have not had any Afib or racing heart so to high a heart rate is not a concern for me.

This really is a very simple fix Tom, the pacemaker should be programmed to fit your lifestyle as much as possible.

Thanks Lynn, the cardiac rehabilitation nurse was to pass on the information to my cardiologist regarding the upper 140 BPM limit. My situation is a bit more complicated as after the surgery I have a fistula between two chambers of my heart. The cardiac rehabilitation nurse was of the opinion it would be better not to put too much pressure on my heart by exerting myself above that limit and exercise to suit my situation. I tend to agree with her. I exercise at a more moderate level and had an echo done at the request of the cardiac rehabilitation nurse. My next appointment with the cardiologist is in September so I can see what he thinks then.

 

[Debster]

Glad your mum is doing well

Thank you so much! She was so very ill pre surgery-and to have had her this long I am so grateful.

 

[Lynn]

TomM, it does sound like your situation is more complicated than mine. While I have complete heart block and wouldn’t survive without the pacemaker, at this time, I don’t have any other heart issues (other than my mechanical valve lol).

Prior to having my pacemaker limit raised, my cardiac rehabilitation kinesiologist was able to give me some great tips on increasing cardiac fitness while staying within the limits of the pacemaker. (interval training, stationary bike ect) It sounds like your rehabilitation nurse is helping you with the same. Good luck