Congestive Heart Failure Expert Forum
Right ventricular lead relocation to RVOT
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Right ventricular lead relocation to RVOT

Wishing to get some outside input on a pacemaker situation.  

I am trying to find out if the right ventricular lead can be removed from the apex and relocated at the right ventricular outlet tract (RVOT)?   Based on the studies I have read, this location does not lead to intra-ventricular dys-synchrony.

I wish to have the lead relocated is because of the possible development of pacemaker mediated cardiomyopathy or dilated cardiomyopathy (DCM).  The reason I feel that I have developed pacemaker mediated cardiomyopathy is because of the length of the implant (1997), over 15 years now; a 100% pacer (rate responsive); implantation at the right ventricular apex; and a decreased EF.   I have had 5 echocardiograms in the past three plus years.  They have ranged from 25% in 2009 to 40% in 2010 and now I am at 30%.  The 25% reading was during an atrial flutter episode which was ablated. I have a pacemaker because of complete heart block.  

To complicate the issue, a bi-ventricular pacemaker is not being considered because I do not qualify.  Even though my EF is at 30%, I am still in good shape at age 59.  I am asymptomatic and non-ischemic.  I exercise by running 15 to 20 miles a week and recently ran a sub 10 minute mile.  I do not have signs of pulmonary edema or swelling of the ankles.  Further, I make sure my weight is kept at a reasonable level.  I am not in heart failure.  

My cardiologist feels the medication I take, 50 mg/day Coreg plus an ACE inhibitor is the best approach and should maintain the EF within a range of 30% to 40%.  I do not have his confidence in the medication and am very concerned that the heart will continue to degrade and the EF will drop even further.  Not the scenario I want.  

I have discussed this issue with my cardiologist and the response is that there are no studies that back up relocating the lead as a plausible solution.  

I will add that I wish to stay in a dual chamber pacemaker because of future cost considerations.  The same reason I do not wish to have a defib.  

Can you please comment?  Thank you.  

Richard


1884349_tn?1353818598
Hi Richard,

Interesting post.  I will be brief:

1. There is no role to relocate the lead to the RVOT
2. If you are being RV paced 100% of the time, because you have a low EF (even without symptoms), one can defend putting in a coronary sinus lead thus upgrading you to a BIV system.  I am sure you can find a cardiologist willing to do this. If you had a normal EF and no symptoms, I would agree that there would be no role for BIV pacing (but such is not the case with you).

Good luck.

Dr. Rich
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1884349_tn?1353818598
Jonathan D. Rich, MDBlank
Northwestern Memorial Hospital
Chicago, IL
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