Can pacemaker implantation exacerbate PVC's?

[Spudfarmer]

I'm 71, had mitral valve repair for MVP 12 years ago.  Have had atrial fib since then, except for a 1 year period following amiodarone/cardioversion, in sinus rhythm.  Developed lung lesions and had to stop drug, and reverted to AFib.  Couple years after valve repair, I developed cardiomyopathy, now stable at about 30% EF.  Also developed LBB block and AV block.  4 months ago I took a Holter test, my rate was 30 to 50, and my cardiologist advised a pacemaker.  He thought there was no other hope for my AFib and used a single lead pacemaker.

My current problem:  Since the pacemaker implantation, I had had increasingly severe PVC's (had them lightly for 25 years), to the point I can't sleep or concentrate.  They are almost constant, seldom get two normal beats in a row, much worse lying down.  This sometimes causes me to get slightly short of breath in bed.  I take Zestril and took Toprol 75mg.  Increases in Toprol have made the PVC's worse, so it has been reduced to 25mg.  

For several years prior, I managed my condition well with diligent exercise.  Now in a matter of months, my quality of life is nil.

Have you ever heard of beta blocker making PVC's worse?  Have you heard of a pacemaker making PVC's worse?
Would Pulmonary Vein Ablation be ruled out because of my heart block(s).

[CCF-M.D.-MJM]

Hi Spudfarmer,

As a potential fellow Irishman, I love  your username.

Your question is very insightful.

1. Have you ever heard of beta blocker making PVC's worse?
Not usually--but I have had a few people tell me this in clinic.  The question is--are they PVCs or paced beats.  Paced beats can feel like PVCs.  A significant percentage of people with single chamber pacemakers will develope a pacemaker syndrome where they feel their paced beats and it makes them feel worse.  From what you describe, it sounds like this may be the case.

A PVI is not ruled out because of your heart block.  In fact, if would stay in sinus rhythm, a lead implanted into your atrium could be used to trigger the ventricular beat, thus making your heart a more efficient pump.  With your left bundle branch block, low ejection fraction, and your symptoms, you are probably a good candidate for a biventricular pacemaker (paces left and right ventricle) and an intracardiac defibrillator.  This is a single device that does both functions. I think at the minimum, I biventricular pacemaker ICD would help, but would not rule out a PVI (pulm vein isolation or ablation).  It is worth thinking about once you know all the risks and benefits.

I hope this helps.  Happy holidays.

[Abeybaby]

GReat questions indeed. I hope you find some relief.  I often wonder whether a beta blocker makes PVC's worse. I have been told that often during bradcardia pvc's often rear their ugly head simply because your rythum is more "junctional" at this point and not originating from the sinus. I would imagine the same would occurr under slower induced heart rates that are beta blocker induced.  I too wonder just how good the beta blockers are with pvc's (excasberate or reduce?) I have had both extremes happen. Sometimes PVC's are at bay with the beta blocker at other times much worse.

Comments?

[hankstar]

I have found that often after being on beta blockers for several years I have experience an increase in PVCs dramatically, after stopping the beta blocker , PVCs reduce or disappear altogether. Coincidental? Still wondering myself as PVCs wax and wane in other persons regardless of beta blockers usuage or not.

Usually PVCs caused by an increase in heartrate or exercise such as I have, beta blockers have been very helpful.Slow heartrates or PVCs that disappear with exercise,beta blockers appparently increase ventricular ectopic beats in those persons.

When it appears that beta blockers help or reduce my PVCs, I take them , when I i suspect it might contribute I tapper off, for the last 16 months 25mg of atenolol 4 times daily seems to have worked wonders for my pvcs, also might be because it is combined with cozaar 50mg daily , who knows? With medication it is all trial and error.

Person that experience PVCs will find that they wax and wane in frequency from time to time  regardless of beta blockers usuage or not, apparently in a small minority of persons there appears to be a definite increase in PVCs while on beta blockers, though the increase appears to be of little clinical significance, even though the PVCs might increase with beat blockers in some, the risk of  more serious ventricular arrhythmia apparently is suppressed with beta blocker usuage.Go figure.

My understanding and opinion only.

Happy Holidays.

[Jackie5910]

I would highly recommend the biventricular pacemaker and ICD.  I had an EF of 30% from DCM.  Some physicians felt that some of my problem was due to the single chamber pacemaker, that being the right ventricle. There were other causes as well.  I had the biventricular/ICD implanted about six weeks ago.  A follow up echo last week showed that my EF had increased to about 40% which is great.  I am taking coreg and lisinopril along with diuretics.  My diuretic use is cut way down from 100mg of torsemide per day to 20 mg.  I am thinking that I may be able to switch to dyazide which is a safer diuretic for me to take. I am feeling so much better, can tolerate exercise better and can breathe and talk and walk and talk which was very difficult before this procedure.  So, it was really worth it for me.  There are some who don't improve and others, I have been told, actually get worse but they are the minority.

[Spudfarmer]

Thank you all for your comments.  The comment by hankstar was interesting, in that my PVC's do go away with exercise.  Even with my low EF, I have good exercise tolerance, no problem while exercising, but sometimes when resting after exercise, they will occur.  Have an appointment with cardiologist in few days, hope he can come up something to help.

[hankstar]

Jackie gave some good advice, zestril and lisinopril are the same medications, coreg(carvedilol) is probably rated a better beta blocker for heart failure. Acebutolol is another beta blocker less likely to increase PVCs.

Maybe you could talk to your cardilogist about the advice/comments you received on this forum from CCF and jackie,very good comments and suggestions.

  Esidrex(hydrochlorothiazide) is a good diuretic also.


Good luck.