Epicardial lead

[Mickenzie]

First I'd like to thank you for having this forum, I think people really apprieciate being able to get answers to their questions. I have posted here once before under the topic area "Pacemaker", and the subject "Lots of questions".  (You might want to read that one first as it has a pretty complete medical history) I am 18 years old, and I was born with Congenital Complete heart block and had my first pacer put in when I was 11. In 1999 I was having a laser lead extraction when my SVC was lacerated from "well above the azygous vein near the Innominate vein, onto the atrium" They did an emergent sternotomy to stop the bleeding in the cath lab, then moved me to the OR and put me on bypass to repair the SVC, get the leads out, close my PFO, and put in a new epicardial system.   In my last posting I asked how epicardial leads were replaced, but didn't get an answer because they usually aren't.  A few days ago I was talking to my heart surgeon in the hall way of the hospital and he said that he didn't think that it was a good idea to put leads in my SVC again. I know they are going to be replaced the next time my pacemaker is changed because of the noise reversion problem I have with this pacer(see first posting). Could you please tell me which incisions they could use, and things about them like why they do it that way, recovery time, pain level,risks, or anything else? My next question is about exercise.  I used to be on the cross country team before my last surgery, and I have started running again.  The upper limit on my pacer is 175, so every time I try to run my heart skips beats because it goes over the limit becuase I'm out of shape.  When I keep running it gets up to the 2:1 block rate (192), so my pulse rate cuts in half.  I was wondering if this could have any negative effect on me other than just feeling bad?
One more question.  2 days ago I felt the littlest bit dizzy while I was sitting in my anatomy class, but I didn't really think much of it.  Yesterday while I was driving to school I all of the sudden felt very dizzy for about 2 or 3 seconds, then it went away and I was just a bit lightheaded for a couple of more minutes. I pulled over and sat there for a while until I was fine again.  Do you think this is just something weird that will pass, or is it something that I should question my cardiologist about? I believe my heart rate was fine during this.  Thank you again, and I'm sorry this was so long!

[CCF-M.D.-CRC]

Dear Mickenzie,

Wow, you've been through quite a bit.  First, the only way to remove epicardial leads it with open heart surgery so they are not usually removed.  If you need new leads a transvenous approach is probably the best way to go.  If there is a problem in using the SVC the pacemaker could be put through the IVC.  This is called a femoral pacemaker and is not done at all centers.  Recovery time and pain levels would be similar to your previous "routine" pacemakers.  

Your second question deals with the programming of your pacemaker.  There are some limits on the upper rate of programming but I think 175 is a bit low for you.  It could probably be increased to 195 or so and this would help with your exercise.  If your pacemaker has a "dynamic AV delay" and "dynamic PVARP" these functions should be turned on.  In addition , the intervals should be programmed as low as possible.  I would mention the problems you are having to your doctor and make an appointment to get the pacer adjusted.

As far as your last question the answer would depend on what was causing the dizziness.  It would be helpful to check your pulse the next time this happens.  If it is slow it could be a problem with the pacer such as lead noise.  IF it is normal then other causes should be investigated.

[A_Orta]

A great testimony to the human spirit ! I admire your dedication.

[DAQ]

Hi,

I too have an epicardial system.  My first two pacers were endocardial but becasue of a deformity of my SVC and innominate vein. I had a patch repair of them both and the epicardial pacer was placed.  After having 3 more pacer surgeries due to muscle stimulation and myopotentials, they gave me yet another pacer with two extention leads that travel across my chest to the left shoulder where the device is now.  I still have the same issues, but at least I know it will not kill me. I need to have a lead change too because having a really long lead with connector leads, they curled up on each other and is causing muscle stimulation, "shoulder jerk disease" as we pacer patients call it. :)  But I was told by a very respected pacer doctor that it is not true "open heart" that is needed but, "open chest".  They often from my understanding, cut and maybe cap the lead off where it enters the heart from the outside and then place the new lead. Open heart is where they cut open the heart, but open chest is just the chest, since the leads are in the tissue.   I was also told that if they do want the entire lead out that they can do this with a tiny cut in the right ventrical because it is an easy repair.  If you need the atrial lead replaced that maybe harder because the atrium is very thin. At least this is what I was told.

I wold ask about getting interrogated to find out what happened with being dizzy.  It maybe that the device and or lead is not working right and this would be the first thing to check out.  

You must check out all your questions with your doctor and see what they say.  It is very important to follow up with them.  They know the most about your condition.  
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Good luck to you.