Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome and thank you for asking on HCM!

I passed carefully through your question and would explain that when considering pacemaker removal (especially intra-cardiac leads), a high level expertise is required and this offered new strategy by utilizing laser techniques, seems to be a safe and rational alternative.

Now, returning to the indications for replacement of an already implanted ICD-pacemaker, at least two points that should be considered:

1- If the implanted device is malfunctioning, then its replacement is an absolute indication.

2- If your ICD pacemaker is properly functioning, and the only reason for its replacement appears to be any indication for special test like MRI (which requires compatible ICD-pacemaker device to avoid electro-magnetic interference), than this decision should be made after carefully reviewing your co-morbidity index (several additional diseases, that may inevitably require MRI testing). You should discuss with your attending physician about these issues.

Another point to consider is the modality of the new proposed pacemaker.

It is well known that a single chamber ventricular pacing device may trigger atrial fibrillation.

Considering the fact that you have 17% of the time atrial fibrillation, it would be advisable that the new device could offer sequential atrio-ventricular pacing and if necessary bi-ventricular pacing (CRT).

Your previous implanted stents and bypass do not seem to impede the newly proposed device implantation.

You should discuss with your doctor on the above mentioned issues.

Hope to have been helpful!

Feel free to ask me again if your have any other uncertainties!

Kind regards,

Dr. Iliri

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Brief Answer:
My opinion as follows:

Detailed Answer:
Hello again!

As I explained you before, replacement of an already implanted pacemaker would be absolutely beneficial if:

1) The actual pacemaker is not functioning properly anymore (end of life battery or newly detected sensing or pacing lead abnormalities due to local underlying fibrosis);

2) If a new cardiac pacing modality with additional beneficial effects is necessary.

Let me explain you on this latter alternative:

a) If your already implanted pacemaker is VVI(R), what means that only a single ventricle is paced (right ventricle), then a more physiological pacing modality such as atrio-ventricular sequential (dual-chamber)pacing (which means two leads one in the right atrium and one in the right ventricle leading to consecutive atrial and ventricular contractions just like the normal cardiac physiology is) would offer a more beneficial treatment strategy and also avoid certain complications due to single chamber pacing (pacemaker syndrome, atrial fibrillation triggering, etc.)

b) If you have an impaired cardiac function due to your previous heart disease, and evidence of cardiac dyssynchrony are present (revealed by ECG and cardiac ultrasound), then you may benefit from what is called cardiac resynchronization therapy (CRT), which is achieved by implanting a three leads pacemaker (biventricular pacing), that is one lead inside the right atrium, one in the right ventricle and one inside the coronary sinus (corresponding the left ventricle). In such case and increase in left ventricular ejection fraction (LVEF) and overall cardiac performance could be attained.


Now, to make it more clear and easy to understand, I could summarize that if you change from a single chamber pacemaker to a dual-chamber pacemaker (DDDR) or a cardiac resynchronization therapy (CRT) according to the underlying medical indications, then I would recommend pacemaker replacement.

In other words, if section 1) is true (pacemaker malfunctioning) or one of the points a) or b) is indicated, then I would totally agree on the decision of pacemaker replacement, as it would offer an improvement on your quality of life.

Hope to have clarified your uncertainties!

Anyway, I remain at your disposal for any further questions.

Regards,

Dr. Iliri

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Brief Answer:
I would explain as follows:

Detailed Answer:
Hello again!

1-Regarding Amiodarone, I would explain that it is a reasonable alternative in the patients with recurrent atrial fibrillation episodes, such as in your case.

It is true that amiodarone may exert potential adverse effect: it may lead to pulmonary fibrosis, liver dysfunction, thyroid dysfunction, abnormal skin and corneal deposits, etc..

It may be safely used under close periodic monitoring, checking additional tests:

- a yearly chest X ray study
- thyroid and liver function tests
- blood electrolyte levels
- ophthalmologist examinations.

Other anti-arrhythmics may be used instead of amiodarone, such as:

- propafenone
- flecainide, but before starting one of them, it is necessary to exclude active cardiac ischemia or a markedly depressed left ventricular ejection fraction, as they both may further depress myocardial function.

2- As I have explained you at the beginning of our thread, a cardiac ultrasound is necessary to evaluate the overall cardiac performance, especially left ventricular ejection fraction.

Also, by means of echo, cardiac contraction dyssynchrony may be revealed and in such way an indication for cardiac resynchronisation therapy (CRT) may be determined. An EF less than 35%, would be a marker of seriously impaired cardiac performance and a determinant for optimization of your current cardiac therapy.

Hope to have clarified your uncertainties!

Wishing all the best,

Dr. Iliri

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