Cleveland_Clinic_Host: Welcome Dr. Wilkoff, and thank you for being with us today. We look forward to an interesting chat today. Welcome! Let's begin with one of the questions!

Speaker_-_Dr__Bruce_Wilkoff: Thank you for having me today.

Pacemaker Device and Leads

smithvolt3: I also send my care link in every three months as I have the leads in my heart that are suspect to breakage. Any more information on the breakage? Thank you.

Speaker_-_Dr__Bruce_Wilkoff: All pacemaker and defibrillator leads are at some risk for breakage. The recent safety alert regarded a lead that had a higher rate of breakage than the prior lead. There is a preferred way to program the defibrillator to reduce the potential for you to have a problem.

Speaker_-_Dr__Bruce_Wilkoff: Some of the programming will prevent shocks from occurring and others will help to notify you and your doctor that the lead may be developing an early problem.

Speaker_-_Dr__Bruce_Wilkoff: It is still not recommended to remove these leads or add a new lead unless there is an actual - not just a theoretical problem - with the lead.

sherrym: My mom has to go in and get her pacemaker replaced next week. What is involved with that? How long do pacemakers usually last? Is the procedure dangerous?

Speaker_-_Dr__Bruce_Wilkoff: A pacemaker usually lasts between 5 and 10 years, depending on how efficient the leads are and the programming of the device.

Speaker_-_Dr__Bruce_Wilkoff: The replacement is a brief and relatively low risk procedure usually done without the patient staying overnight. At the Cleveland Clinic, even patients on anticoagulation, such as Coumadin, do not have the medication stopped before the procedure.

my_joy: when leads have been placed in the vein and scar tissue builds up, how extensive is the scar tissue within the vein? Does the scar tissue reform and occlude the blood vessel after leads have been removed?

Speaker_-_Dr__Bruce_Wilkoff: Every time there is an incision or injury or a lead put into a vein, there is a response from the body. The response is to heal, which produces a scar. Often, there is very little scar. But sometimes the vein will narrow significantly and even block after the placement of a pacemaker lead. When the leads are removed, only a little of the scar tissue is removed.

Speaker_-_Dr__Bruce_Wilkoff: It is sometimes appropriate to open up the vein with an angioplasty or stent but this is rare. Usually the old lead can be removed and the new lead be placed through the same vein.

my_joy: What is the likelihood that the removal of the lead head will trigger an arrhythmic event?

Speaker_-_Dr__Bruce_Wilkoff: Removing a lead is not likely to increase arrhythmias or produce an arrhythmic event. The risk of lead extraction is dependent upon the experience of the surgeon.

Speaker_-_Dr__Bruce_Wilkoff: The most likely problem is internal bleeding however at the Cleveland Clinic, the risk of major complications, including internal bleeding has been one third of 1 percent.

Internal Cardioverter Defibrillator (ICD)

stuart: I have a PCD in my left shoulder. I also have the patches sewn on my heart from a 15 year old PCD system. In the last two months I have had two surgeries to remove as much of the old leads as my doctor could reach without open heart surgery because my body seems to be rejecting it as a foreign body. There has been no growth on any cultures or fever. Have you seen this problem before? I have about four months before my battery needs replacement on the other PCD.

Speaker_-_Dr__Bruce_Wilkoff: PCD stands for pacing cardioverter defibrillator and is an older term for an ICD implantable cardioverter defibrillator.It is unlikely that your body is just rejecting the hardware. However, infections are common without positive cultures.It is important that as much if not all of the hardware be removed before new hardware is implanted as the body has trouble eradicating bacteria from metal and plastic objects.

michaels: My dad had a heart attack. They said he now needs a defibrillator. He does not have any heart rhythm problems. Why would he need a defibrillator?

Speaker_-_Dr__Bruce_Wilkoff: The determination of need for a defibrillator after heart attack is made at least 40 days after the heart attack.If the ejection fraction - which is the amount of blood or the percentage of blood ejected from the heart with every heart beat - is less than 35 percent, then the risk of sudden death is high and the defibrillator will reduce that risk.

Speaker_-_Dr__Bruce_Wilkoff: If you wait for him to have the cardiac arrest, then he would need to be rescued within 10 minutes for survival. Experience has told us that that happens only about 5 out of 100 times. If he has a defibrillator, he has almost a 100 percent chance of survival.

cleveland : Can a defibrillator shock cause damage to your heart?

Speaker_-_Dr__Bruce_Wilkoff: It is clearly better to get a shock than to die from ventricular defibrillation which is 100 percent fatal. However, there is a very small amount of damage that can be done by a shock.This can only be detected by doing very sensitive blood tests and there is no data to suggest that this is a real problem.

alston: Can you explain to me the difference between a pacemaker and a defibrillator?

Speaker_-_Dr__Bruce_Wilkoff: Implantable defibrillators have pacemaker function within them. The pacemaker treats bradycardia or slow rhythms and the defibrillator treats rapid heart rhythms - called tachycardia.An ordinary pacemaker is smaller and is not capable of treating the rapid heart rhythms. The ICD would treat both slow and fast heart rhythms.

johnnyc: If you have a defibrillator, can you still exercise? Is walking ok? Can I lift weights?

Speaker_-_Dr__Bruce_Wilkoff: One of the reasons that people receive implantable defibrillators is so they can return to active lives. Exercise is encouraged. However, only light weights or light weight training is appropriate as it may increase the risk of lead problems. The actual exercise that you do should be determined by the kind of heart disease that you have. The ICD should not restrict your activities much beyond that.

Atrial Arrhythmia

Greybeard: Which is a better choice for atrial flutter, heart ablation or pacemaker? When and why?

Speaker_-_Dr__Bruce_Wilkoff: There are several types of atrial flutter. Often, atrial flutter is confused with atrial fibrillation. Typical atrial flutter is a very specific fast heart rhythm that is very easily cured by ablation and should be considered the first choice therapy.

Speaker_-_Dr__Bruce_Wilkoff: However, there are many atypical types of atrial flutter which are more difficult to treat by ablation but are still sometimes amenable. Often, atrial flutter and atrial fibrillation are persistent no matter what therapy which could include medications, ablation, or even surgery. Especially when the heart rate is poorly controlled - means that it goes too fast with minor amounts of activity.

Speaker_-_Dr__Bruce_Wilkoff: A different type of ablation of the AV node and a pacemaker is an excellent choice.The ablation of the AV node keeps the heart from going too fast. And - the pacemaker keeps the heart from going too slow.There is a sensor in the pacemaker that adjusts the heart rate to be appropriate to the patient's level of activity. All patients with atrial fibrillation and flutter with few exceptions should be considered for anticoagulation therapy as well.

callieh87: I have atrial fib. I am 47 years old & was diagnosed last year. It seems I have episodes of irregular & rapid heart beats just before my period. Is it possible I may be suffering from a hormonal imbalance rather than atrial fib?

Speaker_-_Dr__Bruce_Wilkoff: Well - not all irregular heart rhythms or rapid heart rhythms are atrial fibrillation. The first step is to get a recording of the heart rhythms that you are having. Often people have the sensation of irregular heart rhythms when their heart actually is beating normally. This is the sensation of palpitations and frequently the body is inaccurate in determining what the actual situation is.

ginger26: With a history of AFib after open heart surgery but no signs of it since(6 Months) should I be on anticoagulation therapy? Right now I only take aspirin

Speaker_-_Dr__Bruce_Wilkoff: Atrial fibrillation after open heart surgery is very common about one third of the time. People will have atrial fibrillation in the first month or two.There is little to make us think that atrial fibrillation just after surgery has any long term implications.

Speaker_-_Dr__Bruce_Wilkoff: Anticoagulation long term is not usually necessary. However, you may have other reasons to be on coumadin, such as a mechanical valve, ventricular aneurysm, a history of a stroke, or many other things.

smithvolt3: I was in constant Atrial Fibrillation and had three cardioversion...none of which brought me back to Sinus Rhythm. My ICD went on three times at the end of 2007 one time each occurrence. The last time my ICD went off it brought my heart into sinus rhythm and I have be in sinus rhythm for over 3 months now. I have an appointment this Monday at the clinic with for my six months check up. Is there anything I should do that may help me stay in sinus rhythm?

Speaker_-_Dr__Bruce_Wilkoff: There are many reasons that you may be experiencing atrial fibrillation. Your doctor may want to check for high thyroid levels and valve problems. You may want to make sure that you aren't putting yourself at higher risk with smoking, excess caffeine, alcohol intake, or avoidable stress. It may be appropriate for you to be on a medication to reduce the frequency of the atrial fibrillation episodes.

Speaker_-_Dr__Bruce_Wilkoff: The ICD can also be programmed to handle the atrial fibrillation episodes without a shock and also to help your doctor know how frequent or how rapid your heart rhythm is during these episodes.

AV Nodal Ablation

Greybeard: If the AV Node is ablated, then what controls the heart rate? Is the patient totally reliant on the pacemaker? ... which could fail at some time...?

Speaker_-_Dr__Bruce_Wilkoff: When the AV node is ablated, the patients are usually somewhat dependent upon the pacemaker. However, when we do the ablation, we try to ablate closer to the atrium than the ventricle, which promotes an escape rhythm that makes the patient able to sustain their heart rate without their pacemaker.

Speaker_-_Dr__Bruce_Wilkoff: Also it is rare that a pacemaker would fail.

alston: My husband is 84 years old and a patient at the Cleveland Clinic. He has been in chronic a-fib for 8 months, has had two cardioversions and tried several medications, all to no avail. Now they are saying he needs an aorta valve replacement. Is that a good choice for a man of his age?

Speaker_-_Dr__Bruce_Wilkoff: It depends. Making a decision for surgery involves assessing how the patient feels, how the patient wants to feel and the likelihood that the symptoms would improve with surgery.

Speaker_-_Dr__Bruce_Wilkoff: There are risks to any surgery. The question is does the patient want to live with the risks of not having surgery or living with the risks of having the surgery. I suggest that you ask all these questions to your doctor.

Arrhythmogenic Right Ventricular Dysplasia (ARVD)

stuart23: My doctor just diagnosed me with ARVD. How do you know if you have that for sure? I went in because I was having a lot of arrhythmias. My doctor said I need a defibrillator. Are there other things I need to do to treat this? I am nervous about this diagnosis.

Speaker_-_Dr__Bruce_Wilkoff: ARVD is arrhythmogenic right ventricular dysplasia. This is a genetically inherited condition where the right ventricle and sometimes parts of the left ventricle are partially infiltrated with fatty tissue.

Speaker_-_Dr__Bruce_Wilkoff: Most patients do quite well but patients can have sustained ventricular tachycardia, which can cause fainting or sudden death.

Speaker_-_Dr__Bruce_Wilkoff: An implantable defibrillator is often an appropriate therapy and more appropriate than medications in most situations.

Speaker_-_Dr__Bruce_Wilkoff: You might consider a second opinion about the diagnosis as the reading of an MRI or CT scan or the other tests can be quite subjective.

Complete Heart Block

VivB89: Hi Dr. Wilkoff, I would like to know if research being done to "correct or reverse" total heart block. Also, do you foresee a time when pacemaker batteries will be recharged while still implanted in the patient? Thank you.

Speaker_-_Dr__Bruce_Wilkoff: There is some research being done to genetically engineer a replacement sinus node or AV node. These are the critical natural pacemakers of the heart.This work is still immature but promising. There already has been a rechargeable pacemaker that was produced in the 1970's. Patients were required to recharge their pacemakers by holding a wand over the site for several hours once a week.

Speaker_-_Dr__Bruce_Wilkoff: The problem is that the technology for a good pacemaker kept progressing and the therapy that was available from the rechargeable pacemaker gave the patient inferior therapy. In addition, lithium batteries became available that allowed for 5 - 15 year battery life. Even though we could have 15 years with every pacemaker, both patients and doctors keep asking for smaller pacemakers, which mean smaller batteries and battery lifes in the 5 - 10 year range.

Speaker_-_Dr__Bruce_Wilkoff: There were even nuclear batteries which would still be working 30 years after they were implanted but with very long battery lives - the leads also wear out before the battery.

Heart Failure

jjacksonwriter: Hi Dr. Wilkoff! For a patient with stage 4 congestive heart failure, how effective is a pacemaker for extending lifespan and/or enhancing their quality of life?

Speaker_-_Dr__Bruce_Wilkoff: Usually we classify heart failure by the New York Heart Assoc. Class. I, II, III, IV. If you are referring to Functional Class IV heart failure symptoms that means that you are short of breath at rest without any activity. There are two therapies possible. One is an implantable defibrillator and the other is a biventricular pacemaker.

Speaker_-_Dr__Bruce_Wilkoff: Depending on how persistent the symptoms are, it may be inadvisable to use either therapy however, usually with medications, the heart failure can be reduced to functional class III. Under these circumstances, both a defibrillator and biventricular pacing has demonstrated to significantly prolong life.

Speaker_-_Dr__Bruce_Wilkoff: It is important to understand that only people with systolic heart failure, which is the problem with the squeezing or pumping of the heart has been shown to be helped. People with diastolic heart failure - which is a problem with relaxation of the heart - there is little data that either therapy helps.

Wolff - Parkinson - White syndrome (WPW)

kathryn: My nephew has WPW. I am worried about him. Is it dangerous? How is it treated?

Speaker_-_Dr__Bruce_Wilkoff: WPW is a condition from birth and involves having a second connection between the lower and upper chambers of the heart. Usually the patient will have intermittent rapid heart beating.

Speaker_-_Dr__Bruce_Wilkoff: This is curable with an ablation with very little risk. Although the risk of WPW is small in most patients there are some patients, particularly patients with very frequent or very rapid episodes that should have this ablation.

Speaker_-_Dr__Bruce_Wilkoff: Sometimes medications or no therapy at all is required and the finding on the EKG is only a curiosity rather than a problem.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Wilkoff is over. Thank you again for taking the time to answer our questions today.

Speaker_-_Dr__Bruce_Wilkoff: Thank you for having me.

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