Cleveland_Clinic_Host: Welcome Dr. Wilkoff and thank you for being with us today. Let's begin!

Speaker_-_Dr__Wilkoff: I am happy to be here today

Pacemakers

worried: My father had a pacemaker placed 3 months ago and now has an infection. How often do these devices get infected? If they have to take the device out due to infection. When can they replace it and will it be put in the same area

Speaker_-_Dr__Wilkoff: You should ask your doctor what his local statistics are. The first time a pacemaker or defibrillator is implanted the infection rate should be less than 0.5%. When the pacemaker or defibrillator is replaced, the infection rate is higher and should be less than 3%.

michhope: what is pacemaker syndrome?

sandy_l: How long people do people live with a pacemaker if you have third degree heart block? Do you need to keep getting them? Can they put the pacemaker in other places than on top of your chest. I need a pacemaker and I am young.

Speaker_-_Dr__Wilkoff: Third degree block is also called complete heart block. And - refers to when the impulses from the atrium are blocked completely from going to the ventricle. Usually the ventricular rate is too slow and puts the patient at risk of fatigue, fainting, and occasionally faster serious heart rhythms. Some people are born with heart block and do well for one to three decades before needing a pacemaker. But if heart block develops after birth, it is an absolute indication for continuous pacemaker therapy.

Speaker_-_Dr__Wilkoff: Pacemakers can be placed in other locations. There are ways of putting it under the breast, under muscle tissue, or in the abdominal wall.

jimcala: I have a pacemaker and sometimes I get shoulder pain numbness or tingling in the fingers of the arm that I have the pacemaker in. Is that normal? Is there something wrong with my pacemaker?

Speaker_-_Dr__Wilkoff: Numbness or tingling in the fingers or arm is not common after a pacemaker placement. It is most likely related to irritation of the nerves from your spine, it may be related to arthritis. Rarely it is possible that the nerves could be irritated by the leads in the shoulder or be part of something called thoracic outlet syndrome. You should be evaluated by a pacemaker and potentially a neurology physician.

gerryn: If you have a pacemaker can you still get a mammogram?

Speaker_-_Dr__Wilkoff: Yes but it may be more uncomfortable and the pacemaker does reduce the accuracy of the mammogram. Sometimes the pacemaker will block part of the breast from view.

charlesak: If I need to have a pacemaker - after the pacemaker implant can I drive, and what about airbags? Is it ok to sit in the front seat?

Speaker_-_Dr__Wilkoff: Good question. You can drive after the pain subsides and the incision is healing. Usually that means after about one week. You can sit in the front seat. You can drive. Airbags are fine.

Defibrillator and Pacemaker Wires

coolchris: I have an aunt that needs has an infection in her defibrillator wires. How do you remove the wire? Can she have another one placed in there?

Speaker_-_Dr__Wilkoff: Pacemaker leads and defibrillator leads are placed through veins that lead to the heart. When they are first placed there is little scar tissue to hold them in position. But, with time, the scar tissue can be significant. Special tools including a locking stylet and extraction sheaths are used to gently break up the scar tissue and remove the leads. This is called transvenous lead extraction. Not all pacemaker physicians are capable to perform this procedure. There are several centers including the Cleveland Clinic that are expert and do many lead extractions of patients are referred for lead removal. There is risk but the infection cannot be cured without removing the pacemaker or defibrillator leads and treating with antibiotics.Our experience at the Cleveland Clinic is better than published statistics. Our experience is that less than 0.3% of people have serious complication from this procedure but it is common for 2 -3 % complication rates to be observed.

Speaker_-_Dr__Wilkoff: A new pacemaker can be placed after several days from the other shoulder.

lmartin4: What is your opinion on the Excimer laser lead extraction sheath when removing a defibrillator chip due to infection as cited in PubMed @ Beth Israel Deaconess Medical Center, Boston MA as a safe and effective??

Speaker_-_Dr__Wilkoff: There are several types of lead extraction sheaths. There are steel, teflon, polypropylene, laser, electrosurgical, and other mechanical sheaths. Each of these sheaths are designed to break up safely the scar tissue between the leads and the vein and heart. Excimer laser sheaths are probably the most powerful tool and melt away scar tissue at the tip of the sheath. Being the most powerful tool can also be dangerous. Melting through scar tissue can also melt through the vein wall or the heart and cause life-threatening bleeding. However, serious scar tissue needs serious tools. The most important key to safe lead removal is the experience and skill of the extracting physician. Our experience at the Cleveland Clinic shows that laser lead extraction can be done with major complication rates less than 0.3 percent instead of the 2 to 3 percent reported other places.

lmartin4: What is the frequency of lead wire removals post 3 year implantation and what is the mortality rate of this procedure?

Speaker_-_Dr__Wilkoff: Lead extraction is done for three major indications: infection, lead failure, and venous occlusion. Infections occur for first implants less than 0.5 percent but can present years after implantation. After replacement surgery, the infection rate is 2 to 3 percent.

Speaker_-_Dr__Wilkoff: Lead failure occurs depending on the implant technique, lead construction, and various patient factors. Defibrillator leads fail more commonly than pacemaker leads but the overall failure rate should be less than 5 percent at 5 years.

Speaker_-_Dr__Wilkoff: Venous occlusion can present with patient symptoms of swelling, or the failure to implant a new lead when an old lead has stopped working. This is increasingly an important indication for lead extraction as patients are upgraded from pacemakers to defibrillators or defibrillators to biventricular devices. The frequency of this depends on how the patient indications for a device changes.

jstar55857: How long does the 3 leads pacemaker defibrillator usually last till it must be replaced

Speaker_-_Dr__Wilkoff: Pacemakers, defibrillators and biventricular (3 lead) pacemakers all have lithium based batteries. Because there are three leads and because there is a defibrillator these devices can deplete their batteries more quickly than others. However, most of the battery is used to monitor the heart rhythm. How long your device will last you is sort of like a bottle of ketchup. A teaspoon once a week lasts a long time, a tablespoon every Friday night, much less. On average, between 3 and 5 years.

Defibrillators - ICDs

vogen: I am a 41 yr old athlete with history of aortic heart repair 7 yrs ago, and recently went into cardiac arrest via V-Fib ... no visible damage from cath, and EP study couldn't induce V-FIb, but still decided to put in St.Jude's ICD/Pace ... I am recovering slowly and wondering what is the typical recovery time from this type of episode ... and what are the potential side effects from the cardiac arrest/V-Fib/shock, and the ICD devise long term

Speaker_-_Dr__Wilkoff: You are right to take a long term perspective with this problem. Defibrillators (ICD) are long term strategies to manage your risk of sudden death. Usually the ICD will just monitor your heart rhythm and will not affect your life. You can be confident that it is both watching and will protect you.

Speaker_-_Dr__Wilkoff: However, you need to have your defibrillator checked on a regular basis. This consists of checks either in your physician's office or your defibrillator can be checked from your home using a remote interrogation tool. There is a lot of information stored about you and your heart rhythm in the defibrillator and it is constantly checking itself to make sure it is working well. Recovery from the cardiac arrest depends on how long you were in ventricular fibrillation before you were rescued and if there was any problem with your brain function after the resuscitation. If you have no memory problems now you should be ok. If you had cpr, your chest may be sore for a while. But, long-term, you should do well.

hank: My wife is 40 years old. She had a heart attack, has regular heart beat, but has a low ejection fraction. The doctors want to place an ICD, my wife is reluctant. Does she really need it?

Speaker_-_Dr__Wilkoff: This is a very important question. Patients with scarring on the heart muscle and particularly patients with a low ejection fraction are at high risk for sudden cardiac arrest. There have been several studies examining the risk of death with and without a defibrillator. Her risk is significantly increased if her ejection fraction is 35% or less. It is probably increased even if it is not 35% but we have less information about that. The ICD significantly increases the chances that your wife will be alive if she has it implanted. This is long term strategy to save her life and to help you and her go back to a normal lifestyle.

Speaker_-_Dr__Wilkoff: If she does not have the defibrillator implanted her only chance of survival with a cardiac arrest would be if an emergency squad can rescue her in less than 10 minutes. The chances of that are less than 5 percent. With an implantable defibrillator she would be rescued in seconds and have nearly 100 % chance of survival.

frank: I have an ICD for inducible Vt. Can I still exercise?

Speaker_-_Dr__Wilkoff: Absolutely. The reason that you have a defibrillator is to protect you so that you can go back to life. However, your primary heart disease might limit the types and intensity of your exercise. The defibrillator is less likely to break than your bones are. If you have a particular exercise that you are interested in pursuing, you should discuss this with your electrophysiologist. The one type of exercise that is not a good idea is heavy weight lifting. Light weights are ok.

Atrial Fibrillation

caroln: If you have atrial fibrillation and have a pacemaker and you are still having symptoms, can you get one of those procedures to stop the atrial fibrillation?

Speaker_-_Dr__Wilkoff: The procedure you are referring to is called an atrial fibrillation ablation or a pulmonary vein isolation procedure. It can be done with catheters through your veins or sometimes surgically. Whether you have a pacemaker or not does not determine whether or not you can have an atrial fibrillation ablation. This is a complicated question and you need to have a consultation with an electrophysiologist to make this decision.

Marfan: I have Marfan Syndrome and I had an AVR in 1985. Over the last four or five years I have had increasing bouts of Atrial fib. After falling and having a hemorrhagic stroke in 2005 I have been in Atrial fib constantly. I was cardioverted several times and have taken a number of different medications with out relief. At the recommendation of my cardiologist I was referred to a specialist. Last week I had a cardiac ablation and a St. Jude pacemaker inserted. What should I expect now? So far I feel a little better but I still have some dizziness. Will this resolve itself in due time? They discontinued the cartia and cut the toprol to 25mg 2xday. I take diclophenec for joint issues and coumadin for the valve. I'm hesitant to ask what might be next with heart valves/pacemakers etc but appreciate any information you can share. Thank you very much.

Speaker_-_Dr__Wilkoff: I hope you feel better soon. It sounds like you had an AV node ablation and ventricular rate responsive pacemaker inserted. The AV node ablation will you keep your heart from going too fast in the atrial fibrillation and the pacemaker will keep your heart from going too slowly. There is a sensor in the pacemaker that can be adjusted to give you the appropriate heart rate with various activities.

Speaker_-_Dr__Wilkoff: I don't know the cause of your dizziness which could be from a lot of different things. But, the pacemaker rate response adjustments may help with this matter. The most reassuring part of this therapy is that you can be certain that your heart rate will no longer go too fast from the atrial fibrillation and that the pacemaker can be adjusted to give you the right heart rate at the right times.

jeschr: I had mitral valve repair and the Maze procedure in 2002. Since then I have had 3 ablations and am still having atrial fib and flutter. My dr wants to insert pacemaker and then do AV node ablation. I read on your last month chat that the AV node ablation is rarely done now, am I just to the point that Av node ablation is my only choice?

Speaker_-_Dr__Wilkoff: Sometimes, and AV node ablation and pacemaker is the right answer. However, we have been very successful at the Cleveland Clinic in restoring sinus rhythm in patients who have failed with other attempts. It is not possible to determine this unless you were evaluated in our atrial fibrillation center. We have been successful in Maze patients and previously ablated patients on a frequent basis.

Syncope

lawrence: I have been recently diagnosed with Neurocardiogenic syncope in which I passed out because my heart rate dropped into the thirties. Most of the time I am fine in the low fifties. I don"t know if I will ever need a pacemaker, and I was wondering if you think some further advance in medicine might fix this problem without the use of pacemakers or medicine?

Speaker_-_Dr__Wilkoff: Neurocardiogenic syncope or sometimes called vaso-vagal syncope, is a problem of the autonomic nervous system. It is not usually dangerous but it is hard to treat. We have been doing tilt table examinations for this condition for over thirty years. Dr. Fouad pioneered the use of hemodynamic tilts to determine the particular or predominant cause in individual patients. Pacemakers are sometimes helpful, medications are sometimes helpful, but there appears to be no cure or great alternatives coming up in the near future. However, most people learn to live with some modest accommodations of their activities of living. There are some specialists that you can see to evaluate your options

Bradycardia

runningbarb: I have bradycardia. At first I thought it was because i exercise a lot. My doctor suggested a pacemaker - are there other choices to treat bradycardia. If I need a pacemaker, what kind of pacemaker should I get to help me continue to exercise?

Speaker_-_Dr__Wilkoff: There is a lot of confusion about what is inappropriate bradycardia needing a pacemaker and what is within the normal range of heart rates. Exercise does cause a modest lowering of the heart rate, but normally the heart rate will still increase with exertion. If the heart rate does not increase with exertion, that is called chronotropic incompetence and can sometimes be well treated with a pacemaker. There is no other treatment for bradycardia but sometimes it is the effect of medications and it is sometimes possible to stop those medications

michellel: I am a 35 year old female. Over the past 3 years, I have had 3 ablations for atrial tachycardia. My ekgs show I have sinus bradycardia of about 51 - sometime I have counted 45. I sometimes feel dizzy and tired. Do I need a pacemaker.

Speaker_-_Dr__Wilkoff: Maybe. It sounds like you have developed chronotropic incompetence. The sinus node is supposed to respond to your level of activity and if your heart rate is inadequate with exertion to maintain your cardiac output or blood pressure as manifest by lightheadedness or fatigue, a pacemaker could be the answer. Inside the pacemaker is a sensor that can be set to replace the heart rate response that your sinus node is supposed to give you. A key test would be either a treadmill exercise test or a holter monitor to determine how your heart rate increases with exertion.

Tachycardia

kristyj: I have sinus tachycardia and I am on a beta blocker. It happens when I exert myself. It goes up to 160 with walking around but slows back down if I sit. I do not like the beta blocker. It makes me tired. Is it safe to just have the tachycardia and not be on the beta blocker?

Speaker_-_Dr__Wilkoff: Tachycardia that is persistent can cause a serious problem with your heart muscle - called cardiomyopathy. Beta blockers can cause side effects including fatigue and it is often difficult to manage the long term risk of persistently fast heart rates vs. the side effects. You might discuss with your electrophysiologist the option of a sinus node modification. This is not done frequently or lightly but can be another option.

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

Speaker_-_Dr__Wilkoff: Thank you for having me today.

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