Two Key Concerns About Pacemakers: Evaluation and Alternatives

Q: Two Key Concerns About Pacemakers: Evaluation and Alternatives

Hello Mr. <br>Wang： <br>1. <br>The reason for the implantation of a permanent cardiac pacemaker is due to the discovery of bradycardia with risks of syncope or sudden cardiac death, or directly due to symptoms of syncope determined to be caused by bradycardia, and the underlying

Two issues related to cardiac pacemakers?

Hello Dr.
Huang, my family member has a pacemaker which has caused tricuspid regurgitation.
The surgeon mentioned that observation and further tests are needed to assess whether surgery or other interventions are necessary.
However, there are two points that I couldn't find much information about online, so I would like to ask you:
1.
What diagnostic methods are used to determine if a patient can have their pacemaker removed? The surgeon mentioned that some patients have had their pacemakers removed after initially having them placed.
I recall that my family member received the pacemaker after a 24-hour Holter monitor indicated the need for one.
If they want to remove it, what kind of tests would be necessary to confirm that the pacemaker can be safely taken out?
2.
Regarding the type of pacemaker, the surgeon mentioned that if it cannot be removed and surgery is required, it is possible to replace the pacemaker with one that is implanted outside the heart.
I asked if this refers to a leadless pacemaker, but the doctor said no.
Could you please clarify the name of this type of pacemaker that is implanted outside the heart? Thank you, Dr.
Huang.

Mr. Wang, 30~39 year old female. Ask Date: 2022/02/27

Dr. Huang Yinghe reply Cardiology

Hello Mr.
Wang:
1.
The reason for the implantation of a permanent cardiac pacemaker is due to the discovery of bradycardia with risks of syncope or sudden cardiac death, or directly due to symptoms of syncope determined to be caused by bradycardia, and the underlying cause of the slow heart rate cannot be improved (commonly due to age-related degeneration).
Therefore, the pacemaker is not recommended for removal.
The leads of the pacemaker typically adhere to the inner wall of the vein they pass through after a few months, and removal requires special tools and poses a risk of vascular injury.
Thus, even if the pacemaker lead malfunctions and a new lead needs to be implanted, the old lead is often not removed.
In special circumstances, such as bacterial infection or severe tricuspid regurgitation requiring lead removal or valve repair, surgical intervention is necessary.
2.
Generally, the leads of the pacemaker are inserted into the heart via the subclavian vein (right atrium -> tricuspid valve -> right ventricle), and tricuspid regurgitation is not uncommon (approximately 1 in 4 individuals may experience it), but severe cases requiring surgical intervention are rare.
Another method for pacemaker implantation involves surgically placing the leads on the surface of the heart (in the space between the pericardium and the heart), with the pacemaker battery located in the upper abdomen, referred to as an epicardial pacemaker.
This method avoids the vascular system, reducing the risk of affecting cardiac blood flow; however, the downside is that it requires surgical implantation, and over the long term, the lead position may be more prone to dislodgement.

Reply Date: 2022/02/27

More Info

When considering the management of patients with pacemakers, particularly in the context of potential removal or replacement, there are several key factors to evaluate. Your concerns regarding the evaluation methods for determining whether a pacemaker can be removed, as well as the types of pacemakers available, are valid and important for understanding the patient's treatment options.

1. Evaluation Methods for Pacemaker Removal
To assess whether a patient can safely have their pacemaker removed, several diagnostic tests and evaluations are typically performed. The following methods are commonly used:
- Electrophysiological Studies (EPS): This invasive procedure involves placing catheters in the heart to assess the electrical activity and conduction pathways. It helps determine if the heart can maintain a normal rhythm without the assistance of a pacemaker.

- Holter Monitor: While a 24-hour Holter monitor may have been used to determine the need for the initial pacemaker, it can also be employed again to evaluate the heart's rhythm over an extended period. If the heart shows stable rhythms without significant bradycardia (slow heart rate) or other arrhythmias, it may indicate that the pacemaker is no longer necessary.

- Echocardiogram: This ultrasound test can assess heart function and structure, including the presence of any heart failure or other conditions that may necessitate continued pacing.

- Stress Testing: In some cases, a stress test may be performed to evaluate how the heart responds to physical exertion. If the heart can maintain an adequate rate and rhythm during stress, it may suggest that the pacemaker is no longer needed.

- Clinical Assessment: A thorough clinical evaluation by a cardiologist or electrophysiologist is crucial. They will consider the patient's symptoms, history, and overall cardiac health to make a recommendation regarding the pacemaker.

2. Types of Pacemakers and Alternatives
Regarding the types of pacemakers, the traditional pacemaker is typically implanted under the skin with leads that connect to the heart. However, there are alternatives that may be considered, especially if the patient requires surgical intervention:
- Leadless Pacemakers: These are small devices that are implanted directly into the heart without the need for leads. They are typically used for patients with specific types of bradycardia and can be a good option for those who may have complications from traditional pacemaker leads.

- Subcutaneous Pacemakers: These devices are implanted under the skin but do not have leads that penetrate the heart. They can provide pacing for certain types of arrhythmias and are an alternative for patients who may have issues with traditional lead placement.

- Cardiac Resynchronization Therapy (CRT): For patients with heart failure and specific conduction abnormalities, CRT can be an option. This therapy uses a specialized pacemaker to coordinate the contractions of the heart's chambers.

In summary, the decision to remove or replace a pacemaker involves a comprehensive evaluation that includes various diagnostic tests and clinical assessments. If removal is deemed appropriate, the specific type of alternative pacing device will depend on the patient's individual needs and cardiac condition. It is essential to have a detailed discussion with the cardiologist or electrophysiologist to explore the best options tailored to the patient's health status.

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