**3. Pacemakers to the rescue**

When I was 43 years old, I had some periods of time when I just did not feel well, and I felt like my heart was skipping beats at times and getting extra beats at other times. The results from an electrocardiogram caused my internist to outfit me with a Holter monitor for 24 hours. The results of the Holter monitor test showed I had developed intermittent left bundle branch block. Although it was impossible to tell for sure what was causing the left branch block, it seemed very likely that calcification in the aortic valve was pressing on the nerve going to my left ventricle and causing the nerve to periodically misfire. My internist referred me to a major hospital in the area for evaluation for a pacemaker. The cardiologist at the hospital insisted I needed both a valve replacement and a pacemaker. When he saw that I was not willing to undergo valve replacement, he recommended a pacemaker be implanted but insisted I would need a replacement valve within 2 years at the longest.

I got my first pacemaker when I was 44 years old. It was implanted by a semiretired surgeon who told me he got too tired standing during open heart surgeries but that implanting pacemakers was perfect for him because he did not need to stand very long during the procedure. I laid on the operating table and he gave me an injection of pain killer in my upper right chest. Then he entered the superior vena cava vein going from my right arm into my heart, and he strung the pacemaker leads through the vein into my heart. Once the wires were in place, he made an incision on my chest, forced open a "pocket" under my skin, connected the pacemaker wires, and slid the pacemaker into the pocket. Final steps in the procedure were the stitches and placement of a bandage over the wound, and I was sent home the next day.

The pacemaker was set at 55 beats per minute, and this rate was to cause me problems for many years to come. I found out many years later that the natural pace of my heart was 57 beats per minute. However, the pacemaker setting proved to be too close to my natural pace. Pacemakers are designed to wait and see if the heart will beat on its own. If the heart does not beat, then the pacer sends a signal for the heart to beat. My pacer was a dual pacer, so that the pacer would send a signal both to the top of the heart and to the middle (and lower sections) of the heart as needed. My upper sinus mode always worked well, but the signal had difficulty going through to the lower chambers of the heart. The heart has a sinus node both at the top and middle of the heart, and sometimes my pacer would send a signal for the lower sections of my heart to beat just as the natural signal from my heart was sending a signal. Thus, I frequently got double beats in the lower sections of my heart. Remember, all of this is happening in a fraction of a second, because the average heart will naturally beat 50 or more times per minute. Getting my pacemaker settings in concert with my natural beat settings was an issue for my physicians starting with that first pacemaker.

A few days after getting my first pacemaker, I needed to fly on a business trip from the East Coast to the Mid-West. The first evening of my business trip, my right arm swelled up to about double size. I called my internist back on the East Coast, and he directed me to the Emergency Room (ER) of a hospital near me. Two ER physicians examined me and could not tell what was causing my arm to swell. Out of an abundance of caution, they put me on a mild dose of antibiotics and told me to see the surgeon who had implanted the pacemaker as soon as I returned home. Besides being swollen, my arm had a slightly reddish color to it, but I was not in any pain. Back home and during my visit to the surgeon, he quickly advised that the wires from my pacemaker into my heart had blocked the vein returning blood from my right arm to my heart. We decided to make no medical intervention, and after about 6 weeks, my cardiovascular system grew new veins around the blockage and my arm size and coloration returned to normal. You can still see a lot of "extra" veins in my right chest.

I had one other scare with my first pacemaker about 10 days after it had been implanted. I was attending a professional basketball game with my sons. We were watching the game when my name was announced over the loudspeaker system of the stadium saying I was to contact my pacemaker physician immediately. I went to the stadium office and called the physician at the hospital as directed. The physician told me they had been reviewing my pacemaker data and felt they had made some incorrect settings on the pacemaker and wanted me to come in right away so they could correct the settings. The next morning, they made a number of changes in the pacer parameters. My understanding was that they changed the time the pacemaker would wait to see if the heart was getting a natural signal to beat. I could not feel any difference. They left the pacemaker beats per minute at 55.

My first pacemaker was needed by my heart only intermittently and remained in place for about 16 years. By then, I had semiretired and was scheduled to take a vacation trip from the East Coast of the United States to Australia. Although the battery had some charge remaining, my internist felt it best to swap out the old pacemaker for a new one and not take any chances on a pacemaker failure being so far from home and in a foreign country. I got my second pacemaker when I was 59 years old. Apparently, I was becoming more dependent on the pacemaker, because my second pacemaker lasted less than 5 years.

When I was 62 years old, the internist who had been tending to my heart issues for 35 years, retired for health reasons. He was having a rough time with his hip replacement. His first hip replacement was recalled, and after his second surgery, he got an infection and had to have the second hip removed. He needed to be home in bed and on antibiotics for a month awaiting a third hip surgery. Interestingly enough, he told me before he retired that he would have been a better physician had he been a patient earlier in his life. He felt he had lost control over all of his medical care, and he did not like the feeling of losing control.

A friend recommended a cardiologist to me who was taking new patients. This gentleman made a strong effort to go over my heart valve history, and he was especially interested in any discomfort I might be having in my chest. I told him that occasionally I had angina-like discomfort when I exercised, especially when it was cold, and especially after I had been sitting at my desk at work for a long period of time and then walked several blocks to the subway to go home at night.

This new cardiologist ran a few tests in his office and told me I had a blocked artery in my heart. He showed me a picture from his in-office tests confirming the blockage. He said he could not be certain which artery was blocked, but he was scheduling me for a heart catheterization to determine how much blockage existed and where. He told me that most likely I would be needing bypass surgery. He, personally, did not perform catheterizations, but he recommended a colleague of his, and the next week, I was in the hospital with his colleague performing my third catheterization. The technician assisting in the procedure said to me after the procedure: "In my twenty years of medicine, I have never seen anyone with larger and more wide-open coronary arteries than yours. You will not be needing bypass surgery anytime soon if ever." A few days later, back at my new cardiologist's office, he said he had misread the test data. He said he did not know that the fraction of a second delay in the pacemaker sending a signal for the lower chambers of my heart to beat would cause the tests to be invalid. He apologized profusely for having me undergo a totally unnecessary

#### *Perspective Chapter: Complication Using TAVR – A Patient DOI: http://dx.doi.org/10.5772/intechopen.112120*

catheterization. He unceremoniously dropped his office test results in the trash can next to his desk. He placed the catheterization results in my file as he explained that whatever chest dis-comfort I was having was not due to blocked arteries.

I received my third pacer when I was 64 years old. The placement of my third pacer did not go entirely as planned. I was not sedated for the procedure. The physician implanting the pacer and the technician assisting him started arguing about the size of the pocket and who would close my wound after the replacement pacer was in place. One of them pushed on the pacer when it was in my chest and the leads coming out of the pacer bent around the edge of the pacer. The technician stormed out of the procedure room and the physician closed the wound. Unfortunately, there was a significantly raised area around the pacer where the lead wire for the pacer was bent around the pacer and pushing up my skin above the pacer. The area became puffy in just a couple of days. My pacemaker physician had gone on vacation, and I was scheduled for a business trip from the East Coast to the West Coast. I consulted a different physician, and he believed the puffiness would eventually subside, and it did subside after several weeks. My third pacer lasted about 5 years.

I still have my third pacemaker in my right chest even though it is now inert, and the lead wires still push the skin up around the pacemaker. The reason for leaving the pacemaker in place is interesting. When I got my *fourth pacer*, I was 69 years old, and the leads to the old pacer were deteriorating. I was still semiretired and had moved from the East Coast back to the West Coast, and my new pacemaker cardiologist decided to put in a whole new pacer system on the left side of my chest – new pacemaker and new leads into the heart. He told me that one worry they always have when implanting pacemakers and wires is that an infection might occur on the pacemaker itself or on the wires. If he removed the old pacemaker on the right side at the same time he installed a new pacer system on the left side, and if I got an infection, he would not be able to tell whether the infection was on parts of the old wires still remaining in the right side of my chest, or if the infection was on the new system on the left side of my chest. Removing old wires, especially when they have been screwed into the heart muscle can be life threatening, and in cases like mine, the old pacer is usually removed, but the wires going into the heart are left in place. Hence, he made the very wise decision to leave the entire old system in place (pacer and wires) even though the old pacer was turned off when the new system was implanted.

The new pacemaker system on my left side required the new leads to go through the vein from my left arm into my heart. The procedure was similar to what I had gone through when I got my first pacer, it was just on the opposite side of my chest. The most significant difference was that this physician insisted upon me being under anesthesia for the procedure. Also, this was the first time I was told that I had become "pacemaker dependent." I was told not to worry, however, because the pacemakers were space-age technology. I did not find the space-age language comforting given all the problems that can and had occurred in space. A couple of my friends asked if it was difficult for me to live with the knowledge that if my pacer stopped working, I would die in a matter of seconds. Those questions were not reassuring to me as well. In the long run, I just had to shut out of my mind any worry about whether a pacemaker might stop working.

As mentioned, I received my fourth pacer when I was 69 years old. However, my luck was improving regarding battery life. My new pacemaker physician, working with the pacemaker company representative, decided to set my beats per minute at 50 in order to try and eliminate my double beat problems. That adjustment did work for

a number of years. My fourth pacer lasted for 7 years, and I received my fifth pacer when I was 75 years old. The double beat issue still was not a problem.

As mentioned, I had moved from the East Coast back to the West Coast, and my new cardiologist advised that in addition to my aorta issues, I had a prolapsed mitral valve. He explained that when someone, like me, has a large amount of blood flowing back into the left ventricle of the heart because the aorta valve does not close properly, that it puts pressure on the mitral valve and eventually may cause it to become prolapsed. He believed this was my situation. This is the first time I had been told I had a prolapsed mitral valve.

When I was 79 years old, I had an incident where I felt like I was going to pass out. The incident lasted for about 12 seconds. I saw my pacemaker physician a few days later, and fortunately, the newer pacemakers make a recording of any unusual disturbances in heart rhythm. This was not my first episode of feeling faint. I remember talking to a different physician years earlier about feeling faint, and he told me it was probably the pacer sending a wrong message to my heart. He told me to go into a limp position whenever I had that feeling, and I remember going limp on a few occasions in the past. The faint feeling always went away in a few seconds.

My pacemaker physician informed me that I had suffered a short run (14 seconds) of ventricular fibrillation (VF). He consulted with my cardiologist, and I checked into the hospital that night. The next morning, my pacemaker physician removed my fifth pacemaker and implanted a new combination pacemaker and defibrillator. I was informed that VF is a rapid life-threatening heart arrhythmia. It is sometimes referred to with a married male patient (like me), as "the widow maker." It can be that serious because when the heart is in VF, it cannot pump blood throughout the body. Fortunately, all my runs of VF had been short lived and self-corrected. It is when the VF continues for more than a few seconds that it becomes most dangerous. With the new combination pacemaker and defibrillator, I am now protected against the "widow maker."

While I was still 79 years old, I began having more extra beats and a return of the double beat problem – a worsening of a condition I had off and on since my early 40s. It was determined that I not only had extra beats but that I had atrial flutter as well. Atrial flutter occurs when the heart's electrical system tells the heart to beat faster. My pacemaker physician, in consultation with my cardiologist, recommended I undergo an ablation using a radio frequency procedure to burn out the extra signals. The ablation procedure itself is amazing to me. I was treated by a physician who specialized in such procedures. Using a grid that overlays the heart, the physician was able to determine where in my heart the extra signals were originating. A Radio Frequency (RF) catheter was inserted through my right groin femoral artery and into my heart. In my case, it turned out that the extra beats were coming from one spot in the annulus of the right atrium. The signal would originate in a nerve in the annulus and then travel in a circle around the annulus and cause the same originating nerve to fire again in a continuous loop. The physician burned or ablated the nerve where the extra beat was originating. In addition, he ablated another spot on the annulus just in case the originating nerve was not completely ablated. He did this to prevent any unwanted electrical signal from going in a circle and starting the extra beats to repeat as in the past. As it turned out, this was a smart move by the physician because subsequent tests showed the original unwanted firing of the nerve was still taking place on an intermittent basis. Now, however, the signal was blocked by the second ablation, and the repeated beats ceased. I still get an occasional extra beat, but nothing like before. Also, the physician was able to locate the source of the atrial flutter, my right atrium, and ablate the offending nerve. The atrial flutter has not returned.

My pacemaker physician set my new pacer at 70 beats per minute (bpm). This faster bpm stopped the double beat issue, and any serious problem with double beats has gone away. At first, I felt like my heart was racing. After all, I had been set at 50 bpm for many years, and I could tell the difference. My physician said to try the rate of 70 bpm for 3 months and we would go from there. For a while, I felt like my heart was working overtime and I seemed more tired. By the time 3 months rolled around, I was feeling better, and the double beats had largely subsided. Only occasionally now do I get extra beats that are bothersome. My bpm remains at 70.
