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HouseDoc, Attending Physician
Category: Medical
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Experience:  Licensed by the State of New York
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My 90 year old father is about 8 month post cardiac

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My 90 year old father is about 8 month post cardiac pacemaker implantation. His health has declined severely since the implantation, though several checks by the device tech (or whatever they are called) apparently show it to be functioning properly. He has become increasingly short of breath, unsteady on his feet, and is emotionally labile (which was not true prior to the surgery). He appears to have some abdominal distension. He saw his cardiologist today and is soon scheduled for an echocardiogram and an angiogram. I'm guessing that tricuspid regurgitation, maybe due to adhesions of the pacemaker leads, is the problem. If this is the case, the options are...what? Can the use of clip(s) correct the problem? Do the pacemaker leads have to be removed--and what are the risks of doing so? Is it possible to leave the leads in place and use a clip to "override" the action of the leads (if that is what has occurred)? Does it depend on which of the leaflets is impacted? I realize that this is a bunch of suppositions, but I'm trying to get a general notion of the severity of his situation and the likely outcome of any interventions. I know that 90 seems old, but he is from a long-lived family; his 97 year old brother died just last month; his father was 95 at the time of his death, etc.
Dr. Amit M. Shelat : The shortness of breath can be secondary to a couple of reasons. These can from such things as congestive heart failure, pneumonia, and pulmonary embolism. The lack of adequate oxygenation can affect his cognition. Emotional lability is more likely secondary to other causes such as depression. Patients whom have any type of cardiac surgery are known to develop a depressive disorder for reasons that are not fully understood. As much as it is easy to blame the pacemaker as the cause of all these changes, other possibilities need to be entertained.
Dr. Amit M. Shelat : Patients also have nutritional deficits such as B12, folate and thyroid dysfunctions which can lead them to develop an unsteady gait and mood changes. This also needs to be considered.

I agree. But since the cardiologist is now going to do the echo and the angiogram, she must be suspecting--or seeing--signs of leakage, which I think would be tricuspid regurgitation. I'm aware that a pacemaker lead can become affixed to the valves, and am guessing that is what she is looking for. If that is the case, I want to know if the lead has to be removed, which I know can be dangerous, or if the lead can stay in place and the improperly working valve be repaired with a clip, which I understand can be inserted through the vein...

Dr. Amit M. Shelat : The cardiologist can perform cardiopulmonary bypass during which the pacemaker system is removed and an accurate debridement of the tricuspid tissue is performed. Therefore to answer your question the lead can be removed without damaging the valve, clip placement is not absolute.

That would mean open heart surgery; I was hoping for a less invasive option. My father was very reluctant to have the pacemaker implanted, leery of anesthesia and recovery, and will be extremely resistant to open heart surgery. It scares me that his fear would make it less likely he would have a good outcome. Are you able to speculate as to how urgent such a surgery would be? I should note that his health prior to the implantation was very good, other than for some back pain due to arthritis, and the tachycardia which caused the need for the pacemaker.

Dr. Amit M. Shelat : I would want to know why the cardiologist wants to perform this procedure as there are other causes that need to be ruled out in order to determine the cause of your father's symptoms. If this surgery is elective, then clearly it should be done only after other causes have been ruled out. I think that you need to speak with the cardiologist regarding the reason form this procedure.

Thanks--I hope that my dad will allow me to do so--he doesn't like sharing personal information, nor is he likely to ask if non-heart related problems are at fault. It is frustrating to have to go behind his back, but it sounds as if I may have to do that. Thank you for your time and response; it has been helpful!

Dr. Amit M. Shelat : You're welcome. If you are finished with all your questions, please click accept.
Dr. Amit M. Shelat : Thanks!
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