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  • Interesting article....

    [Interesting article....]

    Author: Heather (65.247.157.---)

    Date: 12-21-02 08:12

    I found this article on the a-fib list I've been reading.......I don't like what I've read really...... I have the dual-chamber pacer and they have my low HR set at 70, which makes me pretty much continuously paced because before my low HR was anywhere from 50-60. So, I'm wondering if I really need it set this high and need this much pacing help, espcially after reading this article.....What do you guys think?? I'm not scheduled to see my local dr. until March 12, which kind of upset me, because the drs. at Mayo said I should have my pacer/ ICD checked 1 mo. after having it implanted, but my local dr. said not to worry about it for 3 mos. after he saw me last. Maybe I should try to get in sooner.

    Heather

    Article:

    ‘Bigger is not always better; more sophisticated is not always an improvement.’

    — DR. BRUCE WILKOFF

    Cleveland Clinic IT DOESN’T challenge the benefit of implanted defibrillators, which zap rapidly irregular heartbeats back to normal. The devices have been shown to prevent cardiac arrest.

    Most of the newer models also feature built-in pacemakers, which help maintain a normal heart rhythm.

    But most patients who need defibrillators are likely only to need less sophisticated devices equipped with a backup pacemaker, the research suggests. The backup pacemaker stimulates the lower heart chamber when the beat becomes too slow.

    The researchers found increased risks with newer models featuring pacemakers that supply electrical impulses to the upper and lower heart chambers.

    The newer, dual-chamber devices can be programmed to continuously regulate the heartbeat — even though most people who get them don’t need that much help, said researcher Dr. Bruce Wilkoff of the Cleveland Clinic.

    Many doctors assumed the extra help would be beneficial for defibrillator patients, since previous research showed that stand-alone dual-chamber pacemakers helped other heart patients do better, Wilkoff said Thursday.

    But in the study, within one year of getting the implants, 26.7 percent of the dual-chamber patients died or were hospitalized with heart failure, compared with 16.1 percent of patients who got only backup pacemaking help.

    STUDY HALTED

    The researchers halted the study early because of the poor results, which could translate into thousands of hospitalizations or deaths worldwide each year.

    “Bigger is not always better; more sophisticated is not always an improvement,” Wilkoff said.

    An estimated 80,000 defibrillators have been implanted worldwide this year. While about three-fourths of them are the more sophisticated devices, only about 5 percent of patients need the extra help, Wilkoff said.

    The study appears in the Dec. 25 issue of the Journal of the American Medical Association.

    A study earlier this year suggesting that millions of heart patients could benefit from defibrillators raised concerns about the costs. The new study could help fine-tune which patients could get by with the less expensive models, said Dr. Sidney Smith, the American Heart Association’s chief science officer.

    Smith noted the new study included many patients with mild heart failure and didn’t address whether dual-chamber devices would be better than less costly ones for the sickest heart patients.

    BACK-UP PACEMAKING BEST

    Wilkoff’s research involved 506 people with heart disease or previous heart attacks, though none required continuous pacemaking help. All had defibrillators containing the more sophisticated pacemakers, but the continuous dual-chamber action was activated in only half the patients.

    Wilkoff said dual-chamber devices may be more risky because continuously stimulating the right ventricle, one of the heart’s lower chambers, may make the pumping action less efficient.

    Defibrillators with pacemaking features are generally small, flat metal devices that come in different shapes and sizes. The devices alone can cost between $16,000 and $25,000. The more sophisticated ones are at the upper end of that range and can cost about $5,000 extra to implant, Wilkoff said.

    The sophisticated devices have other benefits, including helping doctors track heart function, but the results suggest that fewer should be used, Wilkoff said. In most cases, those that are implanted should be programmed to provide only backup pacemaking help, he said.

    Michael Coyle of St. Jude Medical Inc., which made the devices in the study and funded the research, said the results show “that careful attention must be paid to the programming of pacemaker functions” to minimize effects in defibrillator patients who don’t need the extra help.

    Johns Hopkins Medical Institutions’ Dr. David Kass, a paid consultant for Guidant Inc., which makes similar devices, said in a JAMA editorial that more data are needed to determine if the “simpler solution” is best.

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Interesting article....]

    Author: Linda, Bd of Directors (---.wmnsmd.adelphia.net)

    Date: 12-21-02 10:12

    Heather, Who actually wrote this article? I read references in the article as to where the author got his info. As to your situation, it may not apply to you. There are so many different modes of pacing and reasons for each. Take the article with you when you see your cardiologist. Call the office and clarify with them again that you were told to see him within one month, let them know you have questions. You may not be paced in the right ventricle, and that is the focus of the study if I read the article correctly. Some people are only paced from the right atrium and receive rt ventricular pacing only as backup. Too many variables to assume you fit into this picture. You have to talk to your doctor and have him explain your settings and if you fit the picture portrayed in the article. Then go from there. It is always good to question, keep doing so till you understand. Also, you didn't say if you have A fib, and you may be paced with that in mind. Notice, the article didn't address A fib. Lots of little tidbits to consider. Hope this helps ease your mind till you talk to your Dr, Linda

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Interesting article....]

    Author: Heather (65.247.157.---)

    Date: 12-21-02 11:17

    I never saw an actual source for the study, but the articl was in with MSNBC's news/health articles. I don't have a-fib right now. I did have it for 2 mos. and this was a major factor in going to the Mayo. I've been converted since I got my PCD Nov. 11. I feel 100% better! So, I will copy the article and take it with me to the dr. Thanks for your reply!

    Heather

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: Interesting article....]

    Author: Tim Stewart (---.dsl.dytnoh.ameritech.net)

    Date: 12-21-02 12:54

    There were a number of articles published in a variety of news papers and other sources quoting Dr. Wilcoff. All of these referenced a soon to be published study by JAMA which can be read at: http://jama.ama-assn.org. Although I could not find this exact article's source, I will post other related articles that I found.

    Thanks, Tim

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [HEADLINE: DEFIBRILLATORS: NEW DEVICES MORE DANGEROUS THAN OLD, STUDY; FINDS]

    Author: Tim Stewart (---.dsl.dytnoh.ameritech.net)

    Date: 12-21-02 12:56

    Copyright 2002 National Journal Group, Inc.

    American Health Line

    December 20, 2002 Friday

    SECTION: RESEARCH NOTES

    LENGTH: 392 words

    HEADLINE: DEFIBRILLATORS: NEW DEVICES MORE DANGEROUS THAN OLD, STUDY; FINDS

    BODY:

    Newer and "more sophisticated" implanted cardiac

    defibrillators known as dual-chamber devices, which stimulate

    both the heart's right atrial chamber and its right ventricle,

    may be more likely to lead to heart failure or death in patients

    than older, more simple devices that stimulate the ventricle

    only, according to an early release of a study to be published

    in next week's Journal of the American Medical Association, the

    Washington Post reports. The study, conducted by researchers at

    the Cleveland Clinic and other facilities, studied 506

    defibrillator patients at 37 hospitals nationwide. Half of the

    participants received devices set to stimulate both chambers of

    the heart, while the other half had defibrillators programmed to

    stimulate only the ventricle. The study was terminated in

    September after two years after researchers found that about 26%

    of patients with the dual-chamber device were hospitalized for

    heart failure or died, compared to 16% of those with

    ventricle-only stimulation. While it is not completely clear

    why the dual-chamber devices are more dangerous, study lead

    author Bruce Wilkoff said stimulating both parts of the heart

    may cause the beating to become "dangerously uncoordinated,"

    according to the Post (Stein, Washington Post, 12/20). The

    study does not question the benefit of implanted defibrillators

    (Tanner, AP/Las Vegas Review-Journal, 12/19). IS OLDER BETTER?

    The dual-chamber devices cost around $25,000 each, while

    the older models cost around $20,000 each (Burton, Wall Street

    Journal, 12/20). The older and newer devices had never

    previously been tested against each other, the Post reports.

    The study is the most recent of several that have found that

    "the newest, more complicated medical treatments and

    technologies are not necessarily the most effective," the Post

    reports. This week, another study found that diuretics, an

    older class of blood pressure medications, appear to be

    preferable to newer and more expensive blood pressure drugs.

    David Kass of the Johns Hopkins Medical Institutions in

    Baltimore said, "Just because we can do something doesn't

    necessarily mean we should do it" (Washington Post, 12/20). The

    early release of the study is available online at

    http://jama.ama-assn.org/issues/v288.../joc21929.html.

    LOAD-DATE: December 20, 2002

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [HEADLINE: Newer implanted defibrillators are riskier than old, study finds]

    Author: Tim Stewart (---.dsl.dytnoh.ameritech.net)

    Date: 12-21-02 12:57

    Copyright 2002 The Deseret News Publishing Co.

    The Deseret News (Salt Lake City, UT)

    December 20, 2002, Friday

    SECTION: WIRE; Pg. A04

    LENGTH: 724 words

    HEADLINE: Newer implanted defibrillators are riskier than old, study finds

    BYLINE: By Lindsey Tanner AP medical writer

    BODY:

    CHICAGO -- A new study has linked widely used, more sophisticated heart defibrillators with a slightly increased risk of hospitalization and death.

    The study questions the value of a costly pacemaking feature in the newer defibrillators similar to the device implanted in Vice President Dick Cheney last year.

    It doesn't challenge the benefit of implanted defibrillators, which zap rapidly irregular heartbeats back to normal. The devices have been shown to prevent cardiac arrest. Most of the newer models also feature built-in pacemakers, which help maintain a normal heart rhythm.

    But most patients who need defibrillators are likely only to need less sophisticated devices equipped with a backup pacemaker, the research suggests. The backup pacemaker stimulates the lower heart chamber when the beat becomes too slow.

    The researchers found increased risks with newer models featuring pacemakers that supply electrical impulses to the upper and lower heart chambers.

    The newer, dual-chamber devices can be programmed to continuously regulate the heartbeat -- even though most people who get them don't need that much help, said researcher Dr. Bruce Wilkoff of the Cleveland Clinic.

    Many doctors assumed the extra help would be beneficial for defibrillator patients, since previous research showed stand-alone dual-chamber pacemakers helped other heart patients do better, Wilkoff said Thursday.

    But in the study, within one year of getting the implants, 26.7 percent of the dual-chamber patients died or were hospitalized with heart failure, compared with 16.1 percent of patients who got only backup pacemaking help.

    The researchers halted the study early because of the poor results, which could translate into thousands of hospitalizations or deaths worldwide each year.

    "Bigger is not always better; more sophisticated is not always an improvement," Wilkoff said.

    An estimated 80,000 defibrillators have been implanted worldwide this year. While about three-fourths of them are the more sophisticated devices, only about 5 percent of patients need the extra help, Wilkoff said.

    The study appears in the Dec. 25 issue of the Journal of the American Medical Association.

    A study earlier this year suggesting that millions of heart patients could benefit from defibrillators raised concerns about the costs. The new study could help fine-tune which patients could get by with the less expensive models, said Dr. Sidney Smith, the American Heart Association's chief science officer.

    Smith noted the new study included many patients with mild heart failure and didn't address whether dual-chamber devices would be better than less costly ones for the sickest heart patients.

    Wilkoff's research involved 506 people with heart disease or previous heart attacks, though none required continuous pacemaking help. All had defibrillators containing the more sophisticated pacemakers, but the continuous dual-chamber action was activated in only half the patients.

    Wilkoff said dual-chamber devices may be more risky because continuously stimulating the right ventricle, one of the heart's lower chambers, may make the pumping action less efficient.

    Defibrillators with pacemaking features are generally small, flat metal devices that come in different shapes and sizes. The devices alone can cost between $16,000 and $25,000. The more sophisticated ones are at the upper end of that range and can cost about $5,000 extra to implant, Wilkoff said.

    The sophisticated devices have other benefits, including helping doctors track heart function, but the results suggest that fewer should be used, Wilkoff said. In most cases, those that are implanted should be programmed to provide only backup pacemaking help, he said.

    Michael Coyle of St. Jude Medical Inc., which made the devices in the study and funded the research, said the results show "that careful attention must be paid to the programming of pacemaker functions" to minimize effects in defibrillator patients who don't need the extra help.

    Johns Hopkins Medical Institutions' Dr. David Kass, a paid consultant for Guidant Inc., which makes similar devices, said in a JAMA editorial that more data are needed to determine if the "simpler solution" is best.

    On the Net: JAMA: jama.ama-assn.org

    American Heart Association: americanheart.org

    LOAD-DATE: December 20, 2002

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [HEADLINE: Study Links Heart Damage to Pacemaker]

    Author: Tim Stewart (---.dsl.dytnoh.ameritech.net)

    Date: 12-21-02 12:58

    Copyright 2002 The New York Times Company

    The New York Times

    December 20, 2002, Friday, Late Edition - Final

    SECTION: Section A; Page 34; Column 1; National Desk

    LENGTH: 629 words

    HEADLINE: Study Links Heart Damage to Pacemaker

    BYLINE: Reuters

    DATELINE: CHICAGO, Dec. 19

    BODY:

    The common practice of pacing the heartbeat may damage patients' hearts, researchers said today in a study of heart devices that was terminated early because too many patients died.

    The Cleveland Clinic cardiologist who led the study concluded that physicians should switch off the pacemaker function on dual-chamber implantable defibrillators because it may knock the heart out of rhythm and hasten heart failure. The pacemaker uses a mild electrical impulse to continuously control the heartbeat. Defibrillators are implanted in about 100,000 people a year to control irregular heartbeat, which is often a precursor of a heart attack. The device delivers a powerful shock to the heart if it falls out of rhythm or speeds up too much.

    Many of the battery-powered defibrillators in use can deliver electric shocks to both chambers in the heart's right side, which pumps blood to the lungs. The left side of the heart pumps reoxygenated blood returning from the lungs back into the body.

    In a majority of patients with the implanted dual-chamber defibrillator, the device's pacemaking function is also activated. But activating the pacemaker function in the right side of a patient's heart may be throwing off synchronization with the left side, causing the heart to lose efficiency and deteriorate, said the report, which is to appear next Wednesday in The Journal of the American Medical Association.

    "It's easily conceivable that, with the number of defibrillators going in, if three-quarters are being programmed the wrong way, we could be hurting patients," the lead author, Dr. Bruce Wilkoff, said in an interview.

    Of the defibrillators implanted in 506 patients in the study, half were programmed to pace the heart at 70 beats per minute as well as to shock both right-side chambers in the event of an arrhythmia. The other half were programmed to shock the right ventricle in the case of an arrhythmia but only to activate the pacemaker function if the heartbeat fell below 40 beats per minute. (The normal range is 50 to 75 beats a minute.)

    In the study group whose pacemaker function was activated, and who were expected to be healthier, 23 died and 43 became ill enough to require hospitalization. In the other group, 15 died and 30 were hospitalized.

    That was enough for a committee overseeing the study to call a halt a few months early, before more patients were enrolled.

    A spokesman for Medtronic Inc., a leading manufacturer of defibrillators, said the study was flawed because the patients who participated did not need their hearts paced for them. "Physicians know when the patient should have pacing and when they shouldn't," the spokesman, Scott Papillon, said.

    Vice President Dick Cheney, who has had four heart attacks since 1978 and is considered at risk for irregular heartbeat, was implanted with Medtronic's dual-chamber defibrillator last year, but the company said his device was not set to automatically pace his heart.

    The devices used in the 506-patient study were made by St. Jude Medical Inc., which paid for the study, Dr. Wilkoff said.

    He said pacemakers, which have been around for half a century, still have an important use for patients with ailments that dangerously slow their heartbeats.

    But patients with defibrillators who do not need the pacemaking function should probably not use it, Dr. Wilkoff said. The problem, he said, is that many patients who have the devices also take medications that slow their heartbeats, making them sluggish and candidates for the pacemaking function.

    The next generation of heart devices delivers impulses to both sides of the heart to ensure synchronization, he said, though implanting electric leads on the left side was more difficult. http://www.nytimes.com

    LOAD-DATE: December 20, 2002

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [HEADLINE: OLDER HEART DEFIBRILLATORS ALSO COULD BE SAFER, STUDY FINDS]

    Author: Tim Stewart (---.dsl.dytnoh.ameritech.net)

    Date: 12-21-02 12:59

    Copyright 2002 Sentinel Communications Co.

    THE ORLANDO SENTINEL

    December 20, 2002 Friday, FINAL

    SECTION: A SECTION; Pg. A10

    LENGTH: 336 words

    HEADLINE: OLDER HEART DEFIBRILLATORS ALSO COULD BE SAFER, STUDY FINDS

    BYLINE: Rob Stein, The Washington Post

    BODY:

    Heart patients with newer, more sophisticated defibrillators implanted in their chests appear to be more likely to suffer heart failure or die than those with an earlier generation of simpler devices, researchers reported Thursday.

    Based on the findings, thousands of Americans implanted with defibrillators to shock their hearts back into normal rhythms, including Vice President Dick Cheney, should consult their doctors to see whether they should have their devices reprogrammed to operate in the simpler, safer mode, researchers said. Each year, about 50,000 Americans who are at risk for heart failure because of irregular heart rhythms get cardiac defibrillators surgically implanted in their chests to monitor their heartbeats. If the device detects an abnormal rhythm, it zaps the heart with an electric shock to restore a normal beat.

    The devices also have pacemakers built into them to keep the heart beating at the right rate. About 75 percent of the defibrillators now in use have more sophisticated pacemakers, known as dual-chamber devices because they stimulate both the right atrial chamber at the top of the heart and the right ventricle at the bottom. That was thought to be superior because it could synchronize both parts of the heart.

    The new study involved 506 defibrillator patients at 37 hospitals across the country. Half the patients had the pacemakers programmed to stimulate both chambers, while the other half were programmed only to stimulate the ventricle.

    On Sept. 30, about two years into the study, researchers halted the research early after it became clear that patients with the dual-chamber devices were more likely to suffer ill effects. About 26 percent of them were hospitalized for heart failure or died, compared with only about 16 percent of the second group.

    "It was a big surprise," said Bruce Wilkoff of the Cleveland Clinic Foundation, who led the study, which will be published in the Dec. 25 issue of the Journal of the American Medical Association.

    LOAD-DATE: December 20, 2002

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [HEADLINE: Newer pacemakers can kill, study says;]

    Author: Tim Stewart (---.dsl.dytnoh.ameritech.net)

    Date: 12-21-02 13:00

    Copyright 2002 Plain Dealer Publishing Co.

    The Plain Dealer

    December 20, 2002 Friday, Sports Final / All

    SECTION: NATIONAL; Pg. A1

    LENGTH: 607 words

    HEADLINE: Newer pacemakers can kill, study says;

    Greatest threat found in less-severe cases

    BYLINE: Roger Mezger, Plain Dealer Reporter

    BODY:

    Some of the most advanced implantable devices for keeping hearts beating normally are actually causing heart failure and death, according to a study released yesterday.

    "This is a surprise" that will change the way physicians use the devices, said Dr. Bruce Wilkoff, a cardiovascular medicine specialist at the Cleveland Clinic who designed the study.

    The bad outcomes were so unexpected that doctors monitoring the study stopped it early. The findings, not scheduled to appear until next week in the Journal of the American Medical Association, were posted yesterday on the journal's Web site because of their importance to doctors and patients.

    Each year about 100,000 patients have an implant- -able cardioverter defibrillator, or ICD, placed in their chests to guard against very rapid heartbeats that can cause sudden death.

    Vice President Dick Cheney has had an ICD for about a year and a half.

    The battery-operated device senses when the heart beats dangerously fast. Through a wire, it shocks the heart back to normal.

    But an ICD also doubles as a heart pacemaker, stimulating a slow-beating heart to speed up.

    In older ICD models, the pacemaker is always in standby mode, activated only if the heartbeat slows significantly. Newer models, however, have pacemakers that can run all the time, keeping the heart rate constant at about 70 beats per minute.

    Previous studies showed that ICDs that double as full-time pacemakers performed very well among patients with very bad hearts. Cheney, who has suffered four heart attacks, falls into that category.

    But the patients in this new study had not yet developed significant heart failure, Wilkoff said.

    Researchers found that that made a huge difference in how patients responded.

    "What happened was, instead of making things better, it actually made things worse," Wilkoff said.

    All 506 patients in the study received the ICD-pacemaker devices, called dual-chamber ICDs, at 37 hospitals nationwide. In half the patients, the pacemaker was left on all the time. In the other half, it was on standby, programmed to come on only if the heart rate slowed to 40 beats per minute. That mimicks the way that older, much cheaper ICDs work.

    A year after their implants, patients whose pacemakers ran continuously were 60 percent more likely to have died or to have been hospitalized for heart failure.

    St. Jude Medical Inc., which paid for the study and provided the ICDs, said further study was needed to understand why.

    But because of the big difference between the patient groups, the study was stopped three months ago.

    "This is an extremely important finding, that physicians are going to have to take very soberly the thought of how they program their device," Wilkoff said.

    Patients who already have dual-chamber ICDs should ask their doctors whether the pacemaker should be switched to standby mode, he said. That is done with a radio signal.

    For new patients, doctors could choose to go back to basic-model ICDs, which sell for about $16,000. Or they could stick with the $25,000 dual-chamber models and program the pacemaker to come on only as needed.

    ICDs are a $2 billion industry poised to grow sharply next year. The government is expected soon to double the number of people eligible to receive ICDs under Medicare.

    Although only 5 percent of patients need dual-chamber ICDs, those sophisticated models account for 75 percent of sales, Wilkoff said.

    That means it is important for doctors to be careful about which patients they program in dual mode, he said. Improper programming could lead to heart failure or premature death for some.

    LOAD-DATE: December 21, 2002

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: HEADLINE: Newer pacemakers can kill, study says;]

    Author: Linda, Bd of Directors (---.wmnsmd.adelphia.net)

    Date: 12-21-02 16:10

    Thanks Tim, for the info. It will be interesting to read the actual reports. The important thing for our membership to remember is that this study was done in heart failure patients, not HCM patients. Even tho HCM patients may suffer heart failure, this study refers to those secondary to coronary artery disease, etc. I suspect that we will learn that the pacing was actually slowing the electrical impulse thru the ventricles and decreasing the pumping efficiency. The New York Times posting mentions the lack of synchronization between the ventricles and this is the problem the new biventricular pacers are trying to overcome. Notice that the study was terminated early. This is reassuring in that the oversights were effective in detecting adverse outcomes in time to prevent more people from suffering needlessly. Research is necessary, how else would we learn and improve treatments? But, strict oversights must be in place and enforced. I'm a stickler for informed consent, can you tell? Linda

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: HEADLINE: Newer pacemakers can kill, study says;]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 12-22-02 07:09

    This is a general study and those with HCM, as we all know, are not treated as other patients. I am not aware of the effects of this research on those with HCM, but I will ask some of our advisiors for input and report.

    Lisa

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: HEADLINE: Newer pacemakers can kill, study says;]

    Author: Jerry Salzman (---.treas.gov)

    Date: 12-24-02 06:42

    Lisa,

    I would be very interested in hearing any responses since I fall into the continually paced ICD population. I know before the myectomy I needed the continual pacing. However, since the surgery I am wondering whether I need to be on so much Beta Blocker. I tried calling my local cardiologist office but that didn't work since my message was not relayed correctly. I have to wait for an appointment.

    I am also going to get a follow-up appointment at the Cleveland Clinic.

    Jerry

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: HEADLINE: Newer pacemakers can kill, study says;]

    Author: Laura (66.97.93.---)

    Date: 12-25-02 22:15

    Hi Lisa,

    I would like to know (when you speak to the advisors) if the overpacing would have caused my septal wall to have grown the 6mm it has since implant?

    I am not being paced now as my fractured pacer wire has not been replaced with anything new.

    Thank you

    Laura
    NOTE: This is a post from the previous forum message board.
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