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User question:

Does chronic high-volume aerobic exercise lead to progressive fibrotic changes around the leadless pacemaker electrode site that could affect long-term capture thresholds and device longevity?

Claude AI:

Based on the research findings, here's what current evidence suggests about chronic high-volume aerobic exercise and its potential effects on leadless pacemaker performance:

Key Research Findings

Leadless Pacemaker Fibrosis Characteristics: The influence of fibrosis formation on long-term threshold performance is less likely to occur than with conventional pacing systems because the electrode of the leadless system is separated from the screw-in helix by ∼2 mm, instead of being part of the fixation mechanism. This unique design feature of leadless pacemakers may actually provide some protection against electrode-site fibrosis compared to traditional leads.

Exercise and Cardiac Fibrosis - The Complex Picture: Research reveals a nuanced relationship between exercise and cardiac fibrosis:

1. Protective Effects of Moderate Exercise: Exercise attenuates cardiac fibrosis through multiple mechanisms, independently or in combination with other drugs, for a wide range of cardiovascular diseases, and a 13-week AET with 75% VO2max mitigated the aging-associated increase in COL deposition and MMP dysregulation in the left ventricle.

2. Concerns with Extreme Exercise: However, intense exercise (IE) induced myocardial fibrosis (MF) showed contradictory findings in human studies, making the relationship between IE and the development of MF unclear. Some studies show right ventricular damage induced by long-term IE is pathological and the following inflammatory response is essential to the development of exercise induced MF.

3. Reassuring Human Data: Importantly, increasing levels of lifelong fitness are not associated with focal myocardial fibrosis in human studies, and high levels of competitive physical activity do not typically result in myocardial fibrosis.

Clinical Implications for Your Patient

Positive Factors:

• Leadless pacemakers show very stable electrical measures in all patients during follow-up
• The separated electrode design reduces fibrosis risk
• Human studies don't support widespread fibrosis in lifelong endurance athletes

Potential Concerns:

• Mechanical stress caused by attaching the tip tightly damages cardiomyocytes and brings about changes in the pacing thresholds
• Exercise-induced inflammation could theoretically affect the electrode-tissue interface
• Right ventricular effects from intense exercise could be more relevant since leadless pacemakers are placed in the RV

Bottom Line

Current evidence suggests that chronic high-volume aerobic exercise is unlikely to cause clinically significant progressive fibrotic changes around a leadless pacemaker electrode that would substantially affect capture thresholds or device longevity. The protective design features of leadless pacemakers, combined with human studies showing minimal cardiac fibrosis in lifelong endurance athletes, provide reassurance.

However, given the individual nature of tissue responses and the fact that this patient developed AV block from extensive aerobic exercise, close monitoring of pacing parameters during follow-up visits would be prudent to detect any subtle changes in capture thresholds over time.