Some people with heart failure can benefit from cardiac resynchronization therapy (CRT) with a heart failure pacemaker.  During cardiac resynchronization therapy, the heart failure pacemaker delivers small, undetectable electrical signals that help both sides of your heart contract at the same time. The therapy coordinates or "resynchronizes" the heart.

 

Cardiac resynchronization therapy may make you feel better and increase the amount of energy you have. It may also reduce the chance you will have to go to the hospital.

 

Many people experience dramatic improvements in their quality of life and in their heart failure symptoms after receiving a heart failure pacemaker and cardiac resynchronization therapy. They have more energy and can do things they never thought they would do again.

 

When you have heart failure, the right and left ventricles don't contract together. Cardiac resynchronization therapy makes sure the contractions are timed correctly. To do this, a biventricular pacemaker or ICD is connected to your heart. The device sends electrical impulses to the right and left ventricles. These impulses resynchronize the ventricles (make them contract together again). So, more blood is pumped out of the heart.

 

Pacemakers and ICD's are composed of two parts, the generator and the leads. The generator is a smooth, lightweight metal case containing a tiny computer and a battery. The case is often made of titanium. The generator sends out electrical impulses. The leads are wires covered by a soft, flexible material. Most biventricular pacemakers and ICD's have three leads. The leads carry electrical impulses from the generator to the heart.

 

Biventricular pacemakers ensure that contractions of the heart's chambers are timed correctly. In most cases, one lead senses the heart's electrical signals in the right atrium. Based on the timing of these signals, the other two leads send electrical impulses to the right and left ventricles. These impulses synchronize the chambers' contractions. So, blood is pumped out of the heart more efficiently.

 

Dangerously fast heart rhythms sometimes develop in damaged heart muscle. To protect against this, you may be given a biventricular ICD. Like a biventricular pacemaker, an ICD sends electrical impulses to synchronize the right and left ventricles. The ICD can also correct a life-threatening rhythm. It does this by interrupting a heart rhythm that is too fast, returning the heartbeat to normal.

 

The device is placed in your body during a process called implantation. First, an incision is made in the skin below the collarbone. This creates a small pocket to hold the device. A lead is threaded through the incision into a vein in the upper chest. With the help of x-ray monitors, the lead is then guided into a vein on the back surface of the left ventricle. Contrast dye may be injected into the vein to make the pictures on the monitors clearer.

 

The process is repeated to guide leads into the right ventricle and, in most cases, the right atrium. These leads are attached to the heart muscle so they will stay in place. The generator is attached to the leads. Then, the generator is placed in its pocket under the skin.

 

In rare cases, the left ventricular lead cannot be inserted through the vein. If this happens, your doctor may suggest another procedure called epicardial implantation. The chest is opened so the lead can be inserted from outside the heart. Your doctor can tell you more if this is needed.

 

Implantation of a biventricular pacemaker or ICD is not open heart surgery It is a less involved procedure that is done in an operating room or cardiac catheterization laboratory. It takes 2 to 4 hours. In most cases, the device is implanted near the left shoulder.

 

You will be given instructions on how to get ready for the procedure. Before your surgery:

·        You may have an electrocardiogram and an echocardiogram. These tests tell your doctor more about your heart's function.

·        Tell your doctor about all prescription medications you take. Also tell your doctor about all over-the-counter medications, herbs, or supplements you use. You may be asked to stop taking certain medications before your procedure.

·        Do not eat or drink anything after midnight before your procedure.

·        Your doctor or another specialist will talk to you about the pain medications that will be used during the procedure.

 

You will likely be admitted to the hospital for implantation. You can expect the following:

·        The skin where the device will be implanted is washed and may be shaved.

·        You will be given medications to prevent pain.  You may be awake but have medication to relax you. Or, you may be completely asleep.

·        Medications and fluids will be given to you through an IV.

·        Your body will be draped with sheets during the procedure. Only the area where the device is being implanted is exposed. This helps keep the implantation site sterile (germ-free).

Risks and Complications

·        Bleeding or severe bruising

·        Infection or nerve damage at the incision site

·        Puncture of the lung or heart muscle

·        Tearing of the vein or artery wall

·        Clotting or air bubbles in the vein

·        Heart attack, stroke, or death (rare)

 

After surgery, nurses will monitor your health and give you medication to control pain. Most patients go home the day after the procedure. Once you are home:

·        Care for your incision and change the dressing as instructed. Avoid getting the area wet for about a week. Every day, check your incision for signs of infection.

·        You may be told to limit movement of your arm on the side where the device has been implanted. You may also be instructed not to raise that arm above the shoulder for a certain amount of time. Your doctor will tell you more.

·        You can go back to work when your doctors say it is okay. In most cases, it is safe to return to your normal routine soon after surgery. You may even feel well enough to do things you could not do before the implantation. Check with your doctor to make sure it is okay to do these activities.

 

At first, you will need frequent follow-up visits. These will decrease over time. Here are some things you can expect during the first few months:

·        Your doctor may check your incision to be sure it is healing well.

·        Your device may be reprogrammed (have its settings adjusted). Using test results, your doctor will find the best settings for your heart.

·        Your symptoms may better right away. Or, changes may be gradual. Talk to your doctor about any changes in your symptoms.

 

Call your doctor if you have any of these during the week after the procedure:

·        Signs of an infection, such as a fever above 101 degrees; redness, swelling, or warmth at the incision site; drainage from the incision.

·        Worsening of heart failure symptoms.

·        Bleeding from the incision site.

 

A few times each year, your biventricular pacemaker or ICD must be checked. This will ensure the device is working correctly. Settings may be adjusted so the device can best help your heart. You may be glad to know that very few things interfere with your device. In the rare case that an outside signal does affect it, the device won't be damaged. If you suspect a problem, call your doctor.

 

During visits to your doctor or heart failure clinic, the settings of your device will checked. Certain tests, such as an ECG or echocardiogram, may be done to make sure the device is helping your heart as much as it can. From time to time, the settings may be adjusted. This is done using an electronic wand connected to a computer. The wand is simply placed on the skin over the device.

 

During your appointments, your device's battery level will be checked. If it is low, there is still plenty of time to replace the battery before it wears out. Most batteries in biventricular pacemakers and ICD's last several years. If the battery wears out, the entire generator is replaced. This is done during a procedure that is usually simpler and shorter than the original implantation.

 

Biventricular pacemakers and ICD's are well protected. Most machines and devices will not interfere. For instance, microwave ovens and other appliances should not cause problems. Neither should computers, hair dryers, power tools, radios, televisions, electric blankets or cars.

 

A few things create signals that might interfere with your device. These include:

·        Electromagnetic anti-theft systems. These are often near entrances or exits in stores. Walking past one is okay, but avoid standing near or leaning again one.

·        Strong electrical fields. Some things that cause these are radiotransmitting towers and heavy-duty electrical equipment (such as arc welders). These should be avoided. A running engine also makes an electrical field. It is okay to ride in a car, but avoid leaning over the open hood of a running car.

·        Cellular phones, if held too close to your device. (Indoor cordless phones are okay.) When using a cellular phone, hold it to the ear on the opposite side of your device. When not using it, carry the phone on the side away from your device.

·        Very strong magnets. You should never have an MRI (a medical test that uses magnets). Problems may may also be caused by magnets in hand-held security wands (such as those used at airports).

 

Your device comes with an ID card. This card contains important information about the device. You will be given a temporary card when the device is implanted. A permanent card will be mailed to you in about 6 weeks. Show the ID card to any doctor, dentist or other medical professional you visit. Also show it to security guards at the airpot. This way, they know to follow special procedures that prevent the security wand from interfering with your device.

 

When cardiac resynchronization therapy is helping your heart beat, you may have more energy. This makes it easier for you to stay active. Being active exercises your heart and can help you feel better overall. And keeping up with the other parts of your treatment plan can help you live longer and more comfortably.

 

You may find you can do more now than you could before your started cardiac resynchronization therapy. Stay as active as feels comfortable to you. Try these tips:

·        Plan activities like a walk around the block. If the weather is bad, try walking indoor, such as at a shopping mall. Light gardening and swimming are other options that may work for you. Talk to your health care provider about safe choices.

·        Involve family and friends in your activities. You can enjoy yourself and help your heart at the same time.

·        Stay aware of your limits. Even with cardiac resynchronization therapy, you may still have some heart failure symptoms. Stop and rest if you feel tired or short of breath. If you cannot hold a conversation during activity, you are pushing yourself too hard.

 

Stop exercising and call your doctor if you feel any of these symptoms:

·        Chest pain or discomfort

·        Burning, tightness, heaviness, or pressure in your chest

·        Unusual aching in your arm, shoulders, neck, jaw or back

·        Trouble catching your breath

·        A racing or skipping heartbeat

·        Extreme tiredness (especially after exercise)

·        Lightheadedness, dizziness, or nausea

 

Cardiac rehabilitation (rehab) is a supervised, personal exercise program designed to improve your heart's health. This program often takes place at the hospital or another medical center. During cardiac rehab you are shown how to exercise in ways that help your heart the most. While you exercise, your heart rate and blood pressure are watched closely. Ask your health care provider about rehab programs that might be right for you.

 

CRT is one treatment for heart failure. But even if you are feeling better, you must continue with the other parts of your treatment plan. Doing so will help your heart, which helps you feel your best. Your treatment plan may include some of these:

·        Dietary restrictions. You will likely be told to limit salt (sodium). This helps reduce swelling. Reading food labels can help you choose foods low in salt. You may also be told to limit fluid intake or to follow other dietary restrictions based on other health problems. If you have any questions about what is safe to eat or drink, talk to your doctor.

·        Medications. Take all of your medications as prescribed by your doctor. Now that you have started CRT, you may have fewer side effects from medications. So, your doctor may change your medications or dosages. This may improve your quality of life and could even help you live longer.

·        Weighing yourself. Rapid weight gain or swelling can be a sign that fluid is backing up in your body. Weigh yourself at the same time every morning, wearing the same clothes. Do this after urinating and before eating. Call your doctor if you gain 2 or more pounds in a day or it you gain 3 to 5 pounds in a week.

·        Controlling risk factors. You may be able to help your heart by controlling certain risk factors (things that make heart problems more likely). For instance, your doctor may ask you to quit smoking or to lose excess weight. Keeping blood pressure and cholesterol levels under control also helps. Work with your doctor to treat any risk factors you have.