Cardiac Resynchronization Therapy
FAQS
Will CRT Improve My Ejection Fraction?
Yes, CRT can help improve your ejection fraction (EF).
EF is the measurement of how much blood is being pumped out of the left ventricle of the heart. A normal EF ranges from 50% to 70%. People with heart failure who have a poor ejection fraction are at risk for fast, irregular, and sometimes life-threatening heart rhythms. The CRT/ICD combination device can help protect you against these dangerous, fast heart rhythms.
Who Is Eligible to Recieve CRT Device?
People with heart failure who have a poor ejection fraction (less than 35%) are at risk for fast, irregular, and sometimes life-threatening heart rhythms. CRT may be appropriate for people who:
- Have severe or moderately severe heart failure symptoms
- Are taking medications to treat heart failure
- Have delayed electrical activation of the heart
- Have a history of cardiac arrest or are at risk for cardiac arrest
What Happens Before The Procedure
Before the procedure begins, a nurse will help you get ready. You will lie on a bed, and the nurse will start an IV in a vein in your arm or hand. The IV is used to deliver medications and fluids during the procedure.
To prevent infection and to keep the pacemaker insertion site sterile:
- An antibiotic will be given through the IV at the beginning of the procedure
- For men, the left or right side of your chest will be shaved
- A special soap will be used to cleanse the area
- Sterile drapes are used to cover you from your neck to your feet
- A soft strap will be placed across your waist and arms to prevent your hands from touching the sterile area
Will I Be Awake During The Procedure?
Yes, a medication will be given through your IV to relax you and make you feel drowsy, but you will not be asleep during the procedure.
How Is the Device Implanted
The CRT device can be implanted using the endocardial or epicardial approach.
With the endocardial approach (transvenous), a local anesthetic is injected to numb the area, and you will be awake during the procedure. Small incisions are made in the chest where the leads and device are inserted. The leads are inserted through the incision and into a vein, then guided to the heart with the aid of the fluoroscopy machine. Two leads are guided to the right atrium and right ventricle, while the third lead is guided through the coronary sinus to the left ventricle. The lead tips are attached to the heart muscle, while the other ends of the leads are attached to the pulse generator. The generator is placed in a pocket created under the skin in the upper chest. When the endocardial approach is used, the hospital recovery time is generally 24 hours. The endocardial technique is technically challenging. In some cases, this technique may not be successful due to the size, shape, or location of the vein(s). If the endocardial approach cannot be used or is unsuccessful, the epicardial approach will be used.
The epicardial approach may also be used to place the CRT if you are already having surgery to treat another heart condition. With the epicardial (surgical) approach, general anesthesia is given to put you to sleep during the procedure. The leads are guided to the heart with the aid of the fluoroscopy machine. Two leads are guided to the right atrium and right ventricle, while the third lead is guided through the coronary sinus to the left ventricle. The lead tips are attached to the heart muscle, while the other ends of the leads are attached to the pulse generator. The generator is placed in a pocket created under the skin in the lower abdomen. The hospital recovery time is generally 3 to 5 days. Although recovery with the epicardial approach is longer than that of the transvenous approach, minimally invasive techniques enable a shorter hospital stay and quicker recovery time. Your doctor will determine the best implant procedure approach for you, depending on your condition.
How Are The Leads Tested
After the leads are in place, they are tested to make sure lead placement is correct, the leads are functioning properly, and the right and left ventricles are synchronized.
This lead function test is called pacing. Small amounts of energy are delivered through the leads into the heart muscle. This energy causes the heart to contract. You will be asleep for several minutes during the lead function test.
Once the leads have been tested, the doctor will connect them to the device. The rate and settings of your CRT device are determined by your doctor. After the implant procedure, the doctor uses an external device to program final device settings.
What Will I Feel During The Procedure?
With the endocardial approach, you will feel an initial burning or pinching sensation when the doctor injects the local numbing medication. Soon the area will become numb. You may feel a pulling sensation as the doctor makes a pocket in the tissue under your skin for the device. Please tell your doctor what symptoms you are feeling. You should not feel pain. If you do, tell your nurse right away.
With the epicardial (surgical) approach, you will be given anesthesia to put you to sleep during the procedure, so you will not feel anything.
With both approaches, you may feel discomfort at the implant site during the first 48 hours after the procedure. The doctor will tell you what medications you can take for pain relief. Please tell your doctor or nurse if your symptoms are prolonged or severe.
How Long Does the Procedure Last?
The device implant procedure may last from 2 to 5 hours.
Will I Have To Stay At The Hospital?
Yes, you will be admitted to the hospital overnight. Usually you will be able to go home the day after your device was implanted, unless the epicardial approach was used during the procedure.
Risks
What Are the Possible Risks of the Procedure?
A device implant is generally a very safe procedure. However, as with any invasive procedure, there are risks. Special precautions are taken to decrease your risks. Please discuss your specific concerns about the risks and benefits of the procedure with your doctor.
Before the Procedure
Taking Medication
Usually, you will be instructed to stop taking anticoagulant medications, including aspirin or Coumadin, a few days before the procedure. Other blood thinners which need to be stopped include dabigatran, rivaroxaban, apixaban, and edoxaban.
If you take Coumadin, the results of your INR test must be within a suitable range before the implant procedure can be performed.
Your doctor may also ask you to stop taking other medications, such as those that control your heart rate. Do not discontinue any of your medications without first talking to your healthcare provider. If you have diabetes, ask the nurse how to adjust your diabetes medications or insulin.
Ask your heart doctor which medications you should stop taking and when to stop taking them.
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How to Prepare
- Do not eat, drink, or chew anything after 12 midnight before your procedure. This includes gum, mints, water, etc.
- If you must take medications, only take them with small sips of water
- When brushing your teeth, do not swallow any water
- Remove all makeup and nail polish
What to Bring
- A family member to wait with you before the procedure
- Comfortable, easy-to-fold clothing
- Toiletries and any other items you would like to make your stay more comfortable. Please note, these will be kept with whomever accompanies you
- A one-day supply of your prescribed medications
- Do not bring any jewelry, watches, and/or valuables
After the Procedure
What to Expect After the Procedure
In your hospital room, a special monitor (telemetry monitor) will continually monitor your heart rhythm. The telemetry monitor consists of a small box connected by wires to your chest with sticky electrode patches. The box displays your heart rhythm on several monitors in the nursing unit. The nurses will be able to observe your heart rate and rhythm.
You will also have a monitor (small recorder) attached to your chest with sticky electrode patches. The holter monitor records your heart rhythm for 12 hours to ensure that the pacemaker is functioning properly.
A chest X-ray will be done after the device implant to check your lungs and the position of the device and leads. Before you are discharged, the monitor will be removed, and the results will be given to your doctor.
For your safety, a responsible adult must drive you home. Ask your doctor when you may resume driving.
Care for the Insertion Site
You may feel discomfort at the device implant site during the first 48 hours after the procedure. Call your doctor or nurse if your symptoms are prolonged or severe.
Keep the area where the device was implanted clean and dry. Do not scrub the area. Steri-strips may be covering the wound site; they may be removed 3 weeks after the date of the implant. Do not cover the wound unless you have been instructed to do so. You do not need to keep the wound covered with a bandage. Do not use creams, lotions, or ointments on the wound site.
Look at the area daily to make sure it is healing properly. Call your doctor if you notice:
- Increased drainage, bleeding, or oozing from the insertion site
- Increased opening of the incision where the device was implanted
- Redness, swelling, or warmth around the device insertion site
- Increased body temperature (greater than 101 degrees Fahrenheit)
You may take a shower 5 days after the procedure.
Activities Guideline
For the first week after your procedure:
- You may move your arms normally and do not have to restrict arm motion during normal activities. However, do not hold your arms above shoulder level for more than several minutes at a time
- Stop any activity before you become overtired
- Try to walk as much as possible for exercise
- Do not drive for at least one week after your procedure
For the first two weeks after your procedure:
- Do not lift objects that weigh more than 10 pounds for 2 weeks after the procedure
- Avoid activities that require pushing or pulling heavy objects
- Avoid golfing, swimming, tennis, and bowling
Your doctor will tell you when:
- You can resume driving
- You can resume more strenuous activities or heavy lifting
- You can go back to work
Follow-Up
A follow-up device check appointment will be scheduled 2-4 weeks after the implant procedure.
This first follow-up appointment is critical. Adjustments will be made that will help your device last longer. An echocardiogram may be performed as part of your first follow-up evaluation.
About the Device
Device Checks
If you have a biventricular pacemaker (cardiac resynchronization therapy device – CRT):
- After your first follow-up appointment, your pacemaker should be checked every 3 months from home
- Please make sure that you are set up with a remote monitoring transmitter at the time of your first follow-up for a device check
- You will receive instructions on how to use remote monitoring during your first follow-up appointment
- Your biventricular pacemaker should be checked every 6 months
If you have an implantable cardioverter defibrillator (ICD):
- After your first follow-up appointment, your device should be checked every 6 months
- Your device will allow you to use a remote monitoring transmitter. This lets you check your device every night
- You will receive instructions on how to use remote monitoring during your first follow-up appointment.
Every year, around the anniversary of your device implant, you will have an echocardiogram scheduled along with a complete device check. Since the leads are tested during this appointment, this appointment is different than the telephone transmitter check.
Call your healthcare provider if you have any of these signs of infection:
- Increased drainage, bleeding, or oozing from the insertion site
- Increased opening of the incision where the device was implanted
- Redness, swelling, or warmth around the device insertion site
- Increased body temperature (greater than 101 degrees Fahrenheit)
The following symptoms may be related to your device:
- Dizziness
- Palpitations
- Fast or slow heart rates
- Lose or nearly lose consciousness before receiving therapy from the device
- Have numbness or tingling of the arm closest to the device
If you have a telephone transmitter, please call the transmitter line 8 a.m. – 5 p.m., Monday through Friday, to check your device.
If you have a remote monitor, please call the clinic between the hours of 8 a.m. – 5 p.m., Monday through Friday, and we will instruct you to send us a transmission.
Device Therapy
If you receive therapy from your ICD device:
- Stay calm or lie down
- If someone is touching you when the device delivers therapy or fires, he or she may feel a tingling sensation; this is not harmful
- If possible, ask someone to stay with you until you feel better
- If you feel fine after the shock, you do not need to seek medical attention
- Call your doctor within 24 hours
Call your doctor if you:
- Do not feel well within 5 to 10 minutes after receiving the shock; call your doctor or 9-1-1
- Received a shock; this needs to be done within 24 hours of the shock
- Received therapy from the device two or more times in a 48-hour period
- Received therapy from the device before your 6-8 week follow-up visit
What Therapy from Your Device Will Feel Like
You may or may not be able to tell when your device detects and corrects your heart rhythm. It often depends on the type of therapy you receive from the device:
- Pacing: You may or may not feel the impulses. They are usually painless
- Cardioversion: The shock may feel like a thump on the chest, but it only lasts for a moment
- Defibrillation: The shock may feel like a kick in the chest, but it only lasts for a moment. Some patients describe the feeling as a shock from an electrical outlet.
Most of the time, you will be awake for the therapy, but you may lose consciousness prior to the shock.
What to Do With Your Device if You Need Surgery
Your cardiologist will tell you if programming changes are needed before or after your surgery.
Your pacemaker should be checked within 3 months before your surgery; please schedule an appointment with your cardiologist.
If you have an ICD, the shock therapies will need to be programmed off during surgery. Please contact your doctor’s office so they can make arrangements for this.
How Long Your Device Will Last
ICDs and CRT devices last 6 to 8 years.
Living with the Device
Most household appliances do not interfere with pacemakers.
Cell Phones
While your cell phone may not affect your pacemaker, to be safe, use your cell phone on the side opposite of where the device was implanted. Cell phones should not be placed directly against the chest or on the same side as your device.
Headphones
Certain types of headphones may contain a magnetic part that can affect pacemaker function. Keep headphones 1-2 inches away from your pacemaker. Do not keep your headphones in the breast pocket of a shirt or drape them around your neck.
Security Devices
If you must pass through entrances where anti-theft devices or metal detectors are being used for security, be sure to walk quickly through them. If handheld metal detector scanning is necessary, tell the security personnel that you have a pacemaker. You should not hold the metal detector near the device for any length of time.
Powerful Magnets, Magnetic Fields, and Equipment
You will need to avoid strong electric or magnetic fields, such as:
- Some industrial equipment
- Ham radios
- High-intensity radiowaves
- Arc resistance welders
In strong magnetic fields, the device stops monitoring your heart rhythm. Once you are out of these fields, normal device function resumes and there is no damage to the device.
Magnetic Resonance Imaging (MRI)
Some devices are compatible with MRIs. If you have been instructed to have an MRI, contact your implanting physician about the type of device that you have implanted and if this type of testing is safe for you.
Hybrid Cars
Stay about 2 feet away from the engine, and do not keep your smart key near your device. Do not put it in a pocket that is over your device.
We know these are very conservative recommendation, and there have been no reports of adverse outcomes due to exposure to either of these environments. However, this information has been recommended by current sources and is the best information we have at this time.
If you have any questions about the use of equipment around your device, check your device manufacturer website and ask your doctor or nurse.
Electric Fence for Pets
Stay at least a foot away.
We know these are very conservative recommendations, and there have been no reports of adverse outcomes due to exposure to either of these environments. However, this information has been recommended by current sources and is the best information we have at this time.
If you have any questions about the use of equipment around your device, check your device manufacturer website and ask your doctor or nurse.
Carry an ID Card
You will receive a temporary ID card that tells you what type of device and leads you have, the device manufacturer, the date of the device implant, and the name of the doctor who implanted the pacemaker.
Within three months, you will receive a permanent ID card from the device company. It is important to carry this card at all times in case you need medical attention or to tell people you have a pacemaker.
Let your healthcare providers know you have an implanted device. In rare occasions they may want to adjust your treatment plan because you have a pacemaker or defibrillator.
Airport Security
For patients who travel outside of Houston, our cardiology specialists recommend taking a few precautions. Should the security personnel use a wand to clear people, show them your card, and ask them to avoid placing the wand over your implanted heart device. Ask security if there is another method for clearance.