How should I prepare for a CRT pacemaker implantation?
Before the procedure, be sure to talk to you doctor about which of your medications you should and should not take. If you are taking any medications for diabetes, ask your doctor if you need to adjust these medications since you will not be allowed to eat anything before the procedure. If you are taking any blood thinners like warfarin (Coumadin), clopidogrel (Plavix) or aspirin, your doctor may instruct you to change the dose you are taking or stop taking the medication in the days before the procedure.
The night before the procedure, you should not eat anything after midnight; this includes drinking water. If you need to take any pills the morning of the procedure, drink only a sip of water to take them.
Be sure to let your doctor or the anesthesiologist know if you have recently been sick or had an infection, or if you or a family member has ever had a bad reaction to anesthesia.
What happens during the procedure?
When you arrive at the procedure room, you will be asked to lie down on an x-ray table. A nurse will place a blood pressure cuff on your arm and small sticky pads on your chest to allow the doctor to monitor your heart rate and rhythm on an ECG. An IV will be inserted into your arm to deliver your medications. You will be awake during the procedure, but you will receive some medication (sedatives and pain medication) to help calm you, make you sleepy and make you feel as comfortable as possible. You will also be given a local anesthetic to numb the area where the CRT pacemaker will be placed. You should not feel any pain during the procedure, although you may feel some discomfort.
The doctor will clean the area where the pacemaker is to be implanted and a small incision (about 2 inches) will be made under your collarbone. Wires will be placed through a large vein in that area and moved towards your heart. The doctor will use x-rays to make sure the wires are going to the right place. Once in the heart, the wires are tested to make sure they are in the correct location. You may feel your heart racing as the pacemaker takes over for your heart's natural rhythm.
The wires will then be connected to the pacemaker generator, and the generator will be inserted into the same incision. The incision will be closed with stitches. An x-ray will also be done to make sure that the wires and the generator are in the right places.
The entire procedure takes 3 to 5 hours.
What happens after the procedure?
You will rest in bed until the sedative wears off. After that, you will be allowed to eat and drink again. You may feel some discomfort in the area where the CRT pacemaker was placed. Ask your doctor for pain medication if needed. Depending on your age and overall health, you may stay in the hospital anywhere from overnight to a few days. Your doctor will examine your device to make sure it is working properly and may adjust its settings, sometimes using an echocardiogram to see how your heart is working with the device.
Your doctor will talk with you about what level of activity is appropriate after the procedure and for how long you need to limit your activity. Generally, you should avoid contact sports, heavy lifting, and pushing/pulling/stretching of the arm on the side of the implantation for the first 6 weeks. How soon you can resume working depends on the nature of your work and your general health. Ask your doctor before you resume these activities.
Keep the incision site dry including the bandages. Your may be instructed not to shower for the first few days after the procedure. After that you will usually be able to shower with soap and water normally, but you should avoid placing unusual pressure on the pacemaker implant site. Check your wound daily to make sure that it is healing. Let your doctor know if the wound becomes red or swollen, if you notice any pus coming out of the wound, or if you develop fevers or chills. These are signs that the implant site may be infected. Complete recovery from the procedure usually takes 3 to 6 weeks.
Your will be given a temporary card listing the type of CRT pacemaker and wires you have, when it was implanted, and the name of the doctor who performed the procedure. You should receive a permanent card from the pacemaker company by mail within a few months. Be sure to carry one of these cards with you at all times: they inform doctors in any hospital of your device and how to check it if they need to.
What are the risks of the implantation procedure?
Like all surgical procedures, CRT pacemaker implantation carries some risk, but 90% of procedures are successful. Within 6 months of the procedure, 16% of patients experience complications related to movement of the pacemaker leads or mechanical problems with the device; this kind of problem requires another procedure to remove and possibly replace the device.1
It is not know whether women are more likely to have complications after CRT pacemaker implantation; however, women do have slightly higher complication rates after receiving an ICD, a similar procedure.10
Other complications of the implant procedure can include:
- Swelling and bruising where the pacemaker is placed
- Infection of the incision (one in every 70 patients)
- New heart rhythm problems
- Rarely, more serious damage to the blood vessels, nerves, heart, or lungs
Many minor problems can be avoided by carefully following your doctor's instructions before and after the procedure and keeping the wound clean.
Living with a CRT Pacemaker
How often does the pacemaker need to be checked?
The pacemaker needs to be checked periodically to make sure it is working properly, first in the hospital after the procedure and then by your doctor at his or her office. She or he will let you know how often you need to make an appointment to get the pacemaker checked. Usually you will need to have it checked every 6 months, although some of these can be done over the phone.
To check (and adjust if necessary) the pacemaker, the doctor will place a special magnetic wand over the area where it was implanted, connected to a computer that can program and analyze the device. You will not feel anything.
Pacemaker batteries usually last 4 to 8 years, less if your device is a CRT pacemaker combined with an ICD. The battery will not just stop working, but will emit a signal for 6 months before it is due to run out. Your doctor will detect this with the wand during your regular checkup and schedule a procedure to replace your pacemaker.
Will I be able to feel the pacemaker or tell if it is working?
You may be very aware of the feeling of the pacemaker at first, but this will fade with time. You will not be able to hear the device or feel any of the small electrical impulses it supplies to pace your heart.
I have a pacemaker. What should I watch out for?
Because strong electrical and magnetic fields can affect the function of your pacemaker, you should take precautions to avoid them:
- Avoid getting too close to areas or machines that emit strong electric or magnetic fields (for example, stereo speakers)
- Most everyday appliances like microwaves are safe, but you should avoid prolonged close exposure
- If you are unsure whether a machine is safe, keep at least 6 inches between your pacemaker and the machine
- The 6-inch rule also applies to portable electronic devices such as cell phones and iPods; use the ear opposite your CRT pacemaker to talk on the phone, and don't store devices in your breast or jacket pocket
- Airport metal detectors are safe, but the handheld metal detector wands should NOT be held near the pacemaker
- Be sure to tell doctors or medical technicians about your CRT pacemaker before having any tests
- X-rays and CT scans are safe
- MRIs are NOT SAFE because they contain a strong magnetic field
Write down any specific safety questions that occur to you so you can ask your doctor.
- McAlister FA, Ezekowitz JA, Wiebe N, et al. Systematic review: cardiac resynchronization in patients with symptomatic heart failure. Ann Intern Med. Sep 7 2004;141(5):381-390.
- Silverman ME, Pressel MD, Brackett JC, Lauria SS, Gold MR, Gottlieb SS. Prognostic value of the signal-averaged electrocardiogram and a prolonged QRS in ischemic and nonischemic cardiomyopathy. Am J Cardiol. 1995/03/01 1995;75(7):460-464.
- Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. Apr 14 2009;53(15):e1-e90.
- Yarnoz MJ, Curtis AB. Sex-based differences in cardiac resynchronization therapy and implantable cardioverter defibrillator therapies: effectiveness and use. Cardiol Rev. Nov-Dec 2006;14(6):292-298.
- Kelarijani RB, Saleh DK, Chalian M, Kabir A, Ahmadzad Asl M, Dadjoo Y. Gender- and age-related outcomes of cardiac resynchronization therapy: a pilot observational study. Gend Med. Dec 2008;5(4):415-422.
- Zardkoohi O, Nandigam V, Murray L, et al. The impact of age and gender on cardiac resynchronization therapy outcome. Pacing Clin Electrophysiol. Nov 2007;30(11):1344-1348.
- Bleeker GB, Schalij MJ, Boersma E, Steendijk P, van der Wall EE, Bax JJ. Does a gender difference in response to cardiac resynchronization therapy exist? Pacing Clin Electrophysiol. Dec 2005;28(12):1271-1275.
- Alaeddini J, Wood MA, Amin MS, Ellenbogen KA. Gender disparity in the use of cardiac resynchronization therapy in the United States. Pacing Clin Electrophysiol. Apr 2008;31(4):468-472.
- Zhan C, Baine WB, Sedrakyan A, Steiner C. Cardiac device implantation in the United States from 1997 through 2004: a population-based analysis. J Gen Intern Med. Jan 2008;23 Suppl 1:13-19. 10. Peterson PN, Daugherty SL, Wang Y, et al. Gender differences in procedure-related adverse events in patients receiving implantable cardioverter-defibrillator therapy. Circulation. Mar 3 2009;119(8):1078-1084.