Having a cardiac resynchronisation therapy CRT-P device implanted
The aim of this leaflet is to answer any questions you may have about having a cardiac resynchronisation therapy device (CRT-P). It will explain what a CRT-P is and how it works, as well as the benefits and risks of the procedure.
You should have already spoken with your cardiologist about having a CRT-P. This booklet is not meant to replace these discussions, but we hope it will make you feel more comfortable with your decision to have this procedure.
Your cardiologist will answer any questions you may have after reading this booklet. We encourage you and your family to ask questions and are more than happy to talk through any concerns you may have.
The healthy heart
Benefits, risks and alternatives
Having your CRT-P implanted
Recovering from your operation
When can I go back to my normal activities?
Benefits, risks and alternatives
What are the benefits of having a CRT-P?
Many patients feel that their CRT-P gives them peace of mind. They feel safer because it automatically treats their heart condition. The CRT-P device may also help to improve your breathlessness by ‘resynchronising’ your heart to work more effectively.
What are the risks of having a CRT-P?
As with any operation, there are risks in having a CRT-P implanted. A very small number of people will develop a complication because of the surgery.
Potential risks include:
- Infection. You may develop an infection. However, you will be given antibiotics before the procedure to reduce this risk. If you develop an infection after you have left the hospital, you must return to us for evaluation. About two in every 100 patients develop an infection. You might have an infection if: you develop a high temperature, or your wound becomes red and inflamed or warm and painful, or your wound starts to ooze.
- Reaction to medicine. We try to reduce the risk of this by carefully recording any known allergies that you might have. It is not always possible to know if you will react to a medicine that you have not used before.
Reactions to medicines can vary from developing a rash, or feeling sick or unwell, to a drop in your heart rate or blood pressure that needs treatment, problems with breathing, or even death. Our staff is trained to act on any emergency, should you have a reaction to the medicine we give you.
- Hematoma (collection of blood in the tissues causing swelling and bruising). There is a risk of severe bruising or swelling around the site where the CRT-P is implanted. This is more common in people who are taking blood-thinning medicines such as warfarin before their procedure. If this does happen, we may need to take you back to theatre to re-open your wound and drain it. About three to four in every 100 patients have severe bruising.
- Pneumothorax (air in the spaces around the lungs also known as a collapsed lung). The CRT-P wires are inserted into the heart, through a vein in the upper chest area. When this happens, there is a risk that a small puncture may be made in the top of the lung. This can cause air to leak into the spaces around the lungs and partially collapse your lung. If the leak is small, it may be left to heal by itself. Sometimes we insert a chest drain to remove the air and allow your lung to fully inflate again. This happens in about one in every 100 patients.
- Pericardial effusion (blood leak around the heart). When the leads are positioned in the heart, they can damage the heart wall and the sac surrounding the heart (pericardium) may fill with blood. This may heal by itself, or you may need a small drain put in to remove the blood. This happens to about one in every 500 patients.
- Lead displacement. There is a risk that the leads we put in will move after the procedure. If this happens, your CRT-P will not work properly and you will probably need another procedure to have the leads repositioned. You can help to lower the risk of this, by following the instructions on limiting your arm movements after the procedure . This happens in about ten in every 100 patients.
- Blockage in the veins. Sometimes when we put more than one lead through a vein into your heart, there can be problems with the flow of blood through that vein. If this causes a problem for you, the doctors might consider starting you on the blood thinning medicine warfarin or removing one or more of the leads. You would need to come back in for another procedure for this, and the leads would be replaced using a different vein.
- X-rays. Your examination and/or treatment will involve a period of x-ray scanning that will give you a relatively small x-ray dose. In some cases where we need to do more extensive investigation and treatment, there is a small chance that you will get a skin reddening reaction like sunburn, which will fade after a few days. Please ask the radiographer if you require further information.
The vast majority of patients undergoing permanent CRT-P implantation will survive. Some people are more at risk than others depending on their general health and well being. The approximate risk of death is very rare (one in every 1,000).
The cardiologist will discuss the risks with you in more detail before asking you to sign a consent form. Please feel free to discuss all your questions and concerns with him/her.
What are the alternatives?
An alternative to having a CRT-P could be managing your heart failure with medicines.
Usually your cardiologist has considered this before recommending that you have a CRT-P, but has decided that the safest treatment for you is to have a CRT-P fitted. If you would like more information on this option, please feel free to discuss it with your cardiologist.
Asking for your consent
We want to involve you in all the decisions about your care and treatment. If you do decide to go ahead, you will be asked to sign a consent form to confirm that you agree to have the procedure and understand what it involves. It is your right to have a copy of this form. You should be given the leaflet, Helping you decide: our consent policy, which gives you more information. If you are not given this leaflet, please ask us for one.
Having your CRT-P implanted
Will I have a local or general anaesthetic?
Inserting your CRT-P can be carried out under local or general anaesthetic. Your doctor will talk with you about which one would be best for you. You should be given the leaflet, having an anaesthetic, which explains what to expect when you are given the anaesthetic. If you are not given this leaflet, please ask a member of staff caring for you.
What will happen before the procedure?
You will usually remain in hospital while you are waiting to have your CRT-P inserted. If you are taking warfarin or an antiplatelet medicine (for example aspirin, clopidogrel, prasugrel or dipyridamole) you should discuss with your doctor or nurse whether you will need to stop taking it before your operation.
Please let your doctor know if you are taking any other medicines, including anything bought over the counter, and any herbal/alternative preparations. They will let you know if you need to stop any of these before having the procedure.
You cannot to eat or drink anything for six hours before your operation because of the anaesthetic. A nurse will give you a single dose of an antibiotic before the procedure to prevent infection.
If you are having the surgery under general anaesthetic, the anaesthetist (doctor specialising in anaesthesia) will come to see you on the ward before your operation. He/she will ask you questions about your general health and about any previous operations that you have had under general anaesthetic.
What will happen during the procedure?
All our staff is fully trained for these procedures and will be monitoring you closely at all times. In the theatre, the nursing staff will check your details, such as any allergies and when you last ate. They will then help you onto the operating table. A number of staff will be present, including nurses, doctors, radiographers and cardiac physiologists.
A technician will connect you to an electrocardiogram (ECG) machine, which will monitor your heart rhythm during surgery. A nurse will put a cuff around your arm to monitor your blood pressure and a clip on your finger to measure your oxygen levels. These are not painful.
If you are having the procedure under local anaesthetic and have not yet had a needle put into your hand or arm, one will be put in now. All medicines will be given through this needle. We will then assess you before the procedure and give you sedation (to make you sleepy) and a painkiller (morphine). Sedation will be ‘topped-up’ throughout the procedure.
The CRT-P is usually put in on the opposite side to your dominant arm. For example, if you are right handed, it will be put in on the left side. This is usually because the leads will be under less strain on this side. The doctor will then clean the relevant side of your chest with an antiseptic liquid. After this, you will be covered with drapes to make sure the whole area is kept sterile throughout the operation.
The doctor will warn you before they inject the local anaesthetic. At first, the local anaesthetic will sting, but soon the whole area will go numb. You should not feel any pain during the procedure, but you may be aware of pressure in the area where the doctor is working. Please let us know if you feel uncomfortable.
The doctor will put in three wires into your heart through a vein. In some cases, up to four wires may be put in. The wires will be inserted under X-ray guidance. Once in place a cardiac physiologist will test these wires to make sure they have good contact with your heart muscle. The wires either have small prongs or a tiny screw to hold them in position against your heart wall. After the wires are in position, the doctor will make a small pocket under the skin to fit the battery (generator), and will then connect the wires to this.
Once this had been done, your CRT-P will be tested.
When this test has been completed, the doctor will close your wound with dissolvable stitches. It will then be sprayed with an antiseptic solution that will help to protect it from infection and will be left uncovered. The cardiac physiologists will make sure that your CRT-P is programmed correctly and switched on. You will then be ready to return to the ward.
What if I am having a general anaesthetic?
If you are having a general anaesthetic, you will have the same procedure as above, but you will be asleep throughout the surgery. Once you are connected to the monitoring equipment, you will be put to sleep by your anaesthetist. A tube will be passed into your windpipe and connected to a machine called a ventilator. This will control your breathing during the operation. You will have extra monitoring of your blood pressure through a special needle in your wrist because of this, which will be put in once you are asleep.
You will wake up in theatre once the procedure is over and the tube will be removed from your windpipe. When the anaesthetist is happy that you are fully awake, you will be transferred back to your ward.
What happens after my surgery?
After the operation, you will return to the ward. You may need to be attached to a heart monitor to keep an eye on your heart rhythm for 12 to 24 hours. Because of the anaesthetic (local or general) and sedation, you may need an oxygen mask for a few hours to help your breathing. Your nurse will also check your blood pressure and wound regularly for the first few hours.
You can expect to feel drowsy for a few hours following the procedure. As you will have had nothing to drink for a few hours before your surgery, you may need a drip of intravenous fluid. You will need to stay in bed for a few hours. Your nurse will allow you to eat and drink when it is safe.
You will have a chest x-ray to check the positioning of the CRT-P leads in your heart. This is usually done the following morning.
Will my CRT-P be checked before I go home?
Yes. Before you go home, you will be taken down to the Cardiac Outpatient Department to have your CRT-P checked by the cardiac physiologists. This is to make sure that your CRT-P is working as it should be and that it has been programmed correctly before you go home. The cardiac physiologists will give you your ID card with all the technical details for your CRT-P. This gives useful information for anyone needing to treat you or your CRT-P, wherever you are. You will also receive information on how often your CRT-P will need to be rechecked (usually every three to six months), and how to contact the hospital if you have any problems or concerns. Your cardiac physiologist will let you know if your future CRT-P checks can be done at a hospital closer to where you live. Be sure to ask questions if anything is unclear or confusing.
Recovering from your operation
Your wound and the shoulder where the CRT-P has been implanted will be uncomfortable for the first few days. You will be given painkillers by the nursing staff to help with this.
When can I go back to my normal activities?
You should be able return to your normal activities as soon as you feel up to it. On the side of your body where the CRT-P has been inserted, you must not lift your arm above shoulder height for at least four weeks. You will also have to avoid lifting, pushing or pulling heavy objects for the first four weeks. Do not be afraid to move your arm normally, as this will prevent your shoulder from becoming stiff. You may feel a little tired or sore at first, so build up slowly to your normal routine.
There are rules that regulate whether you can drive with your implant, and you will also need to take some precautions before you travel.