Cardiac Resynchronization Therapy (CRT)

What is CRT and how can it help your heart?

Arrhythmias are irregular heart rhythms and can be caused by a variety of reasons, including age, heart damage,
medications and genetics. In heart failure patients CRT, or biventricular pacing, is used to help improve the
heart’s rhythm and the symptoms associated with the arrhythmia. The procedure involves implanting a half-
dollar sized pacemaker, usually just below the collarbone. Three wires (leads) connected to the device monitor
the heart rate to detect heart rate irregularities and emit tiny pulses of electricity to correct them. In effect, it is
"resynchronizing" the heart.

Benefits of CRT
Because CRT improves the heart’s efficiency and increases blood flow, patients have reported alleviations of
some heart failure symptoms - such as shortness of breath. Clinical studies also suggest decreases in
hospitalization and morbidity as well as improvements in quality of life.

Who is a candidate for CRT?

In general, CRT is for heart failure patients with moderate to severe symptoms and whose left and right heart
chambers do not beat in unison. However, CRT is not effective for everyone and is not for those with mild heart
failure symptoms, diastolic heart failure or who do not have issues with the chambers not beating together. It is
also not suitable for patients who have not fully explored correcting the condition through medication therapies.
To date, studies show CRT to be equally effective for both men and women.

Cardiac resynchronization therapy

Cardiac resynchronization therapy is a procedure to implant a device in your chest to make your heart's
chambers squeeze (contract) in a more organized and efficient way. Cardiac resynchronization therapy (CRT)
uses a device called a biventricular pacemaker (also called a cardiac resynchronization device) that sends
electrical signals to both lower chambers of your heart (ventricles). The signals trigger your ventricles to
contract in a more coordinated way, which improves the pumping of blood out of your heart. Sometimes the
device also contains an implantable cardioverter-defibrillator (ICD), which can deliver an electrical shock to
reset your heartbeat if your heart rhythm becomes dangerously erratic.

Why it's done

Cardiac resynchronization therapy is a treatment for heart failure in people whose ventricles don't contract in a
coordinated fashion. If you have heart failure, your heart muscle is weakened and may not be able to pump out
enough blood to support your body. This can be worsened if your heart's chambers aren't in sync with each
other. Cardiac resynchronization therapy may reduce your symptoms of heart failure and lower your risk of
heart failure complications, including death.

Risks
All medical procedures come with some type of risk. The specific risks of cardiac resynchronization therapy
depend on the type of implant and your overall health. Complications related to cardiac resynchronization
therapy and the implantation procedure may include:
 Infection
 Injury to a blood vessel
 Collapsed lung (pneumothorax)
 Compression of the heart due to fluid buildup in the sac surrounding the heart (cardiac tamponade)
 Failure of the device
 Shifting of device parts, which could require another procedure
What you can expect
Cardiac resynchronization therapy requires a minor surgical procedure to implant a device in your chest. You'll
likely be awake during the procedure, though the area where the pacemaker is implanted is numbed and you'll
receive medication to help you relax (conscious sedation). The procedure typically takes a few hours. During
surgery, insulated wires (leads, or electrodes) are inserted into a major vein under or near your collarbone and
guided to your heart with the help of X-ray images. One end of each wire is attached to the appropriate position
in your heart. The other end is attached to a pulse generator, which is usually implanted under the skin beneath
your collarbone.

Cardiac resynchronization therapy devices include:

 Cardiac resynchronization therapy with a pacemaker (CRT-P). The device used for cardiac
resynchronization therapy has three leads that connect the pacemaker to the right upper chamber of your
heart (right atria) and both lower chambers (ventricles).
 Cardiac resynchronization therapy with a pacemaker and an ICD (CRT-D). This device may be
recommended for people with heart failure who also have a risk of sudden cardiac death. It can detect
dangerous heart rhythms and deliver a stronger shock of energy, which is able to reset your heartbeat,
than a pacemaker can deliver.
You'll usually stay overnight in the hospital after cardiac resynchronization therapy. Your doctor will test your
device to make sure it's programmed correctly before you leave the hospital. Most people can return to their
usual activities after a few days.

How do I get ready for the insertion of a CRT device?

You should discuss all the risks and benefits of the procedure with your doctor. He or she will probably tell you
to not eat or drink anything after the midnight before surgery. If you usually take medicines in the morning, ask
your doctor if you can take them with a sip of water. Your healthcare team may ask you to stop taking any
medicines that thin your blood several days before the procedure. If you take medicines for diabetes, ask your
doctor to help you adjust your dose around your surgery. Let your doctor know about:
 Prescription medicines that you take
 Over-the-counter medicines or supplements you take, especially aspirin
 Allergies
 Recent symptoms of colds or infections
 History of problems with anesthesia

What happens during insertion of a CRT device?

Your doctor may Insert your CRT device on an outpatient basis, or as part of your stay in a hospital. Procedures
may vary, depending on your condition and your doctor's practices. Talk with your doctor about what will
happen during your procedure. The actual procedure may take from 3 to 5 hours. You’ll probably be awake but
relaxed and sleepy during the procedure. This is what you can expect:
 In the procedure room you will lie down on an X-ray table.
 An intravenous (IV) line will be put into your hand or arm. Your healthcare team will give you fluids,
antibiotics, and pain medicine through this line.
 Your team will watch your heart, blood pressure, and oxygen level.
 Your doctor will give you medicines to help you relax or fall asleep. The doctor will also numb the area
where the device will be placed. This is usually just under your left collar bone (clavicle).
 Your doctor will make a small cut (incision) and create a pocket under the skin. This pocket will hold
the wires and computer battery pack for the CRT.
 Your doctor will put IV lines in the large vein that feeds your heart. He or she will put CRT wires
(leads) into the vein and feed them into your heart. Special X-rays will be taken to make sure the leads
are in the right place on both sides of your heart.
 Your doctor will test the leads with an electric pulse. It may feel as if your heart is racing.
  If the leads are in the right place and working as they should, they will be attached to the CRT
pacemaker. Your doctor will put the pacemaker through the incision and under your skin.
 Your doctor will then close the incision with sutures or staples and apply a dressing.

What happens after the CRT device is inserted?

You will be moved to the recovery area. You will stay there until the relaxing medicine has worn off. A
healthcare provider will give you pain medicines as needed. You may need to stay in the hospital for a day or
two while your doctor checks and adjusts the settings on your CRT device. After you leave the hospital, it will
be important to follow all of your doctor's advice and keep all follow-up appointments.
Here’s what you can expect once you’re home:
 You should be able to follow your normal diet.
 You may need to limit activities such as lifting, straining, and stretching for the first 6 weeks. Ask your
healthcare provider when you can return to specific activities.
 Keep the dressing clean and dry until your healthcare provider tells you it is OK to remove the dressing
and take a shower.
 Check your incision area for any signs of infection. Let your healthcare provider know if you have any
fever, redness, soreness, discharge, bleeding, or swelling.

Here are likely long-term instructions for living with your CRT device:
 Make sure to have your doctor check the functioning of your device regularly. This should be done at
least once every 6 months.
 Carry a CRT pacemaker identification card and let all your caregivers know about your device.
 Your pacemaker battery will last for about 4 to 8 years. Your doctor will be able to tell about 6 months
before the battery runs down. Replacing the CRT pacemaker is a minor procedure.
 It’s a good idea to keep all electrical devices about 6 inches away from your CRT pacemaker. They can
interfere with its function.
 You may need to stay away from devices that have strong magnetic fields. These include electrical
generators and appliances like microwaves. Talk with your healthcare provider if you have any
questions about what to avoid.
 Most X-rays and metal detectors are safe, but you should avoid metal wands used for airport screenings
and MRI imaging tests.

Next steps
Before you agree to the test or the procedure make sure you know:
 The name of the test or procedure
 The reason you are having the test or procedure
 What results to expect and what they mean
 The risks and benefits of the test or procedure
 What the possible side effects or complications are
 When and where you are to have the test or procedure
 Who will do the test or procedure and what that person’s qualifications are
 What would  happen if you did not have the test or procedure
 Any alternative tests or procedures to think about
 When and how will you get the results
 Who to call after the test or procedure if you have questions or problems
 How much will you have to pay for the test or procedure