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Pacemaker for Heart Failure (Cardiac Resynchronization Therapy)

Treatment Overview

Cardiac resynchronization therapy (CRT) uses a special type of pacemaker called a biventricular pacemaker (say "by-ven-TRICK-yuh-ler") to treat heart failure. This pacemaker sends electrical pulses to make the ventricles pump at the same time.

A biventricular pacemaker is implanted in the chest, and it connects to three thin wires, called leads. The leads go into different chambers of your heart. If there is a problem with your heartbeat, the pacemaker sends a painless signal through the leads to fix the problem. The pacemaker also can speed up your heart if it is beating too slowly.

In some cases, you may get a pacemaker that is combined with a device to shock your heartbeat back to a normal rhythm if it is dangerously fast. The device is called an implantable cardioverter-defibrillator, or ICD. It can prevent sudden death.

Your doctor will put the pacemaker in your chest during minor surgery. You will not have open-chest surgery.

Your doctor makes a small cut (incision) in your chest. The doctor puts the leads in a vein and threads them to the heart. Then your doctor connects the leads to the pacemaker. Your doctor programs the pacemaker and then puts it in your chest and closes the incision.

What To Expect After Treatment

Most people spend the night in the hospital, just to make sure that the device is working and that there are no problems from the surgery. But sometimes the procedure is done as an outpatient procedure, which means you don't need to stay overnight in the hospital.

You may be able to see a little bump under the skin where the pacemaker is placed.

Why It Is Done

When you have heart failure, the lower chambers of your heart (the ventricles) aren't able to pump as much blood as your body needs. Sometimes the heart has a problem with the electrical system that controls the pumping. This means the ventricles don't pump at the right time or the heart has an abnormal rhythm. A pacemaker for heart failure can help the heart pump blood better.

Whether a pacemaker for heart failure is right for you depends on many medical facts. Your doctor will check whether:1, 2

  • You have class III or class IV heart failure. This means that you have trouble doing everyday activities or you can't do them at all. Activity makes you very tired and short of breath, or you have pain or other problems.
  • You are taking medicines for heart failure, but you still have symptoms like being very tired and short of breath.
  • You have an ejection fraction of 35% or less. Ejection fraction is a measure of how much blood your left ventricle pumps. A normal ejection fraction is 55% or more.
  • Tests show that your heart's ventricles are not beating at the right time. These tests may include an electrocardiogram (EKG, ECG) test, an echocardiogram, or an electrophysiology study.

How Well It Works

A pacemaker can help you feel better so you can be more active. It also can help keep you out of the hospital and help you live longer.

  • A large study found that 19 out of 100 people who were treated with a pacemaker for heart failure had to go into the hospital during the study because of heart failure. But 27 out of 100 people treated with medicine alone had to go into the hospital for heart failure.3
  • In the same study, 13 out of 100 people who got a pacemaker for heart failure died during the study, compared with 16 out of 100 who got only medicine.3
  • The combination of a pacemaker and an ICD (implantable cardioverter-defibrillator) can also help people live longer and stay out of the hospital.4

A pacemaker also can help your heart pump better by changing the shape of your heart. In heart failure, the left ventricle often gets too big as it tries to make up for not pumping well. Using a pacemaker may reverse this.

Risks

There are several risks to getting a pacemaker. But risks vary for each person. The chance of most problems is low.

The procedure to implant a pacemaker is safe, and most people do well afterward. Afterward, you will see your doctor regularly to check your pacemaker and make sure you don't have any problems.

During the procedure

If problems happen during the procedure, doctors likely can fix them right away.

  • A lung could collapse (pneumothorax). This happens if air builds up in the space between the lung and the chest wall. But a pneumothorax can be treated and people recover well. This might happen about 1 time out of 100. So about 99 times out of 100, no problems happen.5
  • Serious problems during the procedure are very rare. These problems include heart attack, stroke, or the need for an emergency surgery. These problems might happen 1 time out of 1000.6
  • The pacemaker might not be able to be implanted for several reasons, such as when a vein near the left ventricle is too small, too wide, or too hard to reach to allow a lead to be placed. Sometimes the chest or heart may be too big to place a lead. The chance that a doctor can't place the pacemaker is about 8 out of 100. That means the pacemaker can be placed 92 times out of 100.5

After the procedure

Problems after the procedure can be minor, like mild pain, or serious, like an infection. But your doctor can solve most of these problems. And most people do not have long-term issues with their pacemakers.

Problems include:

  • Pain, bleeding, or bruising soon after the procedure.
  • Infection in your chest near the pacemaker. An infection might happen about 1 time out of 100. This means that about 99 times out of 100 there is no infection.2
  • The pacemaker or leads might not work. This might happen about 7 times out of 100. So 93 times out of 100, the pacemaker and leads do work.7
  • A lead might move out of place. This might happen up to 9 times out of 100. So about 91 out of 100 times, the lead stays in place.7

What To Think About

Daily precautions

Some activities and situations can interrupt the signals sent by the pacemaker to the heart. You may need to adapt some of your activities. Follow your doctor's specific instructions about care and precautions if you have a pacemaker.

If you get a pacemaker, you have to be careful not to get too close to some devices with strong magnetic or electrical fields. These include MRI machines, battery-powered cordless power tools, and CB or ham radios. But most everyday appliances are safe.

Complete the special treatment information form (PDF)special treatment information form (PDF)(What is a PDF document?) to help you understand this treatment.

References

Citations

  1. Epstein AE, et al. (2008). ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation, 117(21): e350–e408. [Correction in Circulation, 120(5): e34–e35.]
  2. Hunt SA, et al. (2009). 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. Circulation, 119(14): e391–e479.
  3. McAlister FA, et al. (2007). Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: A systematic review. JAMA, 297(22): 2502–2514.
  4. Tang ASL, et al. (2010). Cardiac-resynchronization therapy for mild-to-moderate heart failure. New England Journal of Medicine, 363(25): 2385–2395.
  5. Van Rees JB, et al. (2011). Implantation-related complications of implantable cardioverter-defibrillators and cardiac resynchronization therapy devices. Journal of the American College of Cardiology, 58(10): 995–1000.
  6. Akoum NW, et al. (2008). Pacemaker therapy. In EG Nabel, ed., ACP Medicine, section 1, chap. 7. Hamilton, ON: BC Decker.
  7. McKelvie R (2011). Heart failure, search date August 2010. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.

Other Works Consulted

  • Bogale N, et al. (2012). The European CRT survey: 1 year (9–15 months) follow-up results. European Journal of Heart Failure, 14(1): 61–73.
  • Epstein AE, et al. (2008). ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation, 117(21): e350–e408. [Correction in Circulation, 120(5): e34–e35.]
  • Lampert R, et al. (2010). HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm, 7(7): 1008–1026. Available online: http://www.hrsonline.org/Policy/ClinicalGuidelines/upload/ceids_mgmt_eol.pdf.

Credits

By Healthwise Staff
Primary Medical Reviewer Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology
Specialist Medical Reviewer Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology
Last Revised September 12, 2012

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