Biventricular Pacemaker and ICD (Biventricular ICD)
You have a condition called heart failure. It is also known as congestive heart failure (CHF). This condition causes symptoms such as getting tired very quickly and being short of breath. To help treat these symptoms, your healthcare provider is recommending a biventricular pacemaker and implantable cardioverter defibrillator (ICD). This is sometimes called a biventricular ICD. Or it is called cardiac resynchronization pacing with an ICD (CRT-D). A biventricular pacemaker and ICD is a small, lightweight device powered by batteries. This device helps keep your heart pumping normally. It also protects you from dangerous heart rhythms. Read on to learn more about this device and how it works.
Understanding the heart
The heart is made up of 4 sections (chambers) that pump to move blood through the heart. The top 2 chambers are the left atrium and right atrium. These are filling chambers of the heart. The bottom chambers are the left ventricle and right ventricle. These are the pumping chambers of the heart. The heart has an electrical system. This system sends signals that make the atria and ventricles work together. This causes the heart to beat and move blood through the heart and lungs and out to the body.
How the device works
Heart failure weakens your heart muscle. As a result, the ventricles don’t pump as strongly as they should. The pathways that carry the heart's electrical signals are located in the heart muscle. They can also be damaged by CHF. This can cause a bundle branch block. A bundle branch block can throw off the timing of the heart's contraction. This can make the heart's squeezing contraction even weaker.
A biventricular pacemaker and ICD help keep the heart pumping in a more normal way. The pacemaker device keeps the heart from beating too slowly. It tries to restore the normal squeezing pattern of the heart. This is called resynchronization pacing. This can lead to more efficient and stronger heart contraction. The ICD part of the device detects dangerously fast heart rhythms and stops them. If the device detects an abnormally fast heartbeat that can cause cardiac arrest, it will send a "shock" to the heart. The shock stops this dangerous heart rhythm and restores a normal heartbeat.
Before the procedure
Make sure to:
Not eat or drink after midnight or 8 hours before your surgery
Follow instructions from your doctor about bathing the night before and the morning of your procedure. You may need to use a special cleaning solution.
Tell your doctor what medicines you take. This includes over-the-counter medicines such as ibuprofen. It also includes vitamins, herbs, and other supplements. You may need to stop taking some medicines before the procedure, such as blood thinners and aspirin.
Tell your doctor if you are sensitive or allergic to anything. This includes medicines, latex, tape, and anesthetic medicines.
Ask a family member or friend to take you home from the hospital
Tests before your procedure
Before your procedure you may need tests such as:
Blood tests, to test your general health
During the procedure
You will get medicine (anesthesia) so you won’t feel pain. Most likely, you will get medicine (sedation) that will make you drowsy or lightly asleep. The doctor will inject local pain medicine to numb the skin on your chest where the cut (incision) will be made.
The doctor will make an incision where the device will be implanted. This is most often on the left side of the chest just below the collarbone (clavicle).
The doctor makes a small “pocket” for the generator under the skin.
The doctor will put a thin, flexible tube (catheter) into a vein leading to the right atrium. He or she will guide the device’s wires (leads) through the catheter to the heart. The doctor will use an X-ray monitor to move the leads into the right ventricle. He or she will usually also put a lead in the right atrium.
The doctor will put the lead for the left ventricle into a vein that runs along the outside of this chamber. He or she will also use the X-ray monitor to put this lead in the correct spot. The device will stimulate the left ventricle from the outside. The other leads will stimulate the heart from inside the chambers.
The doctor will attach the generator to the leads. He or she will send pulses through the leads to test the generator. This testing may cause your heart to race.
The doctor will then put the generator into the pocket under your skin.
The doctor will program the device based on the heart rate that’s best for you. He or she will check the device to see that it is working.
The doctor will close the skin with stitches (sutures), surgical glue, or staples. Any stitches used will dissolve over time. If glue is used, it will seal the cut and prevent infection. A bandage will be put on the area.
After the procedure
You will spend several hours in a recovery room. Once you are stable and awake, you will be put in a room that can monitor your heart rhythm. Your healthcare team will also watch your breathing and other vital signs. You’ll be given pain medicine if you need it.
The team may place the arm on the side of the device in a sling. This is just for a short time, to keep the arm and shoulder still.
You will have a chest X-ray to make sure the leads are where they should be. The doctor will also check that your lungs were not injured during the procedure.
You can resume a normal diet as soon as you are able. You will be watched overnight. The team will check the device the next morning. You will likely go home the day after your procedure. You may need to take antibiotics for several days to prevent infection.
Recovering at home
Follow all the instructions your healthcare provider gives you for medicines, bathing, exercise, diet, and wound care. Ask your doctor when you can go back to work or start driving again.
Don’t raise your arm above your shoulder on the side of your incision until your doctor says it’s OK to do so. This gives the leads a chance to secure themselves inside your heart.
Make sure to keep all your follow-up appointments. This is so your doctor can download information from your device and check its settings. Be sure to tell your doctor how the device is working for you.
Most devices can now be connected to a wireless home monitoring system via the internet. The monitor can download information from your device and send it to your doctor. This lets your doctor make sure the device is working as it should.
Life with a biventricular pacemaker and ICD
Carry an ID card. When you first get your pacemaker, you’ll be given an ID card to carry. This card contains important information about the device. Show it to any doctor, dentist, or other provider you visit. Pacemakers may set off metal detectors. So you may need to show your card to security personnel.
Be careful when using a cell phone. Hold it to the ear farthest from your pacemaker. Don’t carry the phone in your breast pocket, even when it’s turned off.
Avoid very strong magnets. These include those used for an MRI or in hand-held security wands. Show your ID card when you go through security.
Avoid strong electrical fields. These are made by radio transmitting towers and ham radios. They are also made by heavy-duty electrical equipment. A running engine makes an electrical field. Don't lean over the open hood of a running car. Most household and yard appliances will not cause any problems. If you use any large power tools, such as an industrial arc welder, talk to your doctor.
Keep an eye on the battery. The battery inside the device is checked regularly. It will last 5 to 7 years, depending on how often it paces or has to stop dangerous heart rhythms. Once it starts to run down, you will need to have it changed. This is like the implantation surgery, but it takes less time. This is because the battery/generator is the only part that needs to be replaced.
Be careful when driving. Your device has a defibrillator built in. You may not be allowed to drive for the first 6 months after you get the device. You may also not be allowed to drive for 6 months after the defibrillator delivers a shock. You will not be allowed to work as a commercial driver if you have an ICD.
When to call your healthcare provider
Call 911 if you have chest pain or trouble breathing.
Call your healthcare provider if you have any of the following:
Redness, severe swelling, severe pain, drainage, bleeding, or warmth at the incision site
Incision site or opens up or does not heal well
A fever of 100.4°F (38°C) or higher, or as directed by your healthcare provider
Pain around the generator that gets worse
Swelling in the arms or hands on the side of the incision
Sudden weight gain
Twitching chest or abdominal muscles
Frequent or constant hiccups
A shock from your device
Very fast heartbeat that doesn’t stop
Generator feels loose or like it is wiggling in the pocket under the skin
August 08, 2018
Cardiac implantable electronic devices: Patient follow-up. UpToDate., Cardiac Resynchronization Therapy (CRT). Heart Rhythm Society., Cardiac resynchronization therapy in heart failure: Implantation and other considerations. Tracy CM. Circulation. 2012;126:1784-1800., Cardiac resynchronization therapy in heart failure: Implantation and other considerations. UpToDate., Driving restrictions in patients with an implantable cardioverter-defibrillator. UpToDate., Implantable Cardioverter Defibrillators (ICDs). Heart Rhythm Society.
Image reviewed by StayWell medical art team.,Kang, Steven, MD,Snyder, Mandy, APRN