Patient Education and Consent
Preprocedure
Before implantation of cardiac resynchronization therapy (CRT), educate patients about the indication(s), utility, and potential complications that may be encountered during the procedure.
Following an explanation of the procedure, patients should be offered the opportunity to ask any questions they might have about the procedure.
Query patients whether they are sensitive to or are allergic to any medications, iodine, latex, tape, or anesthetic agents (local and general). Also, elicit all medications (prescription and over-the-counter) and herbal or other supplements patients may be taking.
Educate patients to notify physicians if they have heart valve disease, as prophylactic antibiotics may be required prior to the procedure. Also determine whether patients have a history of bleeding disorders or if they are taking any anticoagulants, aspirin, or other medications that affect blood clotting. It may be to stop some of these medications prior to the procedure.
Patient will need to fast for a certain period of time prior to the procedure, usually overnight.
Patient may receive a sedative prior to the procedure to help them relax.
After obtaining a signed informed consent, surgeons may proceed with the procedure.
Details regarding the pre- and postprocedure care are summarized in the following sections.
Postprocedure
Educate patients about the following points:
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After the procedure, patients may be taken to the recovery room for observation or returned to the hospital room. A nurse will monitor their vital signs.
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Patients should inform the nurse immediately if they feel any chest pain or tightness, or any other pain at the incision site.
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After the period of bed rest has been completed, patients may get out of bed with assistance. A nurse will check their blood pressure while patients lie in bed, sit, and stand. Advise patients to move slowly from the bed to avoid any dizziness from the period of bedrest.
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Patient will be able to eat or drink once completely awake.
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The insertion site may be sore or painful, and pain medication may be administered, if needed.
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Once the patients' blood pressure, pulse, and breathing are stable and they are alert, they will be taken from the recovery room to their hospital room or discharged to home.
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If the procedure is performed on an outpatient basis, patients may be allowed to leave after having completed the recovery process. However, it is common for patients to spend at least one night in the hospital for observation after implantation of an implantable cardioverter-defibrillator.
Preprocedural Planning
The European Society of Cardiology (ESC) developed guidelines in collaboration with the European Heart Rhythm Association (EHRA) and provided recommendations for preimplantation of cardiac resynchronization therapy (CRT), as outlined below. [25]
Recommended
The following are preimplantation recommendations [25] :
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Careful evaluation of comorbidities and an estimate of life expectancy
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Thorough preimplant history and physical examination, including review of vital signs and laboratory tests
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Stable heart failure (HF) status in CRT candidates on guideline-directed medical therapy (GDMT) prior to implantation
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Preimplant comprehensive echocardiogram for quantification of left ventricular (LV) ejection fraction (LVEF) and assessment of cardiac size and function
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Preimplant 12-lead electrocardiogram (ECG), including measurement of QRS duration (QRSd) (120–130 ms) and characterization of QRS morphology
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Continued therapy at a reduced dosage in preoperative patients at high thromboembolic risk on oral anticoagulant therapy with warfarin, with close monitoring of the international normalized ratio (INR 2–3); postoperative use of heparin is discouraged
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Preoperative infection prophylaxis with an antibiotic that has in vitro activity against staphylococci
May be useful
The following preimplantation recommendations may be useful [25] :
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Preimplant formal functional status testing including a quality of life (QOL) measure to monitor CRT response
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Cardiac magnetic resonance imaging (cMRI) to assess cardiac function and provide detailed information about viable myocardium in the distribution of a coronary sinus (CS) branch vein considered for left ventricular (LV) lead implant
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Venous anatomic mapping with computed tomography angiography (CTA) in certain patient populations (eg, those with prior LV lead implant failure or those at risk for abnormal venous anatomy)
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Development of a preimplant strategy to identify and manage atrial fibrillation or frequent premature ventricular contractions (PVCs) that may impair the ability of CRT to deliver therapy continuously
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Patients at low to moderate thromboembolic risk on oral anticoagulant therapy with warfarin: Continued therapy at a reduced dosage (INR 1.5-2) or withholding therapy 3-5 days preoperatively to minimize bleeding risk
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Patients at low-moderate thromboembolic risk on direct thrombin or factor Xa inhibitor agents: Withholding such therapy 2-3 days before surgery to minimize bleeding risk.
Not recommended
CRT implantation should be deferred in patients with acutely decompensated HF, who are dependent on inotropes, or who have unstable ventricular arrhythmias until their medical status is improved. [25]
Echocardiographic dyssynchrony assessment should not be used to exclude patients from consideration for CRT. [25]
Monitoring & Follow-up
The European Society of Cardiology (ESC) and the European Heart Rhythm Association (EHRA) have provided cardiac-resynchronization therapy (CRT) follow-up recommendations, as outlined below. [25]
Recommended
A close degree of cooperation is recommended in the follow-up of the CRT recipient between the heart failure (HF) and electrophysiology follow-up physician.
A minimum in-clinic follow-up interval of 6 months is strongly recommended for CRT recipients.
Remote monitoring and follow-up in addition to in-clinic follow-up is recommended. Patients should be encouraged to initiate a remote transmission if new symptoms or concerns arise.
Follow-up visits that include a patient history, physical examination, device interrogation and testing, and systematic analysis of device data is recommended.
Optimization including upward titration of heart failure drug therapies, if appropriate, is recommended to maximize response to CRT.
Evaluation of LV function or other adjuncts to assess heart failure progression or regression is recommended during follow-up.
May be useful
Catheter ablation of the atrioventricular (AV) node in the setting of atrial fibrillation with native conduction can be useful if CRT is not being delivered consistently.
