16784 Biventricular Pacemaker

Overview

A biventricular pacemaker is a small device, about the size of a matchbox, that is placed under the skin just below your collarbone. It sends tiny, painless electrical signals to both of the lower chambers of your heart (the ventricles) so they squeeze together at the same time. 'Biventricular' simply means 'two ventricles'. Doctors also call this treatment cardiac resynchronisation therapy, or CRT. When the two chambers beat in step, the heart can pump blood more efficiently, which often helps people feel less breathless and less tired. Some biventricular pacemakers also include a built-in defibrillator (a device that can correct a dangerous heart rhythm) — your doctor will explain which type is being suggested for you.

It is not common. Biventricular pacemakers are only offered to a selected group of people with heart failure whose heart tracing shows a particular kind of delay. Many thousands of people around the world live with one, and the number is growing as heart failure care improves.

It is mostly used in adults with heart failure, especially those over 50 who also have an enlarged heart or a delay in the heart's electrical signal (often called a left bundle branch block). It is occasionally used in children and young people, usually those born with heart problems or who have a particular type of heart muscle weakness.

Symptoms

Common symptoms

• Breathlessness when walking, climbing stairs or lying flat
• Feeling very tired or lacking energy for everyday tasks
• Swelling in the ankles, legs or abdomen (tummy)
• A heartbeat that feels fluttering, racing or uneven (palpitations)
• Dizziness or light-headedness, especially on standing
• Unexplained weight gain over a few days from extra fluid

Symptoms in children

• Poor feeding or slow weight gain in babies
• Sweating or breathing fast during feeds or play
• Getting tired quickly when playing with other children
• Blue-ish lips or fingertips in some children with congenital heart problems
• Fainting or near-fainting during exercise

Symptoms in older adults

• Breathlessness that is worse than usual and limits walking or housework
• Swollen ankles that no longer go down with rest
• More frequent falls or unsteadiness, sometimes linked to dizzy spells
• Confusion or memory changes when heart failure becomes less well controlled
• Needing extra pillows to sleep comfortably at night

Causes

Main causes

• Heart failure with a delay in the heart's electrical wiring, most often a left bundle branch block
• Weakened or enlarged heart muscle (cardiomyopathy) from any cause
• Damage to the heart muscle after a heart attack
• Heart problems present from birth (congenital heart disease) in some younger patients
• Changes after certain heart procedures, such as surgery or a treatment for an abnormal heart rhythm

Risk factors

• Coronary artery disease (narrowed arteries supplying the heart)
• Long-standing high blood pressure
• A previous heart attack
• Heart valve disease
• Diabetes and kidney disease
• Being older, and having had heart failure for some time

When to see a doctor

See a doctor urgently if:

• Your breathlessness or swelling is getting worse quickly
• You gain several kilograms (or several pounds) in a few days
• You feel faint, or your heart is racing and uneven
• The skin over your device becomes red, hot, painful or starts to leak
• You feel a repeated twitching or hiccup-like sensation in your chest

Book a routine appointment if:

• You want to discuss whether a biventricular pacemaker could help you
• You have been told your heart tracing shows an electrical delay
• You are due for a device check or your battery needs reviewing
• You are planning travel, a new job or a medical procedure and want advice
• You feel low in mood or anxious about your heart condition

Diagnosis

The decision to offer a biventricular pacemaker is made after a heart specialist reviews your symptoms, examines you and looks at painless tests of your heart's rhythm and pumping. The key test is an ECG (electrocardiogram), which shows whether the electrical signal is delayed. An ultrasound scan of the heart shows how well it is pumping and whether it is enlarged. Your doctor will discuss the benefits and risks with you and only go ahead if it is likely to help.

Tests that may be done

• ECG (electrocardiogram): sticky pads on the chest record your heart's electrical pattern in seconds
• Echocardiogram: a painless ultrasound scan that shows the heart's size, valves and pumping strength
• Blood tests, including one that can show whether the heart is under strain
• Chest X-ray to look at the size and shape of the heart
• A heart rhythm monitor worn at home for a day or longer to catch irregular beats
• Cardiac MRI in some cases, to look more closely at the heart muscle
• A coronary angiogram if the doctor needs to check the heart's arteries

What to expect at your appointment

You will usually be seen in a heart failure or cardiology clinic. Tests are painless and mostly done in one visit. The specialist will explain the results in plain words and talk through the pros and cons of a device, including what it can and cannot do. It is completely fine to take a family member with you and to ask questions before deciding.

Treatment

A biventricular pacemaker is one part of heart failure care, not a stand-alone cure. It works alongside medicines, a healthy lifestyle and regular check-ups. The operation to fit it is usually done under a local anaesthetic, with medicine to help you relax; you stay awake but should not feel pain. The doctor makes a small cut below the collarbone, threads thin leads (wires) through a vein into the heart, and connects them to the device, which sits under the skin. Most people stay in hospital overnight. Your device team then checks that both chambers are being paced in step and fine-tunes the settings.

Self-care at home

• Attend all your device clinic appointments — checks are quick and catch problems early
• Keep the skin over the device clean and dry until your wound has healed
• Carry your device identification card with you at all times
• Keep a daily note of your weight and symptoms if your team asks you to
• Follow your team's advice about driving, and about when you can return to work or exercise
• Tell any doctor, dentist or nurse that you have a pacemaker before any procedure
• Avoid strong magnets and keep headphones and mobile phones a little away from the device, as advised

Medical treatments

Your heart team will usually continue or adjust heart failure medicines that help the heart pump better, remove extra fluid and protect the heart over time. They may also treat related problems such as high blood pressure, an irregular heart rhythm or narrowed heart arteries. If your device includes a defibrillator, it can automatically correct a dangerous rhythm. All medicines are chosen and adjusted by your own doctor, who will explain what each one is for and review them regularly.

When is surgery considered?

The device is fitted during a short procedure, usually under local anaesthetic with sedation. It is offered when tests show your heart's chambers are out of step and your symptoms are likely to improve. Surgery may also be needed later to replace the device when the battery runs low, or to fix a lead if it develops a problem. Your team will explain the small risks of the procedure — such as bleeding, infection or a collapsed lung — and how these are managed.

Living with this condition

After a few weeks of healing, most people settle into a normal routine. The device quietly does its job — you should not feel it working. You will have regular clinic checks, sometimes including a remote monitor kept at home that sends information to your team. Your device card is useful for travel and for any medical appointments. Some people notice a small bump under the skin, which is normal. Airport security can usually be passed by showing your card and asking for a hand search rather than a scanner.

Lifestyle tips

• Take any heart medicines exactly as prescribed, and ask your pharmacist before taking anything new
• Stop smoking if you smoke — your team can offer support
• Limit alcohol and keep to the amount your doctor advises
• Try to keep to a healthy weight, and weigh yourself regularly if asked
• Get your flu and other recommended vaccinations each year
• Tell your team about any travel plans so they can advise on device checks abroad

Diet and exercise

Eating less salt helps reduce fluid build-up, so try to cook more from fresh where you can and go easy on processed foods. Cardiac rehabilitation — a supervised exercise and education programme — is one of the best things you can do; it helps you build stamina safely and meet others in the same situation. Walking, cycling on a static bike and gentle strength work are usually fine. Avoid heavy lifting and strenuous arm movements for the first few weeks after the operation, and check with your team before starting contact sports.

Mental health and emotional wellbeing

It is very normal to feel anxious or low after being told you have heart failure or need a device. You may worry about the device working, about breathlessness, or about the future. These feelings often ease as you recover and gain confidence, but they deserve attention too. Talking therapies, heart support groups and honest conversations with your team can help a great deal. If low mood or worry is affecting your sleep, appetite or daily life, please tell your doctor — support is available and you are not a burden.

Prevention

You cannot always prevent the heart problems that lead to needing a biventricular pacemaker, but you can lower your risk. Looking after your blood pressure, cholesterol and blood sugar, not smoking and staying active all help protect the heart. If you already have heart failure, taking your medicines as prescribed and attending check-ups gives you the best chance of staying well.

Vaccines

Ask your doctor or pharmacist about recommended vaccinations, such as the yearly flu vaccine and others offered to people with heart conditions in your area. Staying up to date reduces the risk of infections that can make heart failure worse.

Screening programmes

There is no general screening programme for this. Heart failure is usually picked up when you see your doctor about symptoms. If you have a family history of heart muscle disease, tell your doctor — they may suggest checks for you and your relatives.

Complications

If left untreated

• Breathlessness and tiredness that steadily get worse
• More frequent stays in hospital for heart failure
• Fluid building up in the lungs, legs or tummy
• Irregular heart rhythms that can be dangerous
• A gradual decline in how well the heart pumps

Long-term outlook

Most people who have a biventricular pacemaker notice a meaningful improvement — easier breathing, more energy and fewer hospital visits — although the amount of benefit varies from person to person and can take a few months to appear. The device works best as part of a wider plan that includes medicines, gentle regular activity and clinic follow-up. Many people live active, fulfilling lives for years with heart failure and a device. Your heart team will be honest with you about what to expect and will adjust your care as your needs change.

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