Cardiac resynchronization therapy (CRT) involves implanting a biventricular pacemaker (CRT-P) to help improve heart function in some heart failure patients. During the procedure, the CRT box is typically placed under the collarbone, after the area has been thoroughly sterilised with antiseptic solution. It's important that you do not move your arm or contaminate the area, and sterile drapes will be used to cover your face temporarily. An anaesthetist will manage your sedation, and local anaesthetic will be used to numb the site and maintain numbness for several hours post-procedure.

The CRT wires are inserted into a vein at the site, and wires are then threaded through the vein and into various locations in the heart, guided by special x-rays. An additional lead is necessary for pacing the left ventricle, which is inserted into the coronary sinus vein from the right atrium and positioned on the outside surface of the left ventricle. This is the most complex and time-consuming part of the procedure, and a suitable vein isn't always present. Once the CRT is connected to the leads, it's placed in a "pocket" under the skin and the incision is closed. In some cases, the device must be checked by intentionally causing dangerous heart rhythms, requiring deep sedation to maintain your comfort.

After the local anaesthetic wears off, you may feel some soreness at the site, which can last a few days. Paracetamol should provide sufficient pain relief, but please inform the nursing staff if you require further pain relief while in the hospital. The length of the procedure will vary, but can take several hours depending on various factors.

After the procedure, a compression bandage may be applied and will be removed after 2 hours. Some patients may have a skin adhesive that should remain dry for 24 hours and can get wet but should not be scrubbed, picked, or soaked. It will gradually peel off by itself over the next few weeks. The stitches in the wound will dissolve and do not require removal.

After the procedure, you will undergo a chest x-ray, and the CRT will be checked with a specialised computer called a programmer. This programmer allows your doctor to assess the CRT's performance and make any necessary adjustments to the program, ensuring it best meets your individual needs. If the checks are satisfactory and you feel well, you will be discharged home on a short course of antibiotics.

Preventing infection is crucial after a CRT implantation, and Dr. Hsieh and his team take every measure to avoid this complication by using antibiotics and sterile techniques. It is important to check your wound daily for any signs of infection, such as fever, redness, heat, increased swelling, or new drainage at the site. If you notice any of these symptoms, please inform your cardiologist immediately. Please do not attempt to manipulate the implant site yourself.

For 2 weeks after the procedure, avoid any strenuous activity involving the arm on the side of the device, and for 4-6 weeks, do not raise the arm above shoulder level. This allows time for the leads to securely attach to your heart tissue and the incision to heal. It's important to avoid hitting or bumping the implant area, so contact sports may not be advisable. However, using the arm for light activities can help prevent a frozen shoulder.

If you've had a CRT-P implantation, you shouldn't drive a private vehicle for 2 weeks, or a commercial vehicle for 4 weeks. You will no longer have an unconditional license but can get a conditional license with routine medical review. If you have a CRT-D, the RTA does not permit you to hold a commercial license except in rare exceptions, and you can't drive a private vehicle with an unconditional license. You should wait for 6 months if you have had a cardiac arrest, but if you have a preventative CRT-D, you can drive after 2 weeks if you haven't experienced any symptoms like dizziness, or after 4 weeks if you have.

Your CRT needs to be checked at 2 weeks, 3 months, and 6 months after the procedure, at a minimum without remote monitoring, or at 2 weeks and 12 months with remote monitoring. If you experience any unusual symptoms, such as difficulty breathing, dizziness, fainting, chest pain, hiccupping, or signs of infection, please report these immediately.

After your CRT implantation, you will need to continue taking your heart failure medications as directed by your doctor. You will receive a Medical Device ID card from the CRT company that you should keep with you at all times to inform medical and security personnel that you have an implanted device. The metal components of the device may set off airport security metal detector alarms, but the security wands should not be held over the device for too long. It's best to speak to your doctor or device manufacturer if you have any doubts about equipment to avoid, as most manufacturers have engineers who can assess whether a piece of equipment's electrical field can cause interference. While mobile phones can potentially interfere with the proper operation of the device, simple precautions such as not carrying the phone directly over the device and holding it up to the ear that is farthest from the device can minimise the risk.

While CRT implantation is a generally safe procedure, there is a small chance that complications may arise. Bruising at the procedure site is the most common side effect, occurring in less than 3% of patients, and up to 10% for those taking blood thinning medications. In rare cases (<1%), patients may require re-operation or blood transfusion due to excessive bruising. Lung puncture is another rare (<1%) complication that may result in a longer hospital stay and the need for a chest tube for several days. Lead displacement in the heart occurs in about 4% of cases, which may require a repeat procedure to reposition the leads. While infection is a rare (<1%) complication, it is the most serious risk and all precautions are taken to prevent it. If the device becomes infected, it may need to be removed. Additionally, significant electromagnetic interference may prevent the device from working properly. The risk of death is less than 1 in 500 cases. Long-term risks may include infection or erosion, lead failure, inappropriate detection of an arrhythmia, and premature battery depletion or device failure. Patients with a CRT-D may still experience lightheadedness, dizziness, or fainting during arrhythmia, despite treatment. Finally, there is a 30% chance that CRT implantation may not improve heart failure.