Fig. 1: X-ray photo before implantation of a CRT system showing the enlarged heart and the central blood accumulation as signs of a severe cardiac insufficiency
Fig. 2: X-ray photo 3 months after implantation of a CRT system showing the well visible improvement of the cardiac insufficiency
Treatment of cardiac insufficiency
When your heart gets weak
For your heart to fulfil its demanding task, apart from a proper blood supply, it needs a good functioning of the heart muscle. The cardiac insufficiency (weakness of the heart muscle) designates a disease in which the heart muscle is weakened to such an extent that it is no longer capable of pumping the blood sufficiently powerful or adequately fast through the blood vessels. In such a case part of the blood accumulates upstream of the heart, and we refer to it as a cardiac insufficiency or a heart weakness.
The cause for a cardiac insufficiency is to be found in an acute or gradual injury of the heart muscle due to, among others:
- cardiovascular disease
- heart attack
- high blood pressure
- heart diseases that directly attack the heart muscle or the cardiac valves
If the symptoms occur all of a sudden and rather quickly, we refer to it as an acute cardiac insufficiency. The chronic cardiac insufficiency, in contrast, often develops slowly and gradually, in most cases over a period of several months or years.
The weak heart muscle causes the patients to feel symptoms that result from the fact that the heart is no longer capable of providing a sufficient blood supply for the body and blood accumulates upstream of the heart. Early symptoms of a cardiac insufficiency are:
- reduced physical fitness
- shortness of breath during hard physical activity, when climbing stairs or exercising
- water retention (edema) in ankles and back of the foot
In the further course of the disease the water retention may also affect other organs eventually resulting in a weight gain. In an advanced case of cardiac insufficiency the patient will feel breathlessness also under slight physical stress or even when at rest. We distinguish between different stages of cardiac insufficiency:
- low-level with the symptoms occurring only under hardest physical stress
- high-level with symptoms such as shortness of breath already in a state of rest
The necessary treatment is determined by the stage of the cardiac insufficiency.
The weak heart can be supported by varied measures
As a matter of principle the primary disease should be optimally treated when a cardiac insufficiency is diagnosed. If the patient suffers from high blood pressure or a cardiovascular disease, it will be necessary in the first place to treat this disease in an optimal way and, secondary, treat the resulting cardiac insufficiency with a well directed approach.
Basically, a healthy lifestyle is of particular importance. This includes regularly checking your weight, maintaining healthy eating and drinking habits, adequate physical exercise and the limited consumption or avoidance of alcohol and nicotine.
Depending on the severity of the cardiac insufficiency and the potential accompanying symptoms the following groups of pharmaceuticals, particularly also in combination, are prescribed:
- ACE inhibitors are to prevent the further advance of the cardiac insufficiency and to mitigate its symptoms
- Diuretics serve to flood out the existing edema
- Angiotensin II receptor antagonists are similar to ACE inhibitors and will be prescribed when, e.g., ACE inhibitors are poorly tolerated
- Beta blockers are to lower the heart rate and the blood pressure as well as reduce the oxygen demand of the heart
- Digitalis glycoside help to increase the contraction force of the heart muscle
In particular cases it may be required to additionally administer vasodilative or rhythm-stabilizing drugs or anticoagulants.
If medication alone is not enough to treat the cardiac insufficiency
In certain situations of a cardiac insufficiency there is no longer a coordinated heart beat between the two ventricles, particularly in the individual wall segments of the left ventricle, which leads to a further deterioration of the cardiac insufficiency. In spite of an optimum medication many patients reach a severe stage of cardiac insufficiency resulting in a considerable restriction of their physical fitness. This again frequently results in a considerable impairment of their quality of life.
Today it is possible to help such patients by providing a targeted stimulation of both ventricles (resynchronization of the heart) by means of advanced pacemakers or defibrillators. The cardiac resynchronization therapy (CRT) harmonizes the activity of the ventricles and thus improves the cardiac insufficiency.
The implantation of such a system for resynchronization therapy – pacemaker or defibrillator – poses a challenge for the surgeons because it requires not only to place a stimulation electrode in the right atrium and another one in the right ventricle; but also it requires an additional electrode to be placed in the left ventricle, which is frequently quite difficult to do. If this electrode is successfully implanted in the proper place, it will facilitate - by a coordinated electrical stimulation - to also noticeably improve the mechanical interaction of the individual heart segments or in the best case to even normalize (resynchronize) this interaction.
Consequently, the pumping function of the heart and thus the cardiac insufficiency improves. Many patients feel noticeably better immediately after implantation of the device already, in others the recovery occurs continuously over the following weeks and months. A parallel continued medication of the cardiac insufficiency and the underlying primary disease is advisable.
If, moreover, the patient suffers from life-threatening cardiac dysrhythmia the resynchronization therapy is usually supplemented by the implantation of a defibrillator. This device will automatically detect any cardiac dysrhythmia, record its features and treat the arrhythmia in accordance with the individual programming of the device. Such a combination of devices for resynchronization therapy and for defibrillation at the same time provide a protection against a sudden cardiac death.
Safety thanks to the most advanced medical equipment
The implantation of a resynchronization system is mostly performed under general anaesthesia, but in particular cases under local anaesthesia as well. In any case the intervention takes place under sterile surgery conditions. The patient is covered with a sterile drape. During the intervention the patient is cared for by means of the most sophisticated circulatory and respiratory monitoring equipment. The implantation of a resynchronization system in the Schüchtermann-Klinik takes about 2 hours.
Cardiac resynchronization therapy: safe and successful
In Germany, every year approximately 3,500 CRT systems are implanted. Since the customary procedure is to implant 3 probes (in the right atrium, in the right ventricle and in the left ventricle), we also call it the 3-chamber system. Despite the underlying severe cardiac insufficiency the risk of this intervention is low as the patient is optimally monitored during the surgery.
The present findings of large international studies reveal that patients suffering from an advanced cardiac insufficiency and an asynchronous activity of the heart particularly benefit from this type of therapy. Physical fitness, quality of life and even the life expectancy will be improved.
Basically, patients wearing a 3-chamber system have to follow the same safety instructions as those wearing a conventional heart supporting device. For more details on this subject please see Treatment of cardiac dysrhythmia.
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