Dual Intervention Success: Managing Bradycardia and Heart Failure with TPI and CRT – D

Tharun1, Carolyn Rebecca2

1Registered Nurse, Medical Intensive Critical Care Unit, Kauvery Hospital, Vadapalani

2Nursing Supervisor, Medical Intensive Critical Care Unit, Kauvery Hospital, Vadapalani

Introduction 

Temporary Pacemaker Implantation (TPI) and Cardiac Resynchronization Therapy with Defibrillator (CRT-D) are critical cardiac interventions for patients with symptomatic bradycardia and heart failure with reduced ejection fraction. TPI provides temporary electrical support to stabilize heart rhythm, whereas CRT-D improves ventricular synchrony and prevents life-threatening arrhythmias through defibrillation.

Heart failure with severe left ventricular (LV) dysfunction and conduction abnormalities may require CRT-D therapy for symptomatic improvement and survival benefit. Brady arrhythmias, especially in elderly patients, can rapidly deteriorate without immediate intervention like temporary pacing support.

Brief Clinical History:

A 73-year-old female, Mrs. Indra, was admitted via the Emergency Department with complaints of:
– Decreased urine output (since morning)
– Bilateral leg swelling (since yesterday)
– Breathlessness (for one week)
– Abdominal pain.

On examination:
– Temperature: 97.4°F
– Pulse: 43/min
– Respiratory rate: 13/min
– Blood pressure: 90/50 mmHg.

The patient was found to be bradycardic and hypotensive. She is a known case of:
– Type 2 Diabetes Mellitus (T2DM)
– Coronary Artery Disease (CAD)
– Chronic Stable Angina (CSA – Class II)
– Severe LV dysfunction (Ejection Fraction – 23%)
– Bilateral osteoarthritis knee.

Past surgical history:
– ASD closure (1978)
– Coronary Angiogram – Triple Vessel Disease
– PCI to LAD, LCX, RCA (2012)

Initial management:
The patient was shifted to the ward for observation. Bradycardia persisted and cardiac monitoring was continued. She was started on Dobutamine infusion at 5 mcg/kg/min. This improved her EF from 23% to 30%.

Cardiology opinion was obtained for persistent bradycardia and worsening heart failure. CRT-D implantation was planned.

ECHO

ECG

Clinical Course

The patient was shifted to the Cath lab for TPI and CRT-D implantation via the right femoral approach. During the procedure, the patient became uncooperative and required sedation and intubation for airway protection. She was connected to a mechanical ventilator.

Post-procedure, the patient was transferred to the Cardiac Care Unit. On stabilization, she was extubated and required minimal oxygen support. After 24 hours of ICU monitoring, she was shifted to the ward.

Medications

– Inj. Magnex Forte 1.5 g
– Inj. Dalacin 300 mg
– Inj. Paracetamol 1 g
– T. Dytor 20 mg
– T. Jaridance 10 mg
– T. Alupent 10 mg
– T. Zolcalm 3/10 mg
– T. Clopilet 75 mg
– T. Chymoral Forte

TPI & CRT – D Overview

TPI (Temporary Pacemaker Implantation): Involves inserting a pacing lead through a vein to the heart and connecting it to an external pulse generator. It is used in emergencies for patients with severe bradycardia or as a bridge to permanent pacing.

CRT-D (Cardiac Resynchronization Therapy with Defibrillator): Devices help synchronize left and right ventricular contractions and provide defibrillation when life-threatening arrhythmias occur. Indicated in heart failure patients with low EF and conduction delays, CRT-D improves cardiac output and survival.

Nursing Interventions

1. Assessment and Monitoring:
– Regular monitoring of vitals and ECG
– Observed for signs of low cardiac output and arrhythmias

2. Cardiac and Respiratory Support:
– Continuous cardiac monitoring
– Oxygen therapy post-extubation

3. Post-Procedural Care:
– Maintained pacemaker site hygiene
– Monitored for infection or hematoma at the insertion site

4. Education and Counselling:
– Educated on CRT-D function and follow-up care
– Advised not to scrub or apply pressure near the device site
– Explained the importance of regular follow-up for device checks

5. Nutritional Support and Recovery:
– Encouraged balanced diet and breathing exercises
– Supported mobilization and posture changes every 4 hours

Discharge Status

The patient recovered well, hemodynamically stable, and was discharged with advice for regular cardiac follow-up and device monitoring.

Conclusion

This case emphasizes the significance of timely intervention with TPI and CRT-D in patients with severe LV dysfunction and symptomatic bradycardia. The coordinated care involving nursing, cardiology, and critical care teams contributed to improved cardiac function and successful recovery. Early diagnosis and prompt cardiac intervention can significantly enhance outcomes in patients with advanced heart failure.

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