Pre-procedure Diagnoses:
1. Tachy-brady syndrome (*) [I49.5]
Post-procedure Diagnoses:
1. Tachy-brady syndrome (*) [I49.5]
Procedures:
1. PACEMAKER SC GEN CHANGE [EP42 (Custom)]
2. PACEMAKER LEAD INSERTION/REVISION/REMOVAL [EP188 (Custom)]
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Patient Name:
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Pre-operative Diagnosis:
Pulse Generator at End of Life
Failed RV lead
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Post-operative Diagnosis:
Same as above
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Procedure Performed :
venogram
Pacemaker Generator change out
Cap functional but unnecessary RA lead
Cap non-functional V lead
Placement of new RV lead
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Anesthesia:
General
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Total IV Fluids & Blood loss;
Minimal blood loss
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Drains:
None
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Specimens Removed:
Boston Scientific S606 implanted 5/17/11.
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Implants and Procedure Description:
After informed consent was obtained, the patient was transported in a nonsedated condition to the OR. The patient was prepped and draped in a sterile fashion and a "timeout" was taken. Visipaque contrast wasn’t administered via IV in the left antecubital vein. We visualized and confirmed the patency of the left subclavian vein
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Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, the old pulse generator was carefully dissected from its pocket in the prepectoral fascia.
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The generator was removed and the leads were tested. The ventricular lead was a Guidant 4456 with serial number 496929. It was tested and found to be fractured and was capped and secured to the pectoralis muscle.. The atrial lead was an active fixation lead, Guidant 4086 with serial number 259504. It was tested and found to have P waves of 0.7 mV, impedance 633 ohms, threshold was AF volts, current AF milliamps. The lead was capped and secured to the pectoralis muscle.
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Percutaneous access was again performed in the left subclavian with placement of a second 0.035 wire. Over the .035 wires, 8 French peel-away sheaths were advanced. The dilators were removed. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an active fixation lead Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 6.8 mV, impedance 1252 ohms, threshold was 0.4 volts, current 0.4 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.
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CLOSURE:
The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator The leads and pulse generator were incorporated in the pocket within a Tyrex antibiotic envelope. The pocket was copiously irrigated with antibiotic solution. The subcutaneous fascia was closed with interrupted 3-0 Vicryl suture. The skin layer was closed with a running subcuticular 4-0 Vicryl suture and Surgiseal adhesive. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.
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