Any help is MUCH appreciated!!!

PREPROCEDURE DIAGNOSES:
1. Atrial fibrillation.
2. Rapid ventricular response.
3. Tachymedia.
4. Cardiomyopathy.

POSTPROCEDURE DIAGNOSES:
1. Atrial fibrillation.
2. Rapid ventricular response.
3. Tachymedia.
4. Cardiomyopathy.

PROCEDURE: Attempted Bi-V pacemaker implant but complicated by dissection of the CS.

PROCEDURE COURSE: Mrs. Young presented to the EP lab in the fasting state. She was in AFib with RVR. The procedure was performed under conscious sedation with the assistance of our anesthesia colleagues. She was administered 2 grams of Ancef prior to the start of the case. After the huddle, she was prepped and draped in usual sterile fashion. After the timeout, a pocket was created in the left subclavian space using a blade, blunt dissection and electrocautery. After hemostasis was achieved in the pocket, using the 1st rib approach, venous access was obtained x 2 over the first guidewire, a 7-French tear-away sheath was placed in the SVC. Through this lead, an MRI compatible Medtronic pace is 5076 lead was advanced into the RV apical septum and the helix was extended despite yielded excellent pacing and sensing parameters with sensing of 14 millivolts and capture threshold of 0.25 volts with a pacing impedance of 532. The sheath was removed and the lead was tied down to the pectoralis fascia with nonabsorbable suture. Over the second guidewire, a 9 French sheath was placed and through this a straight Attain and a Josephson catheter and this was unable to cannulate the CS. Then, we used a medium hook Attain and this too was unable to cannulate the CS and then we used the larger hook Attain and this was able to finally get access into the CS. It was difficult as it was a fairly posterior takeoff but got access that was not overly difficult; however, upon advancing the sheath noted that in placing the sheath in the CS. Then, with a balloon tipped catheter, a venogram of the CS was performed showing that we had dissected the CS. I did try to pass a wire, but it was never in the true lumen and was unable to place a guidewire. She remained hemodynamically stable through this. Given this and I now have an idea of where the CS was located. I think that the best course of action will be to bring her back in approximately 4-6 weeks and place an LV lead at that time and do the AV node ablation. The 9-French sheath was removed and hemostasis achieved with manual pressure. The pocket was then cleansed with vancomycin solution and then a BiV pacemaker was used to plug in the atrial port as there was no plan in putting an atrial lead given that she has now permanent atrial fibrillation. The LV lead port was plugged and the RV pace sense lead was attached to the device and the device and leads were placed into the pocket. Pocket was then closed in 3 layers with absorbable suture. Device check confirmed appropriate capture and sensing of the RV lead then Steri-Strips and dry sterile dressing were placed over the wound. Mrs. Young tolerated the procedure well without apparent complications. A chest x-ray will be obtained tonight. Plan will be to return in approximately 4-6 weeks for addition of an LV lead at that time and AV node ablation. She is set up at VVI 50.