Pre-operative Diagnosis:
( ) Tachycardia- Bradycardia Syndrome- medical control of tachycardia is associated with symptomatic episodes of bradycardia
( ) Documented nonreversible symptomatic bradycardia due to sinus node dysfunction
( X) Documented nonreversible symptomatic bradycardia due to second-degree and/or third-degree atrioventricular block.
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Post-operative Diagnosis:
Same as above
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Procedure Performed :
Implantation of Permanent Pacemaker
Venogram
Repositioning of the RUE mediport
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Surgeon:
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Assistant & Staff:
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Anesthesia:
Moderate Conscious Sedation
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Total IV Fluids & Blood loss;
Minimal blood loss
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Drains:
None
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Specimens Removed:
None
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Implants and Procedure Description:
After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken. During this procedure, I administered moderate conscious sedation using midazolam and fentanyl (totals for each documented in chart.) I was assisted in monitoring the patients level of consciousness, blood pressure, heart rate, arterial saturation, and respiratory rate by an independent, critical care nurse as documented in the chart. Pre-and post procedure assessment and monitoring was performed. My documented intraservice time (continuous face to face time after administration of sedation until I exited the room) was 80 min.
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Venogram
10 cc of contrast was administered via right brachial IV. Patency of the right subclvian vein was confirmed.
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ACCESS and POCKET FORMATION:
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the right pectoralis muscle. Incision was made beneath the left upper chest mediport. I then carefully dissected the port free and moved it medially and rescured it to the chest wall. The pocket was extended inferiorly and laterally from the port.
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The patient was placed in Trendelenburg position. Using ultrasound guidance, percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the superior vena cava under fluoroscopic guidance. Percutaneous access was again performed in the left subclavian with placement of a second 0.035 wire. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, a pocket was formed in the prepectoral fascia.
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VENTRICULAR LEAD:
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 (Medtronic) 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 9.8 mV, impedance 638 ohms, threshold was 0.7 volts, current 1.7 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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ATRIAL LEAD:
Attention was then turned to the atrial lead. Over the second .035 wire a second dilator and sheath were placed. The wire and dilator were exchanged then for the atrial pacing lead. The lead was an active fixation lead (Medtronic) Utilizing curved and straight stylettes, the lead was positioned and secured in the right atrial appendage. It was tested and found to have P waves of 1.8 mV, impedance 483 ohms, threshold was 0.6 volts, current 1.3 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with an 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 (Medtronic ) The leads and pulse generator were incorporated in the pocket. 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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