DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Congestive heart failure.
POSTOPERATIVE DIAGNOSIS: Congestive heart failure.
OPERATION PERFORMED: Placement of biventricular pacing and implanted cardiac defibrillator device via left subclavian vein.
SURGEON: John Doe, MD
ANESTHESIA: Local with monitored anesthesia care.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old man with known congestive heart failure. He is being brought to the operating room today on an elective basis for placement of an ICD device in combination with biventricular pacing capabilities.
DESCRIPTION OF OPERATION: After giving adequate intravenous sedation, the patient’s anterior chest and lower neck were prepped and draped in a sterile manner. An area underneath the left clavicle was then infiltrated with 1% plain Xylocaine. The same area was then incised. The incision was carried down to the level of the pectoralis fascia. Subcutaneous tissue was then dissected off the pectoralis fascia, and a pocket was created large enough to accommodate the pacing ICD generator. The pocket was packed with antibiotic-containing saline soaked sponge. The left subclavian vein was then cannulated three different times using Seldinger technique. Under fluoroscopic guidance, the leads were then advanced into appropriate position within the heart. The ICD lead was readily advanced to the apex of the right ventricle. The atrial lead was also readily placed. Adequate sensing and pacing thresholds were obtained for both.
The left ventricular lead was placed via a catheter directed in the coronary sinus. Once coronary sinus access had been achieved, a coronary sinus venogram was taken. An appropriate vein was identified. It was fairly straightforward to advance the lead into this vein. Adequate sensing and pacing thresholds were readily obtained in this location. Additionally, the lead was appropriately separated from the right ventricular lead so as to be able to get adequate synchronous pacing.
Once all leads had been found to function appropriately, each was affixed to the pectoralis fascia with 2-0 Ethibond suture around each of the provided fixation cuffs. The leads were connected to the pacing ICD generator. The pacemaker worked well from the outset.
The pocket was inspected a final time to make sure that it was thoroughly hemostatic. This being the case, the generator redundant leads were placed in the pocket. Subcutaneous tissues, the pocket, and its contents were copiously irrigated with antibiotic-containing saline solution. Subcutaneous tissue was closed with a running 3-0 Vicryl suture. The skin was closed with a running 4-0 Monocryl subcuticular suture. A dry sterile dressing was applied. The patient was transferred to the postanesthesia care unit in stable condition for ongoing care.
