REFERRING PHYSICIAN: John Doe, MD
PROCEDURES PERFORMED:
1. IV sedation.
2. Fluoroscopically guided implantation of right atrial and right ventricular leads.
3. Implantation of dual chamber defibrillator.
4. Interrogation and programming of defibrillator.
INDICATIONS AND HISTORY: This is a (XX)-year-old female with severe nonischemic cardiomyopathy with ejection fraction less than 20% and episode of complete heart block in the hospital, which required resuscitation and intubation. Therefore, the patient has indication both for dual chamber pacing and defibrillator for prevention of sudden cardiac death.
CONSENT: The risks, benefits, and alternatives of the procedure were explained to the patient. All of the patient’s questions were answered, and she understood and signed informed consent.
DESCRIPTION OF PROCEDURE: The patient was brought to the electrophysiology lab in a fasting nonsedated state. IV sedation was provided with IV Versed and fentanyl. Prophylactic antibiotic was given. The chest was prepped and draped in the usual sterile fashion. After injection of 2% lidocaine in the left pectoral area, an incision was made and extended to pectoralis fascia using electrocautery and blunt dissection and a pocket was created. Using the previous roadmap from earlier this week, access to the right subclavian vein was achieved in two separate locations. Right ventricular lead was advanced under fluoroscopy to the right ventricular apex. This is a lead, model (XX), serial number (XX). R-waves measured more than 12.5, impedance was 452, and threshold was 0.75. The right atrial lead was advanced into the right atrial appendage. This is a Tendril, model (XX), serial number (XX). This was advanced under fluoroscopy through the right atrial appendage and P waves measured 2.4 to 3, impedance 462, and threshold 0.75. Leads were sutured to the muscle. There was no diaphragmatic stimulation. The leads were connected to the device, which was an Atlas DR, serial number (XX). Leads and device were inserted into the pocket and sutured to the muscle, and the pocket was vigorously irrigated with antibiotic solution. The pocket was then closed in two separate subcutaneous layers using 3-0 Vicryl and subcuticular layer using 4-0 Vicryl. The skin was covered with Steri-Strips and pressure dressing. Before the pocket was closed, a high voltage lead impedance was tested at 32 ohms. Also, we interrogated the device, which showed stable parameters, and it was programmed to VVI 60 with long AV delay to allow for intrinsic conduction. Tachy therapies were set at VF zone at 188 beats per minute with maximum therapy. The patient tolerated the procedure well, and there were no complications. DFT was not tested due to the presence of left ventricular thrombus.
CONCLUSION: Successful implantation of dual chamber defibrillator by nonthoracotomy method on the right side.
PLAN:
1. The patient will be observed overnight and can be discharged home with followup in the clinic from an electrophysiologic standpoint.
2. In terms of anticoagulation, we would start Coumadin tonight and also start heparin without bolus after about 12 hours.
3. Particular care should be given to the care of the implant pocket to avoid any hematologic complication.
4. Given usual post-implant care, including chest x-ray, antibiotic, and interrogation will be done.
