CRT DEVICE
EP PROCEDURE NOTE
DATE OF PROCEDURE:
PRE-OPERATIVE DIAGNOSIS:
1. Chronic Systolic LV dysfunction with LVEF <
2. NYHA Class
3. Evidence of Electrical Dyssynchrony with QRS > 130 msec
4. High RV Pacing Burden
POST-OPERATIVE DIAGNOSIS:
1. Successful implantation of CRT ____
PROCEDURES PERFORMED:
1. Left Subclavian Venogram
2. Implantation of CRT____ Device
3. Coronary Sinus Venogram
ELECTROPHYSIOLOGIST: Michael Bui, MD
ASSISTANT:
CLINICAL PROFILE:
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 10 cc
FLUORO TIME: min
DAP: Gycm2
AIR KERMA: mGy
PROCEDURE:
The risks and benefits of the procedure were explained to the patient in
full, and in simple terms. Alternative therapy options were given,
including no procedure. The risks of the procedure include, but are not
limited to: pain, bleeding, infection, pneumothorax, perforation of
vessels or heart, pericardial effusion, lead dislodgement, and death. The
risks of blood transfusion were discussed, and include fever, transfusion
reaction, and infection. All questions were answered, and the patient
voices understanding. The patient acknowledged the risks of the procedure,
and still wanted to proceed.
The patient was brought into the Electrophysiology Lab in a fasting and
hemodynamically stable condition.
A formal time out for patient identification and review of procedure was
performed. The left chest wall was vigorously washed, prepped, and
sterilely draped. The chest wall was anesthetized with lidocaine.
A left subclavian venogram was performed and the left subclavian vein is
patent.
A 4 cm incision was made approximately 2 finger breadths from the left
clavicle. The subcutaneous tissue was carefully dissected down to the
pectoral muscle and pectoral fascia. The dissection was carried
inferiorly to form a subcutaneous pocket with adequate hemostasis
provided by electrocautery.
The left subclavian vein was accessed via the pocket and over the 1st rib
using a technique modified after Dr. Magney, under fluoroscopic guidance,
and two separate sticks were made. Two separate guide wires were inserted
through the left subclavian vein into the level of the IVC.
A peel away sheath was inserted through the one of the guide wires. The
guide wire and dilator was removed. A right ventricular lead was inserted
through the sheath down to the level of the IVC using a straight stylet.
The straight stylet was exchanged for a curved stylet which positioned
the lead through the tricuspid valve into the region of the RV apical
septum. The lead was screwed into the myocardium using a turning tool.
There was acceptable sensing and pacing thresholds obtained at this
position, as well as acceptable impedances. Ten volt Pacing was
performed and did not produce any diaphragmatic stimulation. The
sheath was then peeled away, and the sleeve adapter was advanced over
the lead. The lead was then secured to the muscle using 0-Ethibond
suture.
A peel away sheath was inserted through the other guide wire. The
guide wire and dilator was removed. A right atrial lead was inserted
through the sheath down to the level of the IVC using a straight stylet.
The straight stylet was subsequently exchanged for a curved stylet which
positioned the lead at the right atrial appendage. There was acceptable
sensing and pacing thresholds obtained at this position, as well as
acceptable impedances. Ten volt pacing did not produce diaphragmatic
stimulation. The lead was screwed into the myocardium. The sheath was
then peeled away. The right atrial lead was then secured to the
underlying muscle using 0-ethibond suture.
We then turned our attention to the CRT lead. A 9 French Peel away
sheath was inserted into a guide wire. The guide wire and the dilator were
then removed. A purse string suture was then made around the 9 Fr outer
sheath.
*****************HBP*****************************************
Using a combination of a Rosen wire and an AL2 catheter, we were then able
to cannulate the coronary sinus, and we noted its position on fluoroscopy.
This system was then removed.
We placed a Medtronic 3830 lead through a Medtronic C315-His sheath and guided to the region
where the His Bundle traditionally lies (based on fluoroscopic anatomical
landmarks). We then mapped for His Bundle signals and then pacemapped
around this location. We were able to demonstrated
selective / non-selective His Bundle Capture at this location. We then
applied approximately 8 clockwise rotations to the 3830 Lead body to
attach the lead into the underlying myocardium. We then split the sheath
using a splitting tool without disturbing the newly implanted system.
****************************************************
We then abandoned our His Bundle approach at CRT and decided to go with a
"traditional" route at CRT via LV pacing. Our C315-His sheath and 3830
lead were removed.
******************HBP************************
******************LV LEAD************************
An outer guide long sheath was then inserted through the 9 French Peel
away sheath using a wire.
We used a combination of a Rosen wire and an AL2 catheter to cannulated the
coronary sinus.
The outer sheath was advanced into the coronary sinus. The wire was removed,
and a balloon tipped catheter (that had been previously flushed and checked
for patency) was advanced into the coronary sinus, just past the outer sheath.
Under fluoroscopy, the balloon was deployed and a total of __cc of contrast
was given. Images were taken in both the RAO and LAO projections.
The venogram showed a branch in the _________ aspect of the coronary sinus,
which appeared to provide an excellent anatomic position for cardiac
resynchronization therapy. The balloon-tipped catheter was then removed.
We then placed a Medtronic 130 degree inner subselector catheter and
_______ wire to successfully cannulate this branch. The LV
lead was then advanced into this brach using the over-the-wire technique.
In the LAO projection, the selected branch is in the ____ O'clock position.
This showed excellent pacing and sensing characteristics, as well as normal
impedances. Ten volt pacing did not produce diaphragmatic stimulation.
The outer most 9 French sheath was then split and peeled away without
disturbing the system. Then, the outer sheath (coronary sinus sheath) was
peeled away, split, and removed without disturbing the newly implanted
coronary sinus lead. The coronary sinus lead was securely sutured to the
pectoral using 0 Ethibond sutures placed over the suture sleeve. Adequate
slack was placed in the leads so that they would not be compromised by
maximum inspiration.
*******************LV LEAD***************************
*******************LBAP***************************
*********************************************************************
Ultimately, Cardiac Resynchronization Therapy via a traditional LV lead route was non-feasible and this approach was abandoned. It should be that noted that in patients undergoing CRT with BiV pacing implantation via the CS, crossover to Conduction System Pacing with HBP or LBAP is reasonable (Class IIA) when the CS LV lead placement is unsuccessful or suboptimal. (Chung, Mina et al. "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)
A peel away sheath was inserted through the one of the guide wires. The
guidewire and dilator was removed. A Medtronic C315 sheath was inserted through the peel away sheath and then the 3830 lead was placed through this, and guided into an area that was approximately 1-2 cm distal to the His Bundle Region.
Pacing at this location revealed a characteristic "W" pattern in V1, and then several clockwise rotations were made. The impedence initially rose, and then a series of rotations followed by periodic checking of impedence was made until the impedances started to fall. The C315 sheath was then split using the splitting tool, and then the outer sheath was split and peeled away.
The Stim-QRS peak in lead V5/V6 was _______
Ten volt Pacing was performed and did not produce any diaphragmatic stimulation. The sleeve adapter was advanced over the lead. The lead was then secured to the muscle using 0-Ethibond suture.
*********************************************************************
The pocket was then vigorously washed with an antibiotic containing
solution. The leads were then inserted into the pulse generator, and
attention was made to ensure that the leads were advanced all the way
through to make a complete circuit. The set screws in the header were then
secured to the leads using a torque wrench.
**********************************************
DFT TESTING
At this time, we proceeded with testing of the device. Sedation and
anesthesia was provided by the Anesthesia department. The patient was
induced into ventricular fibrillation via the
Shock on T Method / 50 Hz method / DC Fibber method,
and was successfully defibrillated at ____ Joules through the device
to normal sinus rhythm, with a charge time of ____ seconds, giving an
impedence of ____ ohms. The patient recovered without any sequelae.
Sensing was adequate, with no more than one beat of drop out during
detection.
******************************************************
**********************************************
The pulse generator and leads were then inserted into a Ty-RX
antimicrobial envelope, and then placed into the subcutaneous pocket. It
was then secured to themuscle with an 0-Ethibond suture.
The pulse generator and the leads were inserted into the subcutaneous pocket
andsecured to the muscle with an 0-Ethibond suture.
***********************************************
The pocket was then closed in 3 layers using 2-0 Vicryl for the deep layers
and 4-0 Vicryl for the subcuticular layer. Steri-Strips and a dressing were
then applied over the incision site, and the patient was transported to a
monitored bed.
EQUIPMENT USED:
1. The Pulse Generator is a _, serial #
2. The RA Lead is a _, serial #
3. The RV Lead is a _, serial #
4. The CRT Lead is a _, serial #
MEASUREMENTS THROUGH THE DEVICE:
1. The RA Lead is sensing P waves of _mV, and has a pacing capture threshold
of _V @ _msec, giving a pacing impedance of _ohms.
2. The RV Lead is sensing R waves of _mV, and has a pacing capture threshold
of _V @ _msec, giving a pacing impedance of _ohms.
-The HVB impedance is
-The HVX impedance is
3. The CRT Lead is a
FINAL PROGRAMMING:
Brady Settings:
-Mode: AAI-R <----> DDD-R (MVP) DDD / DDD-R /
-LRL = 60 ppm.
-URL = 130 ppm.
-Paced AV Delay = ____ msec.
-Sensed AV Delay = _____ msec.
-V-V timing is set at LV before RV by -80 msec (physiologic noncapture
for back up pacing)
-V-V timing is set at Adaptive CRT
Tachy Settings:
(1) Monitor Only Zone: 150-170 bpm.
(2) VT Zone: 171-220 bpm.
-Detection time = 2.5 seconds
-Therapies:
-ATP x 3 (88% burst)
-ATP x 3 (91% ramp)
-41J x 6
-Discriminators: Rhythm IQ is enabled
(3) VF Zone: > 220 bpm
-Detection duration: 2 seconds
-ATP x 1 with quick convert
-41J x 8
Tachy Settings:
(1) Monitor Only Zone: 150-170 bpm.
(2) VT Zone: 171-221 bpm.
-Detections: initial = 16; redetect = 12
-Therapies:
-iATP (smart ATP)
-40J x 5
-Discriminators Activated:
-AF/AFl
-Sinus Tachycardia
-Wavelet
-High Rate Time out
-T Wave
-RV lead noise
(3) VF Zone: > 222 bpm
-Detection: intitial = 24/32; redetect = 12/16
-40J x 6
PLAN:
1. Wound Care
2. Physical Activity Limitations: No lifting left arm above left shoulder x
four weeks.
3. CXR + ECG
4. In regards to Antibiotics, based on this instituion's (VA Central Texas)
regulations, oral antibiotics > 24 hours after procedure is not
recommended. This is based on Circulation. 2010; 121:458-77.
5. Follow up with Pacemaker Clinic in 2-4 weeks
6. In its current configuration, this system is MRI compatible with both
3.0 T and 1.5 T machines
6. In terms for MRI compatible, every single component used in his device has
been FDA labeled for MRI. However, it has not been technically FDA
labeled in this configuration. Therefore, MRI would technically be an off
label indication. However, as stated above, every single component used
for this device has been FDA approved and labeled for MRI. In theory, MRI
should be fine, however - if further clarification needed, can contact
with the Medronic Office of Medical Affairs @ 877-359-6415.
HIS BUNDLE PACING
-In addition, it is a Class IIb indication for HBP in that "In patients with
atrioventricular block at the level of the atrioventricular node who have an
indication for permanent pacing, His bundle pacing may be considered to maintain
physiologic ventricular activation" (2018 ACC / AHA . HRS Guidelines on the
Evaluation and Management of Patients with Bradycardia and Cardiac conduction
delay: Kusumoto, Fred et al. Circulation Vol 140, Issue 8, 20 August 2019"