DC-ICD (LEFT SIDED)

EP PROCEDURE NOTE

DATE OF PROCEDURE: 

PRE-OPERATIVE DIAGNOSIS:

POST-OPERATIVE DIAGNOSIS:
1. Successful implantation of DC-ICD.

PROCEDURES PERFORMED:
1. Left Subclavian Venogram
2. Dual-chamber ICD implantation. 

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.  

The pocket was then vigorously washed with an antibiotic containing
solution. The right atrial and the right ventricular 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.  

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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.  

******************************************************

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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
and secured 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 #
           
                                                 
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 

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.  

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 institution's
    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