DC-PPM (RIGHT SIDED)
EP PROCEDURE NOTE
DATE OF PROCEDURE:
PRE-OPERATIVE DIAGNOSIS:
POST-OPERATIVE DIAGNOSIS:
1. Successful Right Sided dual chamber permanent pacemaker implantation.
PROCEDURES PERFORMED:
1. Right Subclavian Venogram
2. Dual-chamber permanent pacemaker 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 right chest wall was vigorously washed, prepped, and
sterilely draped. The chest wall was anesthetized with lidocaine.
A right subclavian venogram was performed and the left subclavian vein is
patent.
A 4 cm incision was made approximately 2 finger breadths from the right
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 right 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 subclavian vein into the level of the IVC.
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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 impedance was made until the impedences 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.
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A peel away sheath was inserted through the one of the guidewires. 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.
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A peel away sheath was inserted through the other guidewire. The
guidewire 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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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 the muscle 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.
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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.
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.
PLAN:
1. Wound Care
2. Physical Activity Limitations: No lifting Right arm above Right 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