GEN CHANGE SC-ICD

EP PROCEDURE NOTE 

PREOPERATIVE DIAGNOSES:
1. ICD Pulse Generator Battery depletion.

POSTOPERATIVE DIAGNOSIS:
1.  Successful Single Chamber ICD Generator Change.

PROCEDURE PERFORMED:
1. Single Chamber ICD Generator change.
2. Removal (explantation) of chronic generator.
 
ELECTROPHYSIOLOGIST:  Michael Bui, MD 

ASSISTANT:  

CLINICAL PROFILE:  

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 5 cc

FLUORO TIME:  min
DAP:  Gycm2
AIR KERMA: mGy

CLINICAL PROFILE: 

DESCRIPTION OF THE 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, damage to existing lead, possible need for new lead,
pneumothorax, perforation of vessels or heart, pericardial effusion, unstable
heart rhythm, radiation exposure, 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 chronic device was interrogated prior to the procedure, and pertinent
information, such as underlying rhythm, programming, thresholds and impedances
were noted.  Tachycardia therapies were temporarily suspended for the procedure.  

The patient was brought into the electrophysiology laboratory in a fasting and
hemodynamically stable condition. The chest wall was vigorously washed and
sterilely draped. The chest wall was anesthetized with Lidocaine.   

An approximately 5-cm incision was made over the old incision line. 

Electrocaudery was used to access the pocket, with adequate hemostasis being
provided throughout. After reaching the capsule, the previous suture material
was ligated and removed from the pocket. The pulse generator was then easily
removed. The wrench tool was used to detach the lead from the pulse generator.
The right ventricular lead was then hooked up to the analyzer to ensure adequate
threshold and impedances. The pocket was then vigorously washed with an
antibiotic containing solution. The new device generator was then obtained and
the previous chronic right ventricular lead was then securely attached to the
pulse generator using a wrench tool. The pulse generator was then placed in the
pocket.  A stay suture was then made to secure the device in the pocket using 0-
ethibond. 

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

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 pocket was closed in 3 layers using 2-0 Vicryl for the deep layers and 4-0
Vicryl for the subcuticular layer. After the procedure, Steri-Strips were
applied to the wound.   The device was then re-interrogated to ensure proper
programming, as well as to check on the impedances and thresholds.   In
addition, special attention was made to ensure that the device was active,
including tachycardia therapies.  The patient was then transported back to a
monitored bed.

EQUIPMENT USED:
1. The new ICD Generator implanted is a  _____.
2. The explanted device is a _____.
3. The chronic right ventricular lead is a ________.

MEASURMENTS:
The Right Ventricular Lead is sensing R waves at   mV, and has a capture
threshold of  ____ V @ ____ msec, giving an 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.  

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.  ECG
3.  Keflex 500 mg po BID x 5 days 
4.  Follow up with Pacemaker Clinic in 2-4 weeks

5.  In its current configuration, this system is MRI compatible with both
    3.0 T and 1.5 T machines