Case 3
Procedure: Dual Chamber Implantable Cardioverter Defibrillator (ICD) Implantation
Pre-Procedure Diagnosis: Hypertrophic Cardiomyopathy, NSVT, SSS, Near Syncope
Procedure: The patient was brought to the Electrophysiology Lab in the
fasting state and continuous electrocardiographic monitoring was
instituted.
Anesthesia was performed by Dr Kiss and will be dictated separately by
him.
The left subclavicular fossa was prepped and draped in the usual sterile
fashion and 1% lidocaine was instilled for local anesthesia. The incision
was made and the dissection was carried down to the level of the
pectoralis major fascia where a subcutaneous pocket was formed using blunt
dissection. The axillary vein was entered with a Micropuncture thin
walled needle without difficulty at two separate locations, guided by
ultrasound, and guide wires were advanced into the central venous
circulation. Using the guide wires and two introducer sheaths, an ICD
electrode was advanced to the right ventricular septum, and a pacing
electrode was advanced to the right atrial appendage under fluoroscopic
guidance. Each electrode was anchored to the underlying pectoralis major
fascia with a single stitch of 2-0 non-absorbable suture.
These leads were attached to a dual chamber ICD which was placed in the
previously formed pocket with electrodes situated beneath it after the
pocket had been flushed with saline solution.
The ventricular electrode is a Medtronic Model # 6935M62 (Serial #
TDL515430V). This is a bipolar, steroid-tipped, active fixation lead.
The R wave was 10 mV, the pacing impedance was 600 Ohms, and the
ventricular capture threshold was 0.75 V @ 0.5 ms. The HVB impedance was
76. There was no diaphragmatic pacing at 10 V.
The atrial electrode is a Medtronic Model # 5076 (Serial # PJN8450680).
This is a bipolar, steroid-tipped, active fixation lead. The P wave was
1.3 mV, the pacing impedance was 650 Ohms, and the atrial capture
threshold was 1.3 V @ 0.5 ms. There was no diaphragmatic pacing at 10 V.
The ICD pulse generator is a Medtronic Evera MRI DR. Model # DDMB1D4,
Serial # PFZ622773S. This device is placed in the subcutaneous location.
No defibrillation threshold testing was performed.
The wound was closed with a running stitch of 3-O absorbable suture and
the skin was closed with a running stitch of 4-O absorbable suture.
Topical skin adhesive was placed over the incision.
The patient tolerated the procedure well.
Case 2
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PROCEDURE: SEDATION: |
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Impression: |
Case 1
PROCEDURES PERFORMED: Coronary Angiography
PROCEDURE:
Informed consent was obtained from the patient, and a time-out was
performed to verify the patient’s identification and planned procedure.
After the Allen’s test was used to confirm patency of the ipsilateral
ulnar artery, the patient’s right radial artery site was prepped and
draped in sterile fashion, and anesthetized with 1% subcutaneous lidocaine
using a 25 gauge needle. The radial artery was then entered by
through-and-through puncture with a 22G angiocath needle. The needle was
then removed, followed by slow withdrawal of the angiocatheter until blood
return was seen, confirming intra-arterial position. A sheath kit wire
was then advanced, allowing for exchange of the angiocatheter for a 5-Fr
hydrophilic sheath. The sheath was then flushed with 2.5 mg of verapamil
diluted in blood, followed by 50 units/kg (up to maximum of 5000 units) of
heparin administered intravenously. A 180 cm Radial Glide Wire (1.5 mm J)
or Versicore wire was used for initial catheter advancement, and a 260 cm
0.035″ J-wire was used for subsequent catheter removal. Standard
angiography was performed using 5 Fr JR4 diagnostic catheters to engage
the left main (LM) and right coronary artery (RCA), respectively.
After the catheter was removed over the J-wire, the existing sheath was
withdrawn half-way out in preparation for removal. A VascBand was
positioned as appropriate, and 12 cc of air used to inflate the band
during simultaneous complete removal of the sheath. The amount of air was
then adjusted as need to ensure hemostasis while ideally allowing patency
of the radial artery as confirmed by pulse oximetry during transient
ipsilateral ulnar artery occlusion. No immediate complications. Estimate
blood loss: minimal. Specimens: none.
I reviewed the patient’s pre-sedation assessment and vital signs,
supervised and directed the moderate sedation with continuous face-to-face
attendance. My intra-service time was 38 min. Please see procedure log
or sedation record for more details.
