Sample Report: Explanation of Pacemaker and Leads with Implantation of ICD and Leads
PREOPERATIVE DIAGNOSIS: Ischemic cardiomyopathy, induced left bundle branch block, and class 3 congestive heart failure.
POSTOPERATIVE DIAGNOSIS: Ischemic cardiomyopathy, induced left bundle branch block, and class 3 congestive heart failure.
PROCEDURES:
1. Explant of dual-chamber pacemaker. This was a Guidant model 1270, serial #630955.
2. Laser extraction of 3 pacing leads. These are a Guidant 4456-203685, a Guidant 4469-304731, and a Guidant 4452-201574.
3. Coronary sinus venography.
4. Implant of coronary sinus lead. This is a Guidant model 4513, serial #401794.
5. Implant of implantable cardioverter-defibrillator Guidant lead 0157, serial #118025. The device is an H135, serial #777049.
6. Defibrillation threshold testing.
COMPLICATIONS: None.
FLUOROSCOPY TIME: 43 minutes, 30 seconds.
LASER TIME: 2 minutes 29 seconds.
DETAILS OF PROCEDURE: This gentleman with permanent atrial fibrillation, ischemic cardiomyopathy, ejection fraction (EF) 25%, and pacing-induced left bundle branch block (underlying heart rate 50 bpm), was brought to the electrophysiology (EP) laboratory in a fasting state. Informed consent was obtained prior to procedure. A radial arterial line was placed by anesthesia. The left shoulder region was prepped and draped in sterile fashion and infiltrated with 1% lidocaine solution. Access over the incision was made, and using blunt and Bovie dissection, the old generator was dissected free. The 3 leads (2 ventricular and 1 atrial) that were still in place were dissected free and exposed. Gentle traction on these leads failed to enable extraction. The first lead addressed was the atrial 4469-304731.
The lead was cut and a Spectranetics locking stylet was advanced down this lead. Traction prevented the lead from being extracted completely. The Spectranetics laser 12-French sheath was utilized, the laser was activated and the lead was easily extracted. The largest amount of scar tissue was at the level of the subclavian vein. A similar procedure was repeated on the 4452 lead, as well as the 4456 lead. Following these procedures, access to the subclavian vein was achieved twice.
Using a modified Seldinger technique, guidewires and sheaths were placed; an 8-French sheath was placed over the first guidewire and the right ventricular ICD lead was advanced to the apex. Stable pace and sense thresholds were obtained and are summarized below. The lead was secured using 0 silk. A 9-French sheath was placed over the remaining guidewire. A hook and Rapido sheath system was advanced to the right atrium. Using contrast, the coronary sinus could not be located. An angled Glidewire was then utilized, but again the coronary sinus could not be cannulated. At this point, a deflectable quadripolar catheter was utilized to cannulate the coronary sinus through the extended hook sheath. This sheath was advanced. A balloon-tipped Swan-Ganz catheter was then advanced and coronary sinus venography was performed. A posterolateral vein was identified.
With some difficulty, the left ventricular coronary sinus lead was advanced over a Whisper wire to a posterolateral vein. Stable pacing and sensing thresholds were obtained. The lead was removed with some difficulty. The lead was secured using 0 silk. All thresholds were then assessed and noted to be stable.
The ICD was attached and defibrillation threshold testing was performed. The results are summarized below. The ICD was positioned in the pocket, and pocket was washed with antibiotic solution and closed in 3 layers using 2-0 and 4-0 Vicryl. The patient tolerated these procedureswell and was transferred to his room in stable condition.
FINDINGS: Underlying rhythm is atrial fibrillation with ventricular rate of approximately 40-50 bpm. The right ventricular R wave measured 12.4 mV, the right ventricular impedance of 50 was 608 ohms, and the right ventricular threshold of 0.5 msec was 0.6 V. The right ventricular-paced QRS complex was 234 msec. The biventricular R wave measured 10.4 mV.The biventricular impedance of 50 was 330 ohms, and the biventricular threshold of 0.5 msec was 2.8 V. The biventricular-paced QRS complex was 168 msec. Ventricular fibrillation was induced with shock on T and covered with a 21-joule/40-ohms countershock. The charge time was 6.7 seconds and there was 100% sensing at least sensitivity.
A 14-J and 7-J shock on T failed to induce ventricular fibrillation. A 1-J shock on T induced ventricular fibrillation and was converted with a 9-joule/41-ohms countershock. Therefore, the defibrillation threshold is €9 J. The device was programmed VVIR 80-130. The VT zone is set at 175-220 bpm, and the VF zone at >220 bpm. The patient will receive adenosine triphosphate followed by 5 J, followed by 4 outputs in the VT zone and 21 J, followed by full output in the VF zone.
IMPRESSION: Successful procedures, as outlined above.
PLAN: Observation overnight. Discharge following assessment.