Sample Report: Implantation of Implantable Cardioverter-Defibrillator (ICD)
PROCEDURES PERFORMED:
1. Dual-chamber implantable cardioverter-defibrillator implantation.
2. Interrogation of reprogramming.
3. Fluoroscopy.
4. Superior vena cava leads x2.
5. Intracardiac atrial and ventricular pacing and recording.
6. Defibrillation threshold testing.
7. Echocardiogram x4.
COMPLICATIONS: None.
ANESTHESIA: ASA classification class III. Deep conscious sedation provided by the anesthesia service.
MEDICATIONS: Ancef 1 g IV given prior to the implantation.
DETAILS OF PROCEDURE: The patient was taken to the clinical laboratory in the fasting state. He has had documented clinical ventricular tachycardia as well as coronary artery disease and left ventricular dysfunction. During electrophysiological study, he was found to have inducible ventricular tachycardia and no reversible cause for his arrhythmia was present. He also has significant sinus node dysfunction with symptomatic bradycardia.The left upper chest was prepared in the usual sterile fashion. Local anesthetic was applied to the skin. A 3-cm incision was performed inferior and parallel to the clavicle. Two separate punctures of the left axillary vein were performed, and the guidewire was left in place. Pocket was manufactured through a combination of sharp and blunt dissection. Good hemostasis was present.
Through the guidewire in the left axillary vein, 2 separate sheaths were placed toward the superior vena cava (SVC). The atrial and ventricular leads were advanced through each of these sheaths and placed primarily into the right atrium.
The right ventricular lead was then advanced into the right ventricular apex. After documenting satisfactory pacing parameters, the lead position was secured. The right atrial lead was then placed in the right atrial appendage. After documenting satisfactory pacing parameters, the lead position was secured with silk sutures. Of note, after removing the sheath for the right ventricular lead, air within the pulmonary artery was noted on the fluoroscopy. The patient developed desaturation and cough. Immediately, a Swan-Ganz catheter was advanced into the pulmonary artery and the air within the pulmonary artery was aspirated. This led to complete resolution of the cough and immediate improvement in desaturations. The Swan-Ganz catheter was removed.
Good hemostasis was present in the pocket. Intracardiac atrial and ventricular pacing and recording was performed. A dual-chamber generator from St. Jude was then connected to the leads and placed in the pocket. The pocket was irrigated copiously with antibiotic solution before and after placement of the generator in the pocket. The pocket was closed in layers with 2-0 and 3-0 Vicryl. Dermabond was applied to the skin.
Defibrillation testing threshold was performed. Two separate episodes of ventricular fibrillation were induced 5 minutes apart. During the first episode, a 20-J shock was delivered, successfully restoring sinus rhythm. Charge time was 3.9 seconds with a defibrillation impedance of 42 ohms and 100% sensing when programmed to a sensitivity of 1.0 mV. For the second episode, a 15-J shock successfully restored sinus rhythm after a charge time of 2.7 seconds. Impedance was 42 ohms and again there was 100% sensing when programmed to a sensitivity of 0.3 mV. At the end of the procedure, no complications were noted and the patient recovered from the sedation well.
FINDINGS:
1. Successful implantation of a dual-chamber Epic DR, model #V235, dual-chamber pulse generator from St. Jude Medical, serial #17060.
2. Implantation of a St. Jude 1688TC, 52-cm lead in the right atrial appendage, serial #DN14249. The measured R wave was 3.1 mV with a pacing impedance of 504 ohms and an acute pacing threshold of 0.9 volts at 0.5 msec.
3. Successful implantation of St. Jude 1580, 65-cm lead in the right ventricular apex, and an acute pacing threshold of 0.8 volts at 0.5 msec.
4. Defibrillation threshold equal to or less than 15 J.
IMPRESSION: Successful implantation of a dual-chamber implantable cardioverter-defibrillator.
RECOMMENDATIONS:
1. Maximize beta blockade for the treatment of his coronary artery disease, his congestive heart failure, and to minimize the possibility of sinus tachycardia being detected as ventricular tachycardia. His clinical tachycardia had a relatively low ventricular rate; therefore, his ventricular tachycardia detection is set at 140 beats per minute.
2. Chest x-ray, antibiotics, electrocardiogram, and observation.