Pacemaker Report
Title of Procedure: Permanent pacemaker implantation.
Procedure in Detail: After detailed description of the procedure, indications, as well as the potential risks, of permanent pacemaker implantation were explained to the patient, and informed consent was obtained. The patient was transferred to the cardiac catheterization lab. The left subclavian area was prepared and draped in the usual sterile manner. The left subclavian vein was accessed by Seldinger technique. A guidewire was placed. The left subclavian vein was accessed, and a separate guidewire was also placed.
A deep subcutaneous pacemaker pocket was then created using the blunt dissection technique without any excessive bleeding. A French 7 introducer sheath was advanced over the guidewire, and the guidewire was removed. A Medtronic bipolar endocardial lead (model #5054 and serial #LEH025605V) was advanced under fluoroscopic guidance, and the tip of the pacemaker lead was positioned in the right ventricular apex. The French 9.5 introducer sheath was advanced over a separate guidewire under fluoroscopic guidance, and the guidewire was removed. Through this sheath, a bipolar atrial screw-in lead by Medtronic (model #4568 and serial #LDD027303V) was selected. It was positioned in the right atrial appendage, and the lead was screwed in. The stimulation thresholds were obtained for the atrial lead. The amplitude was 2.7 mV with resistance of 549 ohms and a pulse rate of 0.5 ms.
Following this, the ventricular stimulation threshold parameters were obtained, including the R-wave entry of 4.6 mV, with resistance of 1427 ohms and a pulse wave of 0.5 ms. Minimum stimulation threshold was 0.4 V for the ventricular lead, and minimal stimulation for the atrial lead was 2 V.
Both the atrial, as well as the ventricular leads, were secured to the deep subcutaneous tissue using 3—0 silk. The subcutaneous pocket was flushed and irrigated using antibiotic solution. Both leads were connected to a Medtronic pulse generator (model #KDR701, brand Kappa DR, serial #PGU107683H). The pulse generator was placed deep within the subcutaneous tissue. The pacemaker pocket was sutured using 3—0 Vicryl. Steri-Strips were applied. Pressure dressing was applied.
The patient tolerated the entire procedure well and remained stable.
Pulse Generator Settings: The pacing mode is DDDR. The rate response is on. The lower rate limit is 60 beats per minute, and the upper rate limit is 120 beats per minute. The upper tracking rate is 120 beats per minute. Paced AV interval is 150 ms and sensed AV interval is 150 ms. Rate adaptive AV interval is off. Retrograde conduction is on. Atrial amplitude is set at 5 V with a pulse wave of 0.76 ms, a sensitivity of 0.18 mV, and a blanking period of 180 ms. Ventricular amplitude is set at 5 V, a pulse wave of 0.46 ms, a sensitivity of 1.4 mV, and a blanking period of 28 ms.
Title of Procedure: Pacemaker generator replacement.
Description of Procedure: The patient was prepped in the usual sterile fashion. The right previous pacer site was in the right subclavian area. An incision was made. The pulse generator was removed. The ventricular lead was checked. Sensitivity was 5.8 mV, voltage 1.3 V, 2.4 mA, resistance 450 ohms. The same pacemaker pocket was used. A pulse generator (Affinity SR, serial number 151974) was placed. The patient was sutured in the usual sterile fashion. The patient tolerated the procedure well.
Title of Procedure: Insertion of transvenous temporary pacemaker by right internal jugular route.
Procedure in Detail: A right jugular stick following Xylocaine anesthesia was made in the triangle between the medial and lateral heads of the trapezius muscles. The internal jugular vein was cannulated initially with needles, using a guidewire. An Arrow introducer sheath was placed. The transvenous pacemaker selected was 3 French. The introducer sheath required a 5 French catheter to maintain a good seal. Intravenous fluid was infused via the side ports of the catheter following good venous return.
The transvenous balloon-type catheter, a flow-directed catheter but without capability of hemodynamic monitoring, was inserted with balloon up to approximately 45 cm and then manipulated between 52 cm from the introducer up to 32 cm from the introducer with best capture seen at 32 cm. Partial capturing was seen at settings at 0.5 mA to 1 mA with good capture at 2 mA. The rate was set at 60 beats per minute with complete capturing. Steri-Strips were used to wrap around the external portion of the catheter, and the catheter was secured to the introducer site port tubing. X-ray was taken showing the tip of the catheter within the right ventricle in good position.
Title of Procedure: Dual-chamber permanent pacemaker placement.
Description of Procedure: The patient was prepared in the usual sterile fashion. The left subclavian approach was selected. A needle was passed into the left subclavian vein with good blood return. A wire was passed through the needle and the needle was removed. Dilator and introducer were passed over the wire. The dilator was removed.
Ventricular lead—Pacesetter 134—60, 58 cm, serial number RL20692, was passed into the right ventricle. Threshold was 0.5 V, 0.7 mA, 780 ohms, 12.0 mV R-wave.
Atrial lead—Pacesetter 148-ATC, 46 cm, serial number NA10957, was passed into the right atrium. Threshold was 0.8 V, 2.4 mA, 480 ohms, 2.0 mV P-wave.
A pacemaker pocket was made in the left anterior chest wall. A pulse generator (Integrity AFXDR model 5342, serial number 256494) was placed into the left anterior chest wall. The patient was sutured in the usual sterile fashion and tolerated the procedure well. A chest x-ray was ordered.
Procedure in Detail: After detailed description of the procedure, indications, as well as the potential risks, of permanent pacemaker implantation were explained to the patient, and informed consent was obtained. The patient was transferred to the cardiac catheterization lab. The left subclavian area was prepared and draped in the usual sterile manner. The left subclavian vein was accessed by Seldinger technique. A guidewire was placed. The left subclavian vein was accessed, and a separate guidewire was also placed.
A deep subcutaneous pacemaker pocket was then created using the blunt dissection technique without any excessive bleeding. A French 7 introducer sheath was advanced over the guidewire, and the guidewire was removed. A Medtronic bipolar endocardial lead (model #5054 and serial #LEH025605V) was advanced under fluoroscopic guidance, and the tip of the pacemaker lead was positioned in the right ventricular apex. The French 9.5 introducer sheath was advanced over a separate guidewire under fluoroscopic guidance, and the guidewire was removed. Through this sheath, a bipolar atrial screw-in lead by Medtronic (model #4568 and serial #LDD027303V) was selected. It was positioned in the right atrial appendage, and the lead was screwed in. The stimulation thresholds were obtained for the atrial lead. The amplitude was 2.7 mV with resistance of 549 ohms and a pulse rate of 0.5 ms.
Following this, the ventricular stimulation threshold parameters were obtained, including the R-wave entry of 4.6 mV, with resistance of 1427 ohms and a pulse wave of 0.5 ms. Minimum stimulation threshold was 0.4 V for the ventricular lead, and minimal stimulation for the atrial lead was 2 V.
Both the atrial, as well as the ventricular leads, were secured to the deep subcutaneous tissue using 3—0 silk. The subcutaneous pocket was flushed and irrigated using antibiotic solution. Both leads were connected to a Medtronic pulse generator (model #KDR701, brand Kappa DR, serial #PGU107683H). The pulse generator was placed deep within the subcutaneous tissue. The pacemaker pocket was sutured using 3—0 Vicryl. Steri-Strips were applied. Pressure dressing was applied.
The patient tolerated the entire procedure well and remained stable.
Pulse Generator Settings: The pacing mode is DDDR. The rate response is on. The lower rate limit is 60 beats per minute, and the upper rate limit is 120 beats per minute. The upper tracking rate is 120 beats per minute. Paced AV interval is 150 ms and sensed AV interval is 150 ms. Rate adaptive AV interval is off. Retrograde conduction is on. Atrial amplitude is set at 5 V with a pulse wave of 0.76 ms, a sensitivity of 0.18 mV, and a blanking period of 180 ms. Ventricular amplitude is set at 5 V, a pulse wave of 0.46 ms, a sensitivity of 1.4 mV, and a blanking period of 28 ms.
Title of Procedure: Pacemaker generator replacement.
Description of Procedure: The patient was prepped in the usual sterile fashion. The right previous pacer site was in the right subclavian area. An incision was made. The pulse generator was removed. The ventricular lead was checked. Sensitivity was 5.8 mV, voltage 1.3 V, 2.4 mA, resistance 450 ohms. The same pacemaker pocket was used. A pulse generator (Affinity SR, serial number 151974) was placed. The patient was sutured in the usual sterile fashion. The patient tolerated the procedure well.
Title of Procedure: Insertion of transvenous temporary pacemaker by right internal jugular route.
Procedure in Detail: A right jugular stick following Xylocaine anesthesia was made in the triangle between the medial and lateral heads of the trapezius muscles. The internal jugular vein was cannulated initially with needles, using a guidewire. An Arrow introducer sheath was placed. The transvenous pacemaker selected was 3 French. The introducer sheath required a 5 French catheter to maintain a good seal. Intravenous fluid was infused via the side ports of the catheter following good venous return.
The transvenous balloon-type catheter, a flow-directed catheter but without capability of hemodynamic monitoring, was inserted with balloon up to approximately 45 cm and then manipulated between 52 cm from the introducer up to 32 cm from the introducer with best capture seen at 32 cm. Partial capturing was seen at settings at 0.5 mA to 1 mA with good capture at 2 mA. The rate was set at 60 beats per minute with complete capturing. Steri-Strips were used to wrap around the external portion of the catheter, and the catheter was secured to the introducer site port tubing. X-ray was taken showing the tip of the catheter within the right ventricle in good position.
Title of Procedure: Dual-chamber permanent pacemaker placement.
Description of Procedure: The patient was prepared in the usual sterile fashion. The left subclavian approach was selected. A needle was passed into the left subclavian vein with good blood return. A wire was passed through the needle and the needle was removed. Dilator and introducer were passed over the wire. The dilator was removed.
Ventricular lead—Pacesetter 134—60, 58 cm, serial number RL20692, was passed into the right ventricle. Threshold was 0.5 V, 0.7 mA, 780 ohms, 12.0 mV R-wave.
Atrial lead—Pacesetter 148-ATC, 46 cm, serial number NA10957, was passed into the right atrium. Threshold was 0.8 V, 2.4 mA, 480 ohms, 2.0 mV P-wave.
A pacemaker pocket was made in the left anterior chest wall. A pulse generator (Integrity AFXDR model 5342, serial number 256494) was placed into the left anterior chest wall. The patient was sutured in the usual sterile fashion and tolerated the procedure well. A chest x-ray was ordered.
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