I should have included the note... sorry about that.
Procedures:
Ultrasound-guided central venous access
Implantation of biventricular ICD utilizing a pre-existing surgically placed left ventricular lead
Indications: 68-year-old man with valvular heart disease, postop day 3 from mitral valve bioprosthetic replacement and tricuspid valve ring repair; persistent atrial fibrillation status post Maze; chronic systolic heart failure with LVEF 20%; intraventricular dyssynchrony due to bifascicular block with QRS duration 160 milliseconds; sick sinus syndrome post Maze procedure, resulting in AV dyssynchrony due to competing junctional escape rhythm.
Techniques: Following informed consent, the patient was brought to the EP lab in a fasting nonsedated state, in junctional escape rhythm with bifascicular block morphology. IV antibiotics were administered. IV sedation was provided by the anesthesiology service. The left anterior chest was prepped and draped in usual sterile fashion. Under ultrasound guidance, vascular access was obtained x3 in the extrathoracic portion of the left subclavian vein. The left subclavian artery and vein demonstrated normal anatomic relationship, with no significant calcification or stenosis of the artery and no thrombosis of the vein. A skin incision was made at the left deltopectoral groove and cutdown was performed to the deltopectoral fascia; a subcutaneous pocket was fashioned. The previously implanted left ventricular lead, which was tunneled to the left prepectoral fascia, was located and pulled into the pocket. The lead was tested, and demonstrated excellent electrical parameters. A 7 French and a 6 French hemostasis sheath were inserted over 2 of the access wires; the 3rd access wire was removed. An ICD lead was delivered to distal RV septal position and deployed. A pacing lead was delivered to right atrial appendage position and deployed. The leads were anchored to the underlying fascia using 2 nonabsorbable sutures around each lead's retention sleeve. A pulse generator was connected to the right atrial, right ventricular, left ventricular leads. The system was placed in pocket. The pocket was irrigated with antibiotic solution and D Stat hemostatic matrix was injected. The skin incision was closed in layers using resorbable sutures and dressed with Steri-Strips. The patient tolerated the procedure well.
Pulse generator: Saint Jude 3357-40Q, SN 9863636, implant 12/11/20
DDDR 60-130
Right atrial lead: Saint Jude 2088TC, SN CAU497664, implant 12/11/20
0.3mV, 380ohms, 1.0V@0.5ms
Right ventricular lead: Saint Jude 7122Q, SN BPA16315, implant 12/11/20
6.6mV, 410ohms, 0.5V@0.5ms
Left ventricular lead: Saint Jude 511212T, SN 293379, implant 12/8/20
250ohms, 1.5V@0.5ms
EBL: 10 cc
Complications: none
Assessment:
Successful implantation of biventricular ICD, utilizing surgically implanted epicardial left ventricular pacing lead