kdoughty
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I'm struggling with this one. Can anyone help??
DESCRIPTION OF PROCEDURE: He was prepped and draped in standard fashion,
exposing the left chest. The old incision was infiltrated with 1% lidocaine.
A 6-cm incision was created through the old incision and carried down until we
engaged the pacemaker pocket. Using sharp dissection, blunt dissection and
electrocautery, we were able to with gentle extraction remove the previously
implanted pacemaker from the pocket and the set screws. The old device was a
Medtronic Adapta, serial [REDACTED], implanted 04/06/2012, and the device was
explanted and discarded. We turned our attention to the right ventricular
lead, which was a Medtronic 5076, 52 cm, serial number [REDACTED], which was
implanted on 04/06/2012. We put a firm stylet down and retracted the set
screw. We retracted the fixation mechanism back into the lead. We dissected
through the fibrous tissue and got through the anchoring sutures. With gentle
traction and rotation, we were able to extract the old lead, which was
performed easily without any complications. The patient tolerated the
procedure satisfactorily, and there were no hemodynamic ______ related to the
extraction. We turned our attention to the venous access and obtained two
axillary vein sticks using modified Seldinger technique, we worked advanced
guide wires into the SVC using a two 9-French sheaths, along was irregular Cook
sheath. The other was a 9-French safe sheath. We implanted the right
ventricular lead first. It was a Boston Scientific Reliance SG, active fix,
single coil, model number 0292, serial [REDACTED], length of lead of 59 cm. Under
direct fluoroscopy, we were able to manipulate the lead until we found a
satisfactory location in the right ventricular apex with optimal sensing and
physical characteristics. At this location in the RV apex, the lead had a
sensed amplitude in excess of 30 mV. We activated the active fixation
mechanism at this location. The sensed amplitude was, again, between 25 and 30
mV. Pacing capture threshold was 0.6 V at 0.5 msec with a pacing impedance of
872 ohms. The lead was sutured to the prepectoral fascia with 0 silk. We
turned our attention to the left ventricular lead. Using a Medtronic guiding
sheath and a Polaris quadripolar catheter, we were able to engage the coronary
sinus os and advance the sheath into the coronary sinus. Contrast venography
was performed, which showed the main CS and a fairly proximal lateral branch,
which appeared to be a satisfactory target for the LV lead. We were able to,
using a Whisper guidewire, place the LV lead with an over-the-wire technique.
The lead was a Guidant Acuity steerable LV lead, length 80 cm, model #4554,
serial [REDACTED]. This lead was manipulated under direct fluoroscopy to find a
physically stable and electrically optimal location in the distal portion of
this lateral branch. At this location, in the standard bipolar configuration,
we had a pacing capture threshold of 1 V at 0.5 msec. There was no
diaphragmatic capture at high pacing outputs. The impedance was 1232 ohms.
All leads were tested and had passed a similar satisfactory characteristics.
The right atrial lead, which was previously implanted 04/06/2012, was left
alone. It had a sensed amplitude of 1.8 mV with a pacing capture threshold of
1 V at 0.5 msec with an impedance of 386 ohms. All leads were anchored to the
prepectoral fascia with 0 silk. The pocket was widened using electrocautery,
and this was widened both laterally and caudally to accommodate the new device.
The pocket was then copiously irrigated with antibiotic solution. The device
was a Boston Scientific Energen CRT-D, model number N140, serial [REDACTED], which
was attached to the leads and set screws deployed. The device was placed in
the pocket. No anchor suture was placed on the device, and the incision was
closed in layers starting with 2-0 Vicryl for the deep layer and 4-0 Vicryl for
the skin. Fluoroscopy confirmed satisfactory positioning of all three leads,
the atrial, the right ventricular and the LV lead with adequate amounts of
slack and a wide dispersion between the right ventricle and the left
ventricular lead. Defibrillation threshold testing was not performed, as the
patient will be loaded with amiodarone and will have DFTs performed after a
satisfactory interval to ensure adequate thresholds. The device was programmed
to DDDR 60-130 with a VT zone of 160 beats per minute and VF zone of 220 beats
per minute. Device was programmed to DDDR 60-130. AV delay was 180/80.
SUMMARY:
1. Satisfactory extraction of a previously implanted pacemaker and right
ventricular pacing lead.
2. Upgrade to biventricular implantable cardiac defibrillator.
DESCRIPTION OF PROCEDURE: He was prepped and draped in standard fashion,
exposing the left chest. The old incision was infiltrated with 1% lidocaine.
A 6-cm incision was created through the old incision and carried down until we
engaged the pacemaker pocket. Using sharp dissection, blunt dissection and
electrocautery, we were able to with gentle extraction remove the previously
implanted pacemaker from the pocket and the set screws. The old device was a
Medtronic Adapta, serial [REDACTED], implanted 04/06/2012, and the device was
explanted and discarded. We turned our attention to the right ventricular
lead, which was a Medtronic 5076, 52 cm, serial number [REDACTED], which was
implanted on 04/06/2012. We put a firm stylet down and retracted the set
screw. We retracted the fixation mechanism back into the lead. We dissected
through the fibrous tissue and got through the anchoring sutures. With gentle
traction and rotation, we were able to extract the old lead, which was
performed easily without any complications. The patient tolerated the
procedure satisfactorily, and there were no hemodynamic ______ related to the
extraction. We turned our attention to the venous access and obtained two
axillary vein sticks using modified Seldinger technique, we worked advanced
guide wires into the SVC using a two 9-French sheaths, along was irregular Cook
sheath. The other was a 9-French safe sheath. We implanted the right
ventricular lead first. It was a Boston Scientific Reliance SG, active fix,
single coil, model number 0292, serial [REDACTED], length of lead of 59 cm. Under
direct fluoroscopy, we were able to manipulate the lead until we found a
satisfactory location in the right ventricular apex with optimal sensing and
physical characteristics. At this location in the RV apex, the lead had a
sensed amplitude in excess of 30 mV. We activated the active fixation
mechanism at this location. The sensed amplitude was, again, between 25 and 30
mV. Pacing capture threshold was 0.6 V at 0.5 msec with a pacing impedance of
872 ohms. The lead was sutured to the prepectoral fascia with 0 silk. We
turned our attention to the left ventricular lead. Using a Medtronic guiding
sheath and a Polaris quadripolar catheter, we were able to engage the coronary
sinus os and advance the sheath into the coronary sinus. Contrast venography
was performed, which showed the main CS and a fairly proximal lateral branch,
which appeared to be a satisfactory target for the LV lead. We were able to,
using a Whisper guidewire, place the LV lead with an over-the-wire technique.
The lead was a Guidant Acuity steerable LV lead, length 80 cm, model #4554,
serial [REDACTED]. This lead was manipulated under direct fluoroscopy to find a
physically stable and electrically optimal location in the distal portion of
this lateral branch. At this location, in the standard bipolar configuration,
we had a pacing capture threshold of 1 V at 0.5 msec. There was no
diaphragmatic capture at high pacing outputs. The impedance was 1232 ohms.
All leads were tested and had passed a similar satisfactory characteristics.
The right atrial lead, which was previously implanted 04/06/2012, was left
alone. It had a sensed amplitude of 1.8 mV with a pacing capture threshold of
1 V at 0.5 msec with an impedance of 386 ohms. All leads were anchored to the
prepectoral fascia with 0 silk. The pocket was widened using electrocautery,
and this was widened both laterally and caudally to accommodate the new device.
The pocket was then copiously irrigated with antibiotic solution. The device
was a Boston Scientific Energen CRT-D, model number N140, serial [REDACTED], which
was attached to the leads and set screws deployed. The device was placed in
the pocket. No anchor suture was placed on the device, and the incision was
closed in layers starting with 2-0 Vicryl for the deep layer and 4-0 Vicryl for
the skin. Fluoroscopy confirmed satisfactory positioning of all three leads,
the atrial, the right ventricular and the LV lead with adequate amounts of
slack and a wide dispersion between the right ventricle and the left
ventricular lead. Defibrillation threshold testing was not performed, as the
patient will be loaded with amiodarone and will have DFTs performed after a
satisfactory interval to ensure adequate thresholds. The device was programmed
to DDDR 60-130 with a VT zone of 160 beats per minute and VF zone of 220 beats
per minute. Device was programmed to DDDR 60-130. AV delay was 180/80.
SUMMARY:
1. Satisfactory extraction of a previously implanted pacemaker and right
ventricular pacing lead.
2. Upgrade to biventricular implantable cardiac defibrillator.
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