Wiki Help please PM REPLACED WITH NEW EPICARDIAL LEAD

Messages
202
Location
Greer, SC
Best answers
0
33202 33228 33233
OR
33236 33202 33212

What are your thoughts?

Procedure:
1. Mini anterior thoracotomy, left
2. Extraction of endocardial left ventricular lead with fluoroscopy
3. Epicardial left ventricular lead placement
4. Cryo intercostal nerve block

Indications:
Mr. X is a 64 y/o gentleman with a re-sychronization permament pacemaker who developed high LV lead thresholds. For these reasons, he was consented for there aforementioned procedures.

Findings:
1. Successful removal of the malfunctioning endocardial LV lead
2. Successful removal of the previously implanted generator
3. Insertion of insertion of two epicardial LV leads; one left capped in the generator pocket

Final Parameters:
Mode: VVIR, LRL 70, URL 130
RA output: 0.5 V @ 0.03ms, RA sensitivity: OFF
RV output: 3.5V @ 0.4ms, RV sensitivity: 1.2mV
LV output: 3.5V @ 0.4ms, LV Polarity: tip-ring

Specimens:
None to pathology. Generator Serena Quad CRT-P & LV endocardial lead both to Medtronic.

Next, a small left anterior thoracotomy was made just lateral to the sternum in the 5th interspace. Dissection was carried down through the pectoralis and intercostal muscles with electrocautery. Care was taken to avoid injury to the left internal mammary bundle, however the lateral venous branch was clipped and divided. With assistance from the aforementioned assistant, the left chest was entered and the pericardium indentified. The phrenic nerve was identified and preserved. The pericardium was elevated away from the heart and incised with metzanbaum scissors. A small, clear pericardial effusion was then slowly drained. The pericardiotomy was then extended caudally and cephalad to expose the left ventricle.

Next, an incision was made overlying the generator pocket in the left anterior chest wall. Dissection was carried down with electrocautery. The generator was encountered and delivered from the pocket. The previously inserted LV and RV leads were removed from the device. The generator was then passed off the field. The malfunctioning LV lead was identified. Under fluoroscopy, a stylet was inserted through the lead to its point of endocardial contact. The lead was then turned counter-clockwise until it released itself without tension. The lead was then withdrawn from the patient and passed off the field. Next, an area of basal left ventricle epicardium was chosen for epicardial lead placement. The first Greatbatch medical bipolar lead then the inserted into the epicardium with 2.25 clockwise turns using the supplied delivery handle. The handle was removed. This lead was then tested to R-waves 8.4 mV, Threshold 0.5V @ 0.4m/s, Impedance 494. Next, a second Greatbatch medical bipolar lead was inserted into another bare area of basal endocardium using the same technique. This lead was tested to Threshold 0.5V @ 0.4ms, Impedance 665. Both leads were then tunneled from the pleural space, through a superior intercostal space and into the generator pocket. The first epicardial LV lead and endocardial RV lead were attached to a Solara CRT-P generator and the system placed on final parameters as stated above. The second LV epicardial lead was capped. The device with its attached leads, in addition to the capped LV epicardial lead were placed within an antibiotic pouch and delivered into the generator pocket.

Hemostasis was verified. A single 24 Fr chest tube was placed through an anterior-inferior incision and directed along the diaphragm and into the pericardium posteriorly behind the heart. Next, in order to affect an intercostal nerve block, the atricure cyro nerve block was affected along the 4th through 6th interspaces posterior to the interspace incision under direct vision. With assistance from the aforementioned assistant, both incisions were closed in layers with 0 and 2-0 Vicryl. Paracostal sutures of No 2 Vicryl were used to close the interspace. 4-0 Monocryl in a running subcuticular manner was used to close the skin. Dermabond was placed over the wounds. At this stage, the procedure was discontinued. The patient remained intubated and was transferred to the CVRU in stable condition.

Complications:
None

Drains:
1 24 Fr pleural / pericardial blake drain

Implants:
1. Medtronic Solara CRT-P (#RNS201061H)
2. Greatbatch Medical LV epicardial lead (#291244) - [attched; tested to threshold 0.5V @ 0.4ms, impedance 494]
3. Greatbatch Medical LV epicardial lead (#291245) - [capped; tested to threshold 0.5V @ 0.4ms, impedance 665]

Blood Products:
None

Vasoactive infusions:
None
 
Top