Hbutler10
Contributor
Indication for Surgery
Symptomatic sinus bradycardia. Recent syncope associated facial fractures.
Preoperative Diagnosis
Symptomatic sinus bradycardia
Postoperative Diagnosis
Same
Operation
Dual-chamber permanent transvenous pacemaker placement with supervision and interpretation. Superior vena cava catheter placement x2 with supervision and interpretation. Percutaneous needle placement left subclavian vein x2 with ultrasound guidance. Dual-chamber permanent transvenous pacemaker programming
Anesthesia
General and 1% lidocaine local
Estimated Blood Loss
10ml
Findings
Dual-chamber permanent transvenous pacemaker was placed with a left subclavian vein approach.
Complications
None
Technique
Timeout performed. Prophylactic antibiotic given. Fire risk assessment completed. Upper chest and neck prepped and draped in a standard fashion. Ultrasound transducer placed in a sterile sleeve. Patient placed in Trendelenburg position and the head turned towards the right side. With continuous ultrasound guidance the left subclavian vein is entered in 2 separate locations with 2 passes of 18-gauge needle. The subclavian vein is quite deep given his body habitus. 2 guidewires were inserted into the superior vena cava. C-arm fluoroscopy confirmed proper positioning of both guidewires. A 5 cm incision made connecting the 2 guidewire insertion sites. Dissection continues through copious subcutaneous adipose tissue. Just anterior to the pectoralis fascia pocket is created for implantation of the pulse generator. Over the more medial wire a 7 French tear-away introducer catheter is passed into the superior vena cava. Through the superior vena cava catheter a Medtronic tined tip steroid tip lead model #407458 is advanced in the superior vena cava and the introducer is removed. Utilizing more lateral wire a 7 French tear-away introducer catheter is advanced into the superior vena cava. Guidewire is removed. Dilator removed. Through the superior vena cava catheter a Medtronic tined tip steroid-tipped preformed atrial J lead model #457445 is advanced into the superior vena cava and the sheath is removed. With continuous C-arm fluoroscopic guidance the ventricular electrode is carefully manipulated across the tricuspid valve to the region of the right ventricular apex. In this position impedance was 1109 ohms with R wave 9.3 mV and voltage threshold is 0.3 V with pulse width 0.5 ms. The lead was stable and there was no diaphragmatic pacing at 10 V. Right atrial lead was positioned in 3 different places and the best place was found to be lateral aspect of the atrium. In this location impedance was 633 ohms and P wave is 6.8 mV. Voltage threshold is 0.4 V at pulse width 0.5 ms. Lead did appear to be stable. There was no diaphragmatic pacing at 10 V. Particular care was taken to leave enough lead in the central venous circulation for both leads. The lead cuffs are secured to subcutaneous tissues with 2 sutures of 0 Ethibond. The leads are connected to a Medtronic MRI compatible generator model number W1 DR 01 and the 2 screws are tightened. Generator is implanted in the previously constructed pocket and sutured to prepectoral fascia with a single suture of 0 Ethibond. Excess leads placed posterior to the generator can. C-arm fluoroscopy reveals leads remain in satisfactory position. Leads are functioning appropriately. Subcutaneous tissues are closed with 2 running layers of 3-0 Vicryl. Skin closed with running 4-0 Monocryl subcuticular stitch. LiquiBond applied. Local anesthetic injected for postop pain relief. The pacemaker is programmed to AAIR–DDDR mode with lower rate 60, upper tracking rate 130 , and upper activity rate 130. Both leads are bipolar and amplitude for both leads is 3.5 V. Post procedure portable chest x-ray is ordered.
Symptomatic sinus bradycardia. Recent syncope associated facial fractures.
Preoperative Diagnosis
Symptomatic sinus bradycardia
Postoperative Diagnosis
Same
Operation
Dual-chamber permanent transvenous pacemaker placement with supervision and interpretation. Superior vena cava catheter placement x2 with supervision and interpretation. Percutaneous needle placement left subclavian vein x2 with ultrasound guidance. Dual-chamber permanent transvenous pacemaker programming
Anesthesia
General and 1% lidocaine local
Estimated Blood Loss
10ml
Findings
Dual-chamber permanent transvenous pacemaker was placed with a left subclavian vein approach.
Complications
None
Technique
Timeout performed. Prophylactic antibiotic given. Fire risk assessment completed. Upper chest and neck prepped and draped in a standard fashion. Ultrasound transducer placed in a sterile sleeve. Patient placed in Trendelenburg position and the head turned towards the right side. With continuous ultrasound guidance the left subclavian vein is entered in 2 separate locations with 2 passes of 18-gauge needle. The subclavian vein is quite deep given his body habitus. 2 guidewires were inserted into the superior vena cava. C-arm fluoroscopy confirmed proper positioning of both guidewires. A 5 cm incision made connecting the 2 guidewire insertion sites. Dissection continues through copious subcutaneous adipose tissue. Just anterior to the pectoralis fascia pocket is created for implantation of the pulse generator. Over the more medial wire a 7 French tear-away introducer catheter is passed into the superior vena cava. Through the superior vena cava catheter a Medtronic tined tip steroid tip lead model #407458 is advanced in the superior vena cava and the introducer is removed. Utilizing more lateral wire a 7 French tear-away introducer catheter is advanced into the superior vena cava. Guidewire is removed. Dilator removed. Through the superior vena cava catheter a Medtronic tined tip steroid-tipped preformed atrial J lead model #457445 is advanced into the superior vena cava and the sheath is removed. With continuous C-arm fluoroscopic guidance the ventricular electrode is carefully manipulated across the tricuspid valve to the region of the right ventricular apex. In this position impedance was 1109 ohms with R wave 9.3 mV and voltage threshold is 0.3 V with pulse width 0.5 ms. The lead was stable and there was no diaphragmatic pacing at 10 V. Right atrial lead was positioned in 3 different places and the best place was found to be lateral aspect of the atrium. In this location impedance was 633 ohms and P wave is 6.8 mV. Voltage threshold is 0.4 V at pulse width 0.5 ms. Lead did appear to be stable. There was no diaphragmatic pacing at 10 V. Particular care was taken to leave enough lead in the central venous circulation for both leads. The lead cuffs are secured to subcutaneous tissues with 2 sutures of 0 Ethibond. The leads are connected to a Medtronic MRI compatible generator model number W1 DR 01 and the 2 screws are tightened. Generator is implanted in the previously constructed pocket and sutured to prepectoral fascia with a single suture of 0 Ethibond. Excess leads placed posterior to the generator can. C-arm fluoroscopy reveals leads remain in satisfactory position. Leads are functioning appropriately. Subcutaneous tissues are closed with 2 running layers of 3-0 Vicryl. Skin closed with running 4-0 Monocryl subcuticular stitch. LiquiBond applied. Local anesthetic injected for postop pain relief. The pacemaker is programmed to AAIR–DDDR mode with lower rate 60, upper tracking rate 130 , and upper activity rate 130. Both leads are bipolar and amplitude for both leads is 3.5 V. Post procedure portable chest x-ray is ordered.
