1.
Tachybrady syndrome.
2. Pauses greater than 3 seconds.
POSTOPERATIVE
DIAGNOSIS:
1.
Tachybrady syndrome.
2. Pauses greater than 3 seconds.
PROCEDURE:
Insertion of dual-chamber permanent
pacemaker.
ANESTHESIA:
General with LMA plus local.
ESTIMATED BLOOD LOSS: 2
mL.
INDICATIONS: The patient is a very pleasant 87-year-old female with multiple medical
problems including hypertension, coronary disease, myocardial infarction,
severe aortic stenosis who is admitted with chest pain and congestive heart
failure. During hospitalization, she exhibited
tachybrady syndrome. Therefore, she was
referred for permanent pacemaker insertion.
The indications, risks, and benefits of the procedure were explained to
the patient and to her daughter. She
consented to the operation.
FINDINGS: The
implanted pacemaker is a St. Jude
Medical Zephyr DR, dual chamber rate responsive
pacemaker, model #5820, serial #1915194.
The right atrial lead is a St. Jude Medical Tendril SDX, model #1688
TC/46 cm, serial #DM84531. The right
ventricular lead is a Tendril SDX, model #1688 TC/52 cm, serial #JU141764. The patient's parameters; P-waves 2 mV,
impedance 380 ohms, and pacing threshold 0.9 volts; R-waves 14.0 mV, impedance
584 ohms, and pacing threshold 0.7 volts.
OPERATION: A
time-out was performed prior to starting the operation. The patient was correctly identified as well
as the procedure. After induction of
general anesthesia and placement of an LMA, the patient's left upper chest and
neck were prepped with DuraPrep and draped sterilely. A 1% Xylocaine was infiltrated locally in the
left infraclavicular region. The patient
was placed in Trendelenburg. The left
subclavian vein was easily accessed on the first take with an 18-gauge
introducer needle. A guidewire was
threaded and the needle removed. The
left subclavian vein was accessed second time again on the first take. A second guidewire threaded. Fluoroscopy was used to confirm correct
position of the guidewires. The patient
was taken out from Trendelenburg. A 3-cm
transverse incision was made over the left pectoral area. The subcutaneous tissues were divided with
electrocautery. A pocket was created
overlying the pectoralis fascia. The two
guidewires were brought into the pocket.
A 7-French introducing dilator was advanced from the first
guidewire. The dilator and guidewire
were removed. Under fluoroscopic
guidance, the right ventricular lead was threaded and the peel-away sheath
removed. Using fluoroscopic guidance,
the lead was positioned over the apex of the right ventricle. The endocardial screw was secured. The patient’s parameters were excellent. The lead was tested with 10 volts, and there
was no evidence of diaphragmatic or chest wall pacing. The lead was secured to the pectoralis muscle
with Ethibond sutures.
A second 7-French introducer and dilator
were advanced over the second guidewire.
The dilator and guidewire were removed.
The right atrial lead was threaded under fluoroscopic guidance. The peel-away sheath was removed. Using the preformed J-wire, the lead was
positioned in the right atrium. Multiple
positions were tested before getting adequate sensing P-waves. The endocardial screw was secured, and the
patient's parameters were obtained and were good. The lead was secured to the pectoralis muscle
with Ethibond sutures. The lead was also
tested with 10 volts, and there was no evidence of diaphragmatic or chest wall
pacing. The leads were inserted into the
appropriate receptacles of the pacemaker generator. The pocket was irrigated with antibiotic
solution. Hemostasis was fine. The generator was inserted into the
pocket. The incision was closed in layers with continuous Vicryl sutures
including the subcuticular layer.
Dermabond and a Coverlet were applied.
The patient
tolerated the procedure well, and there were no complications. Sponge, instruments, and needle counts were
correct. The patient was transported to
the Post Anesthesia Care Unit in stable condition.
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