PREOPERATIVE DIAGNOSIS:
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.
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.
ReplyDeleteWelcome to Novena Heart Centre, Know about HEART ATTACK - symptoms disease, treatment. Novena Heart is national heart center and available Cardiologist Singapore.