DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Sick sinus syndrome.
POSTOPERATIVE DIAGNOSIS:
Successful dual chamber pacemaker implantation.
PROCEDURES PERFORMED:
1. Dual chamber pacemaker implantation.
2. Radiological supervision.
3. Subclavian venogram.
ANESTHESIA: Local with conscious sedation.
ANESTHESIOLOGIST: None.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to the cardiac catheterization laboratory. Demerol 25 mg, Phenergan 12.5 mg, and Kefzol 1 gram IV were used as premedication. The chest was prepped and draped in the usual sterile fashion. Following infiltration of 1% lidocaine, left subclavian venous access was attempted. This was not successful. The injection of contrast was made in the left forearm vein twice to obtain a left subclavian venogram. It was seen that the vessel was small, and there was no flow at the level of the first rib. On the left, with the left subclavian artery as a guide, venous access was achieved and guidewire was inserted.
The left chest was infiltrated with more lidocaine, and an incision was made below the guidewire and parallel to the deltopectoral groove on the left side. This was also carried down to the superficial fascia of the pectoral muscle using sharp dissection and Bovie. A pocket was made over the left pectoral muscle for the placement of the generator. There was good hemostasis. The pocket was irrigated copiously with antibiotic solution containing cefazolin and amikacin. It was then packed with one sponge containing antibiotic solution.
Left subclavian venous access was achieved a second time and another guidewire was inserted medial to first one. Over this more medial guidewire, an #8 French SafeSheath was inserted. Through the sheath, a positive fixation endocardial lead was advanced into the right ventricular apex and screwed in under fluoroscopy. Measurements were made, and they were satisfactory. The sheath was peeled off, and the lead was secured to the underlying muscle using 2-0 silk over its own sleeve. Over the same guidewire, another #8 French SafeSheath was inserted. Through the sheath, a positive fixation endocardial lead was advanced into the right atrial appendage area and screwed in with the aid of curved stylet.
Measurements were made and they were satisfactory. The sheath was peeled off, and the lead was likewise secured to the underlying muscle using 2-0 silk over its own sleeve. A 2-0 silk pursestring suture was made around both leads at the access site to prevent backbleeding from the vein.
The sponge was removed. The pocket was irrigated again with antibiotic solution. The leads were connected to the generator, and the generator was placed in the pocket. It was a good fit. The wound was closed with continuous 3-0 Vicryl subcutaneous suture. The skin edges were closed with continuous 4-0 Vicryl subcuticular suture. The wound edges were then sealed with Dermabond. The patient tolerated the procedure well.
