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Pre-procedure Diagnoses

1. Pacemaker lead malfunction

2. Pacemaker end of life

Post-procedure Diagnoses

1. Pacemaker lead malfunction

2. Pacemaker end of life

3. Subclavian vein occlusion, left

Procedures

1. HC PACEMAKER VVIR SINGLE SYSTEM

2. THORACIC VENOGRAM

3. CARDIAC PACEMAKER REMOVAL

BRIEF OPERATIVE NOTE

Pre-operative Diagnosis:

Pacemaker end of life

Pacemaker lead malfunction, sequela

Post-operative Diagnosis:

Pacemaker end of life

Pacemaker lead malfunction, sequela

Subclavian vein occlusion, left

Procedure Performed :

Pacemaker removal

venogram

Implantation of Permanent Pacemaker- new site

Implants and Procedure Description:

After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken.

ACCESS and POCKET FORMATION:

Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. Utilizing sharp and blunt dissection the old pulse generator was dissected and explanted. The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. I attempted to pass n .035 wire J-wire, then I will E wire and finally a Glidewire into the subclavian vein. It would not cross and I therefore performed sonography by injecting contrast through the access needle into the subclavian vein. This demonstrated occlusion of the left subclavian vein near its origin from the superior vena cava. The old ventricular lead was.

Attention was then directed to the right subclavian vein. While the patient remained in Trendelenburg, percutaneous access was obtained in the subclavian vein utilizing the modified sons technique. In 035 J-wire was then passed into the right atrium. Utilizing sharp and blunt dissection, a pocket was formed in the right prepectoral fascia. This incorporated the 035 wire.

VENTRICULAR LEAD:

Over the .035 wire, an 8 French peel-away sheath was advanced. The dilator was removed, and a second .035 wire was placed through the sheath. The sheath was removed and then reintroduced over one of the .035 wires. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an avtive fixation lead. Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 20.8 mV, impedance 951 ohms, threshold was 0.9 volts, current 1.1 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.

CLOSURE:

The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator. The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated. The subcutaneous fascia was closed with interrupted Vicryl suture. The skin layer was closed with a subcuticular Vicryl stitch. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.

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