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Permanent Pacemaker Insertion Operative Sample

PROCEDURE IN DETAIL:  Informed consent was obtained from the patient.  Complications, benefits, risks, and alternatives to the procedure were explained to the patient.  The patient was brought to the operating room in a fasting state.  Right side of the chest was prepped in the usual sterile fashion.  Lidocaine 1% was used as the local anesthetic.  Systemic sedation was obtained by monitored anesthesia. An 18 gauge needle was introduced into the right subclavian vein.  Through the needle, the guidewire was passed and positioned in superior vena cava under fluoroscopic guidance.  Once the guidewire was in position, the pacer pocket was made on the right side of the chest using electrocautery and blunt dissection. Hemostasis was secured and it was satisfactory. A 9 French introducer along with a sheath was inserted through the preplaced guidewire into the right subclavian vein.  The introducer was removed, and through the sheath, ventricular leads of Medtronic Corporation, model number XXXX-YY cm, serial# XXXXXXXXXX was introduced and advanced under fluoroscopic guidance with the help of J wire.  The J wire was replaced with a straight wire and the lead was positioned in the right ventricular apex.  The following parameters were obtained, which were within acceptable range.  The R-wave amplitude was 14.8 millivolts, lead impedance was 654 ohms, ventricular capturing threshold was 0.4 volts.  There was no diaphragmatic stimulation at 10 volts.  These parameters were within acceptable range. Once the ventricular lead was positioned, another 9 French introducer along with a sheath was inserted through the preplaced guidewire into the right subclavian vein.  This time, the introducer and the guidewire were removed, and through the sheath, atrial leads of Medtronic Corporation, model number XXXX-XX cm, serial number XXXXXXXXXX was introduced and advanced under fluoroscopic guidance into the lower one-third of the right atrial cavity.  The straight wire was replaced with a J-shaped wire and the lead was positioned in the right atrial appendage where the lead was screwed and the following parameters were obtained, which were within acceptable range.  Atrial P wave was 4 millivolts, atrial capturing threshold was 1 volts, lead impedance was 698 ohms.  There was no diaphragmatic stimulation at 10 volts.  All these parameters were within acceptable range.  At this stage, the pocket was reinspected and the hemostasis was satisfactory. Both atrioventricular leads were secured to the chest wall with 2-0 silk.  Both atrioventricular leads were connected to pulse generator of Medtronic Corporation, model number XXXXXX, serial number XXXXXXXXXXX.  The generator was placed in the preformed pocket and the pocket was closed in two layers using 2-0 Vicryl and Monocryl.  Before closing the pacer pocket, the wound was irrigated with thrombin solution as well.  At the end, Steri-Strips were applied to the pacer wound.  The patient tolerated the procedure very well.  X-ray of the chest was obtained, which showed no pneumothorax and both atrioventricular leads were in place.