DESCRIPTION OF OPERATION: The patient was brought to the electrophysiology laboratory in the fasting state after signing informed consent. The left subclavian area was prepped and draped in the usual sterile fashion. Local anesthesia was achieved along the left deltopectoral groove using a combination of 1% lidocaine and 0.5% Marcaine. An incision was extended along the groove, and using a combination of blunt and Bovie dissection, the incision was extended to the level of the prepectoral fascia. A pulse generator pocket was fashioned inferomedial to the incision using blunt dissection in the prepectoral space. The left axillary vein was visualized with a Site-Rite II ultrasound device, and under direct ultrasound visualization, the vein was punctured with a Cook needle and a guidewire was placed. Using a similar ultrasound-guided technique, another guidewire was placed in the left axillary vein using a separate needle stick. Over one guidewire, a 7 French introducer sheath was advanced. Through this sheath, an active fixation pacing lead was advanced using straight and curved stylets. The lead was positioned in the right ventricular septal area at a site with favorable sensing and pacing characteristics, where the lead was actively fixed in the location and securely sutured to the underlying pectoral muscle. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing. Over the second guidewire, another 7 French introducer sheath was advanced, and through this sheath, another active fixation pacing lead was advanced into the right atrium with the aid of a J-tipped stylet. The lead was positioned in the right atrial appendage at a site with favorable sensing and pacing characteristics, where the lead was actively fixed in the location and securely sutured to the underlying pectoral muscle. It should be noted that this original pacing lead did dislodge not long after closure of the wound. The patient was therefore re-prepped and the wound was opened, and the lead was again repositioned in the right ventricular appendage area at a site with favorable sensing and pacing characteristics where the lead was actively fixed in the location and securely sutured to the underlying pectoral muscle. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing. The pulse generator pocket was thoroughly irrigated with antibiotic solution, and the leads were attached to a dual-chamber pacer pulse generator, which was placed into the preformed pocket. The subcutaneous fat and fascia were closed using running 2-0 Vicryl suture. The skin was closed using running 4-0 Monocryl suture. The wound was dressed with Steri-Strips and sterile gauze. The patient left the electrophysiology laboratory in stable condition with proper device function observed on the monitor.
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