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Implantable Cardioverter Defibrillator Sample Report


1.  Implantation of implantable cardioverter defibrillator.
2.  Intraoperative testing of ICD function.
3.  Unsuccessful attempt at placement of left ventricular pacing lead.

1.  Congestive heart failure, NYHA class II.
2.  Dilated nonischemic cardiomyopathy.
3.  Left bundle branch block.

INDICATION FOR PROCEDURE:  This is a (XX)-year-old woman with a history of nonischemic dilated cardiomyopathy. The patient has class II congestive heart failure, on medical therapy, with persistent left ventricular dysfunction, most recently 30% by echocardiography. She was enrolled in the REVERSE trial, which involved placement of a biventricular ICD and then randomization to either back VVI pacing or active cardiac resynchronization pacing. She presented today for anticipated placement of a biventricular ICD.

DESCRIPTION OF PROCEDURE:  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. Pulse generator pocket was fashioned inferomedial to the incision using blunt dissection in the prepectoral space. A left axillary vein was visualized with a Site-Rite II ultrasound device, and under direct ultrasonic visualization, the vein was punctured with a Cook needle, and a guidewire was placed. Using similar ultrasound guided technique, two additional guidewires were placed in the left axillary vein using separate needle sticks. Over one guidewire, a 9 French introducer sheath was advanced, and through the sheath, an active fixation ICD lead was advanced with the aid of straight and curved stylets. The lead was initially positioned in the distal right ventricular apex where sensing characteristics were less than optimal. The lead was drawn back slightly to a more proximal location of the right ventricular apex where acceptable sensing and pacing characteristics were found, and the lead was actively fixed in the location of this site. The lead was securely sutured to underlying pectoral muscles. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing.

Over the second guidewire, a 7 French introducer sheath was advanced, and through this sheath, an active fixation pacing lead was advanced into the right atrium. The lead was initially fixed in an anterior location but dislodged during attempted cannulation of the coronary sinus and ultimately was positioned in a posterior position in the right atrium where sensing and pacing characteristics were favorable. The lead was securely sutured to the underlying pectoral muscle. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing.

Over the third guidewire, a Medtronic extended hook coronary sinus guiding sheath was advanced, and attempts were then made to cannulate the coronary sinus. The coronary sinus proved to be extremely difficult to cannulate due to a very large right atrium and the position of the coronary sinus well off the floor of the atrium. In addition, there was a proximal valve impeding progress of any of our larger and stiffer catheters. It was possible with some effort to cannulate the coronary sinus with a guidewire and MPA-2 catheter, but insufficient support was afforded by the right atrium to allow passage of the sheath, which would dislodge the catheter and guidewire from the vessel.

Other attempts to place a stiffer catheter, including two different steerable EP catheters and a Medtronic Prevail Steerable catheter, were unsuccessful as we could not cannulate beyond the proximal portion of the coronary sinus and thereby also not allow sufficient support to advance the sheath. Extensive efforts were expended in the effort to place the sheath within the coronary sinus, including empiric efforts to cannulate via the middle cardiac vein or a posterolateral vein with guidewire sheath. When it was unable to advance beyond the coronary sinus ostium, ultimately elected to abandon efforts at placement of a left ventricular lead and thereby exit the patient from the research trial.

The guidewire and sheath were removed, and good hemostasis was obtained with digital pressure. The pulse generator pocket was thoroughly irrigated with antibiotic solution. The right atrium and right ventricular leads were attached to a dual chamber ICD, which was placed into the preformed pocket. The patient was sedated with intravenous Brevital, and ventricular fibrillation was induced with a synchronous countershock. The device properly detected arrhythmia and delivered a 15 joule countershock, which resulted in conversion to sinus rhythm. After 5 minutes, the patient remained sedated, and ventricular fibrillation again was induced in a similar fashion. On this occasion, a 10 joule countershock resulted in conversion to sinus rhythm. The patient emerged from anesthesia without difficulty and remained hemodynamically stable throughout the procedure during defibrillator testing.

 The wound was closed using two layers of deep 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 monitor.