Case 3
Procedure: Dual Chamber Implantable Cardioverter Defibrillator (ICD) Implantation Pre-Procedure Diagnosis: Hypertrophic Cardiomyopathy, NSVT, SSS, Near Syncope Procedure: The patient was brought to the Electrophysiology Lab in the fasting state and continuous electrocardiographic monitoring was instituted. Anesthesia was performed by Dr Kiss and will be dictated separately by him. The left subclavicular fossa was prepped and draped in the usual sterile fashion and 1% lidocaine was instilled for local anesthesia. The incision was made and the dissection was carried down to the level of the pectoralis major fascia where a subcutaneous pocket was formed using blunt dissection. The axillary vein was entered with a Micropuncture thin walled needle without difficulty at two separate locations, guided by ultrasound, and guide wires were advanced into the central venous circulation. Using the guide wires and two introducer sheaths, an ICD electrode was advanced to the right ventricular septum, and a pacing electrode was advanced to the right atrial appendage under fluoroscopic guidance. Each electrode was anchored to the underlying pectoralis major fascia with a single stitch of 2-0 non-absorbable suture. These leads were attached to a dual chamber ICD which was placed in the previously formed pocket with electrodes situated beneath it after the pocket had been flushed with saline solution. The ventricular electrode is a Medtronic Model # 6935M62 (Serial # TDL515430V). This is a bipolar, steroid-tipped, active fixation lead. The R wave was 10 mV, the pacing impedance was 600 Ohms, and the ventricular capture threshold was 0.75 V @ 0.5 ms. The HVB impedance was 76. There was no diaphragmatic pacing at 10 V. The atrial electrode is a Medtronic Model # 5076 (Serial # PJN8450680). This is a bipolar, steroid-tipped, active fixation lead. The P wave was 1.3 mV, the pacing impedance was 650 Ohms, and the atrial capture threshold was 1.3 V @ 0.5 ms. There was no diaphragmatic pacing at 10 V. The ICD pulse generator is a Medtronic Evera MRI DR. Model # DDMB1D4, Serial # PFZ622773S. This device is placed in the subcutaneous location. No defibrillation threshold testing was performed. The wound was closed with a running stitch of 3-O absorbable suture and the skin was closed with a running stitch of 4-O absorbable suture. Topical skin adhesive was placed over the incision. The patient tolerated the procedure well.
