kokomax
New
The provider is upgrading from a single chamber ICD to a biventricular ICD with addition of an atiral lead, coronary sinus pacing and placement of new multi-lead ICD pulse generator... After positioning the patient and prepping and draping a sterile field, the region of the existing device in the left deltopectoral groove was liberally infiltrated with a local anesthetic agent. Radiocontrast dye was injected into a peripheral vein in order to determine the location and patency of the axillary/subclavian vein. Following this, a 5 cm long transverse incision was made through the skin and subcutaneous tissue, over the are of the existing pulse generator. The pocket was opened and device freed from the surrounding tissue and removed from the pocket. Hemostasis was readily achieved with electrocautery. The axillary vein was punctured and cannulated using the modified Seldinger technique, leaving a guidewire in place. Venous access was similarly obtained for the second lead. A peel-away sheath was inserted over one guidewire and a coronary sinus guiding sheath was maneuvered into the CS using an AL2 catheter for placement of a left ventricular epicardial venous pacing lead. A CS angiogram was performed and a vein branch selected for lead placement. A thin guide wire was advanced down this branch and the pacing lead advanced over the wire. Satisfactory pacing thresholds and R waves were obtained as below without diaphragmatic stimulation. The CS sheath was peeled and this lead was secured in place at its entry to the vein. Then, the atrial lead was advanced through a peel-away sheath and positioned in the right atrial appendage and screwed in place under fluoroscopic guidance. Satisfactory pacing thresholds and P waves were likewise obtained, as shown below. This lead was then secured in place at its entry to the vein. High-volt pacing was used temporarily and assessment made for diaphragmatic stimulation; there was none. The previously-formed pocket was irrigated with antibiotic solution as was the rest of the incision. After this, the existing RV ICD lead was disconnected from the old pulse generator and connected securely, along with the newly implanted CS and atrial leads to the pulse generator. The leads were wrapped carefully behind the generator, and the generator placed in the pocket. Wireless interrogation was carried out, ensuring normal sensing and pacing function of the entire system. Hemostasis was assured one last time and the pocket closed. The pectoral fascia was closed with 2-0 Vicryl using interrupted sutures. The subcutaneous layer was closed with 3-0 Vicryl using running stitches. Steri-Strips were used for skin closure. A sterile dressing was then applied. Sponge and needle counts were correct at the end.
