Cardiology
Ablation and Cardioversion
PREOPERATIVE DIAGNOSES:
1. Recurrent sustained monomorphic VT requiring cardioversion,
rate 125 plus beats per minute in the absence of an antiarrhythmic medications.
2. Underlying IVCD, shortest duration 135 milliseconds.
Left bundle branch block.
3. Ejection fraction 22+% with congestive heart failure New York
Heart Association III.
4. Ongoing amiodarone therapy over the last few days.
POSTOPERATIVE DIAGNOSES:
1. Successful placement of a dual chamber biventricular
implantable cardioverter-defibrillator.
2. Catheter induced VT, unfortunately the rate is 90 beats per
minute.
1. Surgical placement of a left ventricular epicardial venous
pacing lead.
2. Coexistent surgical placement of an implantable cardioverter-
defibrillator.
3. Surgical placement of an atrial pacing lead.
4. Interrogation and reprogramming of a dual chamber
biventricular implantable fibrillator.
POSTOPERATIVE
RECOMMENDATIONS:
1. While she is in the hospital we are going to turn the VT
portion off for now until she gets better beta blocked so as not to crisscross
onto the VT range.
2. For now DDI 70 beats per minute.
SURGICAL
TECHNIQUE:
Local
anesthesia, appropriate Betadine scrub, conscious sedation.
An
incision was made along the left deltopectoral groove, cephalic vein cutdown.
Placement of two leads in the heart utilizing cephalic vein, specifically
bipolar dual coil active fixation leads at the RV apex and a unipolar epicardial
left ventricular venous lead via the coronary sinus to the anterior lateral
aspect of the left ventricle system.
Subsequently,
left subclavian vein puncture, and placement of a bipolar active fixation lead
to the right atrial appendage.
All
three leads were secured using grommet and three sutures (2-0 silk).
Consequently,
a left subpectoralis pocket created. Bleeding
controlled. Irrigated with
antibiotic solution. Device
attached, placed within the pocket, closed in three layers, muscle layer with 0
Vicryl suture followed by a similar suture followed staples.
PSA
analysis:
1.
Atrium P is 4 millivolts with a pacing threshold of 1.2 volts at 1.0
milliseconds, 1000 ohms.
2.
Right ventricular, 28 millivolts with a pacing threshold 0.9 volts at 1.0
milliseconds, 1700 ohms.
3.
Left ventricle, R 4 millivolts with a pacing threshold of 2.3 volts at
1.0 milliseconds, 785 ohms.
Lead/Device:
1.
Atrial lead, Medtronic Model 5076, serial number PJN4918B.
2.
Right ventricular defibrillator lead, model 6947.
Serial number TDG0173V.
3.
Left ventricular lead, Medtronic Model 4193, serial number VA493.
4.
Defibrillator, Medtronic Model 7277, serial number PK498.
Given
the potential tenuous nature of the left ventricular lead, specific
defibrillation testing not performed at this time.
However, the device was interrogated and reprogrammed.
Specifically, atrium 848, right ventricle 1482, left ventricular 689, R
recoil 39, SVC 52 ohms. Active at 150 beats per minute for now, however, the low rate
will be lower than 90 beats per minute relative to the VT which unfortunately
may require ablation in the future. Dual
chamber pacer for now DDI 70.
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