Pacemaker insertion, defibrillation threshold testing, other EP sample reports for MTs:
PROCEDURE PERFORMED: Left heart catheterization and left ventriculogram.
PROCEDURE IN DETAIL: The patient's left groin was prepped and draped in a sterile manner. Ten mL of 1% lidocaine was used to provide local anesthesia. Next, an 18-gauge needle was utilized to gain access to the left femoral artery. After access was obtained by single-puncture technique, a wire was threaded through a needle and the needle was removed over a wire. Next, a 7-French sheath was placed over the wire and into the left femoral artery. The wire was then removed. We then proceeded with placement of a 6 French JL catheter via the left femoral artery and did selective coronary angiogram of the left coronary system. The angiography did not reveal any coronary disease in either the left main, the left anterior descending or the left circumflex artery or their significant branches. The catheter was then removed over a wire and a 6 French Judkins right catheter was advanced over a wire and selective right coronary angiogram was performed. Again, no coronary artery disease was detected in the right coronary artery. The Judkins right catheter was then advanced into the left ventricular cavity for measurement of the left ventricular end-diastolic pressure. The left ventricular end-diastolic pressure was 12. A left ventriculogram was done via hand injection and no regional wall motion abnormalities were seen, although opacification of the left ventricular cavity was less than ideal. The Judkins right catheter was then removed and the sheath was left in place and sutured in place. The patient tolerated the procedure well.
1. Right heart catheterization.
2. Left heart catheterization.
3. Selective coronary angiography.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old woman with a history of ischemic cardiomyopathy, who presents with anginal equivalent of feeling fatigued and not well. The patient stated that previously when she felt these symptoms, she had a stenosis of her OM that was stented and her symptoms were relieved.
DESCRIPTION OF PROCEDURE: The patient was brought to the cardiac cath lab in a postabsorptive state. Informed consent was obtained. The right groin was prepped and draped in the normal sterile fashion and lidocaine 2% was used to anesthetize the area. The right femoral vein was accessed via Seldinger technique and a 7-French introducer sheath was placed into the vein over a wire. Next, the right femoral artery was accessed via Seldinger technique and a 4-French introducer sheath was placed into the artery over a wire. Then, a Swan-Ganz catheter was floated sequentially through the venous sheath into the RA, then RV and then PA, where hemodynamic tracings were obtained. The cardiac outputs were also obtained. Then, the Swan-Ganz catheter was removed from the vein. Next, the left heart catheterization was performed. A pigtail catheter was advanced over a wire into the left ventricle, where left ventricular pressures were obtained and then a left ventriculogram was performed with 24 mL of contrast given over 3 seconds. The pigtail catheter was then pulled back from the LV to the aortic root, where a gradient was obtained. Then, the pigtail catheter was removed. A 3DRC catheter was then advanced over a wire to the right coronary artery where the right system was imaged in multiple views. Lastly, a JL4 catheter was advanced over a wire where the left system was imaged in multiple views. The angiographic images were reviewed in the cath lab. A decision was made to continue medical management, so both sheaths were removed in the cath lab. The patient went to CVR for recovery.
RIGHT HEART CATHETERIZATION FINDINGS:
RA of 14 mmHg. RV 37/13. PA 42/25, mean of 30. Pulmonary capillary wedge pressure 19. Cardiac output 5.8, cardiac index 2.4. PVR 96. RA saturation 72%, hemoglobin 12.3. PA saturation 70% with hemoglobin of 12.7.
LEFT HEART CATHETERIZATION FINDINGS:
1. Left main coronary arteries are free of significant disease, gives rise to the LAD and circumflex.
2. The LAD has two fairly large but short septal branches, multiple branches from here that are free of significant disease. Then, the LAD continues with a mid 30% stenosis, gives rise to a large diagonal branch that is free of significant disease and the remainder of the LAD continues to the apex.
3. Circumflex gives rise to one large OM branch that bifurcates. This OM has a previously placed stent, which is patent. The superior bifurcating branch is subtotally occluded and the remainder of this OM continues without significant disease. The circumflex then gives rise to another OM which is free of significant disease and the remainder of the circumflex system is free of significant disease.
4. Right coronary artery. This vessel has some luminal irregularities throughout. Then, it gives rise to the PDA and PL branches. The PL branch has an 80% stenosis, which was noted on previous angiogram with a fairly small caliber vessel and is minimally changed from previous. PDA continues without significant disease.
5. The LVEDP is 20. No gradient on pullback from the LV to the aortic root.
6. The LVEF is 55% with moderate apical hypokinesis.
1. Mildly elevated filling pressures.
2. Mild coronary disease of the LAD with stenosis of the PL branch, which is a small caliber artery.
3. Normal LVEF.
The patient is to continue with current aggressive medical management as per the heart failure clinic.
PROCEDURE PERFORMED: Cardiac catheterization.
INDICATIONS: Unstable angina.
DESCRIPTION OF PROCEDURE: The patient was taken into the cardiac cath lab, prepped and draped in the usual sterile fashion, sedated with Versed and fentanyl. The right groin was infiltrated with 2% lidocaine and a 5 French sheath placed in the right common femoral artery. A Judkins left 4, 3DRC and pigtail catheter were used for the diagnostic portion of the procedure.
1. The right coronary artery is a dominant vessel and gives off posterior descending and posterolateral branches. There is a widely patent stent in the midportion at the bifurcation of the PDA. The vessel tapers to 1.5 mm or so and then there is mild diffuse disease in the distal circulation. Half way down the posterior descending, there is approximately a 50% stenosis but this is in the area where the vessel is approximately 1 mm to 1.5 mm in caliber. Of note, there is an RV marginal branch coming high off of the right coronary, which has a proximal 90% stenosis. This is approximately a 2 mm vessel.
2. The left main is free of disease. It bifurcates as a nondominant circumflex and the LAD.
3. The circumflex is nondominant. It gives off marginal posterolateral branches and has mild luminal irregularities throughout its course.
4. The LAD goes to the apex and bifurcates. It gives off a couple of diagonals. There are two widely patent stents in the proximal portion of the LAD. However, between the stents, there is a 50% stenosis and mild luminal irregularities throughout the rest of the LAD system.
5. Left ventricular end-diastolic pressure prior to dye injection is 15 mmHg, ejection fraction is 55% with no segmental wall motion abnormality. No gradient across the aortic valve and no mitral regurgitation.
6. Injection of the right groin revealed the sheath to be in the common femoral artery.
IMPRESSION: Mild to moderate coronary disease as described above with an overall normal ejection fraction.
PROCEDURE PERFORMED: Catheter ablation of the AV node slow pathway.
PROCEDURE IN DETAIL: Catheter ablation procedure was performed immediately following diagnostic comprehensive electrophysiologic study. The high right atrial catheter was removed from the short 8 French sheath in the right femoral vein and the short 8 French sheath in the right femoral vein was removed over a long J-tipped guidewire. This sheath was replaced with an 8 French SRO sheath, which was inserted with a dilator over the J-tipped guidewire. After removal of the guidewire and dilator, the side arm to the SRO sheath was aspirated and flushed with sterile saline. A mapping and ablation catheter was inserted through the SRO sheath and positioned at the atrioventricular junction to record His bundle potentials. The tip of the catheter was then deflected downward in an area anterior to the coronary sinus ostium. Mapping was performed in this area in attempts to identify discrete slow pathway potentials accompanying a low amplitude atrial electrogram and a large amplitude ventricular electrogram. Three sites were selected for radiofrequency energy application. Each of the first two applications were delivered for 20 seconds averaging 44 watts power and 48-50 degrees centigrade temperature. Cardiac rhythm remained sinus through each of these applications prompting termination of the energy application. The second application was delivered slightly cephalad of the initial application. The third application was delivered at a site slightly above the first two applications. Junctional rhythm was observed 11 seconds after RF energy onset and was intermittent throughout the application. Average power during the application was 47 watts. Maximum power was 52 watts recorded 19 seconds after RF energy onset. The application was delivered for 61 seconds. Average temperature was 50 degrees centigrade with a maximum of 56 degrees centigrade recorded 14 seconds after RF energy onset. Average impedance was 98 ohms with a maximum of 110 ohms recorded 2 seconds after RF energy onset. The RF energy applications were delivered during a continuous isoproterenol infusion as retrograde conduction was poor prior to the administration of isoproterenol. Programmed stimulation was performed in the initial 30 minutes after the final RF energy application. AV node reentry tachycardia was no longer inducible. The isoproterenol infusion was discontinued and programmed stimulation was performed at a baseline state. Dual AV node pathway physiology was persistent and a single AV node reentry atrial echo beat was documented. Measured parameters showed no significant change in the PR interval, QRS, or QT interval. AH interval was 112 milliseconds, HV interval 45 milliseconds. The AV node block cycle length was 390 milliseconds. The ventriculoatrial block cycle length was 550 milliseconds. At the completion of the procedure, catheters and sheaths were removed from their femoral venous insertion sites and pressure was applied at the sites to obtain hemostasis. The patient was transferred to the recovery area in stable condition.
PROCEDURE PERFORMED: Insertion of ventricular pacemaker and transvenous lead.
PROCEDURE IN DETAIL: The operative procedure was performed in the cardiac electrophysiology laboratory. The left upper chest was prepped in the usual fashion. Sterile drapes were placed. Local anesthetic was injected subcutaneously. A diagonal incision medial and parallel to the deltopectoral groove was utilized. Electrocautery dissection was carried out through subcutaneous fatty tissues to the prepectoral fascia. The deltopectoral groove was explored. The cephalic vein was localized and ligated distally using 2-0 silk, and 2-0 silk was looped about the cephalic vein proximally. Following cephalic venotomy, a ventricular transvenous lead was inserted and advanced under fluoroscopic imaging to the right atrium. Using a curved stylet, the lead was advanced across the tricuspid valve to the right ventricular outflow tract. Using a second curved stylet, the lead was positioned on the mid right ventricular septum. Cardiac asystole was observed likely due to mechanical trauma to the right bundle branch. The lead was fixed in this location and lead stability appeared good. After removal of the stylet, pacing and sensing threshold parameters were acceptable. Sensing was evaluated following resumption of AV conduction. Pacing at 10 volt output amplitude did not cause diaphragmatic stimulation. The 2-0 silk suture looped about the cephalic vein proximal to the venotomy site was tied snuggly to control backbleeding and the ventricular lead was fixed using the 2-0 silk tie, ligating the cephalic vein distally on the proximal end of the lead suture sleeve. The mid and distal aspect of the suture sleeve were fixed to deep fascia using 2-0 Ethibond. The pulse generator pocket was formed superficial to prepectoral fascia using both blunt and electrocautery dissection. The lead was connected to the pacemaker pulse generator and the pulse generator was placed in the pocket. The pocket was closed using interrupted 3-0 Vicryl. Deep fascia and subcutaneous tissues were closed using running 3-0 Vicryl in two layers. Steri-Strips were applied to the skin edges and a sterile dressing with Tegaderm was placed. The patient tolerated the procedure well and was transferred to the recovery area in stable condition.
PROCEDURE PERFORMED: Insertion of dual chamber atrioventricular sequential pacemaker with atrial and ventricular transvenous leads
PROCEDURE IN DETAIL: The operative procedure was performed in the cardiac electrophysiology laboratory. The left upper chest was prepped in the usual fashion. Sterile drapes were placed. Local anesthetic was injected subcutaneously. A diagonal incision medial and parallel to the deltopectoral groove was utilized. Electrocautery dissection was carried out through subcutaneous fatty tissues to the prepectoral fascia. The deltopectoral groove was explored, but the cephalic vein suitable for cannulation was not found. The pulse generator pocket was formed superficial to the prepectoral fascia using both blunt and electrocautery dissection. The left axillary vein was localized using an ultrasound-guided needle apparatus and the left axillary vein was punctured with ultrasound guidance using a thin-walled needle. A flexible guidewire was inserted. Thin-walled needle was removed. The second axillary vein puncture was performed in a similar manner with ultrasound guidance using a thin-walled needle. A flexible guidewire was inserted. Thin-walled needle was removed. Using the more distal of the two guidewires, a 7-French dilator and sheath was inserted over the guidewire. The guidewire and dilator were removed, and a ventricular transvenous lead was inserted through the sheath and advanced under fluoroscopic imaging to the right atrium. The sheath was removed and torn away. Using a curved stylet, the lead was advanced across the tricuspid valve. Care was taken in the right ventricular outflow tract. A second curved stylet was inserted, and during positioning of the lead in the proximal septal area, complete heart block was observed with multiple nonconducted P-waves. Pacing was initiated through the ventricular lead prior to lead fixation. The patient was monitored for several minutes, but heart block was persistent with no spontaneous ventricular escape mechanism. The remaining 7-French dilator and sheath were inserted over the guidewire. The guidewire and dilator removed and an atrial lead was inserted through the sheath and advanced under fluoroscopic imaging to the right atrium. The sheath was removed and torn away. Using a curved stylet, this atrial lead was advanced across the tricuspid valve to the right ventricular apical area. The lead was fixed at this location to provide temporary pacing support during positioning of the right ventricular lead. Once the lead was fixed, temporary pacing was continued at the rate of 70 beats per minute. The ventricular lead was then positioned slightly distal to the atrial lead position and the ventricle on the septal apex and the lead was fixed using a screw-in mechanism. Lead stability appeared good after removal of the stylet. Pacing characteristics were acceptable in terms of threshold. No spontaneous R waves occurred for evaluation of sensing function. Temporary pacing was then provided via the ventricular lead, which was fixed to deep fascia using 2-0 Ethibond on the proximal and distal ends of the lead suture sleeve. The screw for the atrial lead was retracted and the lead was withdrawn across the tricuspid valve. This lead was positioned in the right atrial appendage at a site showing excellent P-wave amplitudes. The lead was fixed using a screw-in mechanism. Lead stability appeared good following removal of the stylet. Pacing and sensing threshold parameters were acceptable. Pacing at 10 volt output amplitude did not cause diaphragmatic stimulation in either the atrium or the ventricle. The atrial lead was fixed to deep fascia using 2-0 Ethibond on the proximal and distal ends of lead suture sleeve. Atrial and ventricular leads were then connected to the pacemaker pulse generator and the pulse generator was placed in the pocket. The pocket was closed using interrupted 3-0 Vicryl. Deep fascia and subcutaneous tissues were closed using running 3-0 Vicryl in two layers. Steri-Strips were applied to the skin edges. A sterile dressing with Tegaderm was placed. The patient tolerated the procedure well and was transferred to the recovery area in stable condition.
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