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Procedure Note for EP Procedure (Implant Procedure follows)
Op Date:
Primary Operator:
«PHYSICIAN1»
Assisting Operator:
«PHYSICIAN2»
Referring Cardiologist:
«REFERRING»
Primary Care Physician:
«PRIMARY_CARE_PHYS»
Procedures Performed:
Electrophysiology Study (Chronic Atrial Fibrillation)
«PROCDATE»
His Bundle Recording
Right Ventricular Recording
Induction of Arrhythmia with Pacing
Isoproterenol Infusion
93600
93603
93618
93623
Preprocedural
Diagnoses:
1.
2.
3.
4.
5.
6.
7.
8.
Syncope
Paroxysmal Ventricular Tachycardia
Unspecified Paroxysmal Tachycardia
Ischemic Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Primary Dilated Cardiomyopathy
Secondary Dilated Cardiomyopathy
Atrial Fibrillation
780.2
427.1
427.2
414.8
425.1
425.4
425.9
427.31
Postprocedural
Diagnoses:
1.
2.
3.
Inducible Ventricular Tachycardia
Inducible Ventricular Fibrillation
Atrial Fibrillation
427.1
427.41
427.31
INDICATION FOR PROCEDURE: Unexplained Syncope / SCD Risk Assessment
HISTORY: The patient is a «AGE» year old «SEX» that presents with recurrent syncope. There is a history
of prior myocardial infarction and an ischemic cardiomyopathy with an estimated left ventricular ejection
fraction of 40% by most recent echocardiography (xx/xx/20xx). Baseline electrocardiogram shows a left
bundle branch block pattern with a QRS duration of 150 msec. The history does not suggest a vasovagal
mechanism. Holter and event monitoring have not revealed a cause for syncope. Tilt table testing was
without syncopal response. Medications, electrolytes and metabolic factors do not adequately explain his
syncopal episodes. The patient is being referred to the electrophysiology laboratory for electrophysiology
study to evaluate the etiology of syncope. The patient presents to the laboratory with persistent atrial
fibrillation. Coumadin has been stopped because of the possibility of device implantation. A transesophageal
echocardiogram has been performed just prior to the procedure and a preexisting intracardiac thrombus has
been excluded.
DESCRIPTION OF PROCEDURE: The patient gave informed, written and witnessed consent after the
procedure and sedation were explained in full including indications, benefits, risks and alternatives. All
questions were satisfactorily addressed. The patient was transported to the Cardiac Electrophysiology
Laboratory in a fasting, unsedated state. Moderate sedation was administered according to protocol using
intravenous midazolam and fentanyl. The catheter insertion sites were prepared and draped in the usual
sterile fashion. Local anesthesia was achieved with a combination of subcutaneous 2% lidocaine and 2%
bupivicaine. Hemostatic sheaths were placed percutaneously into the vasculature using the modified
Seldinger technique. Diagnostic electrode catheters were positioned using fluroscopic guidance as follows:
Insertion Site
Right Femoral Vein
Right Femoral Vein
Sheath
6F
6F
Catheter
6F CRD-2
6F CRD
Electrodes
4
4
Endocardial Position
His Bundle
RVA/RVOT
12-lead surface ECG and intracardiac electrograms from the above positions were displayed in real time and
recorded. After baseline recordings were obtained including His-Purkinje system conduction time, ventricular
function was evaluated by programmed extrastimulation from the right ventricule. In order to facilitate
arrhythmia induction, programmed pacing was repeated during intravenous isoproterenol infusion. At the end
of the procedure, all catheters and sheaths were removed, and hemostasis of vascular sites was achieved
with manual compression and sterile dressings were applied. The patient was transported to a monitored
holding area in stable condition. Dr. Richard Hongo performed the electrophysiologic study, was present and
personally involved in programmed stimulation, and was immediately available at all times during the
procedure.
FLUOROSCOPY TOTAL: 3.2 min (7 frames/sec)
ESTIMATE BLOOD LOSS: <20 ml
COMPLICATONS: None
FINDINGS:
Baseline Data (msec, [normal range])
Rhythm
Atrial Fibrillation
RR
PR
N/A
[120-200] (>300 = Class IIb)
QRS
[80-120]
QT
[390-440]
His-Purkinje System Function (msec, [normal])
HV
[35-55] (>100 = Class IIa PPM Indication)
Ventricular Function (msec, V1/V2/V3/V4)
(Isuprel)
600/250
400/240
< 400/200
TI
600/250/210
400/240/200
< 400/200/200
TI
600/250/210/200
400/240/200/200
600/250
400/240
TI
600/250/200
400/240/200
TI
600/250/210/200
400/240/210/200
VERP (RVA)
VERP (RVOT)
VT
400/220/200/200*
Sustained monomorphic ventricular tachycardia (TCL 280) was induced with
programmed stimulation (*) and was terminated with ventricular burst pacing.
CONCLUSIONS:
1. Chronic atrial fibrillation
2. Abnormal His-Purkinje conduction, moderately prolonged HV
3. Inducible sustained monomorphic ventricular tachycardia, successful pace
termination
PLAN:
1. Observe at bedrest with right leg straight for 4 hours
2. Recommend / Proceed with implantation of a single-chamber implantable
cardioverter defibrillator
3. Follow-up with Dr. Hongo in the next few weeks to discuss the results of the study
Physician Signature: ______________________________________
Date: ________________
Procedure Note for Implant Procedure
Primary Operator:
«PHYSICIAN1»
Assisting Operator:
«PHYSICIAN2»
Referring Cardiologist:
«REFERRING»
Primary Care Physician:
«PRIMARY_CARE_PHYS»
Procedures Performed:
Insertion of a Dual-Chamber ICD
Op Date:
«PROCDATE»
Cardioverter-Defibrillator System Insertion
Defibrillation Threshold Testing (post EPS)
Fluoroscopy with Interpretation
Venography, Interpretation
Arterial Line Monitoring
33249
93641(-59)
71090-26
36005, 75820
36620
Preprocedural
Diagnoses:
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Congestive Heart Failure
Ventricular Tachycardia
Ischemic Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Primary Dilated Cardiomyopathy
Secondary Dilated Cardiomyopathy
Ventricular Fibrillation
Ventricular Flutter
Cardiac Arrest
Syncope
Sinus Node Dysfunction
Symptomatic Bradycardia
Atrioventricular Block, Unspecified
428.0
427.1
414.8
425.1
425.4
425.9
427.41
427.42
427.5
780.2
427.81
427.89
426.10
Postprocedural
Diagnoses:
1.
2.
Congestive Heart Failure
428.0
INDICATION FOR PROCEDURE: Primary / Secondary Prevention of Sudden Cardiac Death
HISTORY: The patient is a «AGE» year old «SEX» with severe ischemic / nonischemic dilated
cardiomyopathy with a left ventricular ejection fraction  35% and New York Heart Association functional class
II congestive heart failure. The patient has had a documented myocardial infarction more than 40 days prior to
today, and is more than 90 days from last revascularization. The nonischemic dilated cardimyopathy has
been documented to be present for more than 9 months. Sustained ventricular arrhythmia was induced during
electrophysiology study. The patient has presented to the cardiac electrophysiology laboratory for insertion of
an implantable cardioverter-defibrillator. The patient has had symptomatic bradycardia, exacerbated by
betablocker therapy that is needed for treatment of congestive heart failure.
DESCRIPTION OF PROCEDURE: The patient gave informed, written and witnessed consent after the
procedure and sedation was explained in full including indications, benefits, risks and alternatives. All
questions were satisfactorily addressed. The patient was transported to the cardiac electrophysiology
laboratory in a fasting, unsedated state. Moderate sedation was administered according to protocol using
intravenous midazolam and fentanyl. An arterial line was placed in the right femoral artery using a modified
Seldinger technique for continuous blood pressure monitoring. The left upper chest was prepared and draped
in the usual sterile fashion. Local anesthesia was achieved over the anticipated incision site with a
combination of 2% lidocaine and 2% bupivicaine subcutaneously. Cephazolin / Vancomycin 1 gm was
administered intravenously prior to skin incision. A 3-5 cm incision was made just medial and parallel to the
deltopectoral groove using a #15 blade. Using blunt dissection and electrocautery, the incision was extended
to the deep subcutaneous tissue, and a pocket the size of the anticipated device was created just above the
pectoralis fascial layer. Bleeding was controlled with electrocautery and with 2-0 Silk ties as needed. A left
upper extremity venogram was performed using 20-cc of contrast agent. The left axillary and subclavian veins
were widely patent. Using the modified Seldinger approach with micropuncture technique, two J-tipped 0.036”
guidewires were advanced to the right atrium from the left axillary vein. Puncture of the axillary vein was
achieved with guidance from venogram and fluoroscopy. Definitive access of the venous system was
confirmed by advancing the guidewire into the inferior vena cava. An introducer sheath was advanced over
one guidewire, and an active fixation sensing/pacing/defibrillation lead was advanced under fluoroscopic
guidance to the right ventricular apex using curved and straight stylets. Initial positioning of the lead into the
pulmonary artery confirmed eventual placement of the lead in the right ventricle. Appropriate sensing and
capture thresholds were obtained after successful deployment of the distal screw. The introducer sheath was
removed by split sheath technique. A second introducer was advanced over the second guidewire and an
active fixation sensing/pacing lead was advanced under fluoroscopic guidance to the right atrial appendage
using J-curve stylets. Appropriate sensing and capture thresholds were obtained after successful deployment
of the distal screw. The second introducer sheath was removed by split sheath technique. There was no
diaphragmatic or phrenic nerve capture with either lead with a maximum output of 10 volts. The proximal end
of each lead was secured to the underlying fascial layer using two interrupted mattress stitches of 0 Silk over a
lead sleeve. Appropriate lead function was once again confirmed.
Final Transvenous Lead Characteristics:
Lead Position
Right Atrium
Sensing Amplitude (mV)
2.7
746
Impedance ()
Pacing Threshold (V) @ 0.5 ms
0.8
Right Ventricle
12.0
699
0.8
The leads were then connected to the implantable pulse generator and were tested for high voltage lead
impedance. Defibrillation threshold was tested and was found to be appropriate.
Defibrillation Threshold (DFT) Testing:
Trial #
1
Shock Configuration
SVC/ICD  RV
Sensing Threshold (mV)
Least
Induction Method
T-Shock
Rhythm
VF
Cycle Length (ms)
180
Drop Out
2, No Delay
Therapy 1 (ICD, J)
26
Therapy 2 (ICD, J)
31
Therapy 3 (External Biphasic, J)
200
DFT (J)
 26
38
Shock Impedance ()
2
SVC/ICD  RV
Nominal
T-Shock
VF
190
None
31
200
 31
39
The subcutaneous pocket was generously irrigated with a Bacitracin/Neomycin solution. Bleeding was
controlled with electrocautery and with 2-0 Silk ties as needed and ultimately a dry field was observed. The
generator was secured to the fascial layer with a loose mattress stitch using 0 Silk. The fascial and
subcutaneous layers were closed with running stitches of 2-0 and 3-0 Vicryl, respectively. The skin was closed
with a subcuticular stitch of 4-0 Vicryl. The arterial line was removed and hemostasis obtained with manual
pressure. The patient was transported to a monitored holding area in stable condition. Dr. Richard Hongo
performed the implantable cardioverter defibrillator generator insertion, the defibrillation threshold testing,
arterial line insertion, venography with interpretation, fluoroscopy with interpretation, and was immediately
available at all times during the procedure.
CONTRAST AGENT TOTAL: 20 cc (Visipaque)
FLUOROSCOPY TOTAL: 3.4 min (7 frames/sec)
ESTIMATE BLOOD LOSS: <20 ml
COMPLICATONS: None
IMPLANTED MATERIALS:
Device
RA Lead
RV Lead
Manufacturer
GDT
GDT
GDT
Model
VITALITY 2 DR,
FINELINE II EZ 4469
ENDOTAK RELIANCE G 0185
Serial Number
FINAL DEVICE PROGRAMMING:
Ventricular Fibrillation Zone
Detection
200 bpm
Therapy
Defib 41 J (x6)
Ventricular Tachycardia Zone
Detection
171 bpm
Therapy
ATP  CV 31 J  CV 41 J (x3)
Bradycardia Parameters
Mode
DDD
AMS
On
LRL
60
URL
120
AVI/PVI
300/350
RA Output
3.5 V @ 0.4 ms
RV Output
3.5 V @ 0.4 ms
RA Sens
Nominal
RV Sens
Nominal
CONCLUSIONS:
4. Successful insertion of a left-sided dual-chamber implantable cardioverter
defibrillator system
5. Good sensing and pacing thresholds
6. Induction of ventricular fibrillation with appropriate sensing and demonstration of a
defibrillation threshold (DFT)  26 Joules
7. Tachyarrhythmia therapy is active and programmed to detect ventricular fibrillation at
a rate > 200 bpm, and ventricular tachycardia at a rate > 171 bpm
8. Bradycardia parameters are programmed to DDD mode with a long PV and AV
Delay programmed in order to avoid unnecessary RV pacing
9. Widely patent left axillary and subclavian veins
PLAN:
4.
5.
6.
7.
8.
9.
10.
Observe on telemetry unit, pressure dressing overnight
PA and lateral CXR in am to document lead position
Keep wound dry for 3 days
Keep left arm low for 3 weeks, use arm sling as needed
Antibiotics for 5 days
Wound check in 1 week
Device check in 1 month