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REFERRAL INDICATION
1. Tachybrady syndrome.
2. Chronic atrial fibrillation.

PROCEDURES PLANNED AND PERFORMED
1. Implantation of a single-chamber pacemaker.
2. Fluoroscopic guidance for implantation of single-chamber pacemaker.

FLUOROSCOPY TIME: 1.2 minutes.

MEDICATIONS AT THE TIME OF STUDY
1. Ancef 1 g.
2. Benadryl 50 mg.
3. Versed 3 mg.
4. Fentanyl 150 mcg.

CLINICAL HISTORY: The patient is a pleasant 73-year-old female with chronic atrial fibrillation. She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.

RISKS AND BENEFITS: Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent. Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.

DESCRIPTION OF PROCEDURE: The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left deltopectoral groove was prepped and draped in the usual sterile manner. Lidocaine 1% (20 mL) was administered to the area. Percutaneous access of the left axillary vein was then performed. A wire was then advanced in the left axillary vein using fluoroscopy. Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein. The dilator and wire were removed. An active pacing lead was then advanced down in the right atrium. The peel-away sheath was removed. Lead was passed across the tricuspid valve and positioned in an apical septal location. This was an active fixed lead and the screw was deployed. Adequate pacing and sensing function were established. The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue. The pocket was washed with antibiotic-impregnated saline. A pulse generator was obtained and connected securely to the lead. The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch. No acute complications were noted.

DEVICE DATA
1. Pulse generator, manufacturer St. Jude model 12345, serial #123456.
2. Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.

MEASURED INTRAOPERATIVE DATA: Right ventricular lead impedance 630 ohms. R wave measures 17.5 mV. Pacing threshold of 0.8 V at 0.5 msec.

DEVICE SETTINGS: VVI 70 to 120.

CONCLUSIONS
1. Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.
2. No acute complications.

PLAN
1. The patient will be admitted for overnight observation and dismissed at the discretion of primary service.
2. Chest x-ray to rule out pneumothorax and verify lead position.
3. Completion of course of antibiotics.
4. Device interrogation in the morning.
5. Home dismissal instructions provided in a written format.
6. Wound check in 7 to 10 days.
7. Enrollment in Device Clinic.

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