Implantation of Biventricular Pacemaker

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  • NYHA Class II-IV heart failure: Ejection fraction (EF) ≤35%, ischemic or nonischemic cardiomyopathy, left bundle branch block (LBBB) with QRS ≥120 msec (preferably ≥150msec) or frequent ventricular pacing (>40%)
  • NYHA Class III/IV heart failure: Ejection fraction (EF) ≤35%, ischemic or nonischemic cardiomyopathy, non-LBBB with QRS ≥120 msec (preferably ≥150msec)
  • NYHA Class I heart failure: EF ≤30%, ischemic cardiomyopathy, left bundle branch block (LBBB) and QRS ≥150 msec, preferably in normal sinus rhythm
  • NYHA Class II heart failure: EF ≤35%, non-LBBB and QRS ≥150 msec, preferably in normal sinus rhythm
  • NYHA Class I/II: non-LBBB and QRS <150 msec.
  • Infection at time of procedure
    • Suspected
    • Confirmed
  • Risk of bleeding from elevated serum prothrombin time, partial thromboplastin time, or thrombocytopenia
  • During acute heart failure decompensation, hemodynamic instability, or acute myocardial infarction
  • If functional status and life expectancy are limited by noncardiac conditions
  • Sterile mask, gown, gloves, and full sheet **Universal Precautions** **Sterile technique**
  • Antibiotics
    • IV
    • Irrigation
  • Surgical instrument tray
  • Surgical drapes
  • Surgical topical antiseptic solution
  • Marking pen
  • Electrocautery machine
  • Pacing cables and pacing system analyzer for testing the lead(s)
  • Suture
    • Deep layer
    • Subcutaneous
  • Dressing
    • Nonadhesive dressing
    • Skin adhesive
    • Adhesive strips
  • ECG monitor and external defibrillator
  • Anesthesia equipment adequate to support conscious sedation
  • Local anesthetic
    • Lidocaine
    • Bupivacaine
  • Introducer sheath kit for each lead
  • Coronary sinus access sheaths, including inner guiding sheaths
  • Balloon-tipped catheter and iodinated contrast
  • Guidewires of various sizes and firmness
  • Right ventricular lead
  • Right atrial lead
  • Coronary sinus lead
  • Pulse generator
  • Device programmer and/or pacing system analyzer with ability to perform lead interrogation
  • The position, location, and orientation of the existing surgical scar and its relationship with anatomic landmarks including the suprasternal notch, clavicle, and deltopectoral groove is assessed.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Monitor recovery from conscious sedation or anesthesia
    • Respiratory status
    • Blood pressure
    • Cardiac rhythm
  • Monitor for development of hematoma.
  • Monitor for adequate pain control.
  • Obtain chest X-ray to confirm lead position and rule out pneumothorax.
  • Many operators have the patient wear a sling on the ipsilateral arm overnight.
  • Pneumothorax or hemothorax during vascular access
  • Lead dislodgement
  • Lead perforation and cardiac tamponade
  • Hemodynamic instability or respiratory depression from sedation
  • Bleeding or pocket hematoma
  • Device infection or cellulitis
  • Tricuspid valve damage
  • Ventricular tachycardia or fibrillation requiring external shock
  • Pocket pain
  • Acute heart failure decompensation
  • Death
  • Chest X-ray should show stable lead positions. The coronary sinus lead should be in a basal or mid cavity position, preferably in the lateral or posterolateral wall.
  • Ideally, the right atrial lead should have P waves >1.5 mV and threshold <1 V at 0.5 msec. The right ventricular lead should have R waves of >5-7 mV and threshold <1 V at 0.5 msec. The left ventricular lead has R wave values that are not relevant and threshold should be <1.5 V at 0.5 msec.
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