Question

This is a case of a 90-year-old male who presented to the emergency room with swelling in the hands and legs. He has had intermittent problems with swelling on and off. He presented to the emergency room, underwent evaluation with an EKG, which showed third-degree heart block and thus the patient was admitted to the cardiac surgical unit of the hospital with external pacemaker backup ordered. Upon admission, his heart rate was in the 30s. He does have a history of bradycardia in the past, but really never had any problems being symptomatic to that. The patient denies any chest pain, palpitations or orthopnea. During admission, he was also given medications for his hypertension and gastroesophageal reflux disease. The patient was then seen in the cardiac unit by Dr. S who recommended that he undergo pacemaker placement secondary to third-degree heart block. The patient agreed to the planned surgery.

Preoperative diagnosis: symptomatic heart block

Postoperative diagnosis: same

Procedure: permanent dual chamber pacemaker implantation

Following informed consent, the patient was brought to the operating room and was prepped and draped in the usual manner. Following local anesthesia, a venogram was obtained. The left subclavian system was noted to be tortuous but patent. Access to the left subclavian vein was obtained. On two occasions, two guidewires were passed via the left subclavian vein into the inferior vena cava. Using a #10 blade, an incision was made in the left infraclavicular region. Using blunt and bovie dissection, a subcutaneous pocket was made. Using a french-8 introducer, the first pacemaker lead was introduced via the left subclavian vein and guided into the right ventricular apex. Another lead was introduced via the subclavian and was threaded into the right atrial wall. Both leads were secured to the pectoral muscle using #0 ethibond sutures in the collar. Leads were then attached to the pacemaker. Normal placing was noted and the device was placed in the pocket. The pocket was irrigated with gentamicin solution and the operative site was closed appropriately with hemostasis.

Final diagnosis:

• Congestive heart failure

• Third-degree heart block

• Hypertension

• GERD

I am having trouble figuring out what the three procedures that where done.

Answer 1

1. EKG (Electrokardiogram) It is used to assess the rate, rhythm and electrical activity of heart.
2. External pacemaker (patient is diagnosed as third degree heart block in which nerve impulse in SA node not propagate to ventricle.It is a life threatening condition.
3. Permanent dual chamber pacemaker implantation is the intervention for third degree heart block.