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Getting a pacemaker? Watch an implant procedure!

so this is a pacemaker implant we begin

with a sterile prep of the skin we

surround that sterile preparation with

these sterile blue towels so we're

trying to create a very sterile working

environment then the patient gets

covered with this total body sterile

drape like you see here being unfolded

and this is all to minimize infection

the sterile IO ban then goes directly

over the skin and we'll be working

through the IO band patch so here's our

setup so I come into the case I do a

sterile sterile hand scrub I'll get a

sterile gown double glove minimize the

chance of infection here we go with the

double gloves and we are ready to work

so we approach our table the first thing

we'll do is a vena Graham so we're gonna

image the vein through which we're gonna

implant the pacing leads so there is the

vein the large vein flowing down into

the heart and we'll use the location of

that and the edge of the ribs to

actually plan our incision so the

pacemaker sits over the edge of the rib

so here actually identifying it under

the x-ray and using black markers to

show us exactly where our skin incision

should be we numb it up with lidocaine

so the patient is anesthetized won't

feel anything as we make our insertion

that's the lidocaine going into the skin

just under the superficial layer we

apply generous amount so there's no

chance of the patient having any

discomfort at all and there we are

making our incision as plans that the

final pacemaker will sit over the rib

margin which that other straight-line

identified then we extend the incision

down to the muscle this is with electric

cautery as you see here then from the

base of that insertion site through the

muscle we use a needle to gain access to

that large vein which we imaged and

there you see our needle coming in from

the right we're over the first rib we

get a little flash of blood black that

lets us know we're in the vein this is

kind of a delicate step the syringe

comes off and then through that needle

we're gonna pass a guide wire through

the insertion needle through the vein

down into the heart and this is the

tract over which will implant the leads

now it's exchanging that needle for a

series of sheath here's the first sheath

this is

micro puncture kits so the first sheath

is kind of small we remove that remove

the guide wire and then through that

first small sheath we implant the larger

guide wire which will support the sheet

that will use to implant the pacing

leads so there you see that larger guide

wire going in through the veins in down

to the heart out comes the outer sheath

so first of all we'll get the second

access site for the second is insertion

this is the second access site for the

second lead down to the bottom chamber

of the heart

there's our needle accessing the vein

passing the guide wires exactly as

before as we get that second insertion

site and here is the outer sheath the

larger sheath through which will implant

the pacing lead so that goes over the

guide wire into the vein and you can see

is advancing that here into the vein to

guide our lead there it is on the x-ray

image advancing into the vein and now

through that sheath we're advancing that

pacing lead also looks like a wire down

into the heart where we're where we will

position that and here we're shaping the

outers the inner stylet that goes

through the lead body this is gonna lift

the tip of the lead into the final

position we're trying to paste the heart

from the top of the heart if you will

from the conduction system we call it

the HISP undal we want to engage the

normal conduction system directly so

that the pacing of the heart is entirely

physiologic through the normal

conduction system so there we're

advancing that stylet through the lead

this lifts the lead tip as you see and

we're using that to be slowly withdrawn

to engage the conduction system and the

bottom blue line is us recording from

the heart we see that the conduction

system signals are there pacing confirms

that we can pace satisfactorily from

that location and having confirm the

good lead characteristics we extend the

set screw at the tip of the lead

securing it into the heart muscle that

inner stylet is there then carefully

withdrawn as we put just the right

amount of slack on the pacing lead

there's our device wraps helping us with

the lead characteristics as we work

through the case and there again those

beautiful conduction signals that we had

from the start of the procedure our

nurse attends to the patient takes care

of all of that person's needs

sure they're completely comfortable

there we are removing that outer sheath

it's a it's a breakable sheath that we

then peel away to take it off of the

lead and we'll remove that entirely from

the body we anchor the lead to the

muscle directly to the chest muscles

secure it firmly so it cannot move and

matures exactly in that spot so there we

are anchoring the lead to the muscle

with a non resorbable suture there's are

pacing lee beautifully moving with the

motion of the heart at the top of the

heart engaging the conduction system

directly and there we insert the same

sheet like before to advance the lead

for the top chamber and there you see

the second lead now in position in the

top chamber of the heart we record the

electrical signals from the top chamber

beautiful nice current of injury which

is what we look for the width of that

blue signal we can face satisfactorily

from that site and like before we extend

the set screw into the muscle with that

twisting motion the style that will then

be withdrawn we add adequate slack to

the lead remove that outer breakable

peel away sheath just like before take

it away from the body and like the

bottom lead we attach the top lead

firmly to the chest muscles so it cannot

move and we'll mature perfectly in that

sight so this is what we're doing here

it's a little bit tedious but we take it

very seriously so that lead system is

very secure and stable for the patient

here we are opening the pacemaker it's a

sterile device take off the outer cover

there's the pacemaker unit that's the

battery and the computer the leads are

gonna plug directly into that header we

flush out the tissue pocket that we

created with a sterile flush make sure

everything's nice and clean good

hemostasis no additional bleeding there

were implanting the leads into the

header of the pacemaker we use a set

screw again to secure those leads into

the header of the pacemaker so they

can't come out make sure they're secure

this particular patient wanted us to go

under the muscle with the pacemaker we

call that a sub muscular pocket so after

numbing it up we create a tissue plane

under the muscle fibers so the pacemaker

can sit actually below the top layer of

the chest muscle and there we are

creating that extra pocket the pacemaker

is now inside and we are

closing those chest muscle layers over

top of the pacemaker it is so it is

completely underneath the muscle

following this will close the skin we

typically use three layers to close the

skin a nice secure pocket great cosmetic

result

excellent structural integrity minimizes

the chance of infection and there we are

doing the final skin layer to make that

a very nice incision and that will

determine the final cosmetic reasons

salt and the minimum scarring so here we

are placing steri-strips over the

incision site that we have sutured shut

these are the final bandages we'll ask

the patient to keep those dry for the

next seven to ten days that we see them

in the device clinic and we will be the

ones to peel off those strip bandages

they add as much structural integrity as

the final layer of suture and there is

the final result through the IO band we

peel all of the dressings away put the

final dressing over top of our

steri-strips and this patient will be

ready to leave the procedure suite

typically we'll keep them one night

overnight device interrogation in the

morning chest x-ray in the morning then

home the same day and there's the final

position of our lead system moving

beautifully with the motion of the heart

top and bottom chambers his bundle

pacing beautiful pacemaker sitting over

the lateral rib margin will be

comfortable for the patient he will not

even know that it is there