Stimarec returned pacing lead information sheet
European pacing follow-up network
Last modified: 19/09/07
Print this form, fill it and send it to Prof. Luc DE ROY , Université de Louvain, Cliniques universitaires UCL de Mont -Godinne , Av. Thérasse, 1 5530 YVOIR . he will gather the data for Belgium and then send them to Stimarec France.
|
Pulse generator |
Atrial lead |
Ventricular lead |
|
| Implantation date: | |||
| Implantation center: | |||
| Manufacturer: | |||
| Type: | |||
| Serial number: | |||
| Explantation: yes or no
Explanted: yes or no |
| Date of detection of abnormality: |
Clinical symptoms: Death: Syncope: Dizziness: Bradycardia: Tachycardia: None: |
|
| Day or month after implantation: | ||
| Date of last anterior checking: | ||
| Normal: yes or no | ||
| Date of explantation: | ||
| Day or month after explantation: | ||
|
Electrical impulse |
Instead of |
|
| Rate: |
Pacing: Maintained: Intermittent: Lost: |
|
| Regularity: | ||
| Amplitude: A) | ||
| Amplitude: V) | ||
| Duration: A) |
Sensing: |
|
| Duration: V) | Normal: | |
| Shape: A) | Under: | |
| Shape: V) | Over: |
Other abnormalities:
test performed by the doctor after explantation (never wait for the manufacturer's response, give your observation data).
|
Pulse generator |
Atrial lead |
Ventricular lead |
| Temperature: | Threshold: | |
| Load: | Impedance: | |
| QRS amplitude: |
Comments:
Completed by:.................................................. Date: .../.../.......
Name:..............................................
Address:....................................................................................
Lead: Manufacturer:....................... Model:............................. Serial n°: ............................
Implant procedure
Introduction site: ................................ Pacing site:................................................
Thresholds: Analyser used: ...............................Manufacturer:.........................Model:..............
PW:..............ms V:...........Volts I:...........mA
Z:...........ohms R or P:..............mV
Remarks (vein abnormality, iterative stylet intriduction, lead-adapter, early dislodgement, etc...):
......................................................................................................................................................
......................................................................................................................................................
History
First implant (P.M.): Manufacturer:....................... Model:...........................Date:.../.../........
Replacements (P.M.): Dates:.......................
Other reoperations: Dates:..............................
Reasons:....................
Abnormality
Progessive/chronic:..........................................Acute: .................... Date:..................
Symptoms (dizziness, muscle stimulation, etc..)....................................................
Examination: Intermittent loss of capture: O Permanent loss of capture: O
Oversensing: O Undersensing: O
Comments:........................................
Please include ECG strip, photoanalysis, X ray, other relevant documents,etc...)
Reoperation
Date:..../...../.........
Visual aspect:
at opening prior to dissection: .............................
extravenous part of the lead:................................
under ligature:................................................
Thresholds: Analyser used: ...............................Manufacturer:.........................Model:..............
PW:..............ms V:...........Volts I:...........mA
Z:...........ohms R or P:..............mV
Comments:............................................................................................
Other maneuvers (deep inspiration, caught, traction on the lead, endocardial recording, ECG or oscilloscope, etc......):...................................................................................
Conclusion
Lead:
Explanted: O Partially removed: O
Left in place: O Reused: O
Your feeling and comments about this model of lead:...............................................................
..............................................................................................................................................
The lead was: Sent back to the manufacturer: O Picked up by the manufacturer: O Sent to Stimarec for check up: Yes: O No: O Then sent back to the implanting physician: Yes: O No: O
Signature:................................. Please make a drawing of the lead and indicate the obvious damage with an arrow.
Date:
Signature: |
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