INTRODUCTION



CERTIFICATION(DEVICES)PRACTICAL LOGBOOK 2019Candidate Name:Examination Registration No.:INTRODUCTION TO LOGBOOK AND INSTRUCTIONS FOR USEThis logbook supersedes any previous versions and must be used if you have registered to sit the BHRS certification exam in 2018 or after.The logbook forms part of the requirements for British Heart Rhythm Society certification. It is specifically aimed at practitioners with a particular interest in cardiac device implantation and management. A separate logbook exists for cardiac electrophysiology.There is only one logbook covering devices. All sections of the logbook must be completed prospectively and submitted by 31st January 2022. Logbooks submitted after this date will not be marked unless prior written authorisation for an extension has been granted.All case studies must be completed in full and contain appropriate documentation of ECGs, electrograms and measurements.You must obtain verification of the information and completion of the assessment sections from your supervisor, who must be experienced in device management and ideally hold BHRS certification (previously Heart Rhythm UK certificate of accreditation) or the IBHRE qualification (pacing and devices) or the EHRA CP/AP qualifications. Medical device company representatives will not be accepted as a supervisor.How to apply for a log-book extensionOnly one extension will be awarded for exceptional circumstances. No extension will be awarded retrospectively.A request for a log book extension must be put in writing and sent to British Heart Rhythm Society, email admin@Further information on the logbook can be obtained from the British Heart Rhythm Society, E-mail: admin@. Tel: +44 (0)1789 867 526SPECIFIC POINTSAny patient identifiable information present within the logbook will result in an automatic fail. Do not cover patient identifiable information with marker pen - with time this fades. Please pay particular attention to 12 lead ECGs and device interrogation print outsThe logbook is divided into 4 sectionsSection 1: Implanting procedure (as physiologist)Section 2: Follow-up (as physiologist)Section 3: Case studiesSection 4: AssessmentsFor doctors / allied health professionals completing the log you need to take on the role as a cardiac physiologist for ALL sections of the logbook.Please note that no case from section 1 can be used as a case study in section 3.All details of CRT implants / follow ups can be CRT-P or D devices. CRT-D devices can count towards ICDs numbers and CRT/ICD devices can count towards pacemakers but not vice versa.Section 3Please note ALL case studies should include copies of any investigations performed plus copies of pre and post implant 12 lead ECGs.Summary of Information RequiredNumberSection 1: ImplantsPacemaker Implants30ICD / CRT Implants15Section 2: Follow-upPacemakers60ICD10CRT ICD10Section 3: Case studiesPacemakers15ICD5CRT ICD5Section 4: Skills AssessmentImplant assessments3Follow up assessments4BHRS CERTIFICATION: CARDIAC DEVICE LOG BOOKCandidate DetailsNameAddressContact detailsTelephone and/oremailHospitals In Which Work UndertakenTime PeriodAddressSupervisor DetailsNameProfessional title/positionAddressContact detailsTelephone and/oremailEXTRACT FROM SPECIALTY TRAINING CURRICULUM FOR CARDIOLOGY TRAINEES (StRs) AUGUST 2010CORE HEART RHYTHM TRAININGThe necessary skills, attitudes and experience will come from a mixture of attendance at specialist arrhythmia clinics, experiential learning, formal training at study days and/or postgraduate courses. As part of a portfolio you should keep a logbook of cases and procedures observed and undertaken.As a guide, it is likely that in order to gain sufficient experience procedures the trainee will need to be involved in: the implantation as well as the pre- and post- procedure care of at least 25 patients requiring permanent pacemakers; at least five ICD implants and five CRT proceduresADVANCED HEART RHYTHM TRAININGNumbers of ProceduresThere is a widespread perception that numbers of procedures undertaken provide a guide to development of competence but trainees learn at different rates and absolute numbers, however high, may not guarantee competence. Therefore, competence will be assessed using DOPS, (Direct Observation of Procedural Skills). However, to guide planning of training there are indicative minimum numbers of procedures likely to be needed to be completed before competence is achieved.Implantable Devices for Managing Arrhythmias: Implantation of 100 systems by the trainee; 100 follow up patients requiring pacemaker interrogation and/or programming; implantation of 25 ICDs and supervision of 50 patients in programming clinics; implantation of 30 BiV devices and their programming and optimisation in a minimum of 30 patients with heart failure using modern techniques such as tissue Doppler imaging.Continuing Medical Education & Professional DevelopmentTrainees will be expected to have: CCAD-verified training logbooks for procedures and outcomes; attendance of local and national training days – at least 2 per year; certified attendance at BHRS / Heart Rhythm UK arrhythmia and device therapy training days each year; certified attendance at one international EP meeting a year during advanced EP training is highly desirable; certified attendance at live electrophysiology/device courses where appropriate.SECTION 1: DEVICE IMPLANT PROCEDURE (AS PHYSIOLOGIST)Section 130 pacemaker implantsOut of the 30 cases 5 should be for elective generator replacements (box changes)In addition to the 30 pacemaker implants 15 ICD/CRT implants are required of which 5 must include CRT (P or D) devicesSpecify patient symptoms, ECG abnormality and aetiology in addition to their codes. Copies of 12 lead ECGs are not required for completion of section 1Anaesthetic:Local or general. If general, give reasonVascular access:Subclavian, cephalic, otherSutures:Vicryl, Ethibond, etc. Specify suture material used for sleeves and wound closureAntibiotic regimen:Pre and post procedure and peri-procedure (e.g. gentamicin to pocket)SECTION 1: PACEMAKER IMPLANT (AS PHYSIOLOGIST)No. 1Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 2Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 3Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 4Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 5Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 6Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 7Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 8Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 9Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 10Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 11Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 12Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 13Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 14Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 15Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 16Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 17Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 18Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 19Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 20Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 21Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 22Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 23Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 24Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 25Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 26Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 27Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 28Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 29Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:No. 30Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()Ventricular Lead:Sutures Used:Slew rate (Vs-1)Final Pacing Mode:SECTION 1: ICD/CRT IMPLANT (AS PHYSIOLOGIST)No. 1Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 2Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 3Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 4Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 5Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 6Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 7Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 8Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 9Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 10Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 11Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 12Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 13Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 14Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:No. 15Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSComplications up to Discharge:Anaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead:Amplitude (mV)Follow Up Arrangements:Antibiotic Regimen:Impedance ()RV Lead & LV Lead:Sutures used:Slew rate (V/sec)Final Pacing Mode:Details of LV lead placement:Guide catheter(s) used:Vein used:SECTION 2: PACEMAKER FOLLOW-UP (AS PHYSIOLOGIST)No.ImplantDatePatientInitialsGenerator(Manufacturer and model)AmplitudePacingThresholdImpedanceBatteryWound Site OK?Describe any parametersreprogrammed?PacingModeSupervisorInitialsAVAVAVImpV123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960SECTION 2: ICD FOLLOW-UP (AS PHYSIOLOGIST)No.DeviceImplantDatePatientInitialsGenerator(Manufacturer and model)AmplitudePacingThresholdImpedanceWound Site OK?Describe any parametersreprogrammed?PacingModeSupervisorInitialsARVLVARVLVARVLV1ICD2ICD3ICD4ICD5ICD6ICD7ICD8ICD9ICD10ICDSECTION 2: CRT FOLLOW-UP (AS PHYSIOLOGIST)No.DeviceImplantDatePatientInitialsGenerator(Manufacturer and model)AmplitudePacingThresholdImpedanceWound Site OK?Describe any parametersreprogrammed?PacingModeSupervisorInitialsARVLVARVLVARVLV1CRT±D2CRT±D3CRT±D4CRT±D5CRT±D6CRT±D7CRT±D8CRT±D9CRT±D10CRT±DSECTION 3: PACEMAKER CASE STUDIESCase 1CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 1Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 1Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 1Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 2CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 2Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 2Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 2Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 3CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 3Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 3Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 3Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 4CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 4Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 4Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 4Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 5CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 5Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 5Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 5Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 6CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 6Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 6Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 6Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 7CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 7Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 7Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 7Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 8CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 8Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 8Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 8Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 9CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 9Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 9Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 9Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 10CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 10Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 10Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 10Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 11CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 11Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 11Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 11Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 12CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 12Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 12Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 12Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 13CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 13Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 13Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 13Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 14CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 14Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 14Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 14Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 15CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for pacemaker:(Including reference to national / international guidance)IMPLANT DETAILS:No. 15Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()Ventricular Lead, Fixation & Position:Sutures Used:Slew rate (Vs-1)Pacing Mode:POST IMPLANT CHECKS:No. 15Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()Final Pacing Mode:Ventricular Lead Position:PROGRAMMING CONSIDERATIONS:No. 15Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPSECTION 3: ICD CASE STUDIESCase 1CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for ICD:IMPLANT DETAILS:No. 1Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 1Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:Ventricular Lead Position:Shock:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 1Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)INCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 2CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for ICD:IMPLANT DETAILS:No. 2Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 2Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:Ventricular Lead Position:Shock:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 2Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)INCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 3CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for ICD:IMPLANT DETAILS:No. 3Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 3Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:Ventricular Lead Position:Shock:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 3Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)INCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 4CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for ICD:IMPLANT DETAILS:No. 4Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 4Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:Ventricular Lead Position:Shock:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 4Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)INCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 5CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for ICD:IMPLANT DETAILS:No. 5Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialVentricularPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 5Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialVentricularPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:Ventricular Lead Position:Shock:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 5Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)INCLUDE PRINT OUTS OF FINAL DEVICE SET-UPSECTION 3: CRT CASE STUDYCase 1CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for CRT ± D:IMPLANT DETAILS:No. 1Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialRVLVPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil & LV lead:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):IMPLANT PROCEDURE: LV LEADGuide catheter(s) used:LV Lead choice:Was final LV lead position/vein used the operators initial choice?If not why?Vein used:Procedure Length:Screening Time:Radiation Dose:DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 1Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialRVLVPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:RV Lead Position:Shock:LV Lead Position:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 1Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)BiV set upVV settingsINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 2CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for CRT ± D:IMPLANT DETAILS:No. 2Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialRVLVPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil & LV lead:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):IMPLANT PROCEDURE: LV LEADGuide catheter(s) used:LV Lead choice:Was final LV lead position/vein used the operators initial choice?If not why?Vein used:Procedure Length:Screening Time:Radiation Dose:DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 2Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialRVLVPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:RV Lead Position:Shock:LV Lead Position:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 2Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)BiV set upVV settingsINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 3CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for CRT ± D:IMPLANT DETAILS:No. 3Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialRVLVPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil & LV lead:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):IMPLANT PROCEDURE: LV LEADGuide catheter(s) used:LV Lead choice:Was final LV lead position/vein used the operators initial choice?If not why?Vein used:Procedure Length:Screening Time:Radiation Dose:DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 3Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialRVLVPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:RV Lead Position:Shock:LV Lead Position:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 3Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)BiV set upVV settingsINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 4CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for CRT ± D:IMPLANT DETAILS:No. 4Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialRVLVPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil & LV lead:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):IMPLANT PROCEDURE: LV LEADGuide catheter(s) used:LV Lead choice:Was final LV lead position/vein used the operators initial choice?If not why?Vein used:Procedure Length:Screening Time:Radiation Dose:DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 4Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialRVLVPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:RV Lead Position:Shock:LV Lead Position:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 4Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)BiV set upVV settingsINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPCase 5CLINICAL DETAILS:Date: Patient Initials: Clinical History:Investigations performed & results:(Copies to be included)ECG, echocardiogram, Holter monitor, ILR (loop recorder), exercise test, coronary angiogram, tilt test, cardiac MRI, carotid sinus massage, EP StudiesReason for CRT ± D:IMPLANT DETAILS:No. 5Date:Patient Initials:Symptom Implant Code:ECG Implant Code:Aetiology Implant Code:IMPLANT DETAILSMANUFACTURER AND MODELPACING PARAMETERSINCLUDE PAPER PRINT OUTS OF IMPLANT MEASUREMENTSAnaesthetic:Generator:AtrialRVLVPacing Threshold@ 0.5ms (V)Vascular Access:Atrial Lead, Fixation & Position:Amplitude (mV)Procedural Complications:Antibiotic Regimen:Impedance ()RV:Ventricular Lead, Fixation, Position, Single or Dual Coil & LV lead:Shock:Sutures Used:Slew rate (Vs-1)Pacing Mode:Were NICE Criteria met (please specify):IMPLANT PROCEDURE: LV LEADGuide catheter(s) used:LV Lead choice:Was final LV lead position/vein used the operators initial choice?If not why?Vein used:Procedure Length:Screening Time:Radiation Dose:DFT TEST (PLEASE PROVIDE PRINTOUTS OF TEST)Details of VF induction and termination (if not performed state why):POST IMPLANT CHECKS:No. 5Date:Patient Initials:POST IMPLANT CHECKSMANUFACTURER AND MODELPACING PARAMETERSPost-procedural Complications:Wound:Generator Site:AtrialRVLVPacing Threshold@ 0.5ms (V)Atrial Lead Position:Amplitude (mV)CXR (pneumothorax etc.):Impedance ()RV:Final Pacing Mode:RV Lead Position:Shock:LV Lead Position:Driving advice given:PROGRAMMING CONSIDERATIONS:No. 5Date:Patient Initials:PLEASE PROVIDE EXPLANATION OF DEVICE SET-UPTo IncludeChoice of ModeLower RateUpper RateSensor RateRate response set upAV DelaysTachycardia Set-up(No. of zones, rationale for zones ATP set up, SVT discriminators)BiV set upVV settingsINCLUDE PRINT OUTS OF FINAL DEVICE SET-UPSECTION 4: DUAL CHAMBER PACEMAKER IMPLANT MEASUREMENTS – SKILLS ASSESSMENTAssessor:Date:Assessment:1 - 3 Unsatisfactory4 - 6 Satisfactory(0 not applicable)7 - 9 Above expectedSkillAssessment(as per key)PSA ConnectionsA and V lead impedanceR Wave measurementVentricular threshold testExplanation of Wedensky effectP Wave measurementAtrial threshold testStability10VAssessor comments (You must justify each score of 1 – 3 with at least one explanation / example):SECTION 4: ICD IMPLANT MEASUREMENTS – SKILLS ASSESSMENTAssessor:Date:Assessment:1 - 3 Unsatisfactory4 - 6 Satisfactory(0 not applicable)7 - 9 Above expectedSkillAssessment(as per key)Kit selectionDevice set-up pre-implantImplant forms completionP and R wave measurementA and V lead impedanceA and V threshold testsDevice measurementsVF inductionPost-implant set-upAssessor comments (You must justify each score of 1 – 3 with at least one explanation / example):SECTION 4: CRT IMPLANT MEASUREMENTS – SKILLS ASSESSMENTAssessor:Date:Assessment:1 - 3 Unsatisfactory4 - 6 Satisfactory(0 not applicable)7 - 9 Above expectedSkillAssessment(as per key)Kit selectionCoronary vein identificationPSA connectionsA, RV and LV signal measurementA, RV and LV lead impedanceAtrial threshold testRV threshold testLV threshold testVF inductionPost-implant set-upAssessor comments (You must justify each score of 1 – 3 with at least one explanation / example):SECTION 4: DIRECT OBSERVATION OF PROCEDURAL SKILLS (DOPS)Instructions for assessor(s)Please mark each component of the exercise on a scale of 1 (extremely poor) to 9 (extremely good). A score of 1 - 3 is considered unsatisfactory, 4 - 6 satisfactory and 7 - 9 is considered above that expectedPlease note that your scoring should reflect the performance of the trainee against that which you would reasonably expect at their stage of training and level of experienceYou must justify each score of 1 - 3 with at least one explanation/example in the comments box, failure to do so will invalidate the assessmentPlease feel free to add any other relevant opinions about the trainee’s strengths and weaknesses in the space providedSKILLS ASSESSMENT (FOR FOLLOW-UP PROCEDURES)Single chamber pacemakerDual chamber pacemakerICDCRT (P or D)SECTION 4: SINGLE CHAMBER PACEMAKER FOLLOW UP – SKILLS ASSESSMENT1. Interacts appropriately with staff in pacing clinicN/A123456789UnsatisfactorySatisfactoryAbove expected2. Prepares patient appropriatelyN/A123456789UnsatisfactorySatisfactoryAbove expected3. Obtains clinical historyN/A123456789UnsatisfactorySatisfactoryAbove expected4. Appropriate R/P wave measurementN/A123456789UnsatisfactorySatisfactoryAbove expected5. Appropriate lead impedance measurementN/A123456789UnsatisfactorySatisfactoryAbove expected6. Appropriate threshold testN/A123456789UnsatisfactorySatisfactoryAbove expected7. Appropriate retrograde conduction checkN/A123456789UnsatisfactorySatisfactoryAbove expected8. Appropriate diagnostics interpretationN/A123456789UnsatisfactorySatisfactoryAbove expected9. Reprogramming / recommendationsN/A123456789UnsatisfactorySatisfactoryAbove expected10. Overall technical abilityN/A123456789UnsatisfactorySatisfactoryAbove expectedAssessors comments on trainee’s performance on this occasion:Trainee’s comments on their performance on this occasion:Signature of trainee:Signature of supervisor:Date:SECTION 4: DUAL CHAMBER PACEMAKER FOLLOW UP – SKILLS ASSESSMENT1. Interacts appropriately with staff in pacing clinicN/A123456789UnsatisfactorySatisfactoryAbove expected2. Prepares patient appropriatelyN/A123456789UnsatisfactorySatisfactoryAbove expected3. Obtains clinical historyN/A123456789UnsatisfactorySatisfactoryAbove expected4. Appropriate R/P wave measurementN/A123456789UnsatisfactorySatisfactoryAbove expected5. Appropriate lead impedance measurementN/A123456789UnsatisfactorySatisfactoryAbove expected6. Appropriate threshold testN/A123456789UnsatisfactorySatisfactoryAbove expected7. Appropriate retrograde conduction checkN/A123456789UnsatisfactorySatisfactoryAbove expected8. Appropriate diagnostics interpretationN/A123456789UnsatisfactorySatisfactoryAbove expected9. Reprogramming / recommendationsN/A123456789UnsatisfactorySatisfactoryAbove expected10. Overall technical abilityN/A123456789UnsatisfactorySatisfactoryAbove expectedAssessors comments on trainee’s performance on this occasion:Trainee’s comments on their performance on this occasion:Signature of trainee:Signature of supervisor:Date:SECTION 4: ICD FOLLOW UP – SKILLS ASSESSMENT1. Interacts appropriately with staff in pacing clinicN/A123456789UnsatisfactorySatisfactoryAbove expected2. Prepares patient appropriatelyN/A123456789UnsatisfactorySatisfactoryAbove expected3. Obtains clinical historyN/A123456789UnsatisfactorySatisfactoryAbove expected4. Appropriate diagnostics interpretationN/A123456789UnsatisfactorySatisfactoryAbove expected5. Appropriate arrhythmia interpretationN/A123456789UnsatisfactorySatisfactoryAbove expected6. Appropriate R/P wave measurementN/A123456789UnsatisfactorySatisfactoryAbove expected7. Appropriate lead impedance measurementN/A123456789UnsatisfactorySatisfactoryAbove expected8. Appropriate shock lead impedance measurementN/A123456789UnsatisfactorySatisfactoryAbove expected9. Appropriate threshold testN/A123456789UnsatisfactorySatisfactoryAbove expected10. Reprogramming / recommendationsN/A123456789UnsatisfactorySatisfactoryAbove expected11. Overall technical abilityN/A123456789UnsatisfactorySatisfactoryAbove expectedAssessors comments on trainee’s performance on this occasion:Trainee’s comments on their performance on this occasion:Signature of trainee:Signature of supervisor:Date:SECTION 4: CRT FOLLOW UP – SKILLS ASSESSMENT1. Interacts appropriately with staff in pacing clinicN/A123456789UnsatisfactorySatisfactoryAbove expected2. Prepares patient appropriatelyN/A123456789UnsatisfactorySatisfactoryAbove expected3. Obtains clinical historyN/A123456789UnsatisfactorySatisfactoryAbove expected4. Appropriate diagnostics interpretationN/A123456789UnsatisfactorySatisfactoryAbove expected5. Appropriate arrhythmia interpretationN/A123456789UnsatisfactorySatisfactoryAbove expected6. Appropriate R/P wave measurementN/A123456789UnsatisfactorySatisfactoryAbove expected7. Appropriate lead impedance measurementN/A123456789UnsatisfactorySatisfactoryAbove expected8. Appropriate shock lead impedance measurementN/A123456789UnsatisfactorySatisfactoryAbove expected9. Appropriate threshold testN/A123456789UnsatisfactorySatisfactoryAbove expected10. Reprogramming / recommendationsN/A123456789UnsatisfactorySatisfactoryAbove expected11. Overall technical abilityN/A123456789UnsatisfactorySatisfactoryAbove expectedAssessors comments on trainee’s performance on this occasion:Trainee’s comments on their performance on this occasion:Signature of trainee:Signature of supervisor:Date: ................
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