PROCEDURAL ASSESSMENT CHECKLIST PACEMAKER IMPLANT PROCEDURE. Fellow: Supervising Physician: Date of Observation:

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1 PACEMAKER IMPLANT PROCEDURE 9. Placement of diagnostic catheters limitation of fluoroscopy 10. Placement of diagnostic catheters electrogram interpretation 11. Measurement of baseline intervals 12. Assessment of sinus node function 13. Assessment of AV nodal function 14. Assessment of His-Purkinje system function 15. Assessment of retrograde conduction properties 16. Ventricular stimulation protocol 17. Diagnosis of induced arrhythmias 18. Treatment of induced arrhythmias 19. Autonomic manipulation drug administration 20. Catheter removal and hemostasis 21. Patient management decisions planning further treatment 22. Review of results, follow-up plans with patient/family 23. Post procedure check 24. Generation of procedure report *

2 DEFIBRILLATOR IMPLANT PROCEDURE 4. Selection of appropriate implantables (number and length of leads, PG, adaptors etc) 5. Confirm administration of antibiotic 6. Sterile gowning/gloving 7. Preparation of sterile field 8. Administration of local anesthesia 9. Administration of conscious sedation 10. Technique of venous access 11. Lead manipulation/positioning: right ventricle 12. Lead manipulation/positioning: right atrium 13. Coronary sinus intubation/venography as indicated 14. Coronary sinus lead placement as indicated 15. Limitation of fluoroscopy during procedure 16. Interpretation of lead testing using PSA 17. Exclusion of phrenic/diaphragmatic stimulation 18. Lead fixation/suture technique 19. Pocket formation 20. Connection of leads to generator 21. Pocket irrigation with antibiotic 22. Communication/coordination with anesthesia for DFT testing 23. Communication with lab staff for DFT testing 24. VF induction and defibrillation testing 25. Data analysis: confirm appropriate sensing and defibrillation efficacy 26. Wound closure technique 27. Post-operative orders 28. Post procedure device programming 29. Review of procedure, follow-up plans with patient/family 30. Post procedure check 31. Generation of procedure report *

3 DIRECT CURRENT CARDIOVERSION 1. Review of pertinent history, ECGs, medications and allergies 4. Check INR 5. Confirm rhythm 6. Position patient and apply electrodes 7. Check and ensure normal function of defibrillator 8. Check correct synchronization 9. Interrogate/program implanted device as appropriate 10. Coordinate procedural sedation with anesthesia 11. Energy selection and delivery of safe shock therapy 12. Review of post-shock rhythm and 12 lead ECG 13. Observation of patient during recovery 14. Review of results, follow-up plans with patient/family 15. Generation of procedure report *

4 RADIOFREQUENCY ABLATION INVOLVING THE RIGHT ATRIUM OR RIGHT VENTRICLE 9. Placement of diagnostic catheters 10. Performance and interpretation of diagnostic study as outlined in EP study checklist 11. Ablation catheter and/or guide sheath selection 12. Mapping technique(s) limitation of fluoroscopy 13. Selection of temperature/energy levels for ablation 14. Identification of end-point(s) of ablation procedure 15. Post-ablation confirmation of success/failure 16. Catheter removal/hemostasis 17. Review of results, follow-up plans with patient/family 18. Post procedure check 19. Generation of procedure report With occasional * With occasional With continuous

5 RADIOFREQUENCY ABLATION INVOLVING THE LEFT ATRIUM OR LEFT VENTRICLE 9. Placement of diagnostic catheters 10. Performance and interpretation of diagnostic study as outlined in EP study checklist 11. Access to left atrium or ventricle 12. Attain and maintain appropriate anticoagulation 11. Ablation catheter and/or guide sheath selection 12. Mapping technique(s) limitation of fluoroscopy 13. Selection of temperature/energy levels for ablation 14. Identification of end-point(s) of ablation procedure 15. Post-ablation confirmation of success/failure 16. Catheter removal/hemostasis/anticoagulation reversal 17. Review of results, follow-up plans with patient/family 18. Post procedure check 19. Generation of procedure report *

6 DIAGNOSTIC ELECTROPHYSIOLOGIC STUDY 9. Placement of diagnostic catheters limitation of fluoroscopy 10. Placement of diagnostic catheters electrogram interpretation 11. Measurement of baseline intervals 12. Assessment of sinus node function 13. Assessment of AV nodal function 14. Assessment of His-Purkinje system function 15. Assessment of retrograde conduction properties 16. Ventricular stimulation protocol 17. Diagnosis of induced arrhythmias 18. Treatment of induced arrhythmias 19. Autonomic manipulation drug administration 20. Catheter removal and hemostasis 21. Patient management decisions planning further treatment 22. Review of results, follow-up plans with patient/family 23. Post procedure check 24. Generation of procedure report *