The patient was brought to the heart cath lab. Left infraclavicular area was prepared and draped in the usual sterile fashion. Local anesthesia was achieved with 1% plain Xylocaine. Femoral vein was punctured with an 18-guage needle. A guide wire was advanced through the needle. Sterile technique was used throughout the entire procedure. Fluoroscopic guidance was employed for all internal manipulations. Afterward, about a 5-cm skin-entry incision site was made, and a pocket was made with blunt dissection to the pectoralis major fossa using Metzenbaum scissors and Bovie for proper hemostasis. Afterward, a 10 French introducer was advanced over the wire. Trocar was removed. A permanent ventricular lead was advanced through the sheath, which was peeled away and the lead advanced to the right ventricular apex and affixed in the usual fashion. Afterward, the guide wire, which had been preserved after pulling the first sheath away, was used to implant a second sheath, 10 French, whereupon the Oscar atrial screw-in wire was advanced through the sheath. The sheath was retracted, allowing for uncoiling of the J. Then the stay stylet was advanced. Satisfactory pacing numbers were obtained and the lead screwed into the atrial wall with three clockwise screw motions. Prior to this we had obtained satisfactory pacing numbers, threshold numbers, and sensitivity numbers with the ventricular wire.

The permanent leads were affixed to the generator, after silica gel applied, screw caps applied, excess wire coiled behind the generator, all housed in the pocket, wound closed with 2-0 Vicryl, subcutaneous and 3-0 nylon on the skin. Satisfactory pacing was obtained, and the patient returned to his