Transvenous pacing

Indications

• Failure of transcutaneous pacing and chronotropes
  • Sinus Arrest/Bradycardia
  • AV Block - 3rd or 2nd degree
  • Digoxin toxicity
  • Overdrive pacing (e.g., in Torsades de Pointes AFTER return to sinus rhythm to prevent degeneration of rhythm)

Contraindications

• Asystolic cardiac arrest
• Hypothermiabradydysrhythmias

Procedure

1. Site selection: Right IJ or left subclavian for most direct anatomical course
2. Equipment:
   • External generator: Shows rate (bpm), output (mA) and sensitivity
   • Cordis Kit (7 Fr): Gold strip on kit at Harbor. Contains cordis introducer sheath, TV pacer catheter and pacer wire sheath
     • Sheath size (internal diameter) should match pacer wire size (external diameter). Otherwise you will get leakage!
3. Similar to a central line, place single lumen catheter under ultrasound guidance.
4. Pacing catheter
   • Test small balloon for leaks prior to insertion with 1.5mL of air while balloon rests in a container of saline
   • Connect the positive and negative electrodes to the external generator
   • Advance the catheter through the introducer sheath and into cordis hub to roughly 20 cm (catheter has marked bars indicating 10cm)
5. External generator: Set HR 80 (or 10 - 20 bpm above patient's native rate), start at max current output (usually 20 mA), and sensitivity all the way down (paces no matter intrinsic rate)
   • Pearl - Digital generators have "emergency" button that goes to automatic settings
6. Advancing Pacing Catheter: Inflate balloon and advance slowly.
   • Blind approach: Monitor shows pacer spikes followed by a widened QRS (LBBB appearance)
   • Ultrasound approach: Have assistant give a subcostal/parasternal long axis, which gives visualization image of when electrode contacts final resting position
   • Sensing approach: Use alligator clip to connect negative pacer electrode to any precordial lead. Look for ST elevation when RV endocardium engaged.
   • Fluoroscopy: If time permits, use this method in a patient that has prior pacemaker/ICD. Placement of TV pacer with out fluoro can disrupt prior electrode placements.
7. Final resting position is when pacer wire is in RV apex
   • Take note of pacer wire depth in case it is accidentally moved
   • If you overshot your mark (ie IVC/Pulm artery), deflate balloon and pull back. DO NOT PULL INFLATED BALLOON BACKWARD THROUGH A VALVE.
   • Pearl - IVC pacing leads to coughing/hiccuping and ventilator alarms (ie high frequency)
8. Deflate balloon (leave syringe attached) and secure catheter in place
   • Lock sheath onto cordis hub and then fully extend it & curl around while holding pacer wire in place. Sheath gives sterile amount of wire for any future adjustments if needed.
   • Additional sutures can be placed to stabilize it
9. Final Settings
   • Output: Determine threshold level by reducing electrical current settings until capture lost. Final current set to twice the threshold level for pt
   • Sensitivity: Adjust level (not too high or too low) so it allows intrinsic beats (unless you are overdrive pacing), but supplements it if needed. You do not want oversensing or undersensing.
10. Placement confirmation
    • Good to obtain baseline CXR, which should show the catheter tip over the inferior border of the cardiac shadow
    • ECG shows paced QRS exhibiting a LBBB morphology, and a superior QRS axis

Complications

• Related to central venous access
  • Infection, pneumothorax, air embolism, arterial puncture and venous thrombosis
• Related to pacing catheter:
  • Valvular tear(s)/rupture(s)
  • Myocardial Peforation (atria/ventricle/septum) - consider tamponade
• Ventricular Arrhythmias: VT or VF

See Also

• ACLS: Bradycardia
• Transcutaneous pacing

External Links

• First10EM - Emergent Cardiac Pacing
• ACEP - Transcutaneous and Transvenous Cardiac Pacing
• Deranged Physiology: Indications, contraindications and complications of temporary pacing

Videos

• University of Cincinnati
  • Transvenous Pacemaker Placement
• Drexel Video
• Practical Pointers