Insertion and Management of Temporary Pacemakers

Abstract

Temporary pacemakers are used in a variety of critical care settings. These life-saving devices are reviewed in 2 major categories in this review: first, the insertion and management of epicardial pacemakers after and during cardiac surgery; and second, the insertion of transvenous temporary pacemakers for the emergent treatment of bradyarrhythmias. Temporary epicardial pacemakers are used routinely in patients recovering from cardiac surgery. Borrowing from advances in cardiac resynchronization therapy there are many theoretical and untested benefits to pacing the postoperative cardiac surgery patient. Temporary transvenous pacing is traditionally an emergency procedure to stabilize patients suffering from hemodynamically unstable bradyarrhythmia. We review the traditional and expanding use of transvenous pacemakers inside and outside the operating room.

The Use of Subcostal Echocardiographic Views to Guide the Insertion of a Right Ventricular Temporary Transvenous Pacemaker—Description of the Technique

“…11 The pacemaker lead types available for temporary transvenous cardiac pacing vary based on maneuvering technique, polarity, caliber, rigidity, and fixation ability. 2 The rigid nonfloating lead is torque directed and typically positioned using fluoroscopy. Similar to a pulmonary artery catheter, the softer floating lead (with or without a balloon tip) can be floated blindly into the RV or into the right ventricular outflow tract.…”

“…The output current should be set at a maximum (usually 20 mA), the sensitivity at a minimum (asynchronous pacing), and the rate at 10 to 20 beats per minute higher than the patient's native rate. 2 As the lead is advanced to its final position, electromechanical capture is signaled by the appearance of pacing electrocardiogram "spikes" followed by QRS complexes with a left bundle branch block morphology. Once pacing is established, the output current can be reduced gradually to determine the pacing threshold (minimal current that causes electromechanical capture), ideally under 1 mA.…”

“…SYMPTOMATIC BRADYARRHYTHMIAS are the most common indications for the insertion of temporary or permanent pacemakers. 1,2 In the perioperative setting, elective rapid ventricular pacing may be required for certain surgical and percutaneous interventional procedures in patients with structural heart disease. 3,4 For example, the intraoperative management of thoracic endovascular aortic aneurysm repair and transcatheter aortic valve implantation may involve rapid right ventricular pacing to achieve deliberate hypotension, which is needed for stent deployment.…”

“…10 Pacemaker lead insertion can be performed blindly, as often is the case with flow-directed leads used in emergencies, or it can be guided by an electrocardiogram (ECG), fluoroscopy, transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE). 2 A cardiothoracic anesthesiologist is familiar with the transesophageal technique, which commonly is used to guide the placement of catheters and cannulas for anesthetized patients. There are situations when the TEE approach is not feasible for pacemaker lead insertion: interventional procedures increasingly are performed under sedation, or the patient may have contraindications to TEE.…”

Subsequent transepidermal migration of two temporary cardiac pacing wires

“…Moreover, to preserve atrioventricular synchrony in high-risk cases for arrhythmia or cardiac failure as in our patient, dual-chamber pacing with two TCPW rather than single-chamber pacing is commonly used. 1,5 Accordingly, even after removing one wire, the possibility of an additional remaining wire should be considered if the patient still has persisting cutaneous lesions or sense of irritation.…”