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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Temporary cardiac pacing provides electrical stimulation to a heart that is compromised by disturbances in the conduction system, resulting in haemodynamic instability.
A temporary pacemaker to treat a bradydysrhythmia is used when the condition is temporary and when a permanent pacemaker is either not necessary or is not immediately available. Complications are common and include infection, local trauma, pneumothorax, arrhythmias and cardiac perforation.
Temporary transvenous pacing
- Temporary transvenous pacing involves two components - obtaining central venous access and intracardiac placement of the pacing wire.
- The preferred route of access for temporary transvenous pacing is a percutaneous approach of the subclavian vein, the cephalic vein or, rarely, the axillary vein, the internal jugular vein or the femoral vein.
- Although right- or left-sided veins can be used, the right side is traditionally preferred as it is technically easier, and the left side is usually reserved for permanent systems.
- The use of antibiotics should be considered for all wire insertions. Fluoroscopy is the preferred imaging technique but this is often not available, so ultrasound is an acceptable alternative.
Complications of temporary pacing
- An American review suggested a maximum complication rate of 12.6% with considerable variation between studies. Complication rates have certainly improved over time due to technological improvement and increasing operator experience. The most frequent complications are failure to secure venous access, failure to place the lead correctly, infection, thromboembolism, puncture of arteries, lung or myocardium, and life-threatening arrhythmias.
- In one review, 2-18% of patients developed sepsis after temporary pacemaker insertion. Consensus guidelines recommend that temporary pacemaker insertion should be avoided if there is a high probability that permanent pacing will eventually be required.
- Temporary pacemakers must be checked by competent staff at least once daily for pacing thresholds, evidence of infections around venous access sites, integrity of connections, and battery status of the external generator.
- The underlying rhythm should also be assessed and recorded at these checks.
Indications for temporary transvenous cardiac pacing
All the indications for permanent pacing are also suitable for temporary pacing. They include:
- Emergency or acute:
- Acute myocardial infarction with:
- Symptomatic bradycardia (sinus bradycardia with hypotension and type I second-degree atrioventricular (AV) block with hypotension not responsive to atropine).
- Bilateral bundle branch block (BBB).
- New or indeterminate-age bifascicular block with first-degree AV block.
- Third-degree AV block.
- Bradycardia not associated with acute myocardial infarction:
- Second-degree or third-degree AV block with haemodynamic compromise or syncope at rest.
- Ventricular tachyarrhythmias secondary to bradycardia.
- Acute myocardial infarction with:
- Support for procedures that may promote bradycardia.
- General anaesthesia with:
- Second-degree or third-degree AV block.
- Intermittent AV block.
- First-degree AV block with bifascicular block.
- First-degree AV block and left bundle branch block (LBBB).
- Cardiac surgery:
- Aortic surgery.
- Tricuspid surgery.
- Ventricular septal defect closure.
- Ostium primum repair.
- Rarely considered for coronary angioplasty (usually to the right coronary artery) but may be required for angioplasty-induced bradycardia.
- Overdrive suppression of tachyarrhythmias.
Inserting pacing wire
Temporary pacing wires should only be inserted by experienced practitioners. There is evidence that specialist practitioners have a much lower rate of complications than trainees and generalists.
- Ensure that a defibrillator and other resuscitation equipment are immediately accessible.
- The procedure requires strict aseptic technique, using a mask, gown and gloves.
- ECG monitoring is required but the ECG leads should be off the chest.
- Cannulate the appropriate vein, using Seldinger's technique of guidewire and dilators to place a sheath of the correct size to allow passage of the pacing wire.
- Mould the tip of the electrode to give a 20-30° curve for correct positioning in the heart.
- Advance the electrode under ultrasound or fluoroscopic guidance until it lies vertically in the right atrium with its tip pointing towards the free wall on the right side.
- Rotate the wire between the index finger and thumb such that it points towards the patient's left side; advance the wire steadily through the tricuspid valve and along the floor of the right ventricle to the apex.
- Common problems:
- The wire does not cross the tricuspid valve: continue advancing the wire into the right atrium until it catches on the wall and forms a large loop. If it passes into the inferior vena cava or superior vena cava, pull back and push forward again until it does catch. With a large loop in place, rotate the wire until its tip flips through into the ventricle.
- A wire appears to be in correct position but will not capture ventricle at acceptable output: fluoroscopy shows electrode tip is directed upwards towards the left shoulder and directed posteriorly rather than anteriorly.
- Cannot obtain satisfactory pacing; withdraw the wire into the right atrium and repeat the attempt to cross the tricuspid valve.
- Difficulty in positioning the wire at the apex of the right ventricle: pass the tip of the wire into the right ventricular outflow tract and gently withdraw while rotating between the index finger and thumb. When the tip is at a downwards angle, advance towards the apex.
- Set to 70/min or 10/min above the patient's ventricular rate.
- Set a pulse of 3 V (or follow the manufacturer's instructions); at this voltage, should capture ventricle so that each pacing spike is followed by a QRS complex. Determine the voltage threshold by gradually turning down the voltage until capture is lost (usually 0.7-1.0 V) and usually set the pacemaker to deliver a pulse of at least twice threshold.
- Check sensing by setting the pacemaker rate at 10-20/min <spontaneous ventricular rate and check ECG and pulse generator for pacing inhibition.
- Normally set sensitivity to maximum.
- Common problems:
- No spikes seen and no output: usually due to failure of the battery or generator or a loose connection. Otherwise, oversensing is cured by reducing sensitivity or going to fixed rate pacing.
- Spikes seen but no capture: often a loose connection but may be due to exit block causing a high threshold. Check the position of the pacing wire and consider repositioning.
- With the pacing wire positioned correctly and pacing established, remove the introducer sheath carefully.
- Suture the wire to the skin close to the point of insertion and cover with a dressing.
- Arrange a CXR to confirm a satisfactory position of the wire and to exclude a pneumothorax.
Further reading and references
Shenthar J, Singh B, Banavalikar B, et al; Cardiac perforation complicating cardiac electrophysiology procedures: value of angiography and use of a closure device to avoid cardiac surgery. J Interv Card Electrophysiol. 2019 Jun 28. pii: 10.1007/s10840-019-00577-0. doi: 10.1007/s10840-019-00577-0.
Soni S, Hazarika A; Cesarean delivery in congenital heart block and need of temporary pacing: A case report. Saudi J Anaesth. 2019 Jul-Sep13(3):274-276. doi: 10.4103/sja.SJA_757_18.
Kotsakou M, Kioumis I, Lazaridis G, et al; Pacemaker insertion. Ann Transl Med. 2015 Mar3(3):42. doi: 10.3978/j.issn.2305-5839.2015.02.06.
Blanco P; Temporary transvenous pacing guided by the combined use of ultrasound and intracavitary electrocardiography: a feasible and safe technique. Ultrasound J. 2019 Apr 411(1):8. doi: 10.1186/s13089-019-0122-y.
Doring M, Richter S, Hindricks G; The Diagnosis and Treatment of Pacemaker-Associated Infection. Dtsch Arztebl Int. 2018 Jun 29115(26):445-452. doi: 10.3238/arztebl.2018.0445.
Sandoe JA, Barlow G, Chambers JB, et al; Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). J Antimicrob Chemother. 2015 Feb70(2):325-59. doi: 10.1093/jac/dku383. Epub 2014 Oct 29.
Carrion-Camacho MR, Marin-Leon I, Molina-Donoro JM, et al; Safety of Permanent Pacemaker Implantation: A Prospective Study. J Clin Med. 2019 Jan 18(1). pii: jcm8010035. doi: 10.3390/jcm8010035.
Maddali MM; Cardiac pacing in left bundle branch/bifascicular block patients. Ann Card Anaesth. 2010 Jan-Apr13(1):7-15. doi: 10.4103/0971-9784.58828.
Cao Q, Zhang J, Xu G; Hemodynamic changes and baroreflex sensitivity associated with carotid endarterectomy and carotid artery stenting. Interv Neurol. 2015 Jan3(1):13-21. doi: 10.1159/000366231.
Haug B, Kjelsberg K, Lappegard KT; Pacemaker implantation in small hospitals: complication rates comparable to larger centres. Europace. 2011 Nov13(11):1580-6. doi: 10.1093/europace/eur162. Epub 2011 Jun 28.
Temporary Cardiac Pacing; University of Ottowa, 2019
Gurgar M; Manual of ICU Procedures, 2016