Transvenous Pacing

Emergency transvenous pacing is indicated for:

Indications

Contraindications

Anatomy

Equipment

  • Sheath
  • Transvenous pacing wire
  • Pacing adaptor
    To connect wires to pacing system.
    • Black to negative terminal
    • Red to positive terminal
  • Pacing cable (“bridging cable”)
  • External pacing system

Technique

Insertion:

  • Ensure ECG connected
  • Place 5-6Fr introducer
    • Right IJV best for convenience and familiarity
    • Aim to avoid left SCV - may be needed for a permanent system
  • Insert pacing wire through sheath and connect sterile sheath
  • Apply dressing
    The sterile portion of the procedure is now completed.

The wire is easier to float into position without the sterile sheath in situ, and can be done if you have a skilled assistant who can handle the non-sterile aspects of the procedure.

Establish pacing:

  • Set external pacing system
    Consider VVI 80, output 15-20mA, sensitivity threshold 0.8mV.
  • Attach external pacing system to wires
    • Distal lead to negative terminal
    • Proximal lead to positive terminal
  • Inflate balloon
    Ensure balloon is out of the end of the introducer.
  • Slowly insert wire, looking for:
    • ↑ HR to set rate
    • Alternation of QRS morphology ST segment elevation in V1 or LBBB appearance.
  • Secure wire in location
  • Partially deflate balloon (0.5mL)
    • Full deflation of the balloon may ↑ risk of perforation
      Full deflation can be used if there is concern about advancement of the catheter into the PA.
    • No deflation ↑ risk of wire dislodgement
  • Have patient cough to ensure wire doesn’t move
  • Perform pacing check
    • Sensitivity testing
      • Should only be performed if the patient has a haemodynamically stable rhythm with a native HR >30 bpm
      • Sensing threshold should be ideally >5mV
    • Capture testing
      • Capture threshold should be <1mA if the lead is correctly placed
      • Capture threshold >5mA is concerning for lead malposition

Echocardiographic guidance can be helpful for guidance.

Performance of a pacing check is covered in detail under Pacing.

Removal:

Consider removal in the morning in usual business hours to ↓ risk of tamponade.

  • Ensure restoration of a normal rhythm, or availability of alternative pacing
  • Disconnect the pacing box
  • Fully deflate the balloon
  • Remove the wire via the sheath

Complications

High rate of complications, usually as a function of low-volume of practice:

  • Central access
    • Pneumothorax
    • Haemothorax
    • Arterial injury
    • Central vein thrombosis
  • Pacing lead
    • Cardiac perforation
      • Tamponade
  • Pacing
    • Undersensing
      Inappropriate pacing and arrhythmia.
    • Oversensing
    • Diaphragmatic pacing
      Associated with RV perforation.

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.