Emergency Transvenous Pacing

Aka: Emergency Transvenous Pacing, Transvenous Pacemaker, Emergency Cardiac Pacing, Temporary Transvenous Right Ventricular Pacer Wire Placement

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II. Indications

  1. Emergency stabilization of Unstable Bradycardia, where Transcutaneous Pacing is inadequate
  2. Unstable Bradycardia (e.g. third degree AV Block)
  3. Prolonged transport time with higher likelihood of rhythm decompensation
  4. Myocardial Infarction with new Arrhythmia (LBBB, RBBB, Type II second degree AV Block, Third Degree AV Block)
    1. High risk of fatal Bradycardia (up to 43%)
    2. However, first priority is reperfusion!

III. Advantages: Contrast with Transcutaneous Pacing

  1. Requires only one tenth of the delivered energy (milliamps) as Transcutaneous Pacing
  2. Does not require nearly the same level of sedation and analgesia as Transcutaneous Pacing
  3. Does not generate the significant tracing artifacts seen with Transcutaneous Pacing

IV. Equipment

  1. Monitoring
    1. Cardiac monitor
    2. Pulse Oximeter
    3. Blood Pressure monitor
    4. Intravenous Access
  2. Central Venous Line Placement
    1. Ultrasound
    2. Sterile gloves and gown
    3. Skin antiseptics (e.g. Chlorhexidine)
    4. Suture Material
    5. Sterile dressing
    6. Central venous sheath introducer (may be included in Pacemaker kit)
      1. Central venous sheath introducers have 2 ports
        1. Pacer wire port with diaphragm
        2. Side port (to infuse medications and fluids)
      2. Any Central Line may be used that is large enough to pass the pacer wire and balloon
  3. Transvenous Pacemaker Kit
    1. Bipolar Pacemaker Wire with balloon tip (and syringe for balloon)
      1. Transvenous Pacemaker wires are typically 60-70 cm long (marked in 10 cm increments)
      2. Balloon tip allows the wire to float with Blood Flow
        1. Passes through the tricuspid valve and into the right ventricle
        2. Right ventricular apex is the preferred target (but any wall in the ventricle will suffice)
      3. Distal wire has 2 small leads separated by millimeters
        1. Proximal lead (positive)
        2. Distal lead (negative)
      4. Proximal connectors attach to Pacemaker generator specific connectors
        1. Positive Lead (proximal)
        2. Negative lead (distal)
    2. Pacer wire protective sterile sheath
    3. Pacer wire securing tape or dressing
  4. External pacer devices
    1. Pulse generator box
    2. Connecting cables, wires

V. Technique

  1. Preferred Central Line sites (most direct, least tortuous courses)
    1. Right internal Jugular Vein (preferred)
    2. Left subclavian vein
    3. Left internal Jugular Vein (similar wire course as with the left subclavian vein)
    4. Femoral veins may be used as an alternative access point
  2. Place Catheter 6 French sheath (in Pacemaker kit)
    1. Use 6 French instead of 9 French standard Cordis catheter
      1. Larger, 9 French leaks blood and fails to allow adequate Pacemaker wire control
    2. Precaution: Ensure venous placement (non-arterial)
      1. Cordis catheter is a large bore catheter with significant complications if placed arterially
    3. Place using seldinger technique, as with Central Line Placement
      1. Needle placement into vein
      2. Passage of guide wire through needle and removal of introducer needle
      3. Incision at insertion site and dilator insertion
      4. Thread the sheath with stylet over wire and into the vein
      5. Remove the guide wire
      6. Check that blood may be aspirated from side port
  3. Attach the plastic, accordion sheath
    1. Connect the sheath hub to the catheter
    2. Before placing the wire, estimate the insertion length from introducer to right heart
      1. Hold the wire using sterile technique above the patient's chest to estimate
    3. Pacemaker wire threaded through the sterile sheath and into the catheter
    4. Test wire balloon by inserting 1.5 cc air prior to insertion (then deflate)
      1. Correct amount of air should be used (specific syringe is typically in kit)
      2. Balloon air volume may be device specific
  4. Attach the pacer
    1. Connector cable attached to the Pacemaker wire and to the Pacemaker generator
    2. Non-sterile assistant attaches catheter pins to appropriate terminal on generator (pos to pos, neg to neg)
  5. Thread the wire
    1. Deflate balloon (after testing as above)
    2. Pass wire via sterile sheath into 6 French catheter
    3. Wire inserted to the second mark (20 cm)
      1. Allows catheter to pass the end of the introducer sheath and allow for balloon inflation
      2. Balloon inflation is described below
    4. Infusing fluid via the catheter side port may facilitate floating the balloon into the right ventricle
  6. Advance Wire
    1. Turn on Pacemaker generator once tip has cleared introducer sheath
      1. Rate: 100 bpm to allow for early identification of capture (decreased to 60-80 after capture)
      2. Output set to maximum current (20-25 mA)
        1. Setting to maximal output (20-25 mA) allows for early detection of capture
        2. Decrease output once capture occurs (see below)
      3. Sensitivity
        1. Device safety feature suppresses output when exposed to intrinsic or external beats
        2. Set to asynchronous, lowest possible sensitivity (or off) when floating the wire
        3. May increase sensitivity once capture is achieved
    2. Reinflate balloon (by assistant)
      1. Inflate balloon with 1.5 cc air and turn stop-cock
      2. Balloon reinflated to allow floating of wire into the right atrium and right ventricle
    3. Advance the wire to the third mark (30 cm) and beyond as needed
      1. Use a smooth continuous motion
      2. If failure to capture after insertion of pacer wire to estimated length, withdraw wire and try again
        1. Deflate balloon
        2. Withdraw wire to 20 cm
        3. Reinflate balloon
        4. Advance wire
        5. Multiple reattempts may be needed (see troubleshooting below)
      3. Phrenic nerve pacing may occur during pacer wire advancement
        1. Results in severe Tachypnea
        2. If phrenic pacing occurs, deflate balloon and advance pacer wire
    4. EKG Monitor (not the EKG machine or alligator clip)
      1. Observe for electrical and mechanical capture
      2. Electrical tracing will show a Pacemaker spike followed by Wide QRS (LBBB appearance)
        1. Pacemaker spike may not be seen on some monitors
      3. Confirmation of capture and lead placement
        1. Heart Rate will increase from Bradycardia to pacer rate at capture (with wide complexes)
        2. Palpate pulse or auscultate heart sounds
        3. Oxygen Saturation waveform
        4. Bedside Cardiac Ultrasound (Subxiphoid Echocardiogram View)
      4. If transcutaneous pacer is also attached
        1. Transcutaneous pacer rate should be at 60 bpm (to differentiate from transvenous pacer)
        2. Once transvenous capture occurs, turn off the transcutaneous pacer
    5. Deflate balloon once capture is achieved
      1. Open stopcock and allow balloon to deflate spontaneously (syringe fills with air)
      2. After balloon deflation, advance pacer wire another 0.5 cm
      3. If capture lost, reinflate balloon and advance again
  7. Troubleshooting problems passing through the tricuspid valve
    1. Short Stature patient (sharp angle between superior vena cava and tricuspid valve)
      1. Withdraw the introducer by small increments and reattempt
    2. Tricuspid regurgitation pushes balloon backwards into right atrium
      1. Consider threading without balloon inflated
    3. Wire threaded into pulmonary artery
      1. Deflate balloon immediately after pacer capture is achieved
    4. Failure to capture at estimated pacer wire distance (see above)
      1. Withdraw and reattempt (may require 5 repeat trials before wire passes through tricuspid, into RV)
        1. Deflate balloon, withdraw wire to 20 cm (2nd mark), reinflate balloon, advance wire
      2. Modifications
        1. Change the speed of pacer wire insertion (slower or faster)
        2. Pacer wire with predetermined curve by manufacturer
          1. Attempt to pass wire without reinflating balloon
          2. Pull back wire to 20 cm, rotate wire 90 or 180 degrees and reattempt insertion
        3. Wire without predetermined curve (straight wire)
          1. Pull wire completely out of sheath, maintaining sterile technique
          2. Coil pacer wire around 2 fingers to introduce curve
          3. Reinsert and attempt insertion techniques for wires with predetermined curve
      3. Maneuver requiring patient cooperation
        1. Patient placed in right decubitus position
          1. Wire advanced with balloon inflated (may ease passage through tricuspid valve)
        2. Patient takes a deep breath (increasing right ventricular inflow)
          1. Wire is advanced during deep breath
      4. Consider alternative access site other than internal Jugular Vein
        1. Opposite internal Jugular Vein
        2. Femoral vein
  8. Adjust Pacemaker generator output
    1. Decrease pacer output by 50% (e.g. 12.5 mA) and observe for 5-10 seconds to confirm continued pacing
    2. Decrease pacer output by another 50% (e.g. 6.25 mA) and observe again for 5-10 seconds
    3. Continue to decrease to 3 mA, then 1 mA
      1. Decrease pacer output until capture is lost (typically 0.3 mA or less)
      2. Increase again until capture occurs and to approximately 2.5 times lowest capture threshold
    4. Typical pacer output: 2 mA
    5. If pacer output required for capture >5 mA, pacer wire is unlikely to be at right ventricular wall
      1. Most often at tricuspid valve annulus
      2. May attempt repositioning wire, but in emergencies, may be left in place until definitive management
  9. Secure catheter and pacer
    1. Extend sheath to cover pacing catheter and tighten the associated valve (tightens diaphragm around wire)
    2. Sheath may be Sutured to skin via a side tab
    3. Tape wire to patient's skin
  10. Consider confirming lead placement with Bedside Ultrasound
    1. Use Subxiphoid Echocardiogram View

VI. Safety

  1. Safe and effective (95% sucess rate) when performed in the emergency department for Symptomatic Bradycardia
    1. Birkhahn (2004) Ann Emerg Med 43(4): 469-74 +PMID: 15039689 [PubMed]
    2. Piela (2016) Am J Emerg Med 34(8): 1411-4 +PMID: 27133534 [PubMed]

VII. References

  1. Bessman in Roberts (2014) Roberts and Hedges Emergency Procedures, Elsevier, Philadelphia, p. 277-97
  2. Kwon and Warrington (2016) Crit Dec Emerg Med 30(9):10-11
  3. Orman and Bellezzo in Herbert (2016) EM:Rap 16(4): 8-9
  4. Sacchetti in Herbert (2017) EM:Rap 17(5): 1-2
  5. Tycynska (2025) Crit Dec Emerg Med 39(8): 4-15

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