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The Journal of Emergency Medicine, Vol. 32, No. 1, pp. 105–111, 2007Copyright © 2007 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/07 $–see front matter

doi:10.1016/j.jemermed.2006.05.037

TechnicalTips

TEMPORARY TRANSVENOUS PACEMAKER PLACEMENTIN THE EMERGENCY DEPARTMENT

Richard A. Harrigan, MD,* Theodore C. Chan, MD,† Steven Moonblatt, MD,*Gary M. Vilke, MD,† and Jacob W. Ufberg, MD*

*Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, and †Department of

Emergency Medicine, University of California, San Diego Medical Center, San Diego, California

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Abstract—Emergency Department placement of a tem-orary transvenous cardiac pacemaker offers potential life-aving benefits, as the device can definitively control heartate, ensure effective myocardial contractility, and providedequate cardiac output in select circumstances. The pro-edure begins with establishment of central venous access,sually by a right internal jugular or left subclavian veinpproach, although the femoral vein is an acceptable alter-ative, especially in patients who are more likely to bleedhould vascular access become complicated. The indica-ions for the procedure, as well as the equipment needed,re reviewed. Both blind and ECG-guided techniques ofnsertion are described. Methods of verification of pace-

aker placement and function are discussed, as are thearly complications of the procedure. © 2007 Elsevier Inc.

Keywords—transvenous pacemaker; cardiac pacemaker;ardiac procedures

INTRODUCTION

emporary cardiac pacing may be instituted in the Emer-ency Department (ED) for a variety of indications viaeveral different modalities. The goal of temporary car-iac pacing is to restore effective cardiac depolarizationnd myocardial contraction, resulting in the delivery ofdequate cardiac output. Whereas consideration of tem-orary cardiac pacing may begin early in the course of

Technical Tips is coordinated by Gary M. Vilke, M

and Richard A. Harrigan, MD, and Jacob W. Ufber

ECEIVED: 20 October 2004; FINAL SUBMISSION RECEIVED:

CCEPTED: 31 May 2006

105

atient management in the ED—depending upon patienttability—placement of a transvenous cardiac pacemakerTVP) usually is performed after other less invasiveeans of treatment (e.g., pharmacologic, treating the

nderlying cause, transcutaneous pacing) have been ex-lored and exhausted.

Although a variety of pacemaker modalities exist—ransesophageal, epicardial, endocardial, transcutaneous,nd transvenous—it is the latter two methods that havepplicability in the ED. Transcutaneous pacing, which issually employed initially as a temporizing measure, willot be discussed here. Transvenous pacing, which involveslacing a catheter-based electrode into the right side of theeart, is actually two procedures in one: establishing centralenous access, and then introducing and directing the elec-rode through the venous system into the heart. Placementf a TVP involves placement of the electrode into the rightentricle with the goal of pacing the endocardium in a VVIode (Ventricle-paced, Ventricle-sensed, Inhibited sensing

esponse). This is the least complicated approach to rees-ablishing effective cardiac depolarization, and it allows thehysician to pace the heart either asynchronously or in aemand mode, wherein the pacemaker is inhibited when aative impulse is sensed.

This review will focus on the indications for TVPlacement and describe the two common ways the pro-edure may be performed in the ED—blindly and with

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lectrocardiographic (ECG) guidance. Confirmation oflacement and function will be discussed, and commonlyncountered complications will be reviewed.

INDICATIONS AND CONTRAINDICATIONS

arious authorities differ slightly when defining the in-ications for placement of a TVP (1–3). Indications cane viewed with several constructs in mind: emergencys. prophylactic pacemaker placement; treatment of bra-ydysrhythmias vs. tachydysrhythmias; and in patientsxperiencing acute myocardial infarction vs. those whore not. Table 1 lists standard emergent indications forVP placement, and Table 2 depicts commonly acceptedrophylactic indications for the procedure. In most emer-ent circumstances, a transcutaneous pacemaker is uti-ized initially while the patient is prepared for TVPlacement. Transvenous pacing, and in fact pacing ineneral, does not seem to be beneficial in asystolic/radyasystolic cardiac arrest, traumatic cardiac arrest, orn patients with profound hypothermia and bradydys-hythmias (3,4). In the latter group, aggressive treatmentf the underlying condition is paramount, due to theheoretic concern that introducing a pacing wire into aypothermic patient may precipitate terminal dysrhyth-ias. However, in-hospital cardiac arrest victims with

omplete heart block or bradycardia (not those withsystole) may receive some benefit from transvenousacing unresponsive to pharmacotherapy (5).

EQUIPMENT

he equipment needed to insert a TVP includes an in-

able 1. Indications for Emergent Transvenous PacemakerPlacement (1–3)*

radydysrhythmiasSymptomatic sinus node dysfunction

Sinus arrestSinus bradycardia

Symptomatic atrioventricular blockSecond degree atrioventricular block, Mobitz type II

hird degree (complete) atrioventricular blockSymptomatic drug overdose

achydysrhythmiasOverdrive pacing of rhythms refractory to medical

management

The indications are listed with the assumption that: 1) less invasiveeans (e.g., pharmacologic agents and antidotes, transcutaneous

ardiac pacing) have been tried without success or that successs judged to be short-lived; or 2) the patient is experiencingrofound symptomatology (e.g., severe chest pain, dyspnea, orltered state of consciousness; hypotension; shock; pulmonarydema; or acute myocardial infarction).

roducer sheath, pacing catheter, and external pacing

enerator. In addition, an ECG machine and cardiaconitor should be available. Several pre-packaged trays

re available that contain the introducer sheath, pacingatheter, and other equipment necessary for pacemakernsertion.

The external pacing generator is used to deliver thelectrical current, measured in milliamperes (mA),hrough the pacing catheter. Various available generatorshare the same basic features (Figure 1). The pacingenerator has electrical output and cardiac sensing com-onents, which are usually present as dials on the face ofhe generator. An output control dial allows for regula-ion of the current, usually from 0.1 to 20 mA. Thisrincipally determines the ability of the pacemaker tocapture” the heart. A rate control dial selects the pacingate. The pacing generator also has a sensitivity controlhat establishes a threshold, based on the amplitude of theative R wave, required to suppress the pacemaker fromring. Turning the sensitivity control down will lead toxed rate, or asynchronous, pacing, wherein the pace-aker fires regardless of the patient’s underlying rhythm.

ncreasing the sensitivity in concert with modifying theate control will eventually lead to demand, or synchro-ous, pacing. This occurs when the pacing generatorenses intrinsic cardiac activity and inhibits the TVProm firing. In demand mode, the pacemaker senses theatient’s underlying ventricular rate and will not fire asong as the patient’s rate is equal to or faster than the rateet on the pacing generator (2,3).

Various transvenous pacing catheters are availableith basic similarities. Most are bipolar, 3 Fr to 5 Fr in

ize, and approximately 100 cm in length (3). Linesarked at 10-cm intervals on the catheter surface can be

sed to estimate catheter position. Catheters are classi-ed as flexible, semifloating, or rigid/non-floating cath-ters. The latter group carries a higher risk of cardiacerforation, and thus they are generally used only underuoroscopic guidance, where their stiffness yields theenefit of easier manipulation (1). In emergency situa-ions, a semifloating catheter with or without a balloonip is used most commonly (1–3). In the patient inardiac arrest, inflating the balloon carries no benefit, as

able 2. Indications for Prophylactic TransvenousPacemaker Placement (1–3)

cute myocardial infarction (especially anterior distribution)and

Symptomatic sinus node dysfunctionSecond degree atrioventricular block, Mobitz type IIThird degree atrioventricular blockNew left, right, or alternating bundle branch blockNew bifascicular block

ymptomatic patient secondary to failure of permanent

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Temporary Transvenous Pacemaker 107

here is no forward flow of blood to guide an inflatedalloon through the venous system into the right side ofhe heart. The balloon holds approximately 1.5 cc of airnd should be tested for air leak before insertion. At theeading end of the catheter are two electrodes, one ofhich is marked negative and lies distally. Adapters are

upplied in the kit to allow the electrodes to be attachedo the pacing generator or to an ECG lead (Figure 2).

The introducer sheath is used to establish centralenous access. The sheath allows for passage of theacing catheter into the vein and must be at least one sizearger than the pacing catheter. Some sheaths will con-ain an additional port for administration of intravenousuids or medications.

PLACING THE TRANSVENOUS PACEMAKER

reparation and Site Selection

nce all the equipment is available, the patient isrepped in the usual sterile fashion. A wide area shoulde cleaned and the patient generously draped to ensurehat all the equipment remains in a sterile field.

Choosing a central venous access site may depend onhysician preference and experience. Options include thenternal jugular, subclavian, femoral, or brachial veins.he right internal jugular and the left subclavian veinsre often preferred, having demonstrated the highestates of proper placement in code situations; these routesllow for smooth and direct placement, taking advantagef the natural curve of the pacing catheter (2,3). The right

alloon; (B) balloon inflation port; (C) negative electrode; (D)

igure 1. Pacemaker generator. (A) Pacing indicator. (B)ensing indicator. (C) Rate control knob. (D) Pacing output

igure 2. Transvenous pacemaker catheter. (A) Catheter tip with b

ing generator; (F) alligator clip to attach negative electrode

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nternal jugular provides the most direct route to the rightentricle and is associated with the lowest complicationate (6). If the patient is anticoagulated or has receivedhrombolytics, the internal jugular or subclavian routes areot recommended due to poor compressibility of the vas-ular structures. In this case, establishing femoral venousccess is more appropriate. The brachial vein is rarely used,s the catheter is easily dislodged and the site is associatedith a higher risk of infection and thrombosis (1–3).

nsertion Techniques

fter central venous access is obtained and the intro-ucer sheath is secured in place, the TVP can benserted using either ECG guidance or blindly. Manyhysicians prefer the blind technique because it isaster and technically less complex. To perform thelind procedure, the catheter electrodes are connectedirectly to the pacing generator. The catheter is thennserted and the pacing generator turned on. If theatient has a pulse, the balloon can be inflated once itas passed through the introducer sheath, approxi-ately at the 20-cm mark on the catheter; otherwise,

he catheter can be advanced with the balloon down.he pacing generator is set with the output to theaximal current, the pacing rate to between 60 and 80

eats/min, and the sensitivity to the lowest level (com-letely counterclockwise or asynchronous). As theatheter is advanced, the ECG monitor placed on theatient will usually show pacemaker spikes. When theatheter enters the right ventricle and makes contactith the endocardial wall, a left bundle branch blockattern (e.g., wide QRS complex) should be seen aftervery pacemaker spike (if a right-sided V lead issed), indicating capture. If the balloon was up, it canow be deflated and the catheter secured in place. Althoughlind insertion can be performed relatively quickly, theperator receives virtually no feedback as the catheter isdvanced—this being the major drawback of this technique1–3).

lacement with ECG Guidance

lacement with ECG guidance makes use of the TVPatheter’s sensing function and allows the physician toonitor the progression of the catheter as it ap-

roaches the right ventricle by analyzing the variousaveforms that appear as the catheter is advanced.he pacing catheter serves as an intracardiac ECG

ead that localizes the position of the tip of the cath-ter. This technique requires that the negative (distal)

lectrode from the end of the catheter be attached to c

ny of the precordial (V) leads on the ECG machinesing an alligator clip. The rest of the leads should beonnected to the patient in the usual fashion. Progres-ion of the catheter can be marked by recognition of char-cteristic waveforms; the magnitude and polarity of theseaveforms are subject to change as the catheter moves

hrough the heart (Figure 3).Superior vena caval location results in low ampli-

ude P waves and QRS complexes, both with a nega-ive polarity as the sensing electrode lies above theeart, with atrial and ventricular depolarization vec-ors directed (generally) downward and to the left—way from the catheter. As the catheter tip enters theight atrium, the P wave becomes larger (indeed largerhan the QRS complex due to the tip’s closer proxim-ty to the native atrial pacemaker), and both the P wavend the QRS complex are initially negative. However,he P wave will become biphasic and then positive ashe catheter passes down through the right atrium andhe tricuspid valve. Right ventricular entry is signaledy a small positive P wave followed by a deeplyegative QRS complex. When the tip of the catheterngages the right ventricular endocardium, the QRSomplex will show a current of injury with ST seg-ent elevation. If the catheter exits the right atrium

nto the inferior vena cava, the P wave should maintainpositive polarity while the QRS complexes lose

mplitude as the catheter courses further away fromhe heart. This would be the same pattern noted if theemoral approach were used, but in this case it wouldrecede the right atrial tracing. If the catheter traverseshe right ventricle and strays into the pulmonary ar-ery, the P wave will again become negative as theatheter tip travels above the atria, and the QRS com-lex will become smaller due to the increased distancerom the right ventricle (7). If a balloon tip catheter ismployed, the balloon should be inflated when theatheter tip enters the right atrium and deflated whenassing through the tricuspid valve, as this should helpuide the catheter toward its ideal destination withinhe right ventricular apex. Migration toward the rightentricular outflow tract and pulmonary artery favoredy forward flow will thus hopefully be avoided (1–3).

Once the catheter is in position, it should be discon-ected from the ECG machine and attached to the pacingenerator. As with the blind technique, the pacing generators then set with maximal current output, a pacing rate in theange of 60 and 80 beats/min, and the sensitivity to theowest level (asynchronous). A left bundle branch blockattern should be seen after every pacer spike on a surfaceCG, indicating capture. If complete capture does not oc-

ur, the TVP catheter needs to be repositioned.

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Temporary Transvenous Pacemaker 109

erification of Placement

hest radiography should be performed to verify posi-ioning after the TVP is secured, as well as to excludeatrogenic pneumothorax secondary to placement of aentral venous line in the thorax if the subclavian ornternal jugular approaches are employed. The catheterip should be located ideally in the right ventricular apex.

portable anteroposterior chest X-ray study is mostommonly used, and the catheter tip should be visualizedt the anterior-inferior aspect of the cardiac shadow,sually slightly to the left of the thoracic spine. If properlacement is in question, a cross-table lateral view sug-ests right ventricular apex placement when the catheterip overlies the inferior aspect of the cardiac shadow andoints toward the sternum. One study using radiographyo determine catheter placement after blind insertion inhe ED found the right atrium to be the most commonite of catheter misplacement, occurring in 50% of cases,ue to both insufficient advancement as well as coilingithin the right atrium. Successful placement in the rightentricle (10 of 36 cases) was significantly more likely ifn internal jugular approach was used. Interestingly,wo-thirds of TVP catheters in this study were placed viahe less-preferred right subclavian vein approach, which

ay have contributed to the high rate of improper posi-

igure 3. ECG recordings from within the right heart durinid-to-low right atrium; (C) low right atrium-to-tricuspid an

ardium; and (F) surface ECG demonstrating pacemaker carocedures in the emergency department patient with acute

ioning—as this approach accounted for 16 of the 18 t

ight atrial catheter placements. The left subclavian ap-roach, used in six cases, led to two right ventricular andhree inferior vena cava placements, and one right atriallacement (8).

Proper placement can be further verified by the 12-ead ECG. Right ventricular apical location will manifests a left-bundle-branch-like pattern on the ECG, with thexception that there is usually precordial QRS complexoncordance in a negative polarity (Figure 4), whereas arue left bundle branch pattern features QRS complexransition from negative to positive polarity in the mid-recordial leads. The tracing will also feature a leftwardrontal plane QRS axis deviation as the pacemaker-gen-rated impulse emanates from the right ventricular apexnd travels leftward and superiorly.

erification of Function

acing (output) thresholds and sensing thresholds needo be tested after the operator has demonstrated pacingapture; the latter threshold only pertains to those pa-ients who have some sort of underlying rhythm to sense.he pacing threshold is the minimum current needed tobtain capture. To determine this, the pacing generator iset to a high level of current output, and the pacing rate

svenous pacemaker placement. (A) High right atrium; (B)(D) right ventricle; (E) contact with right ventricular endo-Reprinted with permission from (2): Wald DA. Therapeutic

ardial infarction. Emerg Med Clin North Am 2001;19:451–67.

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bove the native rate, if one exists. The output is thenlowly reduced until capture is lost. This test is repeatedeveral times to verify this threshold value. The currenthould then be set to roughly 2–2.5 times the threshold tonsure capture. The ideal pacing threshold is � 1 mA, sohe pacing output is usually set to no more than 2–3 mA;he catheter should be repositioned if this threshold isbove 5–6 mA (1–3).

The sensing threshold needs to be tested only if theacemaker is going to be used in the synchronous oremand mode; i.e., if the patient has an underlyinghythm to be “sensed.” To test the sensing threshold, theate is set to about 10 beats/min below patient’s intrinsicate and the sensitivity dialed clockwise to the highestalue (demand mode). With these settings, the pace-aker should not be firing, only sensing, as indicated by

he flashing of the sensing light and the absence of pacedeats. The sensitivity is then dialed counterclockwise andowered until the pacer starts firing again. This value ishe sensing threshold. The sensitivity control should thene lowered to below the sensing threshold to ensuredequate sensing, and to ensure that inappropriate stimuliuch as T waves, artifact, and muscle twitches are notoversensed” by the unit, resulting in inappropriate sup-

igure 4. 12-Lead ECG demonstrating ventricular paced rharrow pacemaker spikes (arrows). The right precordial leadshe left precordial leads (V4–V6) differ from this classic paeflection. Also note the leftward frontal plane QRS axis de

ression of the pacemaker (1,2). u

A more recent advance in the emergent placement ofransvenous pacemakers in the ED has been the use ofedside ultrasound guidance. Ultrasound imaging pro-ides real-time visualization of the passage of the pacingire into the right ventricle, and can demonstrate contactf the pacing wire with the right ventricular myocardium.ltrasound may also be used to verify positioning oflindly placed pacing wires, and to detect complicationsf this procedure such as interventricular septal perfora-ion (9,10).

Most commonly, a 3.5-MHz linear array probe is usedn the subcostal (also known as subxiphoid) position. Theubcostal view is preferred, as it allows excellent viewsf all four cardiac chambers as well as cardiac wallotion. This position also does not interfere with neces-

ary monitoring equipment such as transcutaneous pac-ng pads or ECG leads. The pacing wire appears as aright linear hyperechoic structure as it enters the heart,nd can be followed as it traverses the tricuspid valvento the right ventricle and contacts the myocardium ofhe right ventricular apex. Capture is quite apparentonographically as the rhythmic contraction of the heartan be seen at the pacing rate.

Two small case series have described success using

Note the characteristic wide-QRS complexes preceded by3) resemble the classic left bundle branch block pattern, yetn that the QRS complexes maintain a principally negative.

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Temporary Transvenous Pacemaker 111

acemaker wires (9,11). The study by Aguilera docu-ented successful placement of tranvenous pacemakerires using ultrasound guidance in 8 of the 9 patients (89%)

n whom it was attempted, a huge improvement over pre-iously reported success rates as low as 10% (8,9).

COMPLICATIONS

omplications of the TVP can be classified as thoseelated to the various phases of the procedure. First,btaining central venous access carries the risk of arterialuncture, pneumothorax, and infection as the most com-only encountered complications, as well as the more

nusual, including air embolism, venous thrombosis andhrombophlebitis, and catheter/guidewire looping andntrapment. Next, there are the risks associated withight-heart catheterization. These include dysrhythmias,ailure to capture, failure to sense, and oversensing.urthermore, the catheter may be misplaced, such as in

he coronary sinus, clues to which include an unexpect-dly high pacing threshold, failure to capture, a rightundle branch block ECG pattern despite right ventric-lar placement, and a posteriorly directed catheter onateral chest X-ray. The catheter may perforate the sep-um, also leading to a right bundle branch block patternn the 12-lead ECG. Clues to ventricular free wall per-oration include loss of capture, chest pain, a new peri-ardial friction rub, and pacing of the thoracic wallusculature. Ventricular perforation may result in hemo-

ericardium, tamponade, and death. Cardiac ultrasounds useful in detecting this complication (1–3,6,12–14).

Three case series from cardiology critical care settingsighlight the relatively high rate of TVP complications6,12,13). The number of complications has been demon-trated to increase the longer the catheter stays in place (6).ailure to capture or failure to sense are relatively commonomplications, occurring in 37–43% of cases (12,13).

SUMMARY

VP placement is a potentially life-saving procedure that

nvolves placing a catheter-based electrode within the

ight ventricle via central venous access, and then stim-lating that electrode and the heart with an externalacing generator to optimize cardiac output. In the Emer-ency Department, the procedure can be performed ei-her blindly or with ECG guidance. After placement, theVP must be tested to ensure adequate capture of theyocardium, as well as to assess its sensing abilities if a

ative rhythm remains.

REFERENCES

1. Jafri SM, Kruse JA. Temporary transvenous cardiac pacing. CritCare Clin 1992;8:713–25.

2. Wald DA. Therapeutic procedures in the emergency departmentpatient with acute myocardial infarction. Emerg Med Clin NorthAm 2001;19:451–67.

3. Bressman ES. Emergency cardiac pacing. In: Roberts JR, HedgesJR, eds. Clinical procedures in emergency medicine, 4th edn.Philadelphia, PA: Saunders; 2004:283–304.

4. Syverud SA, Dalsey WC, Hedges JR. Transcutaneous and trans-venous cardiac pacing for early bradyasystolic cardiac arrest. AnnEmerg Med 1986;15:121–4.

5. Hazard PB, Benton C, Milnor P. Transvenous cardiac pacing incardiopulmonary resuscitation. Crit Care Med 1981;9:666–8.

6. Hynes JK, Holmes DR, Harrison CE. Five-year experience withtemporary pacemaker therapy in the coronary care unit. Mayo ClinProc 1983;58:122–6.

7. Bing OHL, McKowell JW, Hantman J, Messner JV. Pacemakerplacement by electrocardiographic monitoring. N Engl J Med1972;287:651.

8. Syverud S, Dalsey WC, Hedges JR, Hanslits ML. Radiologicassessment of tranvenous pacemaker placement during CPR. AnnEmerg Med 1986;15:131–7.

9. Aguilera PA, Durham BA, Riley DA. Emergency transvenouscardiac pacing placement using ultrasound guidance. Ann EmergMed 2000;36:224–7.

0. Nanda N, Barold S. Usefulness of echocardiography in cardiacpacing. Pace 1982;5:222–7.

1. Macedo W, Sturmann K, Kim JM, Kang J. Ultrasonographicguidance of transvenous pacemaker insertion in the emergencydepartment: a report of three cases. J Emerg Med 1999;17:491– 6.

2. Lumia FJ, Rios JC. Temporary transvenous pacemaker therapy: ananalysis of complications. Chest 1973;64:604–8.

3. Austin JL, Preis LK, Crampton RS, et al. Analysis of pacemakermalfunction and complications of temporary pacing in the coro-nary care unit. Am J Cardiol 1982;49:301–6.

4. Wang HE, Sweeney TA. Subclavian central venous catheterizationcomplicated by guidewire looping and entrapment. J Emerg Med

1999;17:721–4.