Transvenous and Transcutaneous Cardiac Pacing

Published on 22/03/2015 by admin

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Last modified 22/03/2015

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W7 Transvenous and Transcutaneous Cardiac Pacing

Raúl J. Gazmuri

image Before Procedure

Indications

• Treatment of symptomatic bradycardia:

• Sinus bradycardia
• Second- or third-degree atrioventricular block

• Prophylaxis:

• Bradycardia-induced ventricular tachyarrhythmias (e.g., torsades de pointes)
• Increased risk of advanced atrioventricular block (e.g., acute myocardial infarction, infective endocarditis, surgery in patients with underlying conduction defects)

• Overdrive pacing for termination of tachyarrhythmias:

• Supraventricular tachycardia
• Ventricular tachycardia

• Improving hemodynamic function:

• Sequential atrioventricular pacing

Contraindications

• Specific advance directives (e.g., do not attempt resuscitation for cases of pulseless electrical activity)
• Asymptomatic bradycardia
• Severe hypothermia (risk of ventricular fibrillation)

Equipment

• Pacing catheter with pulse generator
• Transcutaneous electrodes with pacing unit (integrated with current cardioverter-defibrillators)

image Anatomy

The heart is located behind the sternum. Its base is at the level of the third intercostal space immediately to the right of the sternum, and its apex is at the level of the fifth intercostal space inferior and usually just medial to the nipple. Transcutaneous pacing can be performed by delivering electric impulses through the chest cavity to “capture” and drive the electrical activity of the heart. Electrodes can be placed on the anterior chest wall, with one electrode below the right clavicle lateral to the sternum and the other electrode below the breast tissue along the midaxillary line. Electrodes can also be placed in an anteroposterior configuration with the anterior electrode placed over the precordium and the posterior electrode at the right infrascapular location. For transvenous pacing, the pacing catheter can be advanced through the brachial (antecubital), femoral, internal jugular (preferable right), subclavian (preferable left), or the right subclavian via supraclavicular access (experienced practitioner).

image Procedure

Transvenous Temporary Pacing

• Admit the patient to an appropriately equipped hospital area with capability for monitoring cardiac rhythm, oxygenation, and vital signs, along with airway management and cardiopulmonary resuscitation.
• Obtain a 12-lead electrocardiogram (ECG).
• Attach monitor leads to the patient, and ensure proper display of the patient’s rhythm.
• Perform procedure under fluoroscopy if available and time permits; otherwise use the ECG and rhythm to guide placement.
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