Written by: Taylor Douglas, M.D.
You are the single provider in a rural Emergency Department, taking care of an unstable bradycardic patient. You are successfully pacing your patient transcutaneously, and now it’s time to get them a more definitive and comfortable method of pacing before they are transferred for cardiology evaluation. For now, they’re receiving as needed fentanyl boluses, so you have a few minutes to collect yourself. Before you place a transvenous pacemaker (TVP), you need to consider reasons why this procedure would not be the right choice for your patient.
When not to insert a TVP
Occlusion MI
Aortic Dissection
Other aortic valvular pathology
These three examples demonstrate that before placement of a TVP, the etiology of the patient’s bradycardia must be established or at least certain diagnoses must be ruled out. If your patient has an OMI, dissection, or valvular pathology, placing a TVP is only delaying the initiation of the necessary treatment and putting your patient at risk of morbidity and/or mortality.
Supplies
Once you’ve decided that TVP is right for your patient, you start to think over the procedure and the necessary supplies. Your mind is initially blank, but then you recall your co-resident did a morning report on this topic and shared a handy list of supplies and steps that you can follow:.
- • TVP kit*
- • Central line bundle including sterile drape, gown, dressing kit, etc.
- • Pacemaker box and wires
- • Ultrasound and probe cover
- • Additional chloraprep and large tegaderms
- • Consider spare TVP kit and/or CVC kit at bedside for supplies if needed
*Common sheath and wire sizes are 5fr and 6fr, common combination is a 5fr pacing wire and a 6fr sheath introducer, not all wires and introducers will work for this if you grab from another kit i.e. trauma cordis is usually 7-8 fr
Non-sterile Prep
Especially if you are performing this procedure with minimal support, you don’t want to try to instruct someone how to do this once you’re already sterile
- • Ensure pacemaker box is charged and turned on
- • Plug cord into “V” port of box
- • Set to VVI (decrease atrial output to 0), HR 70, ventricular output to 10 mA, sensitivity 2 mV
*Temporary pacemakers are always set to VVI, meaning the ventricle is paced, the ventricle is sensed, and the pacemaker is inhibited if an intrinsic beat is sensed, other modes reviewed here*
Image 1. Still image of insertion of packing wires into “V” port [1]
Image 2. Medtronic pacemaker with recommended initial settings [2]
Sterile Prep
- 1. Test balloon
- 2. Place sheath cover over wire (must be done BEFORE inserting wire into patient)
- 3. Lock dilator into Cordis if possible
Image 3. Setup of both ends of pacing wire, including placement of sheath prior to insertion into Cordis. [3]
Placement of catheter
- 1. The same process as Cordis for trauma, similar to central line*
- 2. Venipuncture under ultrasound guidance
- 3. Thread wire
- 4. Dilator is advanced within Cordis, remove after placement
- 5. Flush side port, suture in place including looping of suture through the groove on the catheter
The placement of the wire has already been discussed in a prior post. Jump over to it for more details, and then return to review the troubleshooting steps for common problems. Additionally, check out this video of cordis placement that gives you a visual review and emphasizes the importance of how to grip the catheter and dilator for successful advancement.
Both catheter and wire placement can and should be performed under ultrasound guidance. The ultrasound can serve multiple confirmatory purposes. First, as with all central line placements, for confirmation of venipuncture, threading of wire, and proper placement of the catheter. This is performed by the sterile physician using a sterile probe cover. However, a non-sterile assistant can use the cardiac probe to confirm placement of the catheter by watching for a flush of agitated saline, as well as placement of the pacemaker wire (discussed further below).
Confirmation of TVP location
- • Chest x-ray [4]
- • 12-lead EKG (running during entire procedure): look at QRS complex in leads V1, II, III, aVF [5]
- • Point-of-care ultrasound
Use of point-of-care ultrasound to confirm TVP location
This is an excellent resource if you’re having difficulty during placement or don’t have a running 12-lead EKG for instant feedback while you are floating. This requires a non-sterile assistant who can obtain a subxiphoid cardiac view underneath the sterile field. The balloon can be visualized passing through the tricuspid valve and into the ventricle, and capture can also be assessed from this vantage point. [6]
Image 4. Still image of full connected setup [1]
Determining the capture threshold
- • The goal is to identify the minimum output at which there is still consistent capture.
- • Set the pacemaker well above the native rate, so that the chamber of interest is being paced continuously
- • Start reducing the output until a QRS complex no longer follows each pacing spike.
- • Typically, one might want to set the output to about double the capture threshold (some suggest adding one). [7]
Troubleshooting:
Cannot see any capture, only TC pacing spikes, both set at similar rates
Check all settings with those above
Unable to pass through tricuspid valve
Cannot confirm placement
Difficulty in advancing catheter, not obtaining capture
Failure to sense
Failure to Capture (A pacer spike is present but is not followed by a corresponding waveform (P wave or QRS complex)
References:
[1]EM:RAP Productions. Placing a Transvenous Pacemaker. EM:RAP Productions; 2018. https://www.youtube.com/watch?v=00-T8PcbStE. Accessed March 26, 2021.
[2] Kumar R. Overview Of Temporary Pacemakers. RK.md. https://rk.md/2020/overview-of-temporary-pacemakers/. Published March 4, 2020. Accessed March 29, 2021.
[3]Bohanske M. Transvenous Pacemaker Placement – Part 1: The Walkthrough. TAMING THE SRU: emergency medicine tamed. November 2013. https://www.tamingthesru.com/blog/procedural-education/transvenous-pacemaker-placement-part-1-the-walkthrough. Accessed March 26, 2021.
[4] Harrigan RA, Chan TC, Moonblatt S, Vilke GM, Ufberg JW. Temporary transvenous pacemaker placement in the Emergency Department. The Journal of Emergency Medicine. 2007;32(1):105-111. doi:10.1016/j.jemermed.2006.05.037
[5] Assessment of Pacemaker Malfunction. In: Pacemakers and Cardiac Devices. https://ecgwaves.com/topic/assessment-of-pacemaker-malfunction-using-ecg/. Accessed March 26, 2021.
[6] Sjaus A, Fayad A. The Use of Subcostal Echocardiographic Views to Guide the Insertion of a Right Ventricular Temporary Transvenous Pacemaker—Description of the Technique. Journal of Cardiothoracic and Vascular Anesthesia. 2019;33(10):2797-2803. doi:10.1053/j.jvca.2019.01.033
[7] Yartsev A. Sensitivity and output settings of the temporary pacemaker. Deranged Physiology. https://derangedphysiology.com/main/required-reading/cardiothoracic-intensive-care/Chapter%209125/sensitivity-and-output-settings-temporary-pacemaker. Published June 30, 2015. Accessed March 26, 2021.
[8] Liu M, Han X. Bedside temporary transvenous cardiac pacemaker placement. The American Journal of Emergency Medicine. 2020;38(4):819-822. doi:10.1016/j.ajem.2019.12.013
[9] Gammage MD. Temporary cardiac pacing. Heart. 2000;83(6):715-720. doi:10.1136/heart.83.6.715
[10] Swaminathan A. Pacemaker Basics. REBEL EM. August 2017. https://rebelem.com/pacemaker-basics/. Accessed March 26, 2021.
[11] Nickson C. Temporary Pacemaker Troubleshooting. Life in the Fast Lane. August 2014. https://litfl.com/temporary-pacemaker-troubleshooting/. Accessed March 26, 2021.
[12] Bessman ES. Emergency Cardiac Pacing. In: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. Philadelphia, PA: Saunders/Elsevier; 2010.
[13] Mollenkopf FP, Rhine DK, Dandapantula HK. Temporary Transvenous Pacemakers. In: Taylor DA, Sherry SP, Sing RF, eds. Interventional Critical Care A Manual for Advanced Care Practitioners. Springer International Publishing; 2016:133-146.
[14] Nekic P. Pacemaker Learning Package. Liverpool, Australia: Liverpool Hospital; 2016:1-46. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/306588/Pacemaker_Learning_Package.pdf. Accessed March 26, 2021.
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