• sinus pauses, or
• profound bradycardia of any origin. FAQ
Temporary pacing should also be considered to
How should temporary pacing
increase heart rate in bradycardia-dependent
be initiated in a patient with a
tachycardia that is unresponsive to other therapies
and rarely, for overdrive suppression of tachy-
permanent pacemaker or lead
cardias. The latter are uncommon clinically, but failure?
represent an indication where pacing may play a
A temporary wire can still be placed. The
dramatic role. In each case, it is important to
case for a right internal jugular approach
weigh the possibility of life-threatening arrhyth- is at its strongest in this scenario, as to
mias and the risk of complications encountered ensure that a subclavian approach is
during temporary wire placement. For example, protected for permanent device placement
a patient with stable hemodynamics and a regu- at the time of repair should the initial
lar narrow complex ventricular escape rhythm device, most commonly placed via the
left subclavian vein, be compromised.
> 40 bpm, in the context of complete AV block,
may be monitored closely with transcutaneous
pacing pads in place, while a patient with signif-
icant asystolic periods and unstable, broad com- FAQ
plex escape, leading to syncope not responsive Does temporary pacing lead to
to medical intervention, will derive benefit from pacemaker dependence?
relatively urgent temporary pacing.
It is possible, as pacing has been shown to
How can temporary pacing be promote pacemaker dependence in some
patients, making proper lead placement
delivered? and appropriate monitoring critical.
Temporary pacing is provided via transvenous,
transcutaneous, or epicardial means.
Transcutaneous pacing can be performed as About the authors...
immediate treatment for asystole but typically Dr. Chihrin is a Third Year Medical
requires substantial energy to capture the heart, Student, University of Western
Ontario, London, Ontario.
causing considerable discomfort to most
patients. Epicardial wires can be placed during
cardiac surgery to provide backup pacing in the
Dr. Gould is a Cardiologist, Senior
event of perioperative sinus or AV node injury. Electrophysiological and Pacing
However, most commonly temporary pacing is Fellow at London Health Sciences
provided with a single lead transvenous pace- Center. He has also completed a
PhD in Arrhythmias and Heart
maker. Placement of a balloon-tipped lead can Failure, London, Ontario.
be performed on a stretcher without fluoroscopy
similar to a Swan-Ganz catheter and is aided Dr. Krahn is a Professor and Director
of Education, Division of Cardiology,
considerably by vascular flow directing place- Department of Medicine and is the
ment. Placement of a temporary pacing wire Program Director, Electrophysiology
Training Program, Western University,
with fluoroscopy is easier and safer secondary to London, Ontario.
direct visualization of the lead, making it
Perspectives in Cardiology / August 2007 41
preferable if time permits. Without imaging, a
Carl’s case cont’d... hard-tipped lead can be advanced “blindly”—
that is, advanced with the pacing generator acti-
Recognizing symptomatic third degree vated; observation of ventricular capture and left
atrioventricular block in the context of a recent MI,
you arrange for transfer to the hospital where Carl
bundle branch pattern following each pacing
will receive temporary pacing until the AV block spike will confirm placement in the right ventri-
resolves or a permanent pacemaker is implanted. cle (RV). A more careful, but time consuming,
approach utilizes the pacing wire as an ECG lead
for observation of changes in ECG pattern dur-
ing advancement. While any site within the RV
FAQ will provide adequate temporary pacing, RV api-
What level of monitoring is cal placement affords the greatest stability.
required during temporary Newer temporary pacing wires contain actively-
pacing? fixating helices, which can be affixed to the
endocardium to help maintain positioning, but
Traditional temporary pacing, using require more operator expertise.
standard temporary wires, has been Access sites for transvenous pacing include:
shown to lose capture more frequently • the internal jugular,
when compared to the exceedingly low • subclavian,
risk with permanent pacemakers. • femoral and rarely,
Telemetry should be maintained for the
• the brachial veins.
duration of temporary pacing. Daily
portable chest x-rays can be helpful to The right internal jugular is favourable as it is
assess lead position and anticipate associated with decreased complications and
incipient dislodgement. spares subclavian access for future permanent
pacemaker placement. The femoral vein is
Figure 1. Temporary pacing using an externally placed, reusable permanent pacemaker and disposable
42 Perspectives in Cardiology / August 2007
generally undesirable secondary to increased
incidence of deep vein thrombosis and infection. Take-home message
• Temporary pacing should be provided when
What complications are bradycardia is hemodynamically significant
common? and refractory to other interventions
Complications of temporary pacing have been • The right internal jugular approach is associated
reported to be as high as 35% in a study of with lower complications and protects
subclavian access for future permanent device
British community hospitals,1 but typically
occur in 2% to 10% of patients. Complications
include: • Balloon-guided pacing wires are useful in
• local injury at the venous access site, situations where fluoroscopy is unavailable or
• pneumothorax during subclavian approach, introduces too much delay. However, their
• hemorrhage, efficacy is compromised in states of low blood
• cardiac perforation and pericardial flow
tamponade, • Temporary pacing requires close monitoring
• arrhythmia induction including ventricular including telemetry to avoid dislodgement.
tachycardia and ventricular fibrillation, The duration of temporary pacing using a
• post-procedural lead displacement resulting transvenous approach should be minimized,
in loss of pacing and since complications increase with time
Complication frequency has been inversely
associated with physician expertise. As such, a lead is discarded and a new permanent pacing
minimum of 10 temporary wires should be per- system is implanted at a separate site. Utilized in
formed under guidance for physicians acquiring scenarios where extended temporary pacing is
this skill.2 expected but permanent pacing is not, this
approach improves the reliability of temporary
How long can a patient be paced pacing, decreases monitoring cost and provides
for increased patient comfort and mobility.3 PCard
with a temporary wire?
Most studies have shown a relatively low rate of
infection within one week of traditional transve-
nous temporary pacing. Infection can be reduced 1. Murphy JJ: Current Practice and Complications of Temporary
by avoiding femoral access and maintaining Transvenous Cardiac Pacing. BMJ 1996; 312(7039):1134.
2. ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology: Clinical
high standards of IV access care. Competence in Insertion of a Temporary Transvenous Ventricular
Recently, temporary permanent pacing has Pacemaker. J Am Coll Cardiol 1994; 23(5):1254-7.
3. Chihrin SM, Mohammed U, Yee R, et al: Utility and Cost Effectiveness
been offered at some centers, utilizing active- of Temporary Pacing Using Active Fixation Leads and an Externally
fixation leads and externally placed, reusable Placed Reusable Permanent Pacemaker. Am J Cardiol 2006;
permanent pacemakers, affixed to the skin with
a sterile occlusive dressing (Figure 1). If perma-
nent pacing is required, the system is removed,
the device sterilized for future external use, the
Perspectives in Cardiology / August 2007 43