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Overdrive Pacing
Michael Self; Christopher R. Tainter.
Author Information

Last Update: July 10, 2022.

Go to:

Continuing Education Activity

Temporary cardiac pacing (TCP) is a type of exogenous cardiac pacing in which an external
energy source delivers electrical impulses to stimulate the heart to contract faster than its
native rate. This intervention can be used to over-ride a malignant tachydysrhythmia or
compensate for symptomatic bradycardia. TCP is typically used for dysrhythmias refractory
to pharmacological therapies or cardioversion. This activity reviews the indications,
contraindications, and various techniques for TCP and explains the role of the
interprofessional healthcare team in managing patients who undergo TCP.
Objectives:
 Describe the common indications for temporary cardiac pacing.
 Review the technique involved in various types of temporary cardiac pacing,
including transcutaneous, transvenous, and epicardial.
 Identify the potential complications of temporary cardiac pacing.
 Summarize a structured, interprofessional team approach to provide effective care
to and appropriate surveillance of patients undergoing temporary cardiac pacing.
Access free multiple choice questions on this topic.
Go to:

Introduction
Temporary cardiac pacing (TCP) is a type of exogenous cardiac pacing in which an external
energy source delivers electrical impulses to stimulate the heart to contract faster than its
native rate. This intervention can be used to over-ride a malignant tachydysrhythmia or
compensate for symptomatic bradycardia. TCP is typically used for dysrhythmias refractory
to pharmacological therapies or cardioversion. Temporary cardiac pacing is not a new
intervention; it was first attempted in 1952 when Paul Zoll used hypodermic needles in the
chest wall to deliver a pulsating external current for two patients with asystole.[1] Today,
TCP is available in a broad spectrum of critical care settings, from pre-hospital to the
intensive care unit, delivered via a variety of modalities, including transcutaneous,
transvenous, epicardial, and transesophageal.[2] This activity will focus on temporary
cardiac pacing in critical care settings.
Go to:

Anatomy and Physiology

Exogenous cardiac pacing utilizes an external power source to deliver electrical impulses to
the myocardium, directly stimulating myocardial depolarization and ventricular (or atrial)
contraction and allowing the physician to manipulate the electromechanical conductance of
the heart.
In normal physiology, an electrical impulse is generated at the sinoatrial (SA) node, is
transmitted through the atrioventricular (AV) node, and then down the His-Purkinje system
leading to sequential ventricular depolarization and contraction. In bradydysrhythmias, a
variety of pathologic processes can affect any point in the conduction system, leading to an
insufficient heart rate and, therefore, cardiac output. When used for bradydysrhythmias,
exogenous pacing generates extrinsic electrical impulses that bypass the affected conduction
system causing direct ventricular depolarization. The physician can then stimulate ventricular
contraction at a rate greater than the native ventricular or junctional rate, increasing cardiac
output to meet demand.[2][3]
In contrast, refractory tachydysrhythmias have varied pathophysiology. In supraventricular
tachydysrhythmias, there is often a reentrant pathway that bypasses the AV node or an
ectopic and unregulated pacemaker. Anti-tachycardia pacing (ATP) attempts to correct this
by disrupting the reentrant circuit or over-riding the ectopic pacemaker with an external
electrical impulse at a rate of 10 to 20 BPM greater than the native rate, changing the pattern
of repolarization. In refractory monomorphic ventricular tachycardia, ATP prevents
abnormal ventricular automaticity by changing the pattern of ventricular depolarization and
creating more uniform repolarization. In refractory polymorphic ventricular tachycardia,
increasing the rate of ventricular depolarization decreases the ventricular refractory period,
thereby reducing susceptibility to the R on T phenomenon.[3][4] Using ATP to override a
native dysrhythmia is also called overdrive pacing (ODP).
Temporary transcutaneous pacing (TTCP) uses external pads to transmit an electrical
impulse through the skin, subcutaneous soft tissue, and chest wall to stimulate ventricular
depolarization. Adherent cutaneous pads are used in either the anterior-posterior or anterior-
lateral positions, with the former being preferred.[1]
Temporary transvenous pacing (TTVP) uses central venous access, typically via the right
internal jugular or left subclavian vein, to pass an electrode into the right ventricle (RV).
Electrical impulses are then delivered to the RV endocardium, depolarizing it first, resulting
in a left bundle branch block (LBBB) pattern on an electrocardiograph (ECG).
Epicardial pacing is most often deployed intraoperatively during cardiac surgery. Pacing
electrodes get placed on the epicardium at the right atrium (RA) and RV, or RA, and both
ventricles.[2]
Transesophageal pacing occurs through placing an electrode in either the mid-esophagus,
stimulating the RA, or in the gastric fundus, stimulating the RV through the diaphragm.
Transesophageal pacing is not common due to difficult lead placement and patient
discomfort.[1]
Go to:
Indications
Temporary cardiac pacing may be indicated for any symptomatic bradydysrhythmia when
permanent cardiac pacing is not immediately indicated, unavailable, or too risky, such as
severe hemodynamic instability. The most common indication is symptomatic bradycardia
due to AV nodal block. There are a variety of reversible causes of bradycardia for which
TCP may be indicated, including acute myocardial infarction, electrolyte disturbances, drug
toxicity, damage to the intrinsic conduction system during cardiac surgery or valve
replacement/repair, cardiac trauma, cardiac abscess, myocarditis, heart transplant, and others.
TCP may also be indicated for refractory ventricular tachycardia, electrical storm, or
refractory polymorphic ventricular tachycardia. Prophylactically, TCP may be an option for
preventing tachydysrhythmias such as atrial fibrillation and atrial flutter following cardiac
surgery.[1][2][3][4][5]
Go to:

Contraindications
There are no absolute contraindications to temporary cardiac pacing. However, TCP should
be avoided or used with caution in certain scenarios. The most common reason to avoid any
kind of temporary cardiac pacing is hemodynamically stable bradydysrhythmias with rare or
tolerable symptoms. Clinicians should avoid cardiac pacing in hypothermia (unnecessary)
and prolonged bradyasystolic arrest (futile). Clinicians should also avoid transvenous pacing
in patients with a prosthetic tricuspid valve, as catheter placement may damage the valve or
the catheter may become stuck in the valve, and patients with an excessive risk of bleeding,
including those with acute myocardial infarction receiving thrombolytics, anticoagulants, and
antiplatelet agents.[1][2][3]
Go to:

Equipment
Temporary transcutaneous pacing requires a pulse generator and monitoring unit with
standard defibrillation pads. These are ubiquitous in most medical settings. The pulse
generator must have a pacing function. ECG electrodes, non-invasive or invasive blood
pressure monitoring and pulse oximetry are strong recommendations.[1][6]
Temporary transvenous pacing requires central venous access, typically with a 6 French (Fr)
venous percutaneous introducer sheath, a transvenous pacing catheter, and an external pulse
generator. Ultrasound guidance for central venous access is also a strong recommendation. A
12 lead-capable ECG machine, cardiac monitor, non-invasive or invasive blood pressure
monitoring, and pulse oximetry should be available. This procedure is sterile, and standard
sterile technique is necessary.[1][2][3]
The transvenous pacing catheter is mostly bipolar, 3 Fr to 5 Fr in diameter and 100 cm long.
Lines are typically present at 10 cm intervals to estimate catheter depth. Catheters may be
flexible, semi-floating, or rigid. For most emergent indications, when temporary pacing
would be in order, a semi-floating catheter with a balloon is used. The balloon holds 1.5 ccs
of air and requires testing before insertion. The leading end of the catheter has two
electrodes, of which the negative is most distal. Adapters allow the electrodes to be attached
to the pulse generator.[2][3]
The external pulse generator delivers an electrical current through the pacing catheter,
measured in milliamperes (mA). Generators share the same basic features, including
electrical output and cardiac sensing components. These are present as dials on the
generator’s face. Output control regulates the current delivered, functionally controlling the
ability to obtain electrical capture. Rate control selects the pacing rate. Sensitivity control
establishes the threshold at which a sensed intrinsically generated current inhibits the
pacemaker from firing. This setting is the choice for demand (synchronous) pacing. For most
emergent indications, the sensitivity control is turned to the lowest setting, providing
asynchronous (fixed rate) pacing.[2][3]
Epicardial pacing typically requires an external pulse generator and surgically placed
epicardial pacing electrodes. The electrode location requires confirmation with the surgical
team.[2][7]
Go to:

Technique
Temporary Transcutaneous Pacing (TTCP)
 Depending on the clinical scenario, consider analgesia and/or sedation before or
immediately after, initiating transcutaneous pacing as the electrical current needed
for capture is painful.
 Place the pacing pads in an anterior-posterior (preferred) or anterior-lateral
configuration.
 Attach the pads to the pulse generator, most often a defibrillator with pacing
capabilities. Some pulse generators require the attachment of cardiac monitoring
leads for proper functioning.
 Select the pacing function on the defibrillator.
 Select the desired rate per indication, typically 60 to 80 BPM or 10 to 30 BPM
greater than the intrinsic rate.
 Starting at 70 milliamps (mA), increase the output by 5 to 10 mA until the
initiation of capture, indicated by a wide-complex QRS following every pacer
spike (electrical capture) and signs of improved perfusion (mechanical capture).
 It is critically important to confirm ventricular contraction (mechanical capture), as
it is not difficult to be misled by electrical activity representing a QRS complex,
which is possible by confirming a pulse that matches the set pacemaker rate by
palpation echocardiogram, pulse oximetry, or arterial waveform.
  The current at which capture is obtained is called the threshold current.
 Once capture is confirmed, set the current at 5 to 10 mA higher than the threshold
current to prevent loss of capture.
 If the pacing rate does not get captured at greater than 120 mA, reposition the pads
and repeat the above steps.[1][6]
Temporary Transvenous Pacing (TTVP)
 Ensure that the pulse generator is in good working condition and all equipment is
at the bedside.
 Obtain central venous access using an appropriately sized percutaneous venous
introducer sheath, typically 6 Fr. Inappropriately sized sheaths may be unable to
pass the pacing catheter or may leak around it. The right internal jugular vein and
left subclavian veins are the preferred vessels because of a more direct path to the
right ventricle (RV). Ultrasound guidance for placement is highly recommended.
Detailed instruction on obtaining central venous access is beyond the scope of this
article.
Placement without ECG Guidance
 Connect the pacing electrodes to the pulse generator.
 Insert the catheter into the introducer sheath so that the balloon and electrodes are
past the distal end of the introducer sheath (approximately at the 20 cm mark on
the catheter). Note: do not inflate the balloon while it is within the introducer
sheath.
 Turn on the pulse generator. Set the pacing generator to the desired rate depending
on the indication, typically 60 to 80 BMP or at least 10 BMP greater than the
native rate. The initial output requires setting to 2 to 5 mA. Decrease the
sensitivity to the lowest level.
 Inflate the balloon and advance the catheter slowly. The cardiac monitor will
typically show pacer spikes. When the catheter passes the right ventricle and
contacts the endocardium, a wide QRS complex with an LBBB pattern will follow
every pacer spike (electrical capture). It is also reasonable to intermittently deflate
the balloon to check for capture.
 Deflate the balloon, secure the catheter in place, and make a note of catheter depth.
 Ensure mechanical capture by evaluating: signs of perfusion, peripheral/central
pulse rate equals pulse generator set rate, pulse oximetry waveform, arterial line
waveform.
 Decrease the output slowly until capture is lost. Increase the output to regain
capture; this is the threshold current, typically less than 1 mA. Increase the output
to approximately 2.5 times the threshold current, typically 2 to 3 mA.
  If demand pacing is the goal, adjust the sensitivity such that native cardiac
electrical impulses inhibit the pacemaker. See the section on epicardial pacing
below for a more in-depth discussion of demand pacing.
Placement with ECG Guidance
 Connect the negative (distal) electrode to ECG lead V1 using an alligator clip.
 Insert the catheter into the introducer sheath so that the balloon and electrodes are
past the distal end of the introducer sheath (approximately at the 20 cm mark on
the catheter). Note: do not inflate the balloon while it is within the introducer
sheath.
 Inflate the balloon and slowly advance the catheter. Closely monitor the ECG.
ECG morphology should change predictably with electrode location.
o In the high right atrium (RA), there will be a large negative p-wave,
typically greater than the QRS complex, followed by a negative QRS
complex.
o As the catheter passes through the RA, the p-wave becomes biphasic and
then positive.
o When the catheter passes into the RV, the p-wave becomes smaller and
negative, followed by a deeply negative QRS complex.
o Note: the duration of the QRS complex will depend on the native cardiac
activity. For example, an AV nodal escape rhythm will have a narrow QRS
complex, while a ventricular escape rhythm will have a wide QRS
complex.
o When the catheter makes contact with the right ventricular endocardium, an
injury pattern will result, with a deep, negative QRS complex followed by
marked ST elevation.
 Advance the catheter until observing the RV pattern or RV endocardial pattern.
 Deflate the balloon, secure the catheter in place, and make a note of catheter depth.
 Ensure mechanical capture by evaluating: signs of perfusion, peripheral/central
pulse rate equals pulse generator set rate, pulse oximetry waveform, arterial line
waveform.
 Decrease the output slowly until capture is lost. Increase the output to regain
capture; this is the threshold current, typically less than 1 mA. Increase the output
to approximately 2.5 times the threshold current, typically 2 to 3 mA.
 If demand pacing is the desired goal, adjust the sensitivity such that native cardiac
electrical impulses inhibit the pacemaker. See the section on epicardial pacing for
a more in-depth discussion of demand pacing. [1][2][3]
Epicardial Pacing
 Select the desired parameters on the pulse generator, depending on the clinical
scenario. For the prevention or treatment of tachyarrhythmias, this may be
asynchronous. For the prevention or treatment of bradydysrhythmias, this may be
asynchronous or synchronous (demand) pacing.
 If demand pacing is the objective, adjust the sensitivity such that native cardiac
electrical impulses inhibit the pacemaker. Then set the pacemaker rate. In demand
pacing, this represents the backup rate, and the pacemaker will deliver an impulse
if it does not sense a native electrical impulse at a rate greater than the backup
rate. 
 Adjust the pacemaker output and evaluate for signs of mechanical capture as
described above.[2][7]
Go to:

Complications
Complications of TTCP include pain, failure to obtain capture, loss of capture, and rarely
cutaneous burns. Complications of TTVP are more numerous, and many are related to
central venous access, including infection, bleeding, damage to nearby structures, vein
thrombosis, air embolism, pneumothorax, and others. Additionally, TTVP can sometimes
induce ventricular tachycardia or ventricular fibrillation.[1][2][3][8][9]
Go to:

Clinical Significance
Select clinical pearls regarding TCP include:
 Careful patient selection is paramount as the risks associated with certain types
of TCP outweigh the benefits.
 TCP should be used when maximum medical therapy, including cardioversion
when appropriate, has failed.
 Assuming that electrical capture is equivalent to ventricular or mechanical capture
is one of the most significant pitfalls in TCP. Electrical activity in the form of a
QRS complex is sometimes present without subsequent ventricular contractions.
TTCP is especially prone to this due to the chest wall impedance and greater depth
of the ventricles from the pacing pads. Ensure mechanical capture is present by
confirming a pulse that matches the set pacemaker rate by palpation,
echocardiogram, pulse oximetry, or arterial waveform. Check for signs of
mechanical capture as mentioned above and re-evaluate them frequently,
especially after transfers, procedures, or repositioning.[6]
  Another pitfall related to TTCP is basing capture on the ECG waveform of a
separate cardiac monitor. Many defibrillators/pulse generators require the
placement of their own ECG electrodes, and any decision about electrical capture
should have their basis in ECG waveforms on the defibrillator/pulse generator
itself, rather than a separate cardiac monitor.
 TTVP catheter placement should be confirmed by a chest X-ray. Continuous
echocardiography may also be useful to confirm lead placement.[10][11]
Go to:

Enhancing Healthcare Team Outcomes

Temporary cardiac pacing is a potentially life-saving procedure for refractory dysrhythmias
that can bridge patients to a destination therapy. However, TCP is not without risks, and a
team-based, interprofessional approach can improve outcomes, decrease adverse events, and
increase patient safety. All members of the healthcare team should be aware of the
indications for TCP to improve patient selection, therefore reducing the exposure of patients
to the risks associated with this procedure unnecessarily. Fostering a culture of open,
bidirectional communication may allow all members of the healthcare team to voice their
concerns, potentially preventing adverse events.
During TTCP, a team-based approach involving physicians, nurses, and emergency medical
technicians (EMTs) is essential for timely deployment. A coordinated approach to
defibrillation pad and ECG electrode placement, including rolling the patient for anterior-
posterior pad placement, is necessary. After initiating TTCP, nurses should frequently
evaluate the patient for pain and communicate their concerns to the provider if additional
analgesia or sedation is required. The entire healthcare team should know how to assess for
signs of mechanical capture and alert the appropriate provider if a loss of capture is
suspected.
Temporary transvenous pacing also requires an interprofessional team-based approach. An
interprofessional approach to central venous catheter placement and maintenance has been
shown to decrease the complication rate.[12] Similar to TTCP, all members of the healthcare
team should frequently evaluate for signs of a loss of capture and alert the appropriate
providers if suspected.
Temporary cardiac pacing is a bridge from a variety of diseases to definitive therapy and
often requires an interprofessional approach. Cardiology and electrophysiology specialists
should be involved early to prepare for permanent pacemaker placement, percutaneous
coronary intervention, or other definitive care. In suspected overdoses, toxicology
consultation can guide the initial treatments, provide information on the expected course and
the suitability of a particular poisoning for TCP. In post-cardiac surgery patients, intensive
care management by intensivists and cardiothoracic surgeons has been shown to improve
outcomes and decrease adverse events.[13] Coordination between the intraoperative and
intensive care unit teams regarding epicardial lead placement and intraoperative pacing
requirements is essential for a smooth transition of care. Checklists may decrease adverse
events related to the transfer of care.[14] With the interprofessional approach, patients can
achieve optimal results while experiencing minimal adverse events. [Level 5]
Go to:

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses working in the emergency department, cardiology, or the cardiac surgery ward should
be familiar with external pacing and indications.
Go to:

Review Questions
 Access free multiple choice questions on this topic.
 Comment on this article.
Go to:

References
1.
Gammage MD. Temporary cardiac pacing. Heart. 2000 Jun;83(6):715-20. [PMC
free article] [PubMed]
2.
Sullivan BL, Bartels K, Hamilton N. Insertion and Management of Temporary
Pacemakers. Semin Cardiothorac Vasc Anesth. 2016 Mar;20(1):52-62. [PubMed]
3.
Harrigan RA, Chan TC, Moonblatt S, Vilke GM, Ufberg JW. Temporary
transvenous pacemaker placement in the Emergency Department. J Emerg
Med. 2007 Jan;32(1):105-11. [PubMed]
4.
Kowey PR, Engel TR. Overdrive pacing for ventricular tachyarrhythmias: a
reassessment. Ann Intern Med. 1983 Nov;99(5):651-6. [PubMed]
5.
Blommaert D, Gonzalez M, Mucumbitsi J, Gurné O, Evrard P, Buche M, Louagie
Y, Eucher P, Jamart J, Installé E, De Roy L. Effective prevention of atrial
fibrillation by continuous atrial overdrive pacing after coronary artery bypass
surgery. J Am Coll Cardiol. 2000 May;35(6):1411-5. [PubMed]
6.
Bektas F, Soyuncu S. The efficacy of transcutaneous cardiac pacing in ED. Am J
Emerg Med. 2016 Nov;34(11):2090-2093. [PubMed]
7.
Reade MC. Temporary epicardial pacing after cardiac surgery: a practical review:
part 1: general considerations in the management of epicardial
pacing. Anaesthesia. 2007 Mar;62(3):264-71. [PubMed]
8.
 Carrizales-Sepúlveda EF, González-Sariñana LI, Ordaz-Farías A, Vera-Pineda R,
Flores-Ramírez R. Thermal burn resulting from prolonged transcutaneous pacing
in a patient with complete heart block. Am J Emerg Med. 2018
Aug;36(8):1523.e5-1523.e6. [PubMed]
9.
Hill PE. Complications of permanent transvenous cardiac pacing: a 14-year review
of all transvenous pacemakers inserted at one community hospital. Pacing Clin
Electrophysiol. 1987 May;10(3 Pt 1):564-70. [PubMed]
10.
Pinneri F, Frea S, Najd K, Panella S, Franco E, Conti V, Corgnati G.
Echocardiography-guided versus fluoroscopy-guided temporary pacing in the
emergency setting: an observational study. J Cardiovasc Med (Hagerstown). 2013
Mar;14(3):242-6. [PubMed]
11.
Ferri LA, Farina A, Lenatti L, Ruffa F, Tiberti G, Piatti L, Savonitto S. Emergent
transvenous cardiac pacing using ultrasound guidance: a prospective study versus
the standard fluoroscopy-guided procedure. Eur Heart J Acute Cardiovasc
Care. 2016 Apr;5(2):125-9. [PubMed]
12.
Zingg W, Cartier V, Inan C, Touveneau S, Theriault M, Gayet-Ageron A, Clergue
F, Pittet D, Walder B. Hospital-wide multidisciplinary, multimodal intervention
programme to reduce central venous catheter-associated bloodstream
infection. PLoS One. 2014;9(4):e93898. [PMC free article] [PubMed]
13.
Kumar K, Zarychanski R, Bell DD, Manji R, Zivot J, Menkis AH, Arora RC.,
Cardiovascular Health Research in Manitoba Investigator Group. Impact of 24-
hour in-house intensivists on a dedicated cardiac surgery intensive care unit. Ann
Thorac Surg. 2009 Oct;88(4):1153-61. [PubMed]
14.
Stephens RS, Whitman GJ. Postoperative Critical Care of the Adult Cardiac
Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med. 2015
Jul;43(7):1477-97. [PubMed]
Copyright © 2022, StatPearls Publishing LLC.

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In this Page
 Continuing Education Activity
 Introduction
 Anatomy and Physiology
 Indications
 Contraindications
 Equipment
 Technique
 Complications
 Clinical Significance
 Enhancing Healthcare Team Outcomes
 Nursing, Allied Health, and Interprofessional Team Interventions
 Review Questions
 References

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 Transcutaneous pacing for cardiac emergencies.[Pacing Clin Electrophysiol. 1988]
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 Management of temporary epicardial pacing wires in the cardiac surgical patient. [Br J Hosp
Med (Lond). 2021]
 Pacemaker Indications[StatPearls. 2022]

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