584923

research-article2015
SCVXXX10.1177/1089253215584923Seminars in Cardiothoracic and Vascular AnesthesiaSullivan et al

Review
Seminars in Cardiothoracic and

Insertion and Management of Temporary

Vascular Anesthesia
1­–11
© The Author(s) 2015
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DOI: 10.1177/1089253215584923
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Breandan Lawrence Sullivan1, Karsten Bartels2, and Natalie Hamilton2

Abstract
Temporary pacemakers are used in a variety of critical care settings. These life-saving devices are reviewed in 2 major
categories in this review: first, the insertion and management of epicardial pacemakers after and during cardiac surgery;
and second, the insertion of transvenous temporary pacemakers for the emergent treatment of bradyarrhythmias.
Temporary epicardial pacemakers are used routinely in patients recovering from cardiac surgery. Borrowing from
advances in cardiac resynchronization therapy there are many theoretical and untested benefits to pacing the postoperative
cardiac surgery patient. Temporary transvenous pacing is traditionally an emergency procedure to stabilize patients
suffering from hemodynamically unstable bradyarrhythmia. We review the traditional and expanding use of transvenous
pacemakers inside and outside the operating room.

Keywords
temporary epicardial pacemaker, temporary transvenous pacemaker, cardiothoracic anesthesia, perioperative, critical
care

Introduction surgery to override the intrinsic rate of the patient in an

Temporary pacemakers in the emergency room, intensive
care unit (ICU), or in the operating room can provide clini-
cians with the ability to alter the electromechanical conduc-
tance of the heart. In this review article, we will discuss the
indications, options for placement, and strategies to manip-
ulate temporary pacemakers to optimize hemodynamics.
Epicardial Pacemakers
Indications
In the United States, temporary epicardial pacemaker leads
are often placed prior to weaning from cardiopulmonary
bypass. Temporary leads are often placed secondary to the
surgeon’s preference. In this context, the majority of pac-
ing wires are placed for backup emergency pacing capabil-
ity rather than due to a clear assessment of the actual need
for temporary pacing. The vast majorities of pacing wires
are placed for backup emergency pacing capability. In
many instances, temporary leads are not used in the peri-
operative postoperative period.
Bradyarrhythmias
attempt to increase cardiac output. Additional consider-
ations driving advance this practice are the following: (a)
atrial pacing may decrease the incidence of atrial fibrilla-
tion,2 (b) inotropic medications increase myocardial oxy-
gen consumption and may increase mortality after cardiac
surgery,3 and (c) the left ventricle is less compliant after
cardiopulmonary bypass and cardiac output may be more
dependent on heart rate.4
Heart Block
The use of an epicardial pacemaker for the treatment of
transient heart block represents one of its most obvious
and beneficial indications. While transient heart block
requiring pacing usually gets better, some patients will
become permanently dependent on pacemakers. After cor-
onary artery bypass grafting (CABG), permanent pacing
may be required in up to 4% of patients, while after aortic
or tricuspid valve replacement up to 24% of patients will
require permanent pacing.5
1
University of Colorado Denver, CO, USA
2
University of Colorado, Aurora, CO, USA

Corresponding Author:
Sinus bradycardia, first degree atrioventricular (AV) block, Breandan Lawrence Sullivan, University of Colorado Denver, Mail Stop
and atrial flutter after cardiac surgery can be treated with B113, 12401 East 17th Avenue, Room 727, Denver, CO 80238, USA.
atrial pacing.1 Some centers use atrial pacing after cardiac Email: breandan.sullivan@ucdenver.edu

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2 Seminars in Cardiothoracic and Vascular Anesthesia 
Figure 1.  Epicardial lead placement: (A) Atrial lead placed
at right atrial appendage; (B) Right ventricular lead placed on
diaphragmatic surface of right ventricle (not visible); (C) Leads
exiting the skin for attachment to external pacing generator.
Supraventricular Tachyarrhythmias
The incidence of atrial fibrillation after CABG has ranged
from 15% to 40% and from 37% to 50% after valve sur-
gery and can be as high as 60% in combined valve and
CABG surgery.6,7 Diagnosis of atrial fibrillation can some-
times be difficult especially postoperatively in patients
with a widened QRS. By using existing epicardial pace-
maker leads, diagnosis of the arrhythmia can be greatly
improved.8 The atrial leads can be hooked up to a standard
electrocardiogram (EKG) machine and a separate atrial
EKG can be recorded. This can greatly assist in interpreta-
tion of complex arrhythmias.9
Approaches to Insertion (Surgical Placement)
There are theoretical benefits to placing epicardial pace-
maker leads in positions that mimic the natural conduction
pathway in the heart. However, epicardial pacemaker leads
are traditionally placed on the right atrial appendage (atrial
lead) and at the diaphragmatic surface of the right ventricle
(ventricular lead; Figure 1). Both these positions are ante-
riorly located and are chosen to facilitate placement of the
wires. Unfortunately, placing the electrodes in these posi-
tions does not mimic the intrinsic electrical conduction of
the heart and in certain circumstances can have deleterious
effects on mean arterial blood pressure, cardiac output, and
possibly on coronary blood flow.10
Approaches aimed at mimicking the natural conduction
system of the heart, via pacemaker lead configuration, may
improve postoperative hemodynamics. When right atrial to
right ventricular pacing (RA-RV) was compared to right
atrial biventricular (RA-BiV) pacing in post-CABG patients,
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RA-RV pacing not only decreased mean arterial blood pres-
sure (MAP) and cardiac output (CO), when compared to
sinus rhythm, but also increased left ventricular dyssyn-
chrony and decreased cardiac output when compared to
RA-BiV pacing.11
This finding is indirectly supported by electrophysiologic
studies focused on permanent pacing. For example, Tse and
colleagues compared pacing at the right ventricular outflow
tract to pacing the right ventricular apex in patients with
complete heart block. Here, apically paced patients devel-
oped more myocardial perfusion defects and a worsening in
left ventricular ejection fraction over time.12 Furthermore,
when biventricular leads are placed in heart failure patients
with abnormal conduction systems there is symptomatic
improvement of their heart failure, reverse remodeling of the
left ventricle, and in certain populations even mortality
improvement.13 However, it is important to point out that the
goals of care in the immediate postoperative period after car-
diac surgery represent a very different population as com-
pared to patients presenting electively for placement of a
permanent pacemaker/defibrillator. In a trial examining pro-
phylactic implantation of defibrillators in CABG patients
with left ventricular dysfunction and evidence of risk factors
for sudden cardiac death, there was no survival improvement
5 years after implantation.14 As the authors of this article
point out, solid evidence supported by randomized trials that
suggest a survival benefit of a particular perioperative pacing
approach after cardiac surgery is lacking at this time.
Mimicking the Natural Electrical Vector of the
Heart
Mimicking the natural conduction system of the heart may
be beneficial in certain patient populations and tradition-
ally placed epicardial RA-RV pacemaker leads can be
disadvantageous:
1. Post–cardiac surgery septal dyssynchrony.
Paradoxical septal motion is defined as movement
of the interventricular septum toward the right ven-
tricle with normal myocardial thickening. This
process can result in decrease myocardial perfor-
mance, worsening mitral regurgitation, and may be
misinterpreted as septal ischemia. Paradoxical sep-
tal motion is also seen in patients with left bundle
branch blocks.15 Traditionally, epicardial pace-
maker leads are placed on the anterior surface of
the right ventricle. When the right ventricular lead
is activated this will cause a left bundle branch
block leading to delayed activation and contraction
of the left ventricle. Hence, this iatrogenic left bun-
dle branch block can cause regional wall motion
abnormalities and enhance septal dyssynchrony
after cardiac surgery.
Sullivan et al 3
2. Low ejection fraction with intrinsic conduction
delay. For patients with chronic heart failure with
prolonged QRS (duration greater than 120 ms),
cardiac resynchronization therapy (CRT) has sig-
nificant benefits. The Cardiac Resynchronization-
Heart Failure (CARE-HF) Study showed a 36%
decrease in all-cause mortality in patients with
depressed ejection fraction and prolonged QRS
with CRT when compared to optimal medical ther-
apy alone.13 This landmark trial led to the European
and North American Guidelines being changed to
include CRT for all patients with New York Heart
Association class III and IV heart failure with pro-
longed QRS.16 Interestingly, the benefits of CRT
seem to be highly dependent on location of lead
placement. Pacing the left ventricle in a nonopti-
mal site is associated with worse outcomes as it can
lead to pathologic remodeling of the heart.17-19
Whether these findings using permanent pacemak-
ers can ever be translated to postoperative cardiac
surgery patients is unclear at this time. Could
placement of epicardial leads in patients with low
ejection fraction or patients with advanced heart
failure prevent early hormonally induced patho-
logic ventricular remodeling? While results from
nonoperative patient populations should be consid-
ered with great caution, studying the effects of
perioperative pacing approaches that mimic the
natural conduction pathways in at-risk patients
clearly deserves more effort.
3. Myocardial stunning. After cardiopulmonary
bypass there can be significant myocardial stun-
ning. Myocardial stunning is caused by ineffectual
cardioplegia, ischemia-reperfusion injury, inade-
quate revascularization, or ongoing ischemia. Fluid
status optimization, inotropic medications, pacing,
and mechanical support are all treatment options
used to support patients while their myocardial
stunning improves. Inotropic support has been
linked to increased mortality in propensity matched
retrospective trials.3,20 Mechanical support is
fraught with complications and is usually used as
an extreme last measure. However, while pacing
seems like a potentially benign intervention that
can increase cardiac output, pacing in the setting of
myocardial stunning, however, may not be a benign
intervention. While the duration of pacing required
and the exact mechanism responsible are unclear,
chronic pacing is known to cause regional wall
motion abnormalities and may even impair coro-
nary blood flow.21 The development of CRT was
based on the theory that pathologic electrical con-
duction (prolonged PR intervals, increase in QRS
duration) can induce cellular modifications that
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lead to pathologic ventricular remodeling.22
However, CRT itself, when leads are not optimally
placed, can enhance mechanical dyssynchrony,
that can lead to a decrease in ventricular filling
time, increase in mitral regurgitation, and decrease
overall cardiac performance.23 These consider-
ations beg the question of whether inappropriate
pacing after cardiac surgery leads to electrical and
mechanical disturbances that in consequence could
lead to worse outcomes after cardiac surgery?
Future research should address if enhanced CRT
techniques could play a role to improve outcomes.
Intraoperative Management of Temporary
Pacing
Prior to committing a patient to postoperative pacing, it is
critical to determine what the patient’s underlying rhythm
is. It is important to do this in a safe manner. Weaning from
cardiopulmonary bypass, decannulation, hemostasis, and
chest closure can cause electromechanical interference
with the epicardial pacemaker leads. The patient’s rhythm
can also be in a state of flux, and it is important for the
anesthesiologists to understand how to safely manage the
temporary pacemaker in the operating room and in the
ICU. The underlying heart rhythm should be frequently
reassessed to help determine when the pacemaker is no
longer needed.
Weaning From Cardiopulmonary Bypass
Shortly after the surgeon places the epicardial leads, they
should be tested for their functionality, sensitivity, and
pacing threshold. The sensitivity of the electrodes is
defined as the ability of the pacemaker to detect myocar-
dial voltage. If the pacemaker has an extremely high sensi-
tivity, it will not be able to detect any electrical activity in
the heart. This potentially dangerous mode is known as the
asynchronous mode. The range of the epicardial pacemak-
er’s sensitivity is 0.4 mV to 10 mV for the right atrium and
0.8 mV to 20 mV for the right ventricle. New wires in good
position can detect very low voltages and are able to inter-
pret whether to pace or not, whereas poorly placed older
wires will not be able to sense lower voltages. An easy way
to check the patients pacing threshold is to turn the pace-
maker into a mode where the patient’s heart rate will
inhibit the actions of the pacemaker (DDD, AAI, VVI).
While you are watching the sensing indicator on the pace-
maker box decrease the sensitivity of the pacemaker until
the pacemaker will no longer sense the electrical activity
of the heart. This will reveal the patient’s underlying
rhythm. Next, increase the sensitivity of the pacemaker.
Eventually a minimum voltage will be reached where the
pacemaker will sense every P-wave or possibly every
4 Seminars in Cardiothoracic and Vascular Anesthesia 
Figure 2.  (Left) Cardiotronic pacing generator. (Right)
Medtronic pacing generator. Each has controls to adjust rate,
atrial and ventricular output and sensitivity, mode, and other
fine-tuning features.
QRS. This minimal voltage is the pacing or sensing thresh-
old of the epicardial wires in that particular position on the
heart. The technical manual for the Medtronic 5388 model
dual-chamber pacemaker, which is the most common tem-
porary pacemaker used in the United States, recommends
setting the sensitivity to 2× the pacing or sensing threshold
(Figure 2). This will prevent inadvertently turning the
pacemaker into an asynchronous pacemaker.
The pacemaker leads need to be tested for their output or
capture threshold. This is the current at which the pace-
maker will produce a depolarization. Once the epicardial
leads are connected in the surgical field, the patient’s heart
rate should be increased higher than the native rate; the tech-
nical manual recommends 10 beats per minute higher than
their intrinsic rate. Start with the current at the maximum
settings on the pacemaker (20 mA for the atrial lead and 25
mA for the ventricular leads on the Medtronic 538824) and
slowly turn down the current until capture is lost. This cur-
rent, where capture is lost, is the stimulation threshold. The
technical manual recommends setting the current at 2 to 3
times the stimulation threshold. The pacemaker will default
to a stimulation threshold of 10 mA. On the ventricular lead
an initial stimulation threshold above 5 mA should be fur-
ther investigated, while a stimulation threshold of 2 mA on
the atrial leads should be further investigated. All the con-
nections should be investigated and the surgeons should
make sure that the leads are optimally attached.
The next important step is to determine how the patient
can be successfully and safely paced given the presence or
absence of conduction delays. Atrial pacing should be
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attempted first. If the patient has heart block with a slow
ventricular rate then the patient should be AV- or V-paced
for weaning from cardiopulmonary bypass, decannulation,
and hemostasis. Electrocautery will cause electrical inter-
ference with the pacemaker, leading it to inhibit its pacing
action unless it is programed to an asynchronous mode.
Failure to recognize electrical inhibition will lead to the
patient having long pauses when electrocautery is used.
If the patient is dependent on pacing to maintain ade-
quate hemodynamics, then the pacemaker should be turned
to an asynchronous mode. Asynchronous pacing can put
the patient at risk for R on T phenomenon, and therefore
places the patient at risk for torsades de pointes.
The patient with an underlying rhythm should be paced
in the following hierarchy of pacing: no pacing if sinus
rhythm with adequate rate present, atrial pacing, atrial-ven-
tricular pacing, ventricular pacing. When these pacing strat-
egies have been studied in patients after cardiac surgery that
have intact conduction systems, there is significant hemody-
namic perturbations that the patient experiences as they
descend down the hierarchy of pacing.11
Arrival to the Intensive Care Unit
Once the patient arrives in the ICU, a key part of the transition
of care to the ICU team is communication about the patient’s
rhythm and the hemodynamic goals of the immediate postop-
erative care. If the patient is hemodynamically stable, the
underlying rhythm should be investigated. At this point the
patient should be switched out of their asynchronous pacing
and put in a demand mode. This will greatly decrease the risk
to the patient of having an iatrogenic R on T.
To test the underlying rhythm, the patient should be
placed in a demand-pacing mode and their heart rate should
be slowly turned down. The ICU physician should pay
close attention to the patient’s hemodynamics while the
patient’s rate is turned down. The pacemaker can be set to a
demand mode once the patient’s underlying rhythm
emerges. At this time, the ICU physician needs to decide
what the optimal pacing mode and rate is, given the patient’s
hemodynamics. The authors of this review strongly dis-
courage the practice of unplugging the pacemaker wires
from the pacemaker box in a paced patient to investigate
their underlying rhythm and the practice of turning down
the current rapidly to investigate the patient’s underlying
rhythm. We believe that this practice can put the patient at
risk for an R on T and that this practice may not allow the
patient’s intrinsic pacemaker to initiate pacing.25
Continuous Management of Temporary
Epicardial Pacemaker Wires
Patients that require temporary epicardial pacing to main-
tain normal hemodynamics should be monitored in the
Sullivan et al 5
ICU with continuous telemetry until they have an underly-
ing rhythm that provides them with appropriate hemody-
namic stability. The patients that are being paced for
reasons besides complete heart block do not necessarily
need to be housed in the ICU. These indications include
atrial fibrillation prophylaxis and atrial pacing for
improved cardiac output. Patients after cardiac surgery can
experience multiple temporary rhythm disturbances, with
peak incidences of atrial fibrillation and atrial flutter on
postoperative days 2 and 3.26,27 If the patient is dependent
on their temporary epicardial wires secondary to complete
heart block this may be a transient phenomenon. Once the
epicardial leads are no longer needed, they can be removed
at the bedside. It is highly variable among surgeons and
ICU physicians when the wires are removed. If the leads
are needed, then the patient may need to be evaluated by a
cardiologist for placement of a permanent pacemaker. For
practical purposes, it should be kept in mind that the longer
the epicardial leads are in place and used the higher the
threshold for capture can become.
Complications
The presence or use of are the source of rare but serious
complications: inappropriate sensing leading to an R on T
phenomenon, incomplete removal leading to a retained
foreign body, and bleeding leading to tamponade follow-
ing removal.28 In a prospective observational study of
patients undergoing CABG, there were 3 patient character-
istics that predicted the need for temporary postoperative
pacing: history of arrhythmias, pacing required to come
off cardiopulmonary bypass, and diabetes mellitus.29
Temporary Transvenous Pacemakers
Introduction
Temporary transvenous pacing (TTvP) has been performed
for 60 years to provide temporary ventricular rate support
and thus cardiac output, in patients suffering from severe
or clinically significant episodes of bradycardia or high-
grade heart block and asystole from multiple causes
including acute myocardial infarction. This can be a life-
saving procedure, and temporary pacemakers have become
more common procedures in emergency departments and
ICUs.30 Advances in temporary pacing have allowed the
use of transcutaneous, esophageal, epicardial, as well as
percutaneous transvenous (endocardial) electrodes. All
require an external pulse generator that attaches to the
electrodes, allowing for the adjustment of pacing output,
pacing rate, pacing mode, and sensitivity to intrinsic activity.31
Transcutaneous pacing uses adhesive electrode pads
applied directly to the chest in anteroposterior or antero-
apical configurations. Transvenous pacemaker insertion
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and use can be compromised by pain and ineffective ven-
tricular capture. Esophageal electrodes can be placed into
the esophagus and/or stomach under light sedation for
both atrial and ventricular pacing with improved capture
over transcutaneous pacing, but are rarely used today.32
Indications
The indications for temporary pacing can be generally
qualified as emergent or elective. Management of symp-
tomatic bradycardia is well established and should be
managed according to the published standards by the
American Heart Association guidelines for cardiopulmo-
nary resuscitation and emergency cardiovascular care
(Figure 3).33
Emergent
Emergent pacing is most commonly performed for brady-
arrhythmias. The underlying mechanisms are the follow-
ing: (a) primary abnormality of cardiac automaticity and/
or conduction (idiopathic); (b) unintended side effect of
therapeutic levels of cardio-active drugs (beta-blockers,
calcium channel blockers, digitalis); (c) bradycardia
caused by conduction defect secondary to acute myocar-
dial infarction; (d) failure of previously implanted pace-
maker device; (e) toxicity or overdose of cardioactive
drugs; (f) severe electrolyte abnormalities.34 The goal of
initial management is stabilization by increasing the ven-
tricular rate using both pharmacological and nonpharma-
cological interventions, while identifying and treating a
cause. Prior to transvenous pacing chronotropic medica-
tions like dopamine, epinephrine, isoproterenol, and atro-
pine can be tried (Figure 2). Transcutaneous pacing is an
alternative and can be used in an emergent setting; how-
ever, most patients require sedation to tolerate transcutane-
ous pacing. These drugs and transcutaneous pacing may
temporize a patient’s condition until transvenous pacing
can be initiated either temporarily or via permanent pace-
maker placed by a qualified consultant. TTvP may be
appropriate as a temporizing measure before permanent
pacemaker placement or as a bridge to resolution of revers-
ible causes like drug toxicity or in septic patients who are
otherwise contraindicated for PPM placement. There is
evidence that delaying definitive treatment greater than 24
hours is dangerous, and as soon as a patient can be stabi-
lized with temporary measures an expert should be con-
sulted for evaluation for a permanent pacemaker35 (see
Table 1).36
Elective
TTvP is generally utilized in the perioperative period dur-
ing a surgical or other procedural intervention. If a
6 Seminars in Cardiothoracic and Vascular Anesthesia 

Figure 3.  American Heart Association adult bradycardia algorithm.

Table 1.  Emergent Indications for Temporary Transvenous procedure is likely to cause hemodynamically significant
Pacing36. bradycardia, temporary pacing has been used to prevent
Bradyarrhythmias not associated with acute myocardial this dangerous situation. For example, TTvP has been used
infarction with success in carotid body tumor excision and manipula-
  Symptomatic sinus node dysfunction tion after preoperative embolization of carotid body tumors
  Sinus arrest where carotid sinus hypersensitivity has been found.37
  Sinus bradycardia Temporary transvenous pacing has also been used for
  Mobitz type II 2nd degree AV block more precise deployment of aortic endografts, percutane-
  3rd degree AV block ous aortic valve replacement, and balloon valvuloplasty
  Tachydysrhythmias requiring overdrive pacing refractory to
using rapid ventricular pacing. Controlled hypotension is
medical therapy
  Failure of permanent pacemaker critical to the precise placement of these thoracic aorta
Bradyarrhythmias associated with acute myocardial infarction endografts, particularly, as many aneurysms and dissec-
  Symptomatic sinus node dysfunction tions arise near the left subclavian artery. Inappropriately
  Mobitz type II 2nd degree AV block positioned grafts may compromise the cerebral circulation
  3rd degree AV block or predispose the patient to postdeployment endoleaks.
  New right, left, alternating bundle branch block, or Pulsatile aortic blood flow can exert a force moving the
bifascicular block stent distally. Rapid right ventricular pacing at 130 to 200

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Sullivan et al 7

beats per minute will reduce mean arterial pressure to 40 to

60 mm Hg via loss of AV synchrony and reduction of ven-
tricular filling time, decreasing left ventricular preload,
stroke volume, and cardiac output. Rapid pacing is a safe,
effective, and predictable method of inducing brief con-
trolled hypotension with rapid onset and offset. Pacing is
also titratable to desired systemic blood pressure by merely
adjusting the rate. Brief controlled hypotension can also be
accomplished with pharmacological methods.38 These
require dose titration and are relatively slower in onset and
offset than pacing. In one study, rapid right ventricular
pacing was compared to sodium nitroprusside administra-
tion (3 µg/kg/min) and 0.5 mg/kg adenosine bolus. Rapid
pacing produced the most pronounced (desirable) hypo-
tension, shortest duration, quickest recovery to baseline
blood pressure, shortened overall procedure time, and
more precise positioning without a difference in postpro-
cedural neurologic function.39
Another indication for rapid pacing involves transcuta-
neous aortic valve replacement (TAVR). Transvenous pac-
ing leads are advanced via percutaneous access from the
groin to the right ventricle. Under fluoroscopic guidance a
guidewire is advanced into the left ventricle, and rapid
pacing of 150 to 200 beats per minute is initiated to mini-
mize left ventricular outflow prior to balloon valvuloplasty
of the stenotic aortic valve is performed. The balloon is
removed, and the valve itself is advanced over the guide-
wire and positioned within the native valve annulus (Figure
4). Rapid pacing is again initiated and the valve is expanded
Figure 4.  Control room monitor during transcatheter aortic
with TEE and/or fluoroscopic guidance.40 Transapical valve replacement (TAVR) using temporary transvenous rapid
TAVR is performed using a left anterolateral minithora- ventricular pacing. (Top) Initiation of rapid ventricular pacing.
cotomy with a sheath advanced through a ventriculostomy The rate is set to 180 beats/min to decrease systolic flow
made in the left ventricular apex. Femoral venous access is across the aortic valve and establish controlled hypotension for
established in a similar fashion to the transfemoral balloon valvuloplasty and valve deployment. (Bottom) End of
approach for rapid pacing during balloon valvuloplasty rapid pacing with quick recovery of systemic blood pressure.
and valve deployment. In addition, less rapid ventricular
pacing can be used to titrate blood pressure to surgeon this reason, it is recommended by the manufacturer
preference during closure of the ventriculostomy site. (Medtronic, Inc, Minneapolis, MN) to place TTvP elec-
TAVR with the Medtronic CoreValve (Medtronic, Inc, trodes and continue them for at least 24 hours postproce-
Minneapolis, MN) is currently only approved for trans- dure. In the case of high-grade AV block or severe
femoral deployment. The CoreValve differs from the bradycardia, a permanent pacemaker should be implanted
Edwards-Sapien valve in its construction using a self- according to the guidelines of the Heart Rhythm Society.43
expanding Nitinol frame. Rapid ventricular pacing is not
required for deployment, merely titration of systemic
Approaches to TTvP
blood pressure through pacing to a systolic blood pressure
of 100 mm Hg. The frame continues to expand slightly Each major venous access site has advantages and disad-
postimplantation and has a higher incidence (5.7% t o vantages, and the optimal site is controversial. Goals of
50%) of permanent pacemaker implantation than the site selection should consider ease and speed of placement,
Edwards-Sapien valve (4% to 12%).41 In another study, the a high success rate, low incidence of complications, and
CoreValve prosthesis was associated with a 33.3% inci- avoidance of pacemaker lead misdirection, as malposition
dence of postprocedural permanent pacing.42 This is impairs satisfactory capture.44 Sites include internal and
thought to be due to its length, as contact between the self- external jugular, subclavian, brachial, and femoral veins
expanding Nitinol stent and the subaortic conduction path- and is often dictated by the experience and comfort of the
way being unavoidable during valve deployment.41 For individual performing the procedure. Consideration should

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8 Seminars in Cardiothoracic and Vascular Anesthesia 
be given to the anticipated length of time the pacemaker is
needed. For example, while femoral access can be per-
formed with ease, it can be more difficult to advance the
electrodes to the right ventricle, limits patient mobility, has
a higher risk of venous thromboembolism, and offers the
least stable wire position. Need for PPM should also be
considered, as the left and right subclavian veins are most
often used.31 Choice of site should also include the patient’s
coagulation status during the procedure and the need for
anticoagulation afterwards. The most recent review of
access points for temporary pacing from 1973 to 2004
states that the right internal jugular is the preferred route.
It is likely safest for inexperienced operators, provides the
most direct route to the right ventricle, and is associated
with the lowest rate of loss of ventricular capture.45 One
small study favored right supraclavicular access to the
subclavian/innominate vein with a 94.1% first time suc-
cess rate (100% overall).44 There are no more recent stud-
ies comparing access points.
Technique
Equipment needed to insert TTvP includes an introducer
sheath, pacing catheter, and external pacing generator. In
addition, fluoroscopy should be available and the patient
attached to an EKG monitor. Commercial kits are available
containing necessary supplies and adapters to attach to the
external pacing generator and the EKG lead. The catheters
are approximately 100 cm in length and come in both flex-
ible and rigid varieties with and without a balloon tip. The
external pacing generator delivers electrical current in mil-
liamperes (mA), through the pacing catheter. The rate con-
trol dial selects the pacing rate. The output control dial
regulates the current from 0.1 to 20 mA. This determines the
ability to capture the heart. The sensitivity control estab-
lishes a threshold required to suppress the pacemaker from
firing. Decreasing the sensitivity will lead to asynchronous
or fixed rate pacing at the set rate, regardless of the patient’s
own underlying rhythm, and this is uniform among pace-
makers and has already been discussed above in reference to
epicardial pacemaker leads. Increasing the sensitivity and
modifying the rate will lead to demand (synchronous) pac-
ing, where the pacemaker senses the patient’s underlying
ventricular rate and will not fire unless the patient’s underly-
ing rate drops below the rate set on the generator.36
Fluoroscopic Technique
The availability of portable fluoroscopy can simplify the
procedure and likely increases the success of increasing
the success of placement. After a venous sheath is placed
and secured, multiple methods have been described to
position the lead appropriately in the right ventricular
apex. The lead is advanced through the vein to the right
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atrium, through the tricuspid valve to the right ventricular
apex. A properly placed lead should be seen in the ante-
rior–inferior aspect of the cardiac shadow, usually slightly
left of the thoracic spine in the routine anterior–posterior
direction. This may be difficult to distinguish from place-
ment in the coronary sinus without lateral X-ray, which
will show a more posterior position, while one in the apex
will point toward the apex a few centimeters behind the
sternum.46
Blind Technique
To perform the blind procedure an EKG monitor is attached
to the patient, and the catheter electrodes are connected
directly to the pacing generator. The electrode is inserted
and the generator turned on. If a balloon is present on the
electrode tip, it can be inflated once through the sheath to
help direct the lead. The generator is set to a rate signifi-
cantly greater than the patient’s existing rate, output to
maximal current, and sensitivity to the lowest level. As the
catheter is advanced, pacemaker spikes will be seen on the
EKG monitor, and when the catheter enters the right ven-
tricle and makes contact with the ventricular wall, a left
bundle branch pattern (eg, wide QRS complex) will be
seen after every pacemaker spike indicating capture. The
balloon can then be deflated and the electrode catheter
secured in place.36
EKG-Guided Technique
This technique utilizes the generator’s sensing function to
monitor the transit of the catheter as it nears the right ven-
tricle by interpreting the different waveforms that appear
as the catheter advances. The negative electrode of the
catheter is attached to the V (precordial) lead of the EKG
monitor, while the rest of the leads are attached to the
patient in the usual fashion. The magnitude and polarity of
the waveforms change as the catheter moves through the
heart. A detailed description with images of the various
waveforms is described in Harrigan et al.36 Once the cath-
eter is in position at the right ventricular apex, it should be
disconnected from the EKG monitor and attached the pac-
ing generator. The settings should be set as with the blind
technique to asynchronous mode, and a left bundle branch
pattern should be seen after every pacer spike on the EKG
monitor, indicating capture. If capture does not occur, the
lead needs to be repositioned.36
Verification of Placement, Function, and
Optimization
Chest radiography should be used to confirm placement in
the right ventricular apex as described above and to rule
out pneumothorax if internal jugular or subclavian access
Sullivan et al 9
is used. A 12-lead EKG can further verify placement with
a left bundle branch-like pattern. Pacing (output) and sens-
ing thresholds should be tested after capture has been dem-
onstrated. To determine the pacing threshold (minimum
current needed to obtain capture), the rate is set to at least
10 beats/min faster than the patient’s native rate, or
between 60 and 80 if there is no underlying rhythm.
Reduce the output slowly until capture is lost, and repeat
the measurement. Then set the output to 2 to 2.5 times the
threshold current. Ideal threshold is <1 mA and therefore a
pacing output of 2 to 3 mA. Reposition the catheter if the
threshold is above 5 to 6 mA. The sensing threshold only
needs to be tested if the patient has an underlying rhythm
to be sensed, and if the pacemaker will be used in demand
mode. Set the rate to 10 beats/min below the patient’s
intrinsic rate and increase the sensitivity to the highest
value. The generator should now indicate a flashing light
for each sensed beat, and not pace. Decrease the sensitivity
slowly until the pacer captures, and this setting defines the
sensing threshold. Lower the sensitivity a bit further to
adequately sense the underlying rhythm.36
Postprocedural Care
It is imperative that any patient with TTvP be on continu-
ous telemetry monitoring and cared for by staff familiar
with pacemaker operation. Daily EKG and chest X-ray
should be considered. Daily maintenance requires daily
checks for pacing thresholds, inspection of the skin site for
infection with dressing changes per hospital protocol,
integrity of the connections, and status of the external gen-
erator battery. The underlying rhythm should be assessed
and recorded as well.31 In the absence of contraindications,
it seems reasonable to consider anticoagulation with hepa-
rin, at least when the femoral route is used due to its higher
rate of deep venous thrombosis.10
Complications
The multiple phases of the procedure and the duration the
catheter is in place are the major categories for complica-
tions. In addition to complications from central venous
access, further complications arise from passing the pace-
maker wire into the heart. Not surprisingly, complication
rates are affected by the experience of the physician per-
forming the procedure. Complication rates vary depending
on author, as each seems to use different definitions, and
occurs in 10% to 60%.30,45
Mechanical Effects of the Lead
The lead itself can cause other problems separate from the
obvious risks of central venous access. Arrhythmias again
can occur as the lead passes into the right ventricle. The
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lead can perforate the atrial or ventricular septum as well
as the ventricular free wall resulting in cardiac tamponade.
The lead can become looped or entrapped, damaging the
tricuspid apparatus. It can also be misplaced in the atrium
or coronary sinus.
Electrical Performance of the Lead
Failure to capture or sense are common complications
occurring in 37% to 43% of cases.36 Pacing thresholds can
change based on the patient’s underlying pathology as well
as drug therapy used.31 If pacing suddenly fails, one should
check the connections to the generator and the generator
batteries. If pacing spikes are seen without capture,
increase the output and consider repositioning or replace-
ment of the lead. The lead could become dislodged or
migrate with or without patient movement and require
repositioning or replacement. Undersensing and oversens-
ing may require lead reposition or changes to the sensitiv-
ity of the pulse generator.
Conclusion
Temporary epicardial and temporary transvenous pace-
makers provide clinicians with valuable diagnostic and
therapeutic tools to patients after cardiac surgery and suf-
fering from bradyarrhythmias. While the exact technique
and utilization of epicardial pacemaker wires remains a
topic of debate and research, their use can be extremely
beneficial in the postoperative recovery of patients.
Temporary transvenous pacing can be a life-saving proce-
dure for those with unstable bradyarrhythmias unrespon-
sive to medical therapy. Future research in positioning and
pacing technique of epicardial pacemakers may improve
patient outcomes who present for high-risk cardiac
surgery.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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