Bedside transvenous cardiac pacing

Hemodynamic monitoring and pacing with one catheter: a pilot study

Attempts to incorporate the monitoring of central pressures and pacing into one catheter have heretofore been unsuccessful. Recently, a new catheter for monitoring central hemodynamic pressures, which has a right ventricular port (Chandler pacing port), has been devised, which has been reported to allow for simultaneous acquisition of hemodynamic data and reliable pacemaker function as well. To assess the reliability of this catheter, we studied ten consecutive Swan-Ganz catheterizations utilizing this new catheter system. In all instances, hemodynamic monitoring was established without difficulty. In three instances, because of right heart enlargement, fluoroscopy was necessary to position the pacing probe at the right ventricular apex. In all ten instances, a threshold of less than 2.5 mV was obtained. Isolated PVCs and nonsustained ventricular tachycardia were common during insertion. After initial placement, the threshold for sensing and pacing was assessed every 6 hr. Malfunction occurred in three patients. In all, repositioning was accomplished without marked difficulty; in one it required fluoroscopy. In three instances, the Swan-Ganz pacing catheter system malfunctioned. These data are similar to data utilizing other modalities of temporary pacing and suggest that this catheter may be capable of providing hemodynamic monitoring and pacing from a single percutaneous procedure.

Retention of semifloating electrode catheter

A semifloating electrode was prophylactically inserted in an 84-year-old man because of the presence of bifascicular block and the suspicion of acute myocardial infarction. After 6 days it was decided to remove the electrode, but its extraction was not possible. This case demonstrates that retention of semifloating electrode, although a rare complication of temporary right ventricular pacing, is more than a theoretical hazard.

The use of the balloon-tipped floating catheter in temporary transvenous cardiac pacing

The effectiveness and safety of balloon-tipped, flow guided, electrodes for ventricular pacing as opposed to the fluoroscopy-guided semi-rigid bipolar electrodes have never been compared in a controlled study. A prospective study was therefore undertaken to compare both techniques in semi-elective and emergency procedures. Flow guided electrodes were inserted in 67 patients (group A) and semi-rigid electrodes in 44 patients (group B). The results of group A were judged to be superior to those of group B in four aspects: a) shorter time (6'45" vs. 13'30", p less than 0.0005); b) lower incidence of catheter displacement (13.4 vs. 32.0 percent, p less than 0.05); c) longer interval of time between implantation and catheter displacement (4.4 vs. 1.9 days, p less than 0.0005); d) lower incidence of serious ventricular arrhythmias during insertion (1.5 vs. 20.4 percent, p less than 0.005). Threshold at insertion was not significantly different (0.6 +/- 0.3 vs 0.7 +/- 0.2 milliampere). The superiority of flow-guided electrodes over fluoroscopy-guided electrodes persisted in the comparison of semielective insertions in groups A and B. We conclude that the flow-guided insertion technique is safer, more expeditious and more stable than the fluoroscopy-guided technique in semi-elective as well as in emergency insertions.

Emergency transvenous (subclavian) cardiac pacing in elderly patients

Emergency transvenous cardiac pacing can be performed in elderly patients rapidly, effectively, and with few complications. An experienced physician using the subclavian route usually can achieve effective pacing with equipment priced well within the budget of most community hospitals. Data on 36 patients (age range, 75-94 years) are presented.

Bedside emergency transvenous cardiac pacing: experience in two community hospitals

Emergency bedside transvenous subclavian cardiac pacing in 51 patients over a three-year period in two community hospitals is described. Fifty-three procedures were performed at the bedside with semifloating bipolar pacemaker catheters under continuous electrocardiographic monitoring to assist in the placement of the catheter tip. Of the 53 procedures, initial success in pacing was observed in 41 patients (77%). The largest number of failures to either initiate or maintain pacing was observed in the group with cardiac arrest associated with extensive myocardial infarction and complete heart block. Complications of this procedure were minimal. Only one 10% pneumothorax was noted. This modified technique is easily mastered and may prove lifesaving in an emergency.

Artificial pacemakers: indications and management

The development of artificial pacemakers for the electrical control of the cardiac rhythm has greatly enhanced the physician's ability to treat cardiac dysrhythmias. Pacemakers have been useful in treating Stokes-Adams syndrome and symptomatic bradyeardias; they have helped control the occurrence of tachyarrhythmias and have played an important role in the management of arrhythmias accompanying myocardial infarctions. With their more frequent use, pacemakers have contributed to our knowledge of underlying conduction and natural pacemaker disorders. As new indications for artificial pacemaking have been elucidated, more complex pulse generators have been developed, and newer technics found for their insertion. In spite of recent development the pulse generators in general use have a limited useful lifetime.

This paper reviews the indications for pacemaker insertion that are commonly employed. In addition, an approach to the problem of pulse generator replacement is presented.