Perioperative cardiac pacing using an atrioventricular pacing pulmonary artery catheter

History of right heart catheterization: 100 years of experimentation and methodology development

The development of right heart catheterization has provided the clinician the ability to diagnose patients with congenital and acquired right heart disease, and to monitor patients in the intensive care unit with significant cardiovascular illnesses. The development of bedside pulmonary artery catheterization has become a standard of care for the critically ill patient since its introduction into the intensive care unit almost 40 years ago. However, adoption of this procedure into the mainstream of clinical practice occurred without prior evaluation or demonstration of its clinical or cost-effectiveness. Moreover, current randomized, controlled trials provide little evidence in support of the clinical utility of pulmonary artery catheterization in the management of critically ill patients. Nevertheless, the right heart catheter is an important diagnostic tool to assist the clinician in the diagnosis of congenital heart disease and acquired right heart disease, and moreover, when catheter placement is proximal to the right auricle (atria), this catheter provides an important and safe route for administration of fluids, medications, and parenteral nutrition. The purpose of this manuscript is to review the development of right heart catheterization that led to the ability to conduct physiologic studies in cardiovascular dynamics in normal individuals and in patients with cardiovascular diseases, and to review current controversies of the extension of the right heart catheter, the pulmonary artery catheter.

Temporary Pacemakers

Temporary cardiac pacing may provide definitive, and even life-saving, therapy for transient bradyarrhythmias or as a bridge to permanent pacemaker placement. Other dysrhythmias may also be amenable to therapy with temporary pacemakers. Serious dysrhythmias may develop perioperatively because of a patient's underly ing disease state, drug administration, and/or intraop erative events. The aging nature of the surgical popula tion and the increasing complexity of surgical patients' medical problems will no doubt contribute to a greater likelihood of encountering perioperative rhythm distur bances. It is therefore essential that anesthesiologists be knowledgeable regarding the indications and contra indications for temporary pacing in the perioperative period. This article describes the numerous potential indications for temporary pacing. Anesthesiologists simi larly need to be familiar with the array of temporary pacing techniques currently available. The techniques reviewed include transvenous pacing, pacing pulmo nary artery catheters, transcutaneous pacing, esopha geal pacing, and transthoracic pacing. By combining a working understanding of the use of these techniques with the technical skills necessary to implement these temporary pacing modalities, the anesthesiologist should be able to successfully establish temporary cardiac pacing.

Temporary transmyocardial pacing using epicardial pacing wires and pacing pulmonary artery catheters

This study investigated the feasibility of transmyocardially pacing the heart using one temporary epicardial pacing lead and one endocardial lead of a pacing pulmonary artery catheter. Twenty patients undergoing cardiopulmonary bypass with cardioplegic arrest were studied 10 to 45 minutes and 18 to 30 hours after discontinuation of cardiopulmonary bypass. The Swan-Ganz Flow-Directed Pacing TD Catheter (Baxter Healthcare Corporation) was inserted in one group of 10 patients, and the Swan-Ganz Thermodilution A-V Paceport Catheter (Baxter Healthcare Corporation, Irvine, CA) was used in another group of 10 patients. Using the Pacing TD Catheter, transmyocardial atrial (TMA) pacing was successful in 14 of 16 attempts (87.5%), and transmyocardial ventricular (TMV) pacing was successful in 15 of 16 attempts (93.8%). With the AV Paceport Catheter, TMA pacing was successful in 16 of 18 attempts (88.9%), and TMV pacing was successful in 17 of 19 attempts (89.5%). Transmyocardial atrial-ventricular sequential pacing was achieved in all cases when both TMA and TMV pacing were independently successful. There were no significant differences between catheters in the success rates of either TMA or TMV. It is concluded that transmyocardial pacing is feasible using one temporary epicardial pacing lead and one endocardial lead of a pacing pulmonary artery catheter.

Indications for the use of pacing pulmonary artery catheters in cardiac surgery

Several varieties of pulmonary artery catheters (PACs) with pacing capabilities are now available. Although specific recommendations for prophylactic perioperative placement of pacemakers have been offered previously, the authors believe that those recommendations warrant further examination, taking into consideration the availability of new pacing modalities. Toward this end, the use of pacing PACs in cardiac surgical patients was prospectively examined. In 600 consecutive adult patients with PACs placed prior to cardiopulmonary bypass (CPB), the cardiac anesthesiologist recorded if a pacing PAC was placed, the indications for placing it, and whether the catheter was used to pace. If a pacing PAC was not chosen, the anesthesiologist indicated whether cardiac pacing was needed prior to CPB. In all patients, the presence and specifics of the following five possible indications were documented: sinus node dysfunction/bradydysrhythmias, atrioventricular heart block, fascicular or bundle branch block, cardiac reoperation, and/or valvular heart disease. PACs with pacing capability were placed in 180 of the 600 patients (30.0%) and were used in 34 of these 180 patients (18.8%). In 4 of 420 patients (0.95%) without pacing PACs, cardiac pacing was needed prior to CPB. The following preoperative diagnoses were significant predictors (P less than .05) for the use or need for pacing catheters: sinus node dysfunction/bradydysrhythmias, a history of transient complete atrioventricular block, aortic stenosis, aortic insufficiency, and reoperation. The majority of adult patients undergoing cardiac surgery do not require the use of a pacing PAC prior to CPB.(ABSTRACT TRUNCATED AT 250 WORDS)