A new temporary atrial pacing catheter inserted percutaneously into the subclavian vein without fluoroscopy: a preliminary report

Temporary Transvenous Cardiac Pacing in Patients With Acute Myocardial Infarction Predicts Increased Mortality

Background

Temporary pacemakers (TP) are used in emergency situations for severe bradyarrhythmias secondary to acute myocardial infarction (AMI) and to non-AMI related cardiac disorders. TP have been studied previously in AMI patients treated with thrombolytic therapy; limited information is available on current outcomes in AMI patients treated with percutaneous coronary intervention.

Methods

We reviewed the indications, complications, and mortality associated with TP insertion over a four year period (2003 - 2007) at a university hospital.

Results

Seventy-three temporary pacemakers were inserted (47 men, 26 women) during this period. The mean age was 65.2 years. TP were used in 29 AMI patients (39.7 % of total) and 44 non-AMI patients (60.3% of total). The duration of TP use was 2.6 ± 0.4 days in the whole cohort, 2.46 % of all AMI patients (29/1180) admitted during this period required a TP. Six of these patients requiring a TP required a permanent pacemaker. Eight patients with AMI and a TP died (27.6%). In contrast 8.9 % of AMI patients not requiring a TP died (P < 0.01). There were no statistically significant differences between the AMI and non-AMI groups in the duration of temporary pacing (2.4 ± 0.6 days vs. 2.8 ± 0.4 days), in complications (27.6% vs. 29.5%), or in mortality (27.6% vs. 15.9%). The need for a permanent pacemaker (PPM) differed significantly between the AMI and non-AMI patients (20.7% vs. 54.5%; P < 0.05).

Conclusion

Our results indicate that AMI patients infrequently require a TP and that approximately 20% of these patients require a PPM. These results suggest that early revascularization of the conduction system with current interventional techniques has decreased the need for TP in AMI patients. However, this group requires more intensive monitoring as the mortality rate in this group of patients is significantly higher than the other AMI patients not requiring TP.

Temporary Cardiac Pacing in the Intensive Care Unit

Indications for temporary cardiac pacing have increased substantially in the last several years. Although most temporary cardiac pacing is still carried out to treat symptomatic bradycardia due to atrioventricular conduction system disease or atrial bradycardia (i.e., sinus node dysfunction), temporary pacing is currently used to induce and to terminate some supraventricular tachyarrhythmias, prevent pause-dependent ventricular tachycardia (usually torsades de pointes), and vagally mediated atrial fibrillation, to allow the maintenance of hemodynamic competence in postoperative cardiac patients and to evaluate selected patients with hypertrophic and dilated cardiomyopathies who might benefit hemodynamically from cardiac pacing. The roles of transcutaneous and esophageal pacing have also expanded; transcutaneous pacing is now commonly used in patients at high risk for the development of atrioventricular block, such as those with acute myocardial infarction and bifascicular block. We review available types of temporary pacing leads and pulse generators, the methods by which temporary pacing is accomplished, complications of pacing system insertion, and current indications for this therapy. Guidelines for troubleshooting normal and abnormal pacemaker function in the intensive care unit setting are provided.

Emergency ventricular pacing using a J-electrode catheter without fluoroscopy

The initiation of emergency ventricular pacing may be delayed by a lack of facilities for immediate fluoroscopy or staff members who are skilled in positioning a transvenous electrode catheter. Techniques have been developed to overcome these problems but have been unreliable, expensive and/or uncomfortable for patients. In each of 20 consecutive haemodynamically unstable patients (13 patients with asystole or high-grade atrioventricular block and seven patients with ventricular tachycardia), an attempt was made to pace the ventricle with a Cordis 5-FG (1.67-mm) "atrial J"-electrode catheter, which was inserted transvenously without fluoroscopic guidance. Pacing was initiated successfully in 19 cases within 40 seconds to 30 minutes (median, two minutes) of skin puncture, and in 16 cases within three minutes. Fifteen procedures were performed by operators with experience of less than 10 previous pacing catheter insertions. This study demonstrates that emergency transvenous ventricular pacing can be initiated rapidly and reliably by means of a catheter with a "J" configuration, which is inserted without the use of fluoroscopy. The method can be employed successfully by operators with little experience in pacing techniques. Standard inexpensive equipment is used; the technique is safe and well-tolerated by patients.

Temporary pacing. Indications, modes, and techniques

This article reviews the indications for temporary pacing, describes and illustrates the techniques, discusses the fundamentals of electrical stimulation, and explores special applications, including overdrive and dual-chamber DDD pacing.

Pacemaker reversion for suspected supraventricular tachycardia

Overdrive atrial pacing was employed in twelve patients with suspected supraventricular tachycardia resistant to drug therapy. Eleven of these patients reverted to sinus rhythm with pacing either immediately or after a short episode of atrial fibrillation. In one patient, recordings from the atrial electrode indicated that a broad complex tachycardia was of ventricular rather than supraventricular origin. No complications were encountered and the procedure was well tolerated in all. Overdrive pacing is suggested as a safe alternative to DC cardioversion in drug-resistant supraventricular tachycardia, particularly in the presence of digitalis, in the elderly and in patients with chronic lung disease.

A temporary external DDD pacing unit

A device for temporary external DDD pacing was developed using a modified permanent pulse generator, and temporary atrial and ventricular electrode catheters were inserted pervenously. The atrial lead was a J type and the ventricular lead had a remote anode in the superior vena cava. With a special clamp and appropriate connectors the permanent DDD pulse generator provided unipolar external DDD pacing. The device was evaluated in 13 patients to control bradyarrhythmias or for overdrive pacing in an attempt to control tachyarrhythmias. Nine patients were ambulatory; all had continuous electrocardiographic monitoring. The device was used for 1 to 12 days (mean 4.9). Eight patients benefited from temporary DDD pacing and 7 had permanent DDD pacemakers implanted. In 1 patient, atrial fibrillation developed, 2 patients had brief episodes of ventricular lead displacement and another required reprogramming because of loss of ventricular capture. Results suggest that the device is applicable for a clinical trial of DDD pacing before possible permanent implantation when attempting to improve cardiac output or control arrhythmias.