Temporary Pacing

Temporary transvenous pacing is an established technique that can most often be accomplished quickly and easily by appropriately trained individuals. It is often performed under direct fluoroscopic visualization, but positioning flow-directed balloon catheters using electrocardiographic guidance is an acceptable alternative when fluoros-copy is unavailable. There are a number of indications for temporary pacing. In general, temporary pacing is indicated in any person who is markedly symptomatic from a bradyarrhythmia that is not rapidly reversible by the administration of medications or correction of electrolyte abnormalities (Fig. 5). In addition, the use of temporary pacing prophylactically should be considered in certain situations. Patients with underlying conduction system disease who are undergoing general anesthesia for planned surgical procedures have been the topic of several investigations (96-98). In general, the risk of high-degree block is very low and does not warrant prophylactic pacing, even in patients with advanced conduction-system disease, unless there is a history of syncope or second or third-degree AV block has previously been documented. Notably, a recent study by Gauss and associates prospectively studied 106 patients with asymptomatic bifasicular block (99). Progression to high-grade AV block was observed in only one patient. Patients with underlying LBBB who are undergoing right-heart catheterization, especially with endomyocardial biopsy, may also benefit from prophylactic temporary pacing.

Afib Treatment Steps

Fig. 5. An elderly woman was inadvertently taking 720 mg of sustained-release verapamil daily. She experienced a syncopal episode, and her ECG revealed a slow junctional rhythm without visible P waves. The verapamil was discontinued, and she received a temporary transvenous pacemaker until the effects of the drug dissipated.

Fig. 5. An elderly woman was inadvertently taking 720 mg of sustained-release verapamil daily. She experienced a syncopal episode, and her ECG revealed a slow junctional rhythm without visible P waves. The verapamil was discontinued, and she received a temporary transvenous pacemaker until the effects of the drug dissipated.

There are other methods of temporary pacing, besides the transvenous route, that are relevant to the present discussion. Transthoracic pacing involves the percutaneous introduction of a pacing catheter directly into the right ventricle. Pacing can be accomplished very rapidly, an advantage for emergency situations, especially when venous access is difficult, but the technique has largely been abandoned because of difficulties in finding a stable pacing position and a high incidence of adverse effects. Transesophageal pacing is a relatively safe and easy technique that is generally well-tolerated. It provides an effective means of atrial pacing, because of the proximity of the esophagus to the left atrium. Ventricular capture is inconsistent, so it should not be used in the setting of AV block. Transcutaneous pacing is an established technique that previously was limited by poor patient tolerance (caused by painful contraction of the chest-wall musculature). It involves connecting several large self-adhesive chest electrodes to an external pulse generator. Recent technical advances have improved patient tolerance, making this a viable alternative to transvenous pacing, especially if used prophylactically when the risk of high-degree block is relatively low. Transcutaneous pacing may be somewhat less effective than transvenous pacing, so consistent ventricular capture should be documented before the device is left on standby.

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