How Do You Do Transvenous Pacing?

• The doctor decides which vein to be used for transvenous pacing depending on the condition of the patient and whether they need a permanent pacemaker or a temporary one.
• After securing the central venous access, the transvenous lead is introduced and progressed into the heart.
• While inserting the wire, the doctor will ensure its right path through various tracing methods.
  • Lead marking: The wire has markers on it, these will give an estimation of where the lead is.
  • Continuous electrocardiographic (ECG) monitoring: During the implantation of a transvenous pacing lead, continuous electrocardiographic monitoring is advised. When the tip of the transvenous pacing line meets the right ventricular muscle (myocardium), nearly all patients will have arrhythmias, such as numerous premature ventricular contractions (PVCs) or brief episodes of nonsustained ventricular tachycardia.
  • Fluoroscopy: Fluoroscopy allows direct viewing of the transvenous pacing lead and appropriate positioning of the lead within the right ventricle. While fluoroscopy is not necessarily required for lead insertion through subclavian or internal jugular venous access, it is required for femoral venous access to move the catheter into the right position.
  • Echocardiography: Continuous echocardiographic monitoring is utilized successfully for temporary pacing wire implantation.
    • As the wire reached the ventricle of the heart, a small balloon on the wire is inflated.
    • This balloon secures the lead in place and floats in the blood that flows through the ventricle of the heart.
    • As the lead is secured, the external generator is initiated. Firstly, low electric impulses are used to confirm the location of the lead, and gradually, the intensity of impulses is increased.
    • The position of the balloon is adjusted depending on the heart rate.
    • Once the required heart rate is achieved, it indicates that the lead is at the apex of the heart. Finally, the balloon is deflated.
    • The wire and venous access are secured externally such that the lead stays in position within the heart.
    • A chest X-ray or fluoroscopy is done to confirm the position of the wire.
    • This procedure is done under the influence of anesthesia.

Transvenous pacing is a temporary cardiac pacing procedure that is intended to treat severe disturbances in blood flow from the heart (cardiac output), which is caused by any type of arrhythmia (irregular heartbeats).

Though it is used for any type of arrhythmia, transvenous pacing is the primary treatment for bradycardia (slow heart rate) to keep the patient's heart rate stable to generate enough cardiac output.

Transvenous pacing is a complicated procedure.

The necessary equipment while performing transvenous pacing include:

• Fully stocked temporary pacing wire box (kept in intensive care unit equipment room)
• Check pacing generator is operational before use
• Insert a new 9V battery on every use
• Defibrillator and emergency trolley must be kept handy
• Apply and connect external pacing pads on the patient if not already on
• Continuous cardiac monitoring
• Prepare sedation as prescribed

Potential complications following transvenous pacing include:

• Arrhythmia (irregular heartbeats)
• Micro shock
• Complications related to central venous line (CVL) insertion
• Myocardial perforation
• Infection
• Bleeding around the insertion site
• Arterial puncture and hematoma or blood clot formation
• Pneumothorax (collection of air in the chest cavity, which forces the lungs to collapse)
• Cardiac tamponade (pressure on the heart caused by an abnormal collection of blood between the heart and outer covering of the heart)
• Lead displacement
• Local and systemic infection
• Failure to pace (the pacemaker does not fire impulses)
• Failure to capture (impulses are generated but it doesn’t trigger depolarization of heart muscle)
• Failure to sense (pacemaker cannot detect impulses from heart muscle)
• Accidental disconnection of lead

• Continuous monitoring of electrocardiography is done to ensure that the heart conduction is normal.
• A bedside chest X-ray may be done to locate the lead or to check for complications, such as pneumothorax and cardiac tamponade.
• Close observation for symptoms of irritation, infection, or bleeding at the insertion site.
• Maintain a spare generator and battery at the bedside.