Temporary cardiac pacing provides electrical stimulation to a heart that is compromised by disturbances in the conduction system, resulting in hemodynamic instability.

A temporary pacemaker to treat a bradyarrhythmia or tachyarrhythmia is used when the condition is temporary and when a permanent pacemaker is either not necessary or is not immediately available. Complications are common and include infection, local trauma, pneumothorax, arrhythmias and cardiac perforation. 

External transcutaneous pacing is now available on most modern defibrillators.

Temporary transvenous pacing

  • Temporary transvenous pacing involves two components, i.e., obtaining central venous access and intracardiac placement of the pacing wire.
  • The preferred route of access for temporary transvenous pacing is the internal jugular vein followed by subclavian and femoral veins, but all the major venous access sites (internal and external jugular, subclavian, brachial, femoral) have been used and each is associated with particular problems.
  • The right-sided veins should be used when possible.
  • The use of antibiotics and ultrasound probes should be considered for all wire insertions.

Complications of temporary pacing

  • Complications occur in 10-60% of procedures. The most frequent complications are failure to secure venous access, failure to place the lead correctly, infection, thromboembolism, puncture of arteries, lung or myocardium, and life-threatening arrhythmias.
  • In one series, 20% of patients developed microbiologically-confirmed septicemia when the pacing wire was left in situ for longer than 48 hours.
  • Temporary pacemakers must be checked by competent staff at least once daily for pacing thresholds, evidence of infections around venous access sites, integrity of connections, and battery status of the external generator.
  • The underlying rhythm should also be assessed and recorded at these checks.

Indications for temporary transvenous cardiac pacing

Emergency or acute:

Acute myocardial infarction with:

  • Asystole
  • Symptomatic bradycardia (sinus bradycardia with hypotension and type I second-degree atrioventricular (AV) block with hypotension not responsive to atropine)
  • Bilateral bundle branch block (BBB)
  • New or indeterminate age bifascicular block with first-degree AV block
  • Mobitz' type II second-degree AV block

Bradycardia not associated with acute myocardial infarction:

Asystole
Second-degree or third-degree AV block with hemodynamic compromise or syncope at rest
Ventricular tachyarrhythmias secondary to bradycardia

Elective:

Support for procedures that may promote bradycardia

General anesthesia with:


  • Second-degree or third-degree AV block
  • Intermittent AV block
  • First-degree AV block with bifascicular block
  • First-degree AV block and left bundle branch block (LBBB)

Cardiac surgery:

  • Aortic surgery
  • Tricuspid surgery
  • Ventricular septal defect closure
  • Ostium Primum repair

Rarely considered for coronary angioplasty (usually to right coronary artery) but may be required for angioplasty-induced bradycardia

Overdrive suppression of tachyarrhythmias