Tag Archives: cardiology

Transvenous Pacemaker Placement

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The following tutorial is courtesy of Dr. Colleen Smith.

Supplies

Transvenous pacing trays and pacing generator are located in the green cabinets above the sink in the Cardiac Room.

  1. Transvenous Pacing Electrode Tray containing:
    • TVP catheter
    • Percutaneous sheath introducer w/ syringe/guidewire/dilator
    • Sterile sleeve
    • 2 adapter pins
    • Alligator clamp
    • 3ml syringe that stops at 1.5ml
  2. Pacing generator box with extension connecting cable (attached to the box)
  3. Central line bundle with sterile patient drape, and sterile gown
  4. Sterile gloves
  5.  Ultrasound machine with linear probe and sterile ultrasound probe cover,

Set up pacing generator box 

  1. Turn generator box on by pressing the on button. Insert a new battery if necessary.
  2. Set the mode or sensitivity to demand or asynchronous pacing
  3. Set rate control above the native rate or the transcutaneous pacing rate usually around 80bpm
  4. Turn V (ventricular) output control to the max mAmps (usually 20-25mAmps)

 

Placement (Under sterile field with large patient drape, sterile gown, gloves, etc.)

  1. Place sheath introducer as you would place a Cordis type of central line, confirm venous placement with ultrasound and suture in place.Preferred site: Right internal jugular. Secondary site: Left subclavian (Try to save this for permanent pacemaker if possible.)
  2. Connect the pacing extension cable(s) to the pacing generator box.
  3. Connect the proximal lead of the pacing catheter to the positive (+) port of the pacing extension cables (or generator box
  4. If using ECG to guide placement: Connect the distal or negative (-) lead of the pacing catheter to the V2 attachment of the monitor or ECG machine using the alligator clip in the TVP catheter kit. This lead will now display an ECG waveform based on input sensed by TVP catheter as you place it. *See image below
  5. Thread the STERILE SLEEVE over the TVP catheter PRIOR to inserting the catheter into the introducer. (Keep the sleeve collapsed and pull it far back.) The TVP catheter should go through the blue end of the sleeve first so that the green end of the sleeve can connect with the sheath introducer.
  6. Place the TVP catheter – oriented so that it curves toward the heart.
    • If using the balloon (optional):
      • Only use the syringe that comes in the kit.
      • Check the balloon for leaks by inflating it prior to inserting the catheter.
  7. Inflate the balloon when you have inserted to about 20cm (2 slender dashes on the catheter) and lock it in that position prior to advancing the catheter
  8. ALWAYS deflate the balloon and lock it down prior to retracting the TVP catheter.
  9. Correct placement should occur between 30 and 40cm, consider measuring with TVP catheter over the patient’s chest prior to placing.
  10. If you have gone too far, DEFLATE the balloon and retract the TVP catheter back to the 5-10cm mark, reinflate the balloon (if using) and reinsert the TVP catheter.
  11. Confirm capture with:
    • ECG waveform attached to negative lead of TVP wire (injury pattern, see attached images)
    • Capture on monitor (LBBB with ST elevation at set rate)
    • Cardiac ultrasound (wire visible in right ventricle)
  12. When you have capture. Deflate the balloon and lock it closed. Insert the TVP catheter another 5-10mm.
  13. Secure the green end of the sterile sleeve to the introducer. (This should hold the TVP catheter in place). Pull sleeve open fully and secure the blue end of the sterile sleeve to the TVP catheter. (This ensures continued sterility of the portion of the TVP wire within the sterile sleeve so that it can be adjusted.)
  14. Apply sterile dressing to the introducer insertion site

Procedure Completion (You can now break sterile field)

  1. Connect the distal lead of the TVP catheter to the negative (-) input of the generator box (if not already done.)
  2. Remove the syringe for the balloon and tape it to the wire.
  3. Adjust mAmps by decreasing the ventricular mAmps until you loose capture and then go up x2 (or 20% higher than your lowest capture number)
  4. Obtain a CXR to further confirm placement and location, check for pneumo- or hemothorax.
  5. Obtain a 12 lead ECG to confirm pacing spikes and widened QRS for every beat.

Potential complications

  • Same as any central line: pneumothorax, improper placement, arterial placement, etc.
  • Valve rupture or tear. Caused by retracting the TVP catheter with inflated balloon. Detect by new murmur, acute heart failure, echo.
  • Perforation of the LV causing tamponade. Detect by sudden hypotension with narrow pulse pressure, pericardial effusion on echo. DO NOT REMOVE TVP Catheter.
  • Pulmonary artery rupture or tear. Caused by inflating the balloon in the pulmonary artery. Results in tamponade physiology.
  • Septal wall perforation. Caused by pushing the TVP catheter through the septum. Results in left to right shunt physiology, acute right heart failure, hypoxia

Other Resources

Below is a tutorial put together by Mount Sinai Alumni Anita Vashi

Transvenous pacing ppt

 

EMRAP put together a video tutorial of the process with a different model of pacemaker

https://www.emrap.org/episode/transvenous/transvenous