Emergent transvenous cardiac pacing using ultrasound guidance: a prospective study versus the standard fluoroscopy-guided procedure

Abstract

Aims:

To compare time to active pacing and complication rates associated with temporary transvenous pacemaker (TTVPM) insertion between a fully echo-guided approach of vein access and lead placement, and standard placement of TTVPM under fluoroscopic guidance.

Methods and results:

We performed a prospective single-center observational study enrolling all consecutive patients from 1 January 2008 to 31 December 2012 needing emergent TTVPM placement. According to personal experience and clinical setting, the operators could choose between a fully echo-guided approach of TTVPM placement through the jugular vein and a standard fluoro-guided approach through the femoral vein. Safety and efficacy endpoints were pre-specified, registered, and compared. A total of 113 patients were treated using the echo-guided approach, and 90 via the fluoro-guided approach. The two groups differed with regard to clinical setting at presentation: an acute coronary syndrome was more frequent in the fluoro-guided approach group (39.7% vs. 16.8%, p<0.001), whereas asystole was more frequent in the echo-guided approach group (9.7 vs. 0%). Median time from decision to active pacing was significantly shorter in the echo-guided approach group (22 vs. 43 minutes, p<0.01). The overall complication rates were significantly lower in the echo-guided approach group (15.0% vs. 28.8%, p 0.02), because of lower rates of infections (2.7% vs. 11.1%, p 0.02) and puncture-related hematomas (0 vs. 3.3%, p=0.08). There were no deaths related to TTVPM, but one heart perforation requiring emergent pericardiocentesis occurred in the fluoro-guided approach group. One pneumothorax treated conservatively occurred in the echo-guided approach group, while no differences were observed with regard to sustained tachyarrhythmias (1.8% vs. 2.2%) or malfunctions requiring reposition of the catheter (8.8 vs. 8.9%). Overall, complications delaying permanent pacemaker implant for >48 hours were observed less often in the echo-guided approach group (6.8 vs. 20.7%, p = 0.03).

Conclusion:

Echo-guided insertion of TTVPM through the jugular vein is a feasible and safe alternative to fluoroscopic guidance and may reduce complications and time to active pacing in patients who are not candidates for emergent cardiac catheterization.

Keywords

atrioventricular block cardiac pacemaker complications fluoroscopy heart arrest transthoracic echocardiography.

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References

Betts

. Regional survey of temporary transvenous pacing procedures and complications. Postgrad Med J 2003; 79: 463–6.

Bjornstad

CCL

Gjersten

Thorup

. Temporary cardiac pacemaker treatment in five Norwegian regional hospitals. Scand Cardiovasc J 2012; 46: 137–43.

Gjesdal

Johansen

Gadler

. Temporary emergency pacing: an orphan in district hospitals. Scand Cardiovasc J 2012; 46: 128–30.

Birkhahn

Gaeta

Tloczkowski

. Emergency Medicine-Trained Physicians are proficient in the insertion of Transvenous Pacemakers. Ann Emerg Med 2004; 43: 469–74.

Brignole

Auricchio

Baron-Esquivas

. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2013; 34:2281–329.

Graham

Ozment

Tegtmeyer

. Central Venous Catheterization. N Engl J Med 2007; 356:e21.

Aguilera

Durham

Riley

. Emergency Transvenous Cardiac Pacing Placement Using Ultrasound Guidance. Ann Emerg Med 2000; 36: 224–7.

Pinneri

Frea

Najd

. Echocardiography-guided versus fluoroscopy-guided temporary pacing in the emergency setting: an observational study. J Cardiovasc Med 2012; 14: 242–6.

Leung

Duffy

Finckh

. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med 2006; 48: 540–7.

10.

Tsang

Enriquez-Serano

Freeman

. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002; 77: 429-36.

11.

Hodgkiss Harlow

Back

Brumberg

. Technical factors affecting the accuracy of bedside IVC filter placement using intravascular ultrasound. Vasc Endovasc Surg 2012; 46: 293–9.

12.

Wen

Stock

Heemann

. Agitated Saline Bubble-Enhanced Transthoracic Echocardiography: A Novel Method to visualize the Position of Central Venous Catheter. Crit Care Med 2014; 42: e231–3.

13.

Francis

Williams

Achord

. Clinical competence in insertion of a temporary transvenous ventricular pacemaker. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology. Circulation 1994; 89:1913–6.

14.

Harrigan

Chan

Moonblatt

. Temporary transvenous pacemaker placement in the emergency department. J Emerg Med 2007; 1:105–11.