Transvenous Pacemaker Insertion (Review)

Indications

• Symptommatic bradycardia
• High-degree AV Block
• Failure of Transcutaneous pacing
• Overdrive pacing

Procedure

• Preferred site of entry is R-IJ or L-SCL
• Attach DISTAL lead to negative and attach the PROXIMAL lead to positive on the pacing unit
  
• Check balloon for leaks prior to insertion (inflate with 1.5 mL of air and place in a container of sterile saline)
• Advance the catheter 10 cm and then inflate the balloon
• Turn on the pacer (reasonable initial settings are 80 bpm and current of 20 mA in ASYNCHRONOUS mode)
• Attach the end of the pacing catheter negative terminal to V1
• Advance the pacer until pacer spikes and a widened QRS (LBBB pattern or STE on V1) are seen on monitor
• Deflate the balloon
• Confirm placement with a CXR
  

Procedure Pearls

• Don't place too large of a single lumen access into the R-IJ or L-SCL or there may be leak around the pacer
  
• Put the sterile sheath on the catheter before advancing into the patient
  
• If p-waves on V1 decrease as catheter advances it may have entered the IVC instead of the RA
• If p-waves on V1 become negative as catheter advances it may have entered pulmonary artery
• Bedside ultrasound may be used to confirm pacer location