The Use of Subcostal Echocardiographic Views to Guide the Insertion of a Right Ventricular Temporary Transvenous Pacemaker—Description of the Technique

The need for temporary cardiac pacing may occur in emergency and elective situations and may require transvenous right ventricular lead placement. The treatment of bradyarrhythmias presents the most common perioperative emergency indication. Intraoperatively, temporary rapid right ventricular pacing is accepted as a safe, titratable, and highly reliable method to achieve deliberate hypotension, and it has become a routine practice in the anesthetic management of cardiovascular interventions.The navigation of the lead into the right ventricle often requires fluoroscopy to guide placement and to confirm position. Ultrasound guidance has been accepted widely by perioperative physicians as a safe technique for central venous access. Basic ultrasound and transthoracic echocardiographic skills rapidly are becoming integral to anesthesiologists’ practice. When used to guide transvenous pacemaker wire insertion, subcostal echocardiographic imaging offers attractive advantages over blind or fluoroscopic placement, including rapid deployment, avoidance of radiation, real-time visualization of the lead in relation to the cardiac structures, and early detection of potential complications, such as tamponade.Although several articles on echocardiographic guidance for transvenous pacing have been published in other acute care specialty fields in the last decade, this is the first description of the technique and of the recommended echocardiographic views in a perioperative context. In addition, a review of the current literature is presented, and the specific advantages and disadvantages of the approach are discussed in this article. The need for temporary cardiac pacing may occur in emergency and elective situations and may require transvenous right ventricular lead placement. The treatment of bradyarrhythmias presents the most common perioperative emergency indication. Intraoperatively, temporary rapid right ventricular pacing is accepted as a safe, titratable, and highly reliable method to achieve deliberate hypotension, and it has become a routine practice in the anesthetic management of cardiovascular interventions. The navigation of the lead into the right ventricle often requires fluoroscopy to guide placement and to confirm position. Ultrasound guidance has been accepted widely by perioperative physicians as a safe technique for central venous access. Basic ultrasound and transthoracic echocardiographic skills rapidly are becoming integral to anesthesiologists’ practice. When used to guide transvenous pacemaker wire insertion, subcostal echocardiographic imaging offers attractive advantages over blind or fluoroscopic placement, including rapid deployment, avoidance of radiation, real-time visualization of the lead in relation to the cardiac structures, and early detection of potential complications, such as tamponade. Although several articles on echocardiographic guidance for transvenous pacing have been published in other acute care specialty fields in the last decade, this is the first description of the technique and of the recommended echocardiographic views in a perioperative context. In addition, a review of the current literature is presented, and the specific advantages and disadvantages of the approach are discussed in this article. SYMPTOMATIC BRADYARRHYTHMIAS are the most common indications for the insertion of temporary or permanent pacemakers.1Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al.2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart.Rhythm Society JACC. 2013; 61: e6-75Google Scholar, 2Sullivan B.L. Bartels K. Hamilton N. Insertion and management of temporary pacemakers.Semin Cardiothorac Vasc Anesth. 2016; 20: 52-62Crossref PubMed Scopus (9) Google Scholar In the perioperative setting, elective rapid ventricular pacing may be required for certain surgical and percutaneous interventional procedures in patients with structural heart disease.3Ruiz C.E. Feldman T.E. Hijazi Z.M. et al.Interventional fellowship in structural and congenital heart disease for adults.Catheter Cardiovasc Interv. 2010; 76: E90-105Crossref PubMed Scopus (11) Google Scholar, 4Gammage M.D. Temporary cardiac pacing.Heart. 2000; 83: 715-720Crossref PubMed Google Scholar For example, the intraoperative management of thoracic endovascular aortic aneurysm repair and transcatheter aortic valve implantation may involve rapid right ventricular pacing to achieve deliberate hypotension, which is needed for stent deployment. The goal is to minimize the risk of graft migration by causing a brief reduction in cardiac output.5Tagarakis G.L. Whitlock R.P. Gutsche J.T. et al.New frontiers in aortic therapy: Focus on deliberate hypotension during thoracic aortic endovascular interventions.J Cardiothorac Vasc Anesth. 2014; 28: 843-847Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 6Kahn R.A. Marin M.L. Hollier L. et al.Induction of ventricular fibrillation to facilitate endovascular stent graft repair of thoracic aortic aneurysms.Anesthesiology. 1998; 88: 534-536Crossref PubMed Scopus (68) Google Scholar, 7Pornratanarangsi S. Webster M.W. Alison P. Rapid ventricular pacing to lower blood pressure during endograft deployment in the thoracic aorta.Ann Thorac Surg. 2006; 81: e21-e23Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 8Moon M.C. Dowdall J.F. Roselli E.E. The use of right ventricular pacing to facilitate stent graft deployment in the distal aortic arch: A case report.J Vasc Surg. 2008; 47: 629-631Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 9Nienaber C.A. Kische S. Rehders T.C. et al.Rapid pacing for better placing: Comparison of techniques for precise deployment of endografts in the thoracic aorta.J Endovasc Ther. 2007; 14: 506-512Crossref PubMed Scopus (74) Google Scholar Similarly, deliberate hypotension through the induction of a paced ventricular tachycardia is a common approach used to facilitate the intraoperative management of cerebral aneurysms.10Konczalla J. Platz J. Fichtlscherer S. et al.Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: Results of an interdisciplinary prospective trial.J Neurosurg. 2018; 128: 1741-1752Google Scholar Pacemaker lead insertion can be performed blindly, as often is the case with flow-directed leads used in emergencies, or it can be guided by an electrocardiogram (ECG), fluoroscopy, transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE).2Sullivan B.L. Bartels K. Hamilton N. Insertion and management of temporary pacemakers.Semin Cardiothorac Vasc Anesth. 2016; 20: 52-62Crossref PubMed Scopus (9) Google Scholar A cardiothoracic anesthesiologist is familiar with the transesophageal technique, which commonly is used to guide the placement of catheters and cannulas for anesthetized patients. There are situations when the TEE approach is not feasible for pacemaker lead insertion: interventional procedures increasingly are performed under sedation, or the patient may have contraindications to TEE. In addition, the TEE probe may not be available or the pacemaker may be placed by an anesthesiologist without TEE training. Fluoroscopy commonly is used for intracardiac catheterization, but it requires an imager and a compatible operating table. Moreover, hospitals may dictate that special privileges are obtained by nonradiologist physicians who intend to use fluoroscopy. Given that it requires no sedation or airway management and the equipment is becoming widely available, TTE can fill these gaps. A parallel review of considerations, advantages, and disadvantages is provided in the Table. This article focuses on those aspects of temporary transvenous pacemaker insertion that are relevant when surface echocardiography, the subcostal window in particular, is used as the imaging modality. A detailed description of the recommended echocardiographic views and the visualization of the intracardiac lead is presented. The transvenous temporary pacemaker insertion procedure entails 3 stages: (1) establishing central venous access and inserting the introducer sheath, (2) guiding and positioning the lead into the right ventricle to achieve electromechanical capture, and (3) optimization of the pulse generator settings. When choosing the venous access site, several factors are considered, including the operator's experience, the anticipated duration of pacing, and the coagulation status. For an anatomic alignment, most conducive to successful lead navigation into the right ventricle (RV), the sites most commonly used are the right jugular and the left subclavian veins. Ultrasound imaging is used widely to identify anatomic landmarks, to confirm vessel patency, and to guide cannulation in real time while minimizing complications.11Saugel B. Scheeren T.W.L. Teboul J.L. Ultrasound-guided central venous catheter placement: A structured review and recommendations for clinical practice.Crit Care. 2017; 21: 225Crossref PubMed Scopus (135) Google Scholar The pacemaker lead types available for temporary transvenous cardiac pacing vary based on maneuvering technique, polarity, caliber, rigidity, and fixation ability.2Sullivan B.L. Bartels K. Hamilton N. Insertion and management of temporary pacemakers.Semin Cardiothorac Vasc Anesth. 2016; 20: 52-62Crossref PubMed Scopus (9) Google Scholar The rigid nonfloating lead is torque directed and typically positioned using fluoroscopy. Similar to a pulmonary artery catheter, the softer floating lead (with or without a balloon tip) can be floated blindly into the RV or into the right ventricular outflow tract. A variation of the pulmonary artery catheter design allows for the introduction of 2 endocardial pacemaker wires into the right atrium as well as the ventricle and can be used for dual-chamber pacing.12Vernick W.J. Szeto W.Y. Li R.H. et al.The utility of atrioventricular pacing via pulmonary artery catheter during transcatheter aortic valve replacement.J Cardiothorac Vasc Anesth. 2015; 29: 417-420Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar After the venous sheath is in place, the lead electrodes are connected to the appropriate output ports on the external pacemaker pulse generator. The output current should be set at a maximum (usually 20 mA), the sensitivity at a minimum (asynchronous pacing), and the rate at 10 to 20 beats per minute higher than the patient's native rate.2Sullivan B.L. Bartels K. Hamilton N. Insertion and management of temporary pacemakers.Semin Cardiothorac Vasc Anesth. 2016; 20: 52-62Crossref PubMed Scopus (9) Google Scholar As the lead is advanced to its final position, electromechanical capture is signaled by the appearance of pacing electrocardiogram “spikes” followed by QRS complexes with a left bundle branch block morphology. Once pacing is established, the output current can be reduced gradually to determine the pacing threshold (minimal current that causes electromechanical capture), ideally under 1 mA.2Sullivan B.L. Bartels K. Hamilton N. Insertion and management of temporary pacemakers.Semin Cardiothorac Vasc Anesth. 2016; 20: 52-62Crossref PubMed Scopus (9) Google Scholar This value multiplied by 2 to 2.5 is considered the appropriate final setting for pacemaker output. If required, a further optimization of the settings can include the selection of the sensing threshold. Finally, the lead should be secured at the skin to prevent displacement and a loss of capture. Technical complications during transvenous pacemaker insertion can result from difficulties in vessel identification, trauma or infection at the site of insertion, inadvertent arterial cannulation, difficulty traversing the tricuspid valve, trauma to a tricuspid leaflet or the valvular apparatus, ventricular perforation, arrhythmias, or a failure to achieve or sustain capture. The incidence of complications can be as high as 30% to 50% when infection and a loss of pacing are included.13Murphy J.J. Current practice and complications of temporary transvenous cardiac pacing.BMJ. 1996; 312: 1134Crossref PubMed Scopus (72) Google Scholar Although operator experience cannot be discounted as a significant factor in safe transvenous pacing, there can be numerous patient and equipment-related factors that contribute to complications. Anomalous venous anatomy or stenosis can preclude successful vessel or right atrial (RA) entry. Significant tricuspid regurgitation (TR) and RA dilatation can prevent the advancement of the lead into the RV. Multiple attempts at placement can increase the risk of complications, such as sustained ventricular arrhythmias from a mechanical irritation of the endocardium, significant TR from a tricuspid valve injury, and a free wall perforation of the RV.14López Ayerbe J. Villuendas Sabaté R. García García C. et al.Temporary pacemakers: Current uses and complications.Rev Esp Cardiol. 2004; 57: 1045-1052Crossref PubMed Google Scholar, 15Chang J.D. Manning W.J. Ebrille E. et al.Tricuspid valve dysfunction following pacemaker or cardioverter-defibrillator implantation.J Am Coll Cardiol. 2017; 69: 2331-2341Crossref PubMed Scopus (84) Google Scholar All catheters and lead types can be visualized using surface echocardiography. A case report describes the use of echocardiographic contrast injected into the catheter tip balloon to increase its echocardiographic visibility.16deDiego C. Pai R.K. Farre J. et al.Echocardiographic contrast-guided temporary pacemaker placement.Heart Rhythm. 2005; 2: 1391Google Scholar Anecdotally, a similar enhancement of echogenicity can be achieved by injecting the balloon with saline, although the safety of the maneuver has not been investigated. Preprocedure scanning to ensure adequate acoustic windows is recommended, although in the authors’ experience, conversion to an alternative mode of guidance (TEE or fluoroscopy) owing to poor surface echocardiographic image quality is rare. The assisting echocardiographer uses the subcostal (also referred to as subxiphoid) acoustic window to visualize the right atrium and ventricle. This window provides imaging access away from the sterile field and allows the operator to view the pacemaker tip as it advances into the right side of the heart. The subcostal window is accessed best in a supine position and is not obscured by lung expansion in mechanically ventilated patients, making it particularly useful in a perioperative setting. From the subcostal 4-chamber view (Fig 1), the transducer is rotated counterclockwise and oriented in the sagittal plane until the inferior vena cava (IVC) and the RA are visualized. To obtain the subcostal bicaval view, the transducer is directed further slightly toward the patient's right and angled cephalad until the superior vena cava (SVC) is observed (Fig 2, Video 4).17Tabak B. Elliott C.L. Mahnke C.B. et al.Transthoracic echocardiography visualization of bicaval dual lumen catheters for veno-venous extracorporeal membrane oxygenation.J Clin Ultrasound. 2012; 40: 183Crossref PubMed Scopus (18) Google Scholar Although visualizing the SVC beyond its entry into the RA can be challenging, it is not necessary for successful guidance. The described transducer position allows the pacemaker tip to be followed as it first enters from the SVC into the RA (Fig 3) or passes into the IVC.Fig 2Subcostal bicaval view—2-dimensional image (top image) and a superimposed 3-dimensional drawing of the heart (lower image). IVC, inferior vena cava; RA, right atrium; RV, right ventricle; SVC, superior vena cava: arrow, tricuspid valve.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Wire enters the right atrium. Modified subcostal 4-chamber view showing an out-of-plane image of a pacemaker lead with its cross-section creating a “dot” appearance (arrow) and the associated acoustic artifact. RV, right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Once the lead is in the RA (Video 1), the usual of the lead to the left and through the tricuspid valve are performed by the who can the lead in real To the pacemaker lead as it passes through the tricuspid valve into the RV, the transducer is in the plane to to the subcostal 4-chamber view (Fig Video the valve can the operator to the lead advancement with its The echocardiographer should to identify the lead tip and to it in view as as by making to the transducer The position of the wire tip is in the RV and it can be in the subcostal 4-chamber view (Fig Video To prevent the loss of the lead and the owing to or in patient position, a of in the lead is required to a should be this is considered to be a risk factor for cardiac perforation it to lead and causes of pressure to the B. et perforation by pacemaker and cardioverter-defibrillator experience in treatment and 2012; Scholar the other can lead to catheter which has been to be for a loss of pacing in to of the in 2 of and J.J. Current practice and complications of temporary transvenous cardiac pacing.BMJ. 1996; 312: 1134Crossref PubMed Scopus (72) Google Scholar, Ayerbe J. Villuendas Sabaté R. García García C. et al.Temporary pacemakers: Current uses and complications.Rev Esp Cardiol. 2004; 57: 1045-1052Crossref PubMed Google Scholar Although this description of the technique focuses on the subcostal visualizing the lead in plane is required, views can be The window is to adequate echocardiographic when the patient is positioned supine or mechanically position of the wire positioned in the of the right ventricle. Pacemaker lead in the right ventricle observed from the subcostal This window can be used to and to tricuspid regurgitation by Large Image Figure ViewerDownload Hi-res image Download (PPT) by in and in the and safety of surface echocardiography guided transvenous lead S. et temporary implantation of alternative with reliable during Cardiol. Scholar, transvenous cardiac pacing placement using ultrasound 2000; Full Text Full Text PDF PubMed Scopus Google Scholar In patients who pacemaker insertion an guided by fluoroscopy. that and in the guided in the echocardiography guided and in the it of pacing common in the this to the access site the right jugular site used for the technique to the in the fluoroscopy is to be associated with of loss of S. K. et temporary pacing in the emergency Cardiovasc 2013; 14: Scopus Google Scholar In et pacemaker insertion to the technique in an prospective of emergency There no in complications or pacing the time in the to L. et transvenous cardiac pacing using ultrasound A prospective the Heart Cardiovasc Care. 2016; PubMed Scopus Google Scholar in of safety and the use of echocardiography to guide a temporary transvenous pacemaker wire is by current to be at to fluoroscopy. A review of the echocardiography case for a in endovascular procedures and procedures in which temporary RV transvenous pacemaker insertion under TTE guidance. these thoracic endovascular aortic aneurysm repair elective and 2 and 2 emergency cerebral aneurysm patient emergency to have a heart patient for the elective of aortic aneurysm repair an advanced The pacemaker lead not be placed in 1 patient who to have stenosis when fluoroscopy with an contrast to the placement. The leads the operating in but 2 on complications during the intraoperative complications of introducer sheath placement not Although have focused on emergency indications and procedures performed in emergency and cardiac care the authors’ experience is to the intraoperative S. et temporary implantation of alternative with reliable during Cardiol. Scholar, transvenous cardiac pacing placement using ultrasound 2000; Full Text Full Text PDF PubMed Scopus Google Scholar, S. K. et temporary pacing in the emergency Cardiovasc 2013; 14: Scopus Google Scholar, L. et transvenous cardiac pacing using ultrasound A prospective the Heart Cardiovasc Care. 2016; PubMed Scopus Google Scholar Given the of the with the published not be The authors’ experience of and has TTE technique of echocardiography is a imaging that is of and Although beyond the of this in to the to guide the TTE is an that provides a of cardiac and the operator has the this is to echocardiography and during cardiac Although it has a to image the lead the echocardiography can be used to visualize the lead in the SVC in the with the the operator can to an alternative access J. et by transthoracic echocardiography during central venous catheter insertion: A method to catheter 2013; PubMed Scopus Google Scholar If tricuspid is observed using the lead can be advanced in time with a ventricular to the valve can be to the valve or to identify patients with a significant of TR or leaflet which can to S. 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In to the required for central venous cannulation and temporary cardiac in a IVC, inferior vena cava; SVC, superior vena cava; transesophageal tricuspid transthoracic echocardiography. echocardiography is a safe and technique that an when elective or emergency temporary pacemaker insertion is in have become increasingly in ultrasound and of echocardiography is becoming an integral of ultrasound training. Although in with emergency and care TTE increasingly is at of training.

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