Modified Temporary Cardiac Pacing Using Transvenous Active Fixation Leads and External Re-Sterilized Pulse Generators (original) (raw)

2006, Journal of the American College of Cardiology

To the Editor: Transcutaneous temporary pacing can be unreliable, and the stimulation can be uncomfortable; epicardial pacing requires thoracotomy (1,2). Transvenous percutaneous pacing systems placed "blindly," fluoroscopically, or electrocardiographically have therefore become the mainstay of temporary pacing (1). However, temporary pacing leads have a significant risk of dislodgement, infection, loss of capture, or even chamber perforation (3). In addition to risk of infection with prolonged central venous access, patient immobilization ("bed rest") can result in additional complications and economic burden. As a result, use of temporary pacing systems is limited to no more than a few days (1). However, prolonged temporary pacing may sometimes be required. Treatment of infection in a pacemaker-dependent patient (4), post-operative recovery from cardiac valve surgery (5), or Lyme myocarditis with transient atrioventricular (AV) block (6) are representative of cases where prolonged pacing support may be necessary. We present an alternative approach for modified temporary pacing support to address these scenarios. An active fixation pacing lead is placed fluoroscopically via percutaneous venous access and connected to a re-sterilized external pulse generator. This paper describes our clinical experience with this pacing system. All patients who received modified temporary pacing support by the arrhythmia service at Brigham and Women's Hospital from July 2000 through November 2004 were included in the analysis. The facility is a regional referral center for lead extraction, resulting in a significant number of patients admitted with infected devices. Patient clinical characteristics, details of the implantation procedure, and follow-up results were evaluated. If the commonly accepted indication for pacing (7) was potentially reversible but likely to persist for more than one or two days, or if the patient had a treatable contraindication to permanent hardware implantation, a modified temporary pacing system was considered. New standard active-fixation leads were selected at physician discretion. Pulse generators previously explanted from patients without known infection were re-sterilized and utilized. In a sterile procedure room, venous access was achieved using standard percutaneous technique (without cutdown) (Fig. 1). The pacing lead was advanced under fluoroscopic guidance, fixed to the myocardium, and tested in a standard fashion. The lead was then sutured to the skin using the anchoring sleeve (Fig. 1). After connection to the lead, the pulse generator (programmed SSI) was secured to the skin surface (Fig. 2). After implantation, patients were returned to their hospital beds and, unless contraindicated, were encouraged to ambulate. Plain film chest radiography and interrogation were performed the following day to exclude acute dislodgment. Patients were followed clinically to determine if a permanent device was still indicated and/or if concurrent infection or illness had resolved sufficiently to allow permanent device implantation. At the time of permanent implantation, the external pulse generator was detached followed by retraction of the active fixation mechanism from the myocardium under fluoroscopic guidance.