Transvenous Pacemaker

A woman being worked up for other medical problems develops a supraventricular tachycardia, an arrhythmia where her heart is racing. She is given some beta blockers to slow her heart rate, but they work too well, and she goes into complete heart block. The atria which normally send signals to the ventricles to contract stop communicating. Her heart beats a rate of 30. A rapid response team is called within the hospital, and a cardiologist determines that she will eventually need a permanent pacemaker. For now, she will need a temporary pacemaker.

She is sent to my service in the intensive care unit, and the cardiologist asks us to place a temporary transvenous pacemaker. I'm pretty excited since this is a rare procedure and one of the few opportunities I've had to place a pacemaker. While it's not needed frequently, when the need comes up, I need to know how to put one in.

In fact, the procedure is not all that difficult or different from other lines I've placed. After placing a 5 French introducer sheath into the right neck, I float the pacemaker into the patient's internal jugular vein, superior vena cava, right atrium, and then the right ventricle. The balloon-tipped catheter follows the flow of blood returning from the head to the heart. By using an electrode at the end of the catheter, I can track the electrical activity of the heart and determine where we are. As this one proved a little tricky, we actually got fluro to help us. We used real-time X-ray to follow the path of the pacemaker until it found an effective location in the right heart. When we applied external electrical impulses, the heart followed. That way, we could speed it up as fast as we needed. It gave us peace of mind that her heart block would not be a problem while we scheduled her for the placement of a permanent device.

Image of transvenous pacemaker components shown under Fair Use, from calsprogram.org.