The Temporary

Pacemaker
University Hospitals Case Medical Center
Andrew Plante MD

Objectives
Abnormalities that benefit from temporary pacing
Temporary pacing modalities
Unipolar vs. bipolar temporary pacing leads
Epicardial wire failure
Microshock and how to avoid it
Temporary generator overview
Monitoring temporary pacemaker settings
Sensitivity, stimulation threshold and advanced settings
Antitachycardia pacing
Troubleshooting pacemaker malfunction
Transition to permanent pacemaker
Temporary epicardial lead removal
MRI and temporary pacemaker leads
Conclusions/Review

Overview1
Evolution of temporary epicardial
pacing from simple single
chamber systems to complex
dual chamber systems
Pacing often best method of
treating temporary rhythm
disturbances postoperatively
Knowledge required for
postoperative management of
cardiac surgery patients

NASPE/BPEG Code Permanent vs.

Temporary Pacemakers4

Abnormalities That May Benefit

from Temporary Pacemakers1
Conduction abnormalities

Prolonged AV delay (common after cardiac surgery)

AV Block: 3rd degree or 2nd degree type II
Bifasicular block in a patient with 1st degree heart block
New Onset Bifascicular block in active ischemia
Prolonged QT syndrome with significant bradycardia (prevent torsades)

Tachycardia

AV junctional tachycardia (common after CPB)

For termination of re-entrant SVT or VT
Type I atrial flutter (atrial rate < 320-340 bpm)

Other

Sinus bradycardia, sick sinus syndrome

Following heart transplant
Bradycardia-dependent ventricular tachycardia
Permanent pacemaker malfunction
Drugs, electrolyte imbalances

Overview of the Temporary

Pacemaker9
Ohms Law

V = IR
V:

I:

Voltage
Difference in potential energy between two points
Causes electrons to move through a circuit
Measured millivolts (mV)

Current

R:

The rate or transfer of flow of electricity

Measured in milliampere (mA)

Resistance
Opposition to the flow of electricity
Measured in ohms
http://www.Scienceblogs.com

Temporary Pacing Modalities

Transcutaneous

Impulse delivered via pads/electrodes on patients

chest and back
Requires sedation (painful)

Transvenous

Via venous access/sheath introducer

Captures when in contact with the myocardium

Epicardial

Wires attached directly to the atrium and ventricle

Placed during surgery

Pacing Wires1,3
Unipolar

Single wire attached to

epicardium
Ground wire

Bipolar

Single wire with two insulated

conductors
Both run to the epicardial
surface
Electrical potential required to
attain threshold decreased
Less susceptible to
interference

Pacing Wire Differentiation

Bipolar pacing with dual
chamber modality

Atrial Lead
Blue
Exits on right of sternum
Usually higher than V lead

Ventricular Lead
Brown
Exits on left of sternum
Usually lower than A lead

Epicardial Wire Failure2,5,6

Inflammatory reaction around wire/myocardium interface
Increased resistance requires increased voltage to
maintain effectiveness of pacing current (I = V/R)
Inflammation accelerated with higher energy
Increases in stimulation threshold usually occur after 4
days in atrial and ventricular leads
Failure to pace in >60% of right atrial wires after 5 days
Few remedies (limit initial energy, other modalities,
permanent pacing, steroids?)

Microshock10
Skin resistance is bypassed
20 mA can produce fatal dysrhythmias
Epicardial wire:

Low resistance connection to the heart

Teflon coated (distal tip conduction vs.
cracks in teflon)

Avoid microshock induced arrhythmias

Touch a large metal object

to discharge static electricity
Handle wires with
non-conductive gloves
Place wires in micro centrifuge
tubes when not in use
http//.vendorweb.humantech.com

Temporary Generator11

Temporary Lead Connections11

Temporary leads are
connected at the the top
of the pacing generator
Connections can be via
socket device connections
or directly with the pacing
wire in emergency
conditions

Generator Indicators11

One set of pace/sense LEDs for the atrium and

ventricle
Green LED for pacing stimulus
Orange LED for sensing indication
Setup Indicators identify chambers setup to
pace/sense

Rate and Output Adjustments11

Upper dials adjust the pacing
rate (PPM) and atrial and
ventricular output
Pacing range 30 PPM to 200
PPM
Atrial output range 0.1 mA to
20 mA
Ventricular output range
0.1mA to 25 mA

Pacing Parameter Adjustments11

The menu key activates
the lower screen and the
four menus

Sensitivity/AV
interval/Tracking
Upper Rate/PVARP
Rapid Atrial Pacing
Dial-A-Mode

Daily Checklist
1.

Assess need for ongoing pacing

2.

Underlying rhythm and patients hemodynamic response

Review ECGs/strips/recordings of any abnormal rhythms
having occurred in the last 24 hours

Review pacemaker settings

3.

Mode, rate, outputs

Sensitivities and thresholds

If abnormalities in pacing are otherwise unexplained,

review the following:

Maximum tracking rate

AV interval
Post ventricular atrial refractory period

Underlying Rhythm1
Best done by turning down pacing rate and
allowing endogenous rhythm to appear
Turning down pacing energy output until loss of
capture or disconnecting the pacing wires can
result in an inability to re-establish capture

Rate1
Cardiac output is the product of stroke
volume and heart rate
After a point, as heart rate increases,
stroke volume falls and oxygen demands
increase
With temporary pacemakers, optimal heart
rate is rarely titrated to cardiac output and
is usually left at 80 to 90 bpm

Mode and Outputs

These values are readily available and
reviewed by looking at the upper screen
on the generator
These values can also be found on the
nursing flow sheet

Temporary Pacemaker Settings11

Sensitivity1,11

Sensitivity
value

Minimum current pacemaker can sense

The lower the number, the greater the sensitivity
Effects initiation of pacemaker response
(inhibition vs. triggering)
If sensitivity value is set too low (too sensitive),
may have interference

Increasing sensitivity (you can see more)

Checking Sensitivity1,11,12
1. Set pacemaker rate below endogenous rate
2. Place pacemaker in VVI, AAI or DDD mode
3. Slowly increase sensitivity number (pacemaker becomes less
sensitive)
4. Stop when sense indicator stops flashing
5. Pacing should now be asynchronous in chamber being tested
(Danger: R-on-T)
6. Turn the sensitivity number down (pacemaker becomes more
sensitive) until sense indicator flashes with each endogenous
depolarization (in time with P or R on surface ECG)
7. The number this first occurs at is the pacing threshold
8. UH protocol: generator set at half the pacing threshold (twice as
sensitive as necessary to sense activity)
9. If no endogenous rhythm, sensitivity typically set at 2 mV

Capture/Stimulation Threshold1,12
Minimum pacemaker output required to
stimulate an action potential in the
myocardium
Should not be checked if there is no
underlying rhythm (may lose capture)
If no underlying rhythm, watch for
occasional missed beats which may
indicate a rise in the capture threshold

Checking the Stimulation

Threshold1,12
1.
2.
3.
4.
5.

Set the pacemaker above the patients endogenous

rate so that pacing is consistent in the chamber of
interest
Reduce the pacemaker energy output until a QRS
complex no longer follows each pacing spike
This value is the capture threshold
UH Protocol: the output is set at twice the capture
threshold to allow a margin of safety if the final value
will be <10 mA
UH Protocol: thresholds >10mA accelerate fibrosis at
the lead/myocardium interface and can cause cardiac
dysrhythmia, weigh the risks and benefits before
selecting a capture threshold in this instance

Factors Affecting Stimulation

Threshold13

Advanced Settings of the

Temporary Pacemaker15
AV delay
Post ventricular atrial refractory period
(PVARP)
VA interval (atrial escape interval)
Upper rate limit (maximum tracking rate)
Blanking periods

AV Delay14,15
Interval following atrial depolorization
before a ventricular spike is delivered
Allows the pacemaker to perform the
function of the AV node
In a review of 13 patients undergoing
cardiac surgery, the optimal AV delay
varied between 0.100 and 0.225 s
In most patients, the default setting is
sufficient

Post Ventricular Atrial Refractory

Period (PVARP)15
Set to help avoid retrograde conduction between
the ventricle and atrium through the AV node or
an accessory pathway
More than 50% of patients receiving
pacemakers are susceptible
Retrograde pulses are sensed as atrial
contractions which then trigger ventricular
contraction and a loop occurs
PVARP set to avoid this by adjusting the atrial
refractory period
Disadvantage of setting a long PVARP is that it
limits the maximum rate of atrial tracking

VA Interval (Atrial Escape

Interval)11
Interval from ventricular sensed or paced
event to an atrial paced event
Determined by the AV interval and the
lower rate limit settings
Not independently adjustable

Upper Rate Limit (Maximum

Tracking Rate)11,15
The fastest the pacemaker will pace the ventricle
in response to a sensed atrial event
Automatic defense against ventricular
overpacing in rapid atrial tachycardia
Causes introduction of a controlled type II
Wenkebach block
Gradually lengthens the AV interval until it is
long enough so that the next atrial depolarization
falls within the PVARP
Most pace generators set this automatically
based on the AV interval and the PVARP

Blanking Periods11
Atrial or ventricular blanking periods begin
immediately after an impulse is delivered
in the other cardiac chamber
No sensing occurs so no timing intervals
can be reset
This prevents cross-talk between leads
and is usually preset and not adjustable

Antitachycardia Pacing15
Overdrive pacing can effectively treat
tachyarrhythmias in some instances
Exceptions: V-Fib, A-Fib and sinus tach
When attempting overdrive pacing, V-tach
or V-fib may result
Be prepared for DC cardioversion

AV Junctional Tachycardia15,16
Rates usually 100-120 bpm
Common following cardiac surgery
Can be managed with AOO, AAI, DOO, or
DDD
Pacing rate is increased to ~120% of
endogenous rate
Once 1:1 capture occurs, rate is reduced
Often establishes a stable, slower sinus
rhythm

Atrial Flutter16,17
Overdrive pacing effective in type I atrial flutter
with < 320-340 atrial bpm, but not in type II
(higher bpm)
Set the pacemaker to just above the flutter rate
and then gradually increase until the atrial
complexes on the surface ECG change
morphology
Typically occurs at 10-20 bpm faster than the
flutter rate
Pacemaker is then slowed to an acceptable rate

Troubleshooting15,18
In a study of 1675 patients undergoing
cardiac surgery over 18 months, the
incidence of temporary epicardial
pacemakers requiring troubleshooting was
0.4%
No other data is available specific to the
incidence of troubleshooting with
temporary pacemakers

Troubleshooting11
Failure to pace

Output from the pacer does not occur when

its required

Failure to capture

Electrical output occurs but does not cause

cardiac contraction

Failure to sense

Intrinsic electrical activity is not recognized

Failure to Pace15
No electrical output at the pacing wire tip when
the set pacing mode requires an output
Absence of pacing spikes on the surface ECG
(differentiates between failure to pace and
failure to capture)
May be related to:

Lead malfunction or disconnection between lead and

generator
Insufficient battery power to generate a paced beat
Cross-talk causing inhibition from another lead
Oversensing of extraneous interference

Failure to Pace11

Bradycardia with rate set at 90 bpm

Distinguish from failure to capture by
absence of pacing spikes

Failure to Pace12,15
Make sure all connections between the
patient and the pacing generator are intact
Try changing generator battery or a new
generator unit
If cross-talking is suspected, try adjusting
sensitivities
Eliminate sources of external interference

Failure to Capture15,19
Electrical output occurs at the lead tip but fails to
generate a cardiac contraction
Must be checked by comparison with the A-line or pulse
oximeter waveform
Caused by an increase in the resistance at the
lead/myocardium interface (fibrosis)
Increased threshold may also be secondary to:

Acute or ongoing MI
Electrolyte imbalances (Hyperkalemia or acid/base disorders)
Medications (specifically the antiarrhythmics)
Following cardiac defibrillation

Most common problem encountered with temporary

pacemakers

Failure to Capture20

Atrial pacing spikes do not cause a p-wave

Failure to Capture12,15
View rhythm in different leads, verify with
A-line or pulse oximeter
Increase pacing output (mA)
Check connections
Change battery, cables, generator
Consider reversing polarity of leads

Failure to Sense15
Occurs for many of the same reasons as
failure to capture
Must be distinguished from a normal
pacemaker with inappropriate settings
(overly long intervals or refractory periods)

Failure to Sense20

Intrinsic activity not recognized

Atrial spikes regardless of presence of p
wave

Failure to Sense20

Low probability but potential for temporary

pacemaker to generate an R-on-T pacing
spike leading to ventricular arrhythmias

Failure to Sense12,15
Check all pacemaker settings, consider
resetting to factory defaults
Increase pacemakers sensitivity
(decrease mV)
Check electrolytes
Check pH/ABG
Consider conversion to unipolar pacing

Uncommon Causes of Pacemaker

Malfunction15
Cross-talk

Occurs in a dual chamber system with AV pacing and ventricular

sensing (DVI, DDD, DDI)
Sensing of one lead depolarization by another causing an
inappropriate response
In atrial sensing systems this is less serious because ventricular
pacing persists

Pacemaker-mediated tachycardia

Occurs only in VDD or DDD

Atrial sensing of a ventricular depolarization which is interpreted
as an endogenous atrial depolarization
Leads to a new ventricular depolarization (loop)
Atrial blanking period guards against this
Can also occur when reentrant loops are present

Transition to Permanent Pacing21,22

A study of 222 patient undergoing CABG at an
academic institute showed 19 requiring
temporary pacing and 2 requiring permanent
pacemaker placement
This number is higher but poorly defined in
patients with valve surgery
Risk factors for permanent pacemaker
requirement following cardiac surgery include:
Age
Preoperative bundle branch block
Prolonged cardiopulmonary bypass
Suboptimal intra-operative myocardial protection

Indications for Permanent Pacing1

Common indications:

Complete heart block

Sinus node dysfunction
Sick sinus syndrome
Other tachy-brady syndromes

A-fib with slow ventricular response

Second degree Mobitz type II with inadequate
ventricular rate

Epicardial Lead Removal1,5

Pacing wires generally start to fail after ~5 days
of continuous pacing
Often removed once patient has left the ICU
Wires should not be removed in a patient who is
therapeutically anticoagulated
Wires occasionally become caught and must be
cut at the skin and allowed to retract (no
evidence of increase in adverse events)
Monitor after removal for complications

Complications with Lead

Removal7,8
Cardiac tamponade

Becks triad (jugular venous distension, hypotension,

muffled heart sounds)
Pulsus paradoxus

Ventricular or other dysrhythmia

Always monitor continuous ECG with removal

Acute MI or other compromise secondary to

damage to coronary anastomoses

Observe for signs and symptoms of MI or acute

coronary artery dissection

Thoracic wall hematoma

Apply pressure as needed over removal site

Protocol for Lead Removal12

1.

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Review patient condition for appropriateness of lead removal (hemodynamic

status and underlying rhythm, electrolytes, coagulation status, etc)
Hand washing and contact precaution as needed (non-sterile gloves required to
limit microshock)
Remove dressing and cut the sutures holding wires in place
Inform the patient they may feel a burning or pulling sensation during removal
Apply slow, steady tension to the pacing wires until the epicardial wire is fully
removed
If gentle traction is not successful, the pacing lead should be pulled as far as is felt
safe and cut as close to the skin as possible allowing it to retract
After removal, inspect each wire for integrity and presence of tissue
Observe removal site for bleeding
Apply a sterile occlusive dressing over the exit site
Monitor the patient hemodynamically for signs of complication
UH Protocol: patient must be monitored for a minimum of 30 minutes in the ICU
after removal of epicardial leads before transfer of care
UH Protocol: overall the patients vital signs should be monitored at a minimum
every 15 minutes x 4, every 30 minutes x 2 and then every hour x 2 after lead
extraction

MRI and Temporary Pacing Leads1

MRI involves magnetic fields and radiofrequency pulses
The temporary pulse generator contains too much
ferrous material to be allowed into the magnetic field
MRI therefore is not possible in a patient dependent on
temporary epicardial pacing
With epicardial wires alone, theoretical concern that
current may be induced in the epicardial wire by either
pulsating movement in the magnetic field or from the
MRI radiofrequency pulse
Energy transfer to the wire causes heating, up to 20
degrees celsius at the tipe
Patients with epicardial wires that have been cut at the
skin have reportedly undergone MRI safely

Conclusions
Although the temporary pacemaker used in
postoperative cardiac patients can be managed with
limited knowledge, suboptimal patient care often results
After this review you should understand:

Background regarding temporary pacemakers and their use

The temporary pacemaker and its function
The important basics of rate, sensitivities, thresholds and outputs
Troubleshooting to improve outcomes with the temporary
pacemaker
UH ICU protocols involving the temporary pacemaker
Management and removal of temporary pacing wires
Postoperative management of temporary pacing systems

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4.

5.
6.
7.
8.
9.
10.
11.

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