Alternative Pacing Techniques in the Catheterization Laboratory

We have to be obliged to Cary Lunsford, Laura Minarsch, and their crew for keeping the interest alive in a simple and potentially life-saving technique that does not cost anything.

Coronary pacing was introduced in the early 80’s to rid coronary angioplasty (PCI) of the necessity to preventively insert a pacemaker lead before starting PCI. In conjunction with the contrast media used in the early years of PCI, bradycardia was notorious when dilating the right coronary artery. Pacing was usually only required for a very brief period of time and had to be installable within the minute to avoid cardiac massage likely to cause rib fractures, for one thing.

Preventively inserted pacemakers needed an additional puncture in the groin with discomfort and a risk of arterio-venous fistulae. More importantly, they caused an occasional cardiac perforation with tamponade. The initial report of transcoronary pacing¹ kind of paved the way to do away with preventive pacemaker insertion. Although few people adopted the technique properly before stopping to introduce preventive pacemaker leads, the initial and following publications on transcoronary pacing^2-7 provided a legal parachute for those having already decided or being about to decide to performe their PCIs without prearrangements for right ventricular pacing.

The authors also mention the important fact that coronary pacing may not always be possible in emergency situations (no possibility to place the coronary guidewire into a myocardial branch which is necessary for an adequate pacing threshold, loss of the guiding catheter position in the coronary ostium due to physician or patient movements during the turmoil of asystole, etc.). Yet, there is always the option of pacing the left ventricle as the authors correctly point out.^3,7,8 By the way, if the need arises during right heart catheterization, a simple guidewire is more rapidly inserted for right ventricular pacing than a genuine pacemaker lead and it serves the same purpose.⁹

Moreover, pacing over guidewires comes in handy when pacing is required for another purpose, i.e., stabilization of an aortic valvuloplasty balloon in children or in adults during percutaneous valve implantation¹⁰ or for stenting of a coarctation. Again, the patients are saved an additional puncture in the groin or the neck, and the hospital saves cost and physician time.

Catheterization laboratories adopting such pacing techniques are to be commended, but they also have to be reminded to use the technique in occasional test runs. In real emergencies, time counts, and some additional material, such as the cables to connect the pacemaker with the guidewire and the skin electrode (which may be a needle, as described in the paper, or any ECG patch on the skin) have to be found and connected within the minute.

Dr. Meier can be contacted at bernhard.meier@insel.ch.

References

1. Meier B. Coronary pacing for bradycardia during balloon angioplasty. N Engl J Med 1984;311:800.
2. Meier B, Rutishauser W. Coronary pacing during percutaneous transluminal coronary angioplasty. Circulation 1985;71:557–561.
3. de la Serna F, Meier B, Pande AK, et al. Coronary and left ventricular pacing as standby in invasive cardiology. Cathet Cardiovasc Diagn 1992;25:285–289.
4. Meier B. Pacing in the left heart — often forgotten because rarely needed. Cathet Cardiovasc Diagn 1997;42:33.
5. Mixon TA, Cross DS, Lawrence ME, et al. Temporary coronary guidewire pacing during percutaneous coronary intervention. Catheter Cardiovasc Interv 2004;61:494–500; discussion 502–493.
6. Meier B. Emergency pacing during cardiac catheterization: it is all there already. Catheter Cardiovasc Interv 2004;61:501–502.
7. Meier B. Coronary or left ventricular pacing, the easy and obvious way out of asystole during cardiac catheterization. J Invasive Cardiol 2011;23:2.
8. Meier B. Left ventricular pacing for bradycardia in the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2004;62:31.
9. Vogel R, Meier B. Emergent mechanical and electrical guidewire pacing of the right ventricle for aystole in the cardiac catheterization laboratory. J Invasive Cardiol 2005;17:490.
10. Navarini S, Pfammatter JP, Meier B. Left ventricular guidewire pacing to simplify aortic balloon valvuloplasty. Catheter Cardiovasc Interv 2009;73:426–427.