Temporary Cardiac Pacing Complications
Temporary cardiac pacing is utilized to reestablish circulatory integrity and normal hemodynamics in cases of bradyarrhythmia until resolution or initiation of long-term therapy. The two main types of temporary cardiac pacing include transcutaneous and transvenous pacing. Transcutaneous pacing is the most immediate method to provide temporary pacing, however, it can be highly uncomfortable for the patient and its efficacy varies. Transvenous pacing is the preferred approach as it is more comfortable for the patient and more durable overall. Although there are no absolute contraindications to temporary pacing in patients with a symptomatic bradyarrhythmia and life-threatening hemodynamic instability, temporary pacing does not come without risks. In this blog post, the complications of both transcutaneous and transvenous cardiac pacing are discussed.
There are many advantages to transcutaneous pacing such as wide availability, ease of use, quick deployment and decreased risk of serious complications in comparison to invasive techniques such as transvenous pacing, however, pain secondary to electrical induced muscular contraction is a big drawback to this method. Other complications include failure to capture and skin burns. The pain that occurs from transcutaneous pacing primarily is the result of muscle contractions from the high current output levels. Proper sedation with benzodiazepine and analgesia with opiates are essential for patient undergoing transcutaneous pacing to lessen discomfort and pain until transvenous pacing can be initiated. Failure to capture is another common complication. There are many reasons the electrodes may have failure to capture with one of the most common being suboptimal placement of the electrodes. This can easily be corrected by avoiding bony structures and correct placement of the negative electrode anteriorly. Additionally, there could be poor contact between the skin and the electrode secondary to sweat, hair or debris which can be avoided via hair trimming and proper cleaning and drying of area prior to electrode placement. Furthermore, in cases with prolonged pacing, the pacing threshold may change resulting in failure to capture and can be corrected by increasing the threshold. Underlying conditions such as pericardial effusion, pneumothorax, myocardial ischemia or metabolic derangement may raise the pacing threshold or effect ability the to capture, thus correcting these conditions is important in management of the patient. Although rare, a more serious complication of transcutaneous pacing includes skin burns. This complication is more common in children, however, both Carrizale-Sepulveda (2018) and Muschart (2014) document case studies in which a patient had a third-degree burn post transcutaneous pacing. To minimize this complication, the patient’s skin should be inspected frequently and electrodes repositioned as necessary.
The preferred method for temporary cardiac pacing in most patients is transvenous pacing largely due to patient comfort and durability over time. This method does not come without its drawbacks, especially since it is invasive in nature, and complications can arise from a variety of causes. Complications from transvenous pacing are due to venous access, the transvenous pacing lead or the external electromagnetic interference. Complications are broad and include infection, arterial injury, bleeding, pulmonary embolism, pneumothorax, air embolism, catheter knotting, myocardial perforation, lead dislodgement and disconnection, extracardiac stimulation and various arrhythmias including ventricular tachycardia and ventricular fibrillation. A study by Metkus (2019) tracked patient outcomes post transvenous cardiac placement in 360,223 patients between 2004 and 2014. The researchers found that overall, in-hospital mortality was 14.1% and 37.9% of patients required permanent pacemaker placement. The complications found from this study are detailed in the chart below.
Metkus et al, 2019
Some areas to highlight include pericardial tamponade occurring in 0.6%, pneumothorax in 0.9% and non-pericardial bleeding in 2.4% of the study population. In general, this study concluded that transvenous placement of temporary cardiac pacers is overall safe with low rates of complications. Although researchers discovered that the rates of pericardial tamponade associated with placement of the transvenous pacer slightly increased over the study period and suggested clinicians be mindful of this and other serious complications of placement. Another study by Tjong (2019) conducted a systemic review evaluating complications of temporary transvenous cardiac pacing spanning from the 1970’s to 2019 comparing rates across the decades. This study categorized the complications into the areas of complicated access, cardiac perforation, device complications, infections, arrhythmia, thrombotic event and procedure related death. The study results can be viewed in the table below.
Tjong et al, 2019
Overall, complications due to transvenous cardiac pacing have decreased over the years. Between 2010-2019, the most common complication was due to device complications at 12.9%, followed by complicated access at 4.2% and infections at 3.6%. Other complications between 2010-2019 are minimal at less than 1.0%. Some common reasons for device complications include malsensing or malpacing, reintervention, lead dislodgement and multiple placement attempts. Overall, the researchers found that complications rates for transvenous pacing remain high at 22.9%, although rates have decreased overtime.
In conclusion, temporary cardiac pacing is a life-saving tool in the case of symptomatic bradycardia with hemodynamic instability and should be utilized in management when indicated. Both transcutaneous and transvenous cardiac pacing come with their own set of complications that the clinician should be cognizant of to mindfully work towards reducing.
POST BY: TESSA NELSON (MS4, CWRU)
FACULTY EDITING BY: DR. COLIN MCCLOSKEY
References
Carrizales-Sepúlveda, Edgar Francisco et al. “Thermal burn resulting from prolonged transcutaneous pacing in a patient with complete heart block.” The American journal of emergency medicine vol. 36,8 (2018): 1523.e5-1523.e6. doi:10.1016/j.ajem.2018.04.038
Doukky, Rami et al. “Using transcutaneous cardiac pacing to best advantage: How to ensure successful capture and avoid complications.” The Journal of critical illness vol. 18,5 (2003): 219-225.
Estes, N A Mark. “Temporary Cardiac Pacing.” UpToDate, 1 Mar. 2019https://www.uptodate.com/contents/temporary-cardiac-pacing?search=temporary+cardiac+pacing&source=search_result&selectedTitle=1~75&usage_type=default&display_rank=1#H542216583.
Metkus, Thomas S et al. “Complications and Outcomes of Temporary Transvenous Pacing: An Analysis of > 360,000 Patients From the National Inpatient Sample.” Chest vol. 155,4 (2019): 749-757. doi:10.1016/j.chest.2018.11.026
Muschart, Xavier. “Burns to be alive: a complication of transcutaneous cardiac stimulation.” Critical care (London, England) vol. 18,6 622. 12 Nov. 2014, doi:10.1186/s13054-014-0622-x
Tjong, F V Y et al. “A comprehensive scoping review on transvenous temporary pacing therapy.” Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation vol. 27,10 (2019): 462-473. doi:10.1007/s12471-019-01307-x
Young, Michael P, and Theodore H Yuo. “Overview of Complications of Central Venous Catheters and Their Prevention in Adults.” UpToDate, 11 Nov. 2020, https://www.uptodate.com/contents/overview-of-complications-of-central-venous-catheters-and-their-prevention-in-adults?search=temporary+cardiac+pacing&topicRef=1005&source=see_link.