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Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency Department
YAJEM-158655; No of Pages 2 American Journal of Emergency Medicine xxx (xxxx) xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency Department Renata Portasio Lerner, MD PhD ⁎, Astrid Haaland, MD, Judy Lin, MD Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
a r t i c l e
i n f o
Article history: Received 4 August 2019 Received in revised form 12 December 2019 Accepted 14 December 2019 Available online xxxx Keywords: Transvenous pacemaker Transesophageal echocardiogram Emergency Department Emergency pacing
a b s t r a c t Placement of a transvenous pacer is an important procedure mainly used to treat hemodynamically unstable brady-arrhythmias. In the Emergency Department (ED), wire placement into the right ventricle is typically performed blindly, or in some cases, under transthoracic ultrasound guidance. This case report describes a patient with extensive cardiac history who presented after a witnessed arrest, and after return of spontaneous circulation, sustained an unstable bradycardia requiring emergent transvenous pacer placement while in the ED. A temporary pacer wire was placed transvenously without successful capture. Transesophageal echocardiography was then utilized to guide and adjust the pacer wire placement helping to successfully achieve capture. To our knowledge, this is the first report to describe transesophageal echocardiogram-assisted placement of a transvenous pacer wire while in the ED. © 2018 Published by Elsevier Inc.
1. Introduction Placement of a temporary transvenous pacer (TVP) is an Emergency Medicine procedure essential to treating brady-arrhythmias [1,2]. The procedure involves inserting an electrode catheter (EC) in the right ventricle (RV), and delivering an electrical stimulation to depolarize cardiac tissue thus restoring adequate heart rate [3]. In the Emergency Department (ED), EC placement is typically performed blindly. After implantation, the catheter is connected to an external pacing generator. An EKG left bundle branch block pattern indicates capture. Blind EC placement comes with risks including prolongation of time to TVP placement, procedure failure or other complications [4]. Placement under fluoroscopy is often not possible emergently and as such, transthoracic echocardiogram (TTE) has been described as an adjunct [6-14]. Nevertheless, EC visualization with TTE may be limited in patients with poor transthoracic windows, such as patients with chronic obstructive pulmonary disease, mechanical ventilation or obesity [14]. In this report, we describe use of transesophageal echocardiogram (TEE) in the ED to guide TVP placement. 2. Case presentation We present a case of an 82-year-old female with a past medical history of atrial fibrillation, coronary artery disease status post left circumflex stent, congestive heart failure with left ventricular ejection fraction ⁎ Corresponding author at: Department of Emergency Medicine, 965 48th St., Brooklyn, NY 11219, USA. E-mail address: [email protected] (R.P. Lerner).
of 35%, and moderate mitral regurgitation who was brought in by ambulance in cardiac arrest. Chest compressions were started by the patient's son upon finding the patient unresponsive. On arrival, Emergency Medical Services (EMS) found the patient in asystole, with intermittent bradycardia through 30 min of Advanced Cardiac Life Support (ACLS). The patient was intubated and received calcium chloride 1 g, sodium bicarbonate 50 mEq, and epinephrine 1 mg intravenously. In the ED, cardiopulmonary resuscitation (CPR) was continued for an initial rhythm of asystole, and the patient was given 1 g of calcium chloride and 1 mg of epinephrine. Transthoracic echocardiography views were suboptimal and a TEE was placed through a bite block by a TEEcredentialed faculty. During CPR, TEE was utilized to identify reversible cardiac arrest causes, monitor for cardiac activity and check for compression adequacy. Per ACLS, the patient was given another 2 rounds of 1 mg epinephrine, and a femoral pulse was palpated. The patient was started on epinephrine and fentanyl drips and treated with antibiotics for potential infection. An electrocardiogram (ECG) showed a heart rate of 38, and peaked T waves. The patient was given atropine 1 mg, sodium bicarbonate 100 mEq, 10 units of insulin, and 50 mLl of D50 intravenously for a venous blood gas potassium level of 7 mmol/LL [3.4–4.8 mmol/L]. Transcutaneous pacing was initiated without capture and a decision was made to place a transvenous pacer. The linear probe was used to obtain a right internal jugular central venous access and an introducer sheath was secured. As the TEE was not actively being utilized, initial EC insertion attempts were performed blindly. Two attempts were unsuccessful and TTE could not visualize the EC. We then used the TEE transducer, in the bicaval view, to visualize the EC as it entered the superior vena cava (Video 1) into the right atrium (Video 2). The mid-esophageal four chamber view was obtained demonstrating
Please cite this article as: R.P. Lerner, A. Haaland and J. Lin, Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.12.027
2
R.P. Lerner et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
the EC in the RV (Video 3), however there was no capture by TEE (Video 4). The EC was readjusted until achieving capture, evidenced by a heart rate increase (Video 5). Pacer output was 12 mA, with a heart rate of 80 beats per minute in the ventricular paced, ventricular sensed inhibited sensing response mode. ECG confirmed a ventricularly-paced rhythm. The patient was admitted to the Cardiac Intensive Care Unit (CCU). Several hHours later in the CCU, the patient was found pulseless. After 30 min of ACLS, CPR was stopped, and the patient expired.
Declaration of competing interest
3. Discussion and conclusion
References
Successful capture rate in ED TVP placement is reported to range from 10 to 90% [3,8,18]. TTE has been used as an adjunct but the presence of transcutaneous pacer/defibrillator pads, body habitus, bowel gas, and CPR requirements may preclude its use. Requirement of multiple views may also limit pacer visualization. TEE bypasses some TTE limitations due to its position behind the heart. Ideally, a mid-esophageal RV-inflow view is utilized as it follows the EC from the RA into the RV. The bicaval and mid-esophageal four chamber views, however, are useful widely taught alternatives viewsws-added="true"> in cardiac arrest [21,22,26]. Limitations of TEE include equipment cost, lack of widespread ED TEE curriculum, and TEE contraindications in some patient populations. Use of TEE for operating room permanent pacemaker insertion has been described [24,25]. Transesophageal echocardiogram-placed temporary pacemakers have only been described in intensive care settings [15-17]. To our knowledge, TEE has not been utilized in the ED for TVP placement. Here, we describe ED placement of TEE to aid cardiac resuscitative efforts, and to adjust TVP wire to achieve capture. Further studies should be performed to compare this method to other techniques. Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2019.12.027. Author contributions Drafting of the manuscript: RPL. Critical revision of the manuscript for important intellectual content: RPL, AH, JL. Grant support None. Presentations None. Publications (print and online) None. Funding None. Disclaimers None. Uncited references
The authors have no independent disclosures or conflicts of interest. Acknowledgements RPL would like to acknowledge Dr. Jonathan Weltz for proof reading assistance.
[1] Timothy PR, Rodeman BJ. Temporary pacemakers in critically ill patients: assessment and management strategies. AACN Clin Issues 2004;15(3):305–25. [2] Sullivan BL, Bartels K, Hamilton N. Insertion and management of temporary pacemakers. Semin Cardiothorac Vasc Anesth 2016;20(1):52–62. [3] Harrigan RA, et al. Temporary transvenous pacemaker placement in the Emergency Department. J Emerg Med 2007;32(1):105–11. [4] Metkus TS, et al. Complications and outcomes of temporary transvenous pacing: an analysis of N360,000 patients from the national inpatient sample. Chest 2019;155 (4):749–57. Evans GL, Glasser SP. Intracavitary electrocardiography as a guide to pacemaker postitioning. JAMA 1971;216(3):–485. [6] Ferri LA, et al. Emergent transvenous cardiac pacing using ultrasound guidance: a prospective study versus the standard fluoroscopy-guided procedure. Eur Heart J Acute Cardiovasc Care 2016;5(2):125–9. [7] Schwartz C, et al. Use of two-dimensional echocardiography in detection of an aberrantly placed transvenous pacing catheter. Am J Med 1986;80(1):133–8. [8] Aguilera PA, Durham BA, Riley DA. Emergency transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med 2000;36(3):224–7. [9] Blanco P, Nomura JT. An atypical misplacement of a temporary pacing catheter diagnosed and resolved by ultrasound. Am J Emerg Med 2014;32(10):1296 e1–3. [10] Blanco P. Temporary transvenous pacing guided by the combined use of ultrasound and intracavitary electrocardiography: a feasible and safe technique. The Ultrasound Journal 2019;11(8). [11] Nanda NC, Barold SS. Usefulness of echocardiography in cardiac pacing. Pacing Clin Electrophysiol 1982;5(2):222–37. [12] Drinkovic N. Subcostal echocardiography to determine right ventricular pacing catheter position and control advancement of electrode catheters in intracardiac electrophysiologic studies. M mode and two dimensional studies. Am J Cardiol 1981;47(6): 1260–5. [13] Macedo Jr W, et al. Ultrasonographic guidance of transvenous pacemaker insertion in the emergency department: a report of three cases. J Emerg Med 1999;17(3): 491–6. [14] Sjaus A, Fayad A. The use of subcostal echocardiographic views to guide the insertion of a right ventricular temporary transvenous pacemaker-description of the technique. J Cardiothorac Vasc Anesth 2019. [15] Krishnan U, et al. First report of the use of transesophageal echocardiography to position a temporary pacing wire. J Cardiothorac Vasc Anesth 2014;28(1):110–1. [16] Kumar B, et al. Intraoperative transesophageal echocardiography for positioning transvenous temporary pacing wire. J Cardiothorac Vasc Anesth 2015;29(1):e2–3. [17] . Donker DW, C.E., Bouman EAC, Pragt E, Bergmans DCJJ, Transoesophageal echocardiography allows bedside guidance of temporary pacing catheter placement. A novel practical approach for the intensive care unit. Neth J Crit Care, 2010. 14: p. 206–209. [18] Birkhahn RH, et al. Emergency medicine-trained physicians are proficient in the insertion of transvenous pacemakers. Ann Emerg Med 2004;43(4):469–74. Pinneri F, et al. Echocardiography-guided versus fluoroscopy-guided temporary pacing in the emergency setting: an observational study. J Cardiovasc Med (Hagerstown) 2013;14(3):–246. Arntfield R, et al. Focused transesophageal echocardiography by emergency physicians is feasible and clinically influential: observational results from a novel ultrasound program. J Emerg Med 2016;50(2):–294. [21] Guidelines for the use of transesophageal echocardiography (TEE) in the ED for cardiac arrest, Ann Emerg Med 2017;70(3):442–5. [22] Arntfield R, et al. Focused transesophageal echocardiography for emergency physicians-description and results from simulation training of a structured fourview examination. Crit Ultrasound J 2015;7(1):27. Fair 3rd J, et al. Transesophageal echocardiography during cardiopulmonary resuscitation is associated with shorter compression pauses compared with transthoracic echocardiography. Ann Emerg Med 2019;73(6):610–6. [24] Plotkin IM, et al. Percutaneous coronary sinus cannulation guided by transesophageal echocardiography. Ann Thorac Surg 1998;66(6):2085–7. [25] Artrip JH, et al. Transesophageal echocardiography guided placement of a coronary sinus pacing lead. Ann Thorac Surg 2002;74(4):1254–6. [26] Sloth E, Blaivas M. The future of cardiopulmonary resuscitation: what if a TEE probe could shock, sense and pace? Resuscitation 2011;82(9):1253.
[5,19,20,23]
Please cite this article as: R.P. Lerner, A. Haaland and J. Lin, Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.12.027
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency Department Renata Portasio Lerner, MD PhD ⁎, Astrid Haaland, MD, Judy Lin, MD Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
a r t i c l e
i n f o
Article history: Received 4 August 2019 Received in revised form 12 December 2019 Accepted 14 December 2019 Available online xxxx Keywords: Transvenous pacemaker Transesophageal echocardiogram Emergency Department Emergency pacing
a b s t r a c t Placement of a transvenous pacer is an important procedure mainly used to treat hemodynamically unstable brady-arrhythmias. In the Emergency Department (ED), wire placement into the right ventricle is typically performed blindly, or in some cases, under transthoracic ultrasound guidance. This case report describes a patient with extensive cardiac history who presented after a witnessed arrest, and after return of spontaneous circulation, sustained an unstable bradycardia requiring emergent transvenous pacer placement while in the ED. A temporary pacer wire was placed transvenously without successful capture. Transesophageal echocardiography was then utilized to guide and adjust the pacer wire placement helping to successfully achieve capture. To our knowledge, this is the first report to describe transesophageal echocardiogram-assisted placement of a transvenous pacer wire while in the ED. © 2018 Published by Elsevier Inc.
1. Introduction Placement of a temporary transvenous pacer (TVP) is an Emergency Medicine procedure essential to treating brady-arrhythmias [1,2]. The procedure involves inserting an electrode catheter (EC) in the right ventricle (RV), and delivering an electrical stimulation to depolarize cardiac tissue thus restoring adequate heart rate [3]. In the Emergency Department (ED), EC placement is typically performed blindly. After implantation, the catheter is connected to an external pacing generator. An EKG left bundle branch block pattern indicates capture. Blind EC placement comes with risks including prolongation of time to TVP placement, procedure failure or other complications [4]. Placement under fluoroscopy is often not possible emergently and as such, transthoracic echocardiogram (TTE) has been described as an adjunct [6-14]. Nevertheless, EC visualization with TTE may be limited in patients with poor transthoracic windows, such as patients with chronic obstructive pulmonary disease, mechanical ventilation or obesity [14]. In this report, we describe use of transesophageal echocardiogram (TEE) in the ED to guide TVP placement. 2. Case presentation We present a case of an 82-year-old female with a past medical history of atrial fibrillation, coronary artery disease status post left circumflex stent, congestive heart failure with left ventricular ejection fraction ⁎ Corresponding author at: Department of Emergency Medicine, 965 48th St., Brooklyn, NY 11219, USA. E-mail address: [email protected] (R.P. Lerner).
of 35%, and moderate mitral regurgitation who was brought in by ambulance in cardiac arrest. Chest compressions were started by the patient's son upon finding the patient unresponsive. On arrival, Emergency Medical Services (EMS) found the patient in asystole, with intermittent bradycardia through 30 min of Advanced Cardiac Life Support (ACLS). The patient was intubated and received calcium chloride 1 g, sodium bicarbonate 50 mEq, and epinephrine 1 mg intravenously. In the ED, cardiopulmonary resuscitation (CPR) was continued for an initial rhythm of asystole, and the patient was given 1 g of calcium chloride and 1 mg of epinephrine. Transthoracic echocardiography views were suboptimal and a TEE was placed through a bite block by a TEEcredentialed faculty. During CPR, TEE was utilized to identify reversible cardiac arrest causes, monitor for cardiac activity and check for compression adequacy. Per ACLS, the patient was given another 2 rounds of 1 mg epinephrine, and a femoral pulse was palpated. The patient was started on epinephrine and fentanyl drips and treated with antibiotics for potential infection. An electrocardiogram (ECG) showed a heart rate of 38, and peaked T waves. The patient was given atropine 1 mg, sodium bicarbonate 100 mEq, 10 units of insulin, and 50 mLl of D50 intravenously for a venous blood gas potassium level of 7 mmol/LL [3.4–4.8 mmol/L]. Transcutaneous pacing was initiated without capture and a decision was made to place a transvenous pacer. The linear probe was used to obtain a right internal jugular central venous access and an introducer sheath was secured. As the TEE was not actively being utilized, initial EC insertion attempts were performed blindly. Two attempts were unsuccessful and TTE could not visualize the EC. We then used the TEE transducer, in the bicaval view, to visualize the EC as it entered the superior vena cava (Video 1) into the right atrium (Video 2). The mid-esophageal four chamber view was obtained demonstrating
Please cite this article as: R.P. Lerner, A. Haaland and J. Lin, Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.12.027
2
R.P. Lerner et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
the EC in the RV (Video 3), however there was no capture by TEE (Video 4). The EC was readjusted until achieving capture, evidenced by a heart rate increase (Video 5). Pacer output was 12 mA, with a heart rate of 80 beats per minute in the ventricular paced, ventricular sensed inhibited sensing response mode. ECG confirmed a ventricularly-paced rhythm. The patient was admitted to the Cardiac Intensive Care Unit (CCU). Several hHours later in the CCU, the patient was found pulseless. After 30 min of ACLS, CPR was stopped, and the patient expired.
Declaration of competing interest
3. Discussion and conclusion
References
Successful capture rate in ED TVP placement is reported to range from 10 to 90% [3,8,18]. TTE has been used as an adjunct but the presence of transcutaneous pacer/defibrillator pads, body habitus, bowel gas, and CPR requirements may preclude its use. Requirement of multiple views may also limit pacer visualization. TEE bypasses some TTE limitations due to its position behind the heart. Ideally, a mid-esophageal RV-inflow view is utilized as it follows the EC from the RA into the RV. The bicaval and mid-esophageal four chamber views, however, are useful widely taught alternatives viewsws-added="true"> in cardiac arrest [21,22,26]. Limitations of TEE include equipment cost, lack of widespread ED TEE curriculum, and TEE contraindications in some patient populations. Use of TEE for operating room permanent pacemaker insertion has been described [24,25]. Transesophageal echocardiogram-placed temporary pacemakers have only been described in intensive care settings [15-17]. To our knowledge, TEE has not been utilized in the ED for TVP placement. Here, we describe ED placement of TEE to aid cardiac resuscitative efforts, and to adjust TVP wire to achieve capture. Further studies should be performed to compare this method to other techniques. Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2019.12.027. Author contributions Drafting of the manuscript: RPL. Critical revision of the manuscript for important intellectual content: RPL, AH, JL. Grant support None. Presentations None. Publications (print and online) None. Funding None. Disclaimers None. Uncited references
The authors have no independent disclosures or conflicts of interest. Acknowledgements RPL would like to acknowledge Dr. Jonathan Weltz for proof reading assistance.
[1] Timothy PR, Rodeman BJ. Temporary pacemakers in critically ill patients: assessment and management strategies. AACN Clin Issues 2004;15(3):305–25. [2] Sullivan BL, Bartels K, Hamilton N. Insertion and management of temporary pacemakers. Semin Cardiothorac Vasc Anesth 2016;20(1):52–62. [3] Harrigan RA, et al. Temporary transvenous pacemaker placement in the Emergency Department. J Emerg Med 2007;32(1):105–11. [4] Metkus TS, et al. Complications and outcomes of temporary transvenous pacing: an analysis of N360,000 patients from the national inpatient sample. Chest 2019;155 (4):749–57. Evans GL, Glasser SP. Intracavitary electrocardiography as a guide to pacemaker postitioning. JAMA 1971;216(3):–485. [6] Ferri LA, et al. Emergent transvenous cardiac pacing using ultrasound guidance: a prospective study versus the standard fluoroscopy-guided procedure. Eur Heart J Acute Cardiovasc Care 2016;5(2):125–9. [7] Schwartz C, et al. Use of two-dimensional echocardiography in detection of an aberrantly placed transvenous pacing catheter. Am J Med 1986;80(1):133–8. [8] Aguilera PA, Durham BA, Riley DA. Emergency transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med 2000;36(3):224–7. [9] Blanco P, Nomura JT. An atypical misplacement of a temporary pacing catheter diagnosed and resolved by ultrasound. Am J Emerg Med 2014;32(10):1296 e1–3. [10] Blanco P. Temporary transvenous pacing guided by the combined use of ultrasound and intracavitary electrocardiography: a feasible and safe technique. The Ultrasound Journal 2019;11(8). [11] Nanda NC, Barold SS. Usefulness of echocardiography in cardiac pacing. Pacing Clin Electrophysiol 1982;5(2):222–37. [12] Drinkovic N. Subcostal echocardiography to determine right ventricular pacing catheter position and control advancement of electrode catheters in intracardiac electrophysiologic studies. M mode and two dimensional studies. Am J Cardiol 1981;47(6): 1260–5. [13] Macedo Jr W, et al. Ultrasonographic guidance of transvenous pacemaker insertion in the emergency department: a report of three cases. J Emerg Med 1999;17(3): 491–6. [14] Sjaus A, Fayad A. The use of subcostal echocardiographic views to guide the insertion of a right ventricular temporary transvenous pacemaker-description of the technique. J Cardiothorac Vasc Anesth 2019. [15] Krishnan U, et al. First report of the use of transesophageal echocardiography to position a temporary pacing wire. J Cardiothorac Vasc Anesth 2014;28(1):110–1. [16] Kumar B, et al. Intraoperative transesophageal echocardiography for positioning transvenous temporary pacing wire. J Cardiothorac Vasc Anesth 2015;29(1):e2–3. [17] . Donker DW, C.E., Bouman EAC, Pragt E, Bergmans DCJJ, Transoesophageal echocardiography allows bedside guidance of temporary pacing catheter placement. A novel practical approach for the intensive care unit. Neth J Crit Care, 2010. 14: p. 206–209. [18] Birkhahn RH, et al. Emergency medicine-trained physicians are proficient in the insertion of transvenous pacemakers. Ann Emerg Med 2004;43(4):469–74. Pinneri F, et al. Echocardiography-guided versus fluoroscopy-guided temporary pacing in the emergency setting: an observational study. J Cardiovasc Med (Hagerstown) 2013;14(3):–246. Arntfield R, et al. Focused transesophageal echocardiography by emergency physicians is feasible and clinically influential: observational results from a novel ultrasound program. J Emerg Med 2016;50(2):–294. [21] Guidelines for the use of transesophageal echocardiography (TEE) in the ED for cardiac arrest, Ann Emerg Med 2017;70(3):442–5. [22] Arntfield R, et al. Focused transesophageal echocardiography for emergency physicians-description and results from simulation training of a structured fourview examination. Crit Ultrasound J 2015;7(1):27. Fair 3rd J, et al. Transesophageal echocardiography during cardiopulmonary resuscitation is associated with shorter compression pauses compared with transthoracic echocardiography. Ann Emerg Med 2019;73(6):610–6. [24] Plotkin IM, et al. Percutaneous coronary sinus cannulation guided by transesophageal echocardiography. Ann Thorac Surg 1998;66(6):2085–7. [25] Artrip JH, et al. Transesophageal echocardiography guided placement of a coronary sinus pacing lead. Ann Thorac Surg 2002;74(4):1254–6. [26] Sloth E, Blaivas M. The future of cardiopulmonary resuscitation: what if a TEE probe could shock, sense and pace? Resuscitation 2011;82(9):1253.
[5,19,20,23]
Please cite this article as: R.P. Lerner, A. Haaland and J. Lin, Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the Emergency..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.12.027