Outcomes of emergency department placement of transvenous pacemakers

Clinical Question

Are emergency physicians able to successfully place TVPs and what prognosis / hospital course do these patients undergo?

Bottom Line

EP placed TVPs have a high rate of successful capture and patients undergoing this procedure have a good prognosis.

Major Points

Successful pacemaker capture was achieved in 41(95.4%) of TVP attempts
Majority of patients that received TVP were transferred to ICU 41 (95.4%) the rest to the EP lab (4.6%)
Four patients (9.3%) expired during their hospital stay
31 (72%) discharged to home, 5 (11.6%) to a subacute rehabilitation facility, 3 (7%) to a nursing home after inpatient stay

Design

  • Retrospective Review
  • 36 month period
  • n = 43
  • Single Center (OLLMC Camden, NJ)

Population

Inclusion Criteria

Any ED record that had procedure note indicating transvenous pacemaker was placed (nursing or physician notes)

Exclusion Criteria

Placement during cardiac arrest / chest compressions
Patients who developed cardiac arrest after placement included

Baseline Characteristics

  • Age 76.6 years, female 62.7%
  • Initial heart rate 18-50 (mean 34.5)
  • Lowest systolic BP: 0-206 (mean 102)
  • Rhythm
    • 3rd degree (33%)
    • Junctional (21%)
    • A-fib/flutter (16%)
    • Sinus bradycardia (12%)

Interventions

  • Chart review for procedure note indicating TVP placement
  • Data Gathered from ED and Inpatient chart
    • Age
    • Gender
    • Emergency Physician
    • Vital Signs
    • Initial Cardiac Rhythm
    • Pacemaker Parameters
    • Clinical Circumstances
    • Pacemaker Success
    • Permanent Pacemaker Placement
    • Complications
    • Patient Disposition

Outcomes

  • Transvenous pacemaker attempts were unsuccessful in 2 patients.
  • Thirty nine (89%) patients had a post procedure chest x-ray
    • Apex of the right ventricle 19 (44%)
    • Elsewhere in the right ventricle 18 (41%)
    • Right atrium 1 (2%)
    • Coronary sinus 1 (2%)
  • All study patients were transferred from the ED with a perfusing cardiac rhythm,
    • 41 (95.4%) critical care unit
    • 2 (4.6%) EP laboratory
  • 26 (60%) patients received permanent pacemakers
  • Four (9.3%) patients expired during their hospital stay
  • Remaining discharged
    • 31 (72%) home
    • 5 (11.6%) sub-acute rehabilitation facility
    • 3 (7%) nursing home
  • No immediate or delayed complications identified from the TVPs placed in the ED during this study.

Criticisms

  • Retrospective
  • Single center
  • High volume TVP placement
  • Significantly different complication rate (Birkhahn et al)
  • No breakdown of which physician was placing TVPs
  • Broad range of heart rate / systolic pressures in subjects
  • Outcome versus conservative management may be similar

Reference

Additional Reading

http://hqmeded-ecg.blogspot.com/2015/07/emergency-transvenous-cardiac-pacing.html

Thank you to Dr Jennifer White for facilitating this months journal club and all the faculty/residents/students for their attendance