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Transvenous Cardiac Pacing

Background

This article describes transvenous cardiac pacing. In a healthy heart, electrical impulses are generated in the sinoatrial (SA) node (sinus node), which is near the junction of the superior vena cava (SVC) and the right atrium (RA). The specialized cells of the SA node generate electrical impulses faster than other parts of the conduction system and with automaticity; therefore, these cells are usually the dominant natural pacemakers of the heart. The impulse is then conducted through the RA and left atrium (LA) and reaches the atrioventricular (AV) node.

The AV junction, which is at the base of the interatrial septum and extends into the interventricular septum, has two main parts: the AV node in the upper part, and the bundle of His in the lower part. In a healthy heart, the AV node is the only electrical connection between the atria and the ventricles. The inherent delay in transmitting the electrical impulse from the atria to the ventricles provides the appropriate diastolic duration to enable ventricular filling.

The His bundle divides into the left and right bundle branches and then into the Purkinje fibers, which conduct the impulse rapidly through the ventricles to produce rapid and simultaneous ventricular contractions. In general, symptomatic abnormalities of the conduction system are the main indications for cardiac pacing, a method by which a small pulsed electrical current is artificially delivered to the heart.

Of the several methods for temporary pacing of the heart (transcutaneous, transvenous, transesophageal, transthoracic, and epicardial), transvenous and transcutaneous cardiac pacing are the most commonly used. The main factor that dictates the use of one approach instead of another is the urgency of the need for pacing.

In an emergency where a patient is experiencing cardiac symptoms or asystole, transcutaneous pacing is the method of choice. Nevertheless, transvenous pacing has the following advantages over the transcutaneous method:

Enhanced patient comfort

Greater reliability

Ability to pace the atrium

However, because transvenous pacing requires central venous access, it cannot be initiated as fast as transcutaneous pacing can, and it is associated with several complications that result from obtaining venous access.

A common scenario is one in which transcutaneous pacing is employed first in an emergency, followed by transvenous placement of a lead that will enable a longer period of pacing and evaluation in patients who may require permanent pacing later during their hospitalization.

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