Today’s POTD comes inspired by a confusing kit, a rare procedure, and honestly a Strayer Voice Note. For our rising ones, our outgoing twos, and my loyal threes- this is a procedure that is not an everyday one and one that is worth spending our time talking about. So let’s dive in-
TVP: Transvenous Pacer
Indications: unstable bradycardia (bradycardia + hypotension +/- AMS) or unresponsive to medication therapy
A good first place to start is the TVP Checklist which can be found in the JIT (Just in Time) Resource and now attached to this email.
I have attached a homemade video highlighting the usual trouble spots with our equipment/attaching the wires. I would recommend troubleshooting (aka connecting the wires/making sure everything fits PRIOR to poking the patient this way you can determine if someone needs to run up to CCU or for other materials).
For all of the TVPs (grand total of maybe four) I have been a part of, I think there are two big issues, and here is my approach to troubleshooting:
Connecting the wires:
Do not lose your disposable adaptors
Make sure you really push the adaptors into the end of the wires, this will require brut strength and avoidance of all ultrasound gel
Make sure these adaptors fit snug in your generator
Either directly into the ventricle (top) part of the generator
OR into the non-disposable adaptors into the extension cable
Check this before you get started with poking the patient
Floating the wire and getting capture
Make sure all of your wiring is secure, tight, and allows for electricity to flow appropriately
Balloon up going forward, balloon down with withdrawing
Start looking for capture at 40 cm, do not push more than 50 cm
A little bit of luck, a whole lot more patience
Next, I want to highlight some of the equipment/big pictures:
Preferred site of central venous access: Right internal jugular or left subclavian
Generator Box:
These are found in the blue box located in the cardiology cabinet in resus 51.
The generator box should be checked twice daily by the resus resident, though on occasion these will go upstairs to the CCU with a patient- in this case, the CCU should bring one down as an exchange.
Extension Cable:
This may or may not come with an extension cable, also shown here but important to note that, you do not need this (but may want it).
The extension cable allows you the have more slack on the wire, please see attached video on how to insert the extension cables and wiring to give you that increased slack
Nondisposable adaptors that allow for our wires to be attached to the extension cable
Wire: Parts of the wire:
Electrodes: two electrodes, one proximal end and one distal end; the reusable 2 mm adapters we have in our kit that insert into the electrodes are EXTREMELY difficult to fully push into the end of the wires which may be responsible for difficulty with capturing, please make sure these are fully inserted
Balloon: on the opposite side of the electrodes, is the part that enters the heart, check for an air leaks prior to entering into the patient
3 way stop cock: used to inflate the balloon, use special syringe for this (see below)
Plastic Sheath: Unfortunately there is a correct way to put this on and an incorrect way
This MUST be threaded over the wire prior to inserting the wire
Thread the wire through the smaller cap of the sheath, the larger cap is the piece that connects to cordis
Cordis/Cordis Cap:
Regular run of the mill cordis
I am sure there is a more formal name, but I think of it as a party hat for the cordis that goes on top and tucks in. This allows the wire to pass through the cordis, and lock into place with the protective sheath on top
Balloon Syringe:
Specialized syringe that gives a set amount of air to avoid overfilling the balloon
Battery:
The generator box relies on 9V batteries. Please check that your generator has a functioning battery before you use it, if you need another battery both the charge nurses (south and north) have batteries they can give you to replace
Just some general reminders about TVPs:
Mode/Sensitivity: We are using ventricle pacing
Rate:
Usually chose between 60-100 bpm
If a patient is being transcutaneously paced while you are placing the TVP, set the two pacing systems to a different rate therefore you can tell when a patient is being paced by which system.
Example: if your patient is being transcutaneously paced, set this to 70 bpm but your TVP to a rate of 80, this way when you are watching the monitor if the patients HR all the sudden becomes 80, you know that they are now being transvenously paced
Output:
Maximum: 20-30 mA
Simplified Review of the Steps:
Place the Cordis
Place sterile sheath over pacing wire in the correct orientation
Assure generator is on, with settings at appropriate levels
Inflate the balloon as soon as the wire is inserted past the level of the Cordis sheath (approximately 15-20 cm), lock the balloon inflated using the syringe
Advance the wire:
Floating: fast and smooth movements
Inflate the wire when advancing
De-inflate the wire when withdrawing
Wire should be at least 40 cm deep without capture, do not advance beyond 50 cm
Capture will look like:
LBBB on EKG or monitor
Manual pulse at the desired rate
Identify the capture threshold
Aka decrease the threshold until you use capture, use a capture right above that
Identify appropriate output
Aka 2-3x the threshold determined above
Secure the wire
Suture in place
Sterile dressing
Tape the generator to somewhere STABLE (aka not in a place that can accidentally be ripped off by the patient, family, or anyone)
Get confirmation on EKG and CXR
Call the CCU
Couple of things are attached to this email and below:
EMRAP’s How to place a TVP:
https://www.youtube.com/watch?v=00-T8PcbStE&t=18s
A useful video going through the steps
Kings County’s Review of Troubleshooting TVPs:
https://blog.clinicalmonster.com/2021/04/15/transvenous-pacemaker-placement-and-troubleshooting/
-Also attached is the JIT TVP Checklist
-A homemade video highlighting some of our equipment and its pitfalls
Hopefully this did not confuse anyone more, I am thinking we will soon need a video with our equipment to enter the JIT Folder but for now, hopefully this helps!
Until next time!
Moayedi S, Torres M. Cardiac Pacing. In: Swadron S, Nordt S, Mattu A, and Johnson W, eds. CorePendium. 5th ed. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recMOAnz71cN3N0OF/Cardiac-Pacing#h.i374rmm1hkxn. Updated November 3, 2023. Accessed March 19, 2025.
https://blog.clinicalmonster.com/2021/04/15/transvenous-pacemaker-placement-and-troubleshooting/
https://www.emra.org/emresident/article/device-series-tvp