Electrophysiology Corner

Emergent Mechanical and Electrical Guidewire Pacing of the Right Ventricle for Asystole in the Cardiac Catheterization Laborator

Rolf Vogel, MD, PhD and Bernhard Meier, MD
Rolf Vogel, MD, PhD and Bernhard Meier, MD
Case Report. A 72-year-old female with severe symptomatic mitral stenosis, chronic atrial fibrillation, and left bundle branch block was admitted to the hospital for percutaneous balloon valvuloplasty. Catheterization of the right ventricle was complicated by a complete atrioventricular block with asystole, presumably due to an irritation of the right bundle branch by the 5 French multipurpose catheter (Cordis Corporation, Miami, Florida). Immediate and sufficient hemodynamic stabilization (Figure 1) was achieved by the induction of nonsustained ventricular runs by mechanical stimulation of the right ventricular wall with a 0.035 inch J-Tip Emerald™ Guidewire (Cordis Corporation). The wire was then brought in full contact with the right ventricular wall. The external end of the wire was connected to the cathode of an external pacemaker using an alligator clamp while its anode was connected to a skin electrode at the left thigh of the patient. Pacing could immediately be established at a heart rate of 80 beats per minute (Figure 1, bottom). It was continued until a conventional temporary pacing electrode had been inserted via a second access to the right femoral vein. Subsequently, the patient underwent successful mitral valvuloplasty. The atrioventricular block persisted and a permanent pacemaker was implanted the following day. Discussion. In the event of asystole in the cardiac catheterization laboratory, any already-established electrical access to the heart should be used for emergent right ventricle, left ventricle,1 or coronary pacing.2 The time gain of pacing using a catheter-insulated guidewire rather than inserting a transvenous pacemaker amounts to at least a couple of minutes. This is essential in the event of complete asystole, as the need for cardiac massage develops after the first minute. Guidewire pacing can usually be installed within one minute, thereby obviating the situation where mechanical resuscitation becomes necessary while struggling to introduce a venous pacemaker system into the right ventricle. Cardiac massage, with all its deleterious effects, is thus avoided. The time to electrical hook-up can be bridged by mechanical provocation of ventricular contractions with the guidewire. If pacemaker dependence persists or the access used for pacing is needed to proceed with the intervention, conventional ventricular pacing can be installed under the protection of the technique as described in this case report. It is our experience that guidewire pacing can be successfully performed with all customary wires when the following steps are considered: 1) guarantee close contact between guidewire and myocardium. Place the guidewire into a septal branch in case of coronary pacing; 2) connect the pacemaker’s cathode to the guidewire by means of an alligator clamp and turn the output of the pacemaker to its maximum; the use of the anode is associated with higher pacing thresholds; 3) if pacing fails, scratch the coating of the wire with the alligator clamp.
References
1. Meier B. Left ventricular pacing for bradycardia in the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2004;62:31. 2. Meier B, Rutishauser W. Coronary pacing during percutaneous transluminal angioplasty. Circulation 1985;71:557–561.