The Alpha-bent and Tunneling: A Novel Technique for Fixing the Transvenous Pacer Lead during Temporary Transvenous Pacing in the Emergency Department.

The last step in the management of symptomatic bradycardia according to the advanced cardiac life support algorithm is temporary transvenous pacemaker insertion (TPI). TPI done by an emergency physician in the emergency department (ED) is on the rise particularly in South India owing to the increased incidence of yellow oleander poisoning. As in ED, we use passive fixation leads, fixation of a transvenous pacer lead is very important. In the following case series, we describe two novel techniques namely, "the alpha-bent" and "tunneling" for fixing the transvenous pacer lead. This technique of fixing the lead reduces lead displacement thus minimizing the potential complications. Copyright:

INTRODUCTION

Temporary transvenous pacing is one of those rare procedures that is performed in the emergency department (ED). However, in South India, the incidence of yellow oleander poisoning is very high. Yellow oleander is a plant that is commonly found along the roadside. All parts of the plant, such as seeds, leaves, and flowers, are poisonous. The toxic substances in these plants contain cardiac glycosides that produce a digoxin-like effect and cause dangerous hyperkalemia that results in various forms of bradyarrhythmia. Thus, most of these patients end up getting temporary transvenous pacing done in the ED. Once the pacer has been placed, it is important not to displace the lead, while transporting the patient. In the following series of cases, we describe a novel method of fixing the transvenous pacer lead, which prevents the displacement of passive fixation leads.

CASE REPORTS

Case 1

A 17-year-old male presented to the ED with an alleged history of consumption of four crushed yellow oleander seeds. At the time of his presentation to the ED, the patient had a pulse rate of 30 beats/min with a blood pressure of 100/70 mm Hg. The electrocardiograph (ECG) showed sinus bradycardia with sinus node dysfunction and an escape rhythm arising from the low atrium/coronary sinus [Figure 1a]. The decision to place a transvenous pacer was taken in the ED, and a 7 Fr introducer sheath was placed, with a 6 Fr pacer lead being passed through the introducer sheath. Using a continuous cardiac monitor, the position of the lead was confirmed and the transvenous pacer was set in single-chamber paced, single-chamber sensed and inhibition to sensing mode with a rate of 80 beats/min, a pacing output of 5 mV, and a sensing output of 2 mV. Once the pacing was confirmed with a 12-lead ECG [Figure 1e], which showed a left bundle branch block morphology, the transvenous pacer lead was fixed using the alpha-bent and the tunneling techniques.

Figure 1

Showing 12-lead-electrocardiograph of the 4 patient's pre- and post-pacing. (a-d) Shows 12-lead-electrocardiographs before pacing. (e-h) Shows 12-lead- electrocardiograph after pacing

Case 2

A 27-year-old female presented to the ED with an alleged history of consumption of two crushed seeds of yellow oleander. At the time of her presentation to the ED, the patient had a pulse rate of 32 beats/min with a blood pressure of 90/60 mm Hg. The ECG report of this patient showed a sinus rhythm with a high degree of AV block.[Figure 1b] Hence, the patient was paced temporarily using a transvenous pacer in the ED and confirmed with 12-lead ECG [Figure 1f], and it was fixed in the same way as described in Case 1.

Case 3

A 34-year-old male presented to the ED with an alleged history of consumption of three crushed yellow oleander seeds. At the time of his presentation to the ED, the patient had a pulse rate of 46 beats/min with a blood pressure of 70/40 mm Hg. The ECG report of this patient showed sinus node dysfunction with junctional bradycardia.[Figure 1c] Hence, the patient was paced temporarily using a transvenous pacer in the ED and confirmed with 12-lead ECG [Figure 1g], and it was fixed in the same way as described in Case 1.

Case 4

A 23-year-old male presented to the ED with an alleged history of consumption of eight crushed yellow oleander seeds. At the time of his presentation to the ED, the patient had a pulse rate of 16 beats/min with a blood pressure of 90/60 mm Hg. The ECG of this patient showed a sinus node dysfunction with sinus pause and sinus arrest.[Figure 1d] Hence, the patient was paced temporarily using a transvenous pacer in the ED and confirmed with 12-lead ECG [Figure 1h] and it was fixed in the same way as described for Case 1.

DISCUSSION

The displacement of transvenous pacer leads is a common problem, especially when it is placed in the ED. The displacement of transvenous pacer leads can lead to disastrous complications such as asystole, symptomatic bradycardia, syncope, and sudden cardiac death. This occurs most commonly when we shift patients for investigations or to the intensive care units or when the patient moves about. A study conducted by T. R. Betts on complications in temporary transvenous pacemaker insertion on 144 patients found that the rate of lead displacement was 16% overall and 14.4% after immediate placement of the pacemaker lead.[1] A systematic review performed by Tjoing et al. on the complications of temporary transvenous pacemakers found that the rate of lead displacement was 11.5% (before 1980), 2.6% (1980–1989), 14.1% (1990–1999), 3.1% (2000–2009), 3.4% (2010–2019), and 4.6% overall.[2] The declining rate may be attributed to the use of active fixation screws for the temporary transvenous pacemaker. This is called a temporary permanent pacemaker.[3]

A study by de Cock et al. found that the rate of lead dislodgement in the active fixation group is 5.5%, compared to the rate of lead dislodgement in the passive fixation group, which is 33.3%.[4] However, in developing countries like India, the use of active fixation leads for temporary transvenous pacing is limited. Moreover, to use an active fixation lead for a temporary pacemaker, the patient needs to be shifted to a procedure room with fluoroscopy. This is almost impossible when patients are hemodynamically unstable and the procedure needs to be performed at their bedside. Hence, to reduce the complication of lead displacement, we have developed a novel method of fixing the lead– the alpha-bent.

The alpha-bent

The alpha-bent is a bent in the shape of alpha, made near the entry point of the pacer lead through the introducer sheath. This prevents any longitudinal force applied on the pacemaker lead from being transmitted to the intravascular (portion of the lead inside the introducer sheath) and the intracardiac portions of the lead, thereby preventing the displacement of the lead. The longitudinal force applied to the free end of the pacer lead gets cutoff at either point A or point B [Figure 2a]. In addition, the tunneling of the pacer lead under the skin might provide extra stability and prevent the lead from getting dislodged.

Figure 2

(a) Shows the alpha-bent technique. The lead is bent in the shape a b of alpha, the Greek alphabet. The sutures are placed at the upper limb and lower limb of the alpha and the junction between 2 limbs at the X of alpha. Thus these sutures form an equilateral triangle. (b) If a longitudinal force is applied on the free end of the transvenous pacer lead, the force is nullified at the places marked with X.

Procedure steps

Bend the transvenous pacer in the shape of the alpha, after confirming the correct location of the pacer lead [Figure 2b]

Place a suture with a nonabsorbable suture material, preferably silk, (as other materials such as prolene reduce friction between the suture and the lead) at the site where the alpha makes the “X”

Following this, place two sutures on the upper and lower limbs of the alpha so that the three sutures form an equilateral triangle

In addition, one more suture can be placed at the apex of the alpha so that the four sutures form a diamond or two equilateral triangles

The tunneling technique can also be employed to reinforce the sutures and stabilize the transvenous pacer lead.

Tunneling

Tunneling is a technique of passing the pacer lead under the skin to add an extra layer of stability during fixation. Conventionally, this technique is used for an external ventricular drain. However, the use of the conventional tunneling technique in the transvenous pacer lead is not practically feasible, as the end is not blunt.[5] Hence, we improvised, and this improvisation includes the folding of two layers of skin over the pacer lead, thereby sandwiching the pacer lead between the two layers of skin. The following steps should be performed while performing our improvised tunneling procedure:

Step 1: With a nonabsorbable suture material, take a skin bite 1 cm away from the position of the pacer lead. (Preferably silk, as other materials such as prolene reduces friction between the lead and the suture material) [Figure 3a]

Figure 3

Shows the steps of the tunneling technique. (a) With a nonabsorbable suture material, take a skin bite 1 cm away from the position of the pacer lead. (b) Lift the ends of the silk to elevate two folds of skin. (c and d) Make a knot with the elevated folds of skin while maintaining the traction. This will create two layers of skin over the pacer lead

Step 2: Lift the ends of the silk to elevate two folds of skin [Figure 3b]

Step 3: Make a knot with the elevated folds of skin while maintaining the traction. This will create two layers of skin over the pacer lead [Figure 3c and d]

CONCLUSION

The scope of emergency medicine and emergency physicians is increasing in India. Emergency physicians are expected to handle all emergencies with limited resources. Hence, in a setting where fluoroscopy is not immediately available and there is no time, emergency physicians should know how to perform transvenous pacing. Our method of fixing the transvenous pacer lead, namely, “the alpha-bent” and “tunneling,” will improve the fixation of the lead, thereby decreasing the rate of lead displacement, especially when it is performed in the ED.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.