Temporary Epicardial Pacing After Cardiac Surgery

Published:August 27, 2022DOI:
      Temporary epicardial pacing frequently is employed after cardiac surgery, and can have a significant impact on a patient's hemodynamics, arrhythmias, and valvulopathies. Given that anesthesiologists often are involved intimately in the initial programming and subsequent management of epicardial pacing in the operating room and intensive care unit, it is important for practitioners to have a detailed understanding of the modes, modifiable intervals, and potential complications that can occur after cardiac surgery. Because this topic has not been reviewed recently in anesthesia literature, the authors attempted to review relevant epicardial pacemaker specifics, discuss modes and parameters that apply to the perioperative period, present an algorithm for mode selection, describe the potential effects of epicardial pacing on valvulopathies and hemodynamics, and, finally, discuss some postoperative considerations.

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        • Reade MC.
        Temporary epicardial pacing after cardiac surgery: A practical review: Part 1: General considerations in the management of epicardial pacing.
        Anaesthesia. 2007; 62: 264-271
        • Reade MC.
        Temporary epicardial pacing after cardiac surgery: A practical review. Part 2: Selection of epicardial pacing modes and troubleshooting.
        Anaesthesia. 2007; 62: 364-373
        • Schulman PM
        • Rozner MA
        • Sera V
        • et al.
        Patients with pacemaker or implantable cardioverter-defibrillator.
        Med Clin North Am. 2013; 97: 1051-1075
        • Khorsandi M
        • Muhammad I
        • Shaikhrezai K
        • et al.
        Is it worth placing ventricular pacing wires in all patients post-coronary artery bypass grafting?.
        Interact Cardiovasc Thorac Surg. 2012; 15: 489-493
        • Imren Y
        • Benson AA
        • Oktar GL
        • et al.
        Is use of temporary pacing wires following coronary bypass surgery really necessary?.
        J Cardiovasc Surg (Torino). 2008; 49: 261-267
        • Puskas JD
        • Sharoni E
        • Williams WH
        • et al.
        Is routine use of temporary epicardial pacing wires necessary after either OPCAB or conventional CABG/CPB?.
        Heart Surg Forum. 2003; 6: E103-E106
        • Bethea BT
        • Salazar JD
        • Grega MA
        • et al.
        Determining the utility of temporary pacing wires after coronary artery bypass surgery.
        Ann Thorac Surg. 2005; 79: 104-107
        • Asghar MI
        • Khan AA
        • Iqbal A
        • et al.
        Placing epicardial pacing wires in isolated coronary artery bypass graft surgery–a procedure routinely done but rarely beneficial.
        J Ayub Med Coll Abbottabad. 2009; 21: 86-90
        • Alwaqfi NR
        • Ibrahim KS
        • Khader YS
        • et al.
        Predictors of temporary epicardial pacing wires use after valve surgery.
        J Cardiothorac Surg. 2014; 9: 33
        • Berdajs D
        • Schurr UP
        • Wagner A
        • et al.
        Incidence and pathophysiology of atrioventricular block following mitral valve replacement and ring annuloplasty.
        Eur J Cardiothorac Surg. 2008; 34: 55-61
        • Hasan S
        • Lewis CT.
        A new method of temporary epicardial atrioventricular pacing utilizing bipolar pacing leads.
        Ann Thorac Surg. 2005; 79 (discussion 1387): 1384-1387
        • Manuel L.
        Temporary epicardial pacing wires post-cardiac surgery: A literature review.
        Gen Thorac Cardiovasc Surg. 2022; 70: 595-601
        • Lazarescu C
        • Kara-Mostefa S
        • Parlanti JM
        • et al.
        Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.
        J Cardiothorac Vasc Anesth. 2014; 28: 506-511
        • Yiu P
        • Tansley P
        • Pepper JR.
        Improved reliability of post-operative ventricular pacing by use of bipolar temporary pacing leads.
        Cardiovasc Surg. 2001; 9: 391-395
        • Aser R
        • Orhan C
        • Niemann B
        • et al.
        Temporary epicardial pacemaker wires: Significance of position and electrode type.
        Thorac Cardiovasc Surg. 2014; 62: 66-69
        • Medtronic
        Medtronic 5392 Dual Chamber Temporary External Pacemaker.
        Minneapolis, MN2020
        • Hang C
        • Ding L
        • Cheng S
        • et al.
        A soft and absorbable temporary epicardial pacing wire.
        Adv Mater. 2021; 33e2101447
        • Ellenbogen KA
        • Kaszala K.
        Cardiac Pacing and ICDs.
        John Wiley & Sons, Chichester, UK2014 (Sixth ed.)
        • Joshi SB
        • Salah AK
        • Mendoza DD
        • et al.
        Mechanism of paradoxical ventricular septal motion after coronary artery bypass grafting.
        Am J Cardiol. 2009; 103: 212-215
        • Clancy DJ
        • McLean A
        • Slama M
        • et al.
        Paradoxical septal motion: A diagnostic approach and clinical relevance.
        Australas J Ultrasound Med. 2018; 21: 79-86
        • Sullivan BL
        • Bartels K
        • Hamilton N.
        Insertion and management of temporary pacemakers.
        Semin Cardiothorac Vasc Anesth. 2016; 20: 52-62
        • Naqvi TZ
        • Chao CJ.
        Adverse effects of right ventricular pacing on cardiac function: prevalence, prevention and treatment with physiologic pacing [e-pub ahead of print].
        Trends Cardiovasc Med. 2021; (Accessed July 5th, 2022)
        • Cannesson M
        • Farhat F
        • Scarlata M
        • et al.
        The impact of atrio-biventricular pacing on hemodynamics and left ventricular dyssynchrony compared with atrio-right ventricular pacing alone in the postoperative period after cardiac surgery.
        J Cardiothorac Vasc Anesth. 2009; 23: 306-311
        • Schmidt C
        • Frielingsdorf J
        • Debrunner M
        • et al.
        Acute biventricular pacing after cardiac surgery has no influence on regional and global left ventricular systolic function.
        Europace. 2007; 9: 432-436
        • Russell SJ
        • Tan C
        • O'Keefe P
        • et al.
        Optimized temporary bi-ventricular pacing improves haemodynamic function after on-pump cardiac surgery in patients with severe left ventricular systolic dysfunction: A two-centre randomized control trial.
        Eur J Cardiothorac Surg. 2012; 42: e146-e151
        • Garcia-Bengochea JB
        • Fernandez AL
        • Calvelo DS
        • et al.
        Temporary epicardial left ventricular and biventricular pacing improves cardiac output after cardiopulmonary bypass.
        J Cardiothorac Surg. 2012; 7: 113
        • Weisse U
        • Isgro F
        • Werling C
        • et al.
        Impact of atrio-biventricular pacing to poor left-ventricular function after CABG.
        Thorac Cardiovasc Surg. 2002; 50: 131-135
        • Fanari Z
        • Hammami S
        • Hammami MB
        • et al.
        The effects of right ventricular apical pacing with transvenous pacemaker and implantable cardioverter defibrillator on mitral and tricuspid regurgitation.
        J Electrocardiol. 2015; 48: 791-797
        • Vaturi M
        • Kusniec J
        • Shapira Y
        • et al.
        Right ventricular pacing increases tricuspid regurgitation grade regardless of the mechanical interference to the valve by the electrode.
        Eur J Echocardiogr. 2010; 11: 550-553
        • Gu W
        • Maus TM.
        Intraoperative epicardial pacing-induced dyssynchrony leading to severe mitral regurgitation and hemodynamic instability.
        J Cardiothorac Vasc Anesth. 2021; 35: 2239-2241
        • Cronin B
        • Danforth D
        • Pollema T
        • et al.
        Ventricular pacing-induced tricuspid regurgitation after cardiopulmonary bypass.
        J Cardiothorac Vasc Anesth. 2020; 34: 851-853
        • Salukhe TV
        • Henein MY
        • Sutton R.
        Pacing in heart failure: Patient and pacing mode selection.
        Eur Heart J. 2003; 24: 977-986
        • Safavi-Naeini P
        • Saeed M.
        Pacemaker troubleshooting: Common clinical scenarios.
        Tex Heart Inst J. 2016; 43: 415-418
        • Moses HW.
        A Practical Guide to Cardiac Pacing.
        6th ed. Lippincott Williams & Wilkins, Philadelphia, PA2007
        • Eberhardt F
        • Hanke T
        • Heringlake M
        • et al.
        Feasibility of temporary biventricular pacing in patients with reduced left ventricular function after coronary artery bypass grafting.
        Pacing Clin Electrophysiol. 2007; 30: S50-S53
        • Elmi F
        • Tullo NG
        • Khalighi K.
        Natural history and predictors of temporary epicardial pacemaker wire function in patients after open heart surgery.
        Cardiology. 2002; 98: 175-180
        • Hayes DL
        • Friedman PA.
        CardiacPacing, Defibrillation and Resynchronization: A Clinical Approach.
        2nd ed. Wiley-Blackwell, Chichester, UK2008
        • Barold SS
        • Stroobandt R
        • Sinnaeve AF.
        Cardiac Pacemakers Step By Step: An Illustrated Guide.
        Futura, Elmsford, NY2004
        • Yang F
        • Tiano J
        • Mittal S
        • et al.
        Towards a mechanistic understanding and treatment of a progressive disease: Atrial fibrillation.
        J Atr Fibrillation. 2017; 10: 1627
        • Sanchez-Quintana D
        • Lopez-Minguez JR
        • Pizarro G
        • et al.
        Triggers and anatomical substrates in the genesis and perpetuation of atrial fibrillation.
        Curr Cardiol Rev. 2012; 8: 310-326
        • Kalahasty G
        • Ellenbogen K.
        The role of pacemakers in the management of patients with atrial fibrillation.
        Med Clin North Am. 2008; 92 (xi-xii): 161-178
        • Blommaert D
        • Gonzalez M
        • Mucumbitsi J
        • et al.
        Effective prevention of atrial fibrillation by continuous atrial overdrive pacing after coronary artery bypass surgery.
        J Am Coll Cardiol. 2000; 35: 1411-1415
        • Chung MK
        • Augostini RS
        • Asher CR
        • et al.
        Ineffectiveness and potential proarrhythmia of atrial pacing for atrial fibrillation prevention after coronary artery bypass grafting.
        Ann Thorac Surg. 2000; 69: 1057-1063
        • Levy T
        • Fotopoulos G
        • Walker S
        • et al.
        Randomized controlled study investigating the effect of biatrial pacing in prevention of atrial fibrillation after coronary artery bypass grafting.
        Circulation. 2000; 102: 1382-1387
        • Debrunner M
        • Naegeli B
        • Genoni M
        • et al.
        Prevention of atrial fibrillation after cardiac valvular surgery by epicardial, biatrial synchronous pacing.
        Eur J Cardiothorac Surg. 2004; 25: 16-20
        • Gerstenfeld EP
        • Hill MR
        • French SN
        • et al.
        Evaluation of right atrial and biatrial temporary pacing for the prevention of atrial fibrillation after coronary artery bypass surgery.
        J Am Coll Cardiol. 1999; 33: 1981-1988
        • Kurz DJ
        • Naegeli B
        • Kunz M
        • et al.
        Epicardial, biatrial synchronous pacing for prevention of atrial fibrillation after cardiac surgery.
        Pacing Clin Electrophysiol. 1999; 22: 721-726
        • Joglar JA
        • Wan EY
        • Chung MK
        • et al.
        Management of arrhythmias after heart transplant: current state and considerations for future research.
        Circ Arrhythm Electrophysiol. 2021; 14e007954
        • Vaseghi M
        • Boyle NG
        • Kedia R
        • et al.
        Supraventricular tachycardia after orthotopic cardiac transplantation.
        J Am Coll Cardiol. 2008; 51: 2241-2249
        • Voruganti D
        • Shantha G
        • Dugyala S
        • et al.
        Trends and outcomes of atrial fibrillation-flutter hospitalizations among heart transplant recipients (from the National Inpatient Sample).
        Am J Cardiol. 2020; 125: 87-91
        • Oupadia P
        • Ramaswamy K.
        Images in clinical medicine. "R-on-T" phenomenon.
        N Engl J Med. 1998; 338: 1812
        • Chemello D
        • Subramanian A
        • Kumaraswamy N.
        Cardiac arrest caused by undersensing of a temporary epicardial pacemaker.
        Can J Cardiol. 2010; 26: e13-e14
        • Schulman PM
        • Stecker EC
        • Rozner MA.
        R-on-T and cardiac arrest from dual-chamber pacing without an atrial lead.
        Heart Rhythm. 2012; 9 (Accessed July 10, 2022): 970-973
      1. McClurken JB. Minimizing complications from temporary epicardial pacing wires after cardiac surgery. Pennsylvania Patient Safety Reporting System (PA PSRS) Patient Safety Advisory. 2006.

        • Elmistekawy E
        • Gee YY
        • Une D
        • et al.
        Clinical and mechanical factors associated with the removal of temporary epicardial pacemaker wires after cardiac surgery.
        J Cardiothorac Surg. 2016; 11 (8)
        • Cote CL
        • Baghaffar A
        • Tremblay P
        • et al.
        Incidence of tamponade following temporary epicardial pacing wire removal.
        J Card Surg. 2020; 35: 1247-1252
        • Mahon L
        • Bena JF
        • Morrison SM
        • et al.
        Cardiac tamponade after removal of temporary pacer wires.
        Am J Crit Care. 2012; 21: 432-440
        • Bougioukas I
        • Jebran AF
        • Grossmann M
        • et al.
        Is there a correlation between late re-exploration after cardiac surgery and removal of epicardial pacemaker wires?.
        J Cardiothorac Surg. 2017; 12: 3