title: Emergent transvenous cardiac pacing using ultrasound guidance: a prospective study versus the standard fluoroscopy-guided procedure.
abstract: OBJECTIVE
  To compare time to active pacing and complication rates associated with temporary transvenous pacemaker (TTVPM) insertion between a fully echo-guided approach of vein access and lead placement, and standard placement of TTVPM under fluoroscopic guidance.
  
  
  RESULTS
  We performed a prospective single-center observational study enrolling all consecutive patients from 1 January 2008 to 31 December 2012 needing emergent TTVPM placement. According to personal experience and clinical setting, the operators could choose between a fully echo-guided approach of TTVPM placement through the jugular vein and a standard fluoro-guided approach through the femoral vein. Safety and efficacy endpoints were pre-specified, registered, and compared. A total of 113 patients were treated using the echo-guided approach, and 90 via the fluoro-guided approach. The two groups differed with regard to clinical setting at presentation: an acute coronary syndrome was more frequent in the fluoro-guided approach group (39.7% vs. 16.8%, p<0.001), whereas asystole was more frequent in the echo-guided approach group (9.7 vs. 0%). Median time from decision to active pacing was significantly shorter in the echo-guided approach group (22 vs. 43 minutes, p<0.01). The overall complication rates were significantly lower in the echo-guided approach group (15.0% vs. 28.8%, p 0.02), because of lower rates of infections (2.7% vs. 11.1%, p 0.02) and puncture-related hematomas (0 vs. 3.3%, p=0.08). There were no deaths related to TTVPM, but one heart perforation requiring emergent pericardiocentesis occurred in the fluoro-guided approach group. One pneumothorax treated conservatively occurred in the echo-guided approach group, while no differences were observed with regard to sustained tachyarrhythmias (1.8% vs. 2.2%) or malfunctions requiring reposition of the catheter (8.8 vs. 8.9%). Overall, complications delaying permanent pacemaker implant for >48 hours were observed less often in the echo-guided approach group (6.8 vs. 20.7%, p = 0.03).
  
  
  CONCLUSIONS
  Echo-guided insertion of TTVPM through the jugular vein is a feasible and safe alternative to fluoroscopic guidance and may reduce complications and time to active pacing in patients who are not candidates for emergent cardiac catheterization.
authors: Cardiovascular Department, Ospedale Alessandro Manzoni, Lecco, Italy la.ferri@ospedale.lecco.it.
authors: Luca A
authors: LA
authors: Ferri
authors: Cardiovascular Department, Ospedale Alessandro Manzoni, Lecco, Italy.
authors: Andrea
authors: A
authors: Farina
authors: Cardiovascular Department, Ospedale Alessandro Manzoni, Lecco, Italy.
authors: Laura
authors: L
authors: Lenatti
authors: Cardiovascular Department, Ospedale Alessandro Manzoni, Lecco, Italy.
authors: Franco
authors: F
authors: Ruffa
authors: Cardiovascular Department, Ospedale Alessandro Manzoni, Lecco, Italy.
authors: GianLuca
authors: G
authors: Tiberti
authors: Cardiovascular Department, Ospedale Alessandro Manzoni, Lecco, Italy.
authors: Luigi
authors: L
authors: Piatti
authors: Cardiovascular Department, Ospedale Alessandro Manzoni, Lecco, Italy.
authors: Stefano
authors: S
authors: Savonitto
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D002339:Carotid Arteries / Q000000981:diagnostic imaging; D005260:Female; D005471:Fluoroscopy / Q000379:methods; D006352:Heart Ventricles / Q000000981:diagnostic imaging; D006801:Humans; D007601:Jugular Veins / Q000000981:diagnostic imaging; D008297:Male; D010138:Pacemaker, Artificial; D011446:Prospective Studies; D015641:Radiography, Interventional / Q000379:methods*; D014463:Ultrasonography / Q000379:methods; D018084:Ultrasonography, Interventional / Q000379:methods*
keywords: atrioventricular block; cardiac pacemaker; complications; fluoroscopy; heart arrest; transthoracic echocardiography.