The Intracavitary Compass: Intracavitary Electrogram Guided Temporary Pacing when Fluoroscopy is Unavailable

Temporary transvenous pacemaker (TPM) placement without fluoroscopy is typically guided solely by surface electrocardiogram (ECG), a technique lacking anatomical precision and associated with procedural risks. We describe a safer alternative based on continuous intracavitary electrogram (I-EGM) monitoring, obtained directly from the pacing lead during implantation. In a patient with complete atrioventricular block and urgent indication for renal replacement therapy, we used an active-fixation lead to allow real-time correlation between lead progression under fluoroscopic visualization and intracavitary electrogram signals. We were able to accurately identify the lead’s passage through the right atrium, right ventricle, and its endocardial contact point prior to final fixation. This technique, which we refer to as the “intracavitary compass,” enhances both safety and accuracy in temporary pacemaker placement, particularly in settings where fluoroscopy is unavailable.