The Use of Subcostal Echocardiographic Views to Guide the Insertion of a Right Ventricular Temporary Transvenous Pacemaker—Description of the Technique

The need for temporary cardiac pacing may occur in emergency and elective situations and may require transvenous right ventricular lead placement. The treatment of bradyarrhythmias presents the most common perioperative emergency indication. Intraoperatively, temporary rapid right ventricular pacing is accepted as a safe, titratable, and highly reliable method to achieve deliberate hypotension, and it has become a routine practice in the anesthetic management of cardiovascular interventions. The navigation of the lead into the right ventricle often requires fluoroscopy to guide placement and to confirm position. Ultrasound guidance has been accepted widely by perioperative physicians as a safe technique for central venous access. Basic ultrasound and transthoracic echocardiographic skills rapidly are becoming integral to anesthesiologists' practice. When used to guide transvenous pacemaker wire insertion, subcostal echocardiographic imaging offers attractive advantages over blind or fluoroscopic placement, including rapid deployment, avoidance of radiation, real-time visualization of the lead in relation to the cardiac structures, and early detection of potential complications, such as tamponade. Although several articles on echocardiographic guidance for transvenous pacing have been published in other acute care specialty fields in the last decade, this is the first description of the technique and of the recommended echocardiographic views in a perioperative context. In addition, a review of the current literature is presented, and the specific advantages and disadvantages of the approach are discussed in this article.