if a permanent endocardial lead is used for longer-term temporary pacing, the lead could be placed essentially anywhere in the right ventricle. With the lead positioned in the right ventricle, the QRS should generally have a left bundle branch block morphology and a superior axis (ie, an upright QRS complex in lead I and aVL). https://www.uptodate.com/contents/temporary-cardiac-pacing/print 12/19 7/6/23, 11:03 AM Temporary cardiac pacing - UpToDate A physical examination should be performed immediately following transvenous lead placement, with subsequent daily assessments, to evaluate for any of the following: Pericardial friction rub, which may be indicative of cardiac perforation Hypotension with muffled heart sounds and jugular venous distension, suggesting cardiac tamponade Asymmetrical or absent breath sounds, suggesting a pneumothorax Management for the duration of temporary pacing Continuous ECG monitoring is mandatory during the entire time the patient has a temporary cardiac pacemaker, and a separate intravenous access is recommended should there be a need for drug therapy. Daily chest radiographs are not mandatory, but a chest radiograph should be repeated if there is evidence of failure to capture or failure to sense, or if a ventricular tachyarrhythmia occurs, all of which suggest potential electrode dislodgement. Daily ECGs are also not needed. Patients with temporary pacemakers require a daily check of pacing thresholds to make certain that there is proper capture. The need to continue temporary cardiac pacing should be reevaluated daily, with device removal if the patient has recovered stable intrinsic electrical activity or consideration of permanent cardiac pacing if indicated. If there are any episodes of failure to sense a premature ventricular complex/contraction (PVC; also referred to a premature ventricular beats or premature ventricular depolarizations) or an intrinsic normally conducted QRS complex, the sensing of the temporary pacemaker should be reevaluated. In most institutions a special dressing may be applied that is felt to resist infection. Some of the occlusive and transparent dressings that are available can be left in place for up to seven days. Fever and/or local erythema or drainage at the venous access site would suggest an infection and should prompt appropriate evaluation and, if needed, removal of the temporary pacing system. All connections and pacemaker programmed settings should be checked routinely. If the patient has a permanent endocardial lead placed and attached to an externalized permanent pacemaker when it is assumed that longer duration temporary pacing will be necessary, the patient can have unrestricted movement other than limitation of arm/shoulder restriction on the ipsilateral side of the temporary pacemaker. SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Arrhythmias in adults" and "Society guideline links: Cardiac implantable electronic devices".) https://www.uptodate.com/contents/temporary-cardiac-pacing/print 13/19 7/6/23, 11:03 AM Temporary cardiac pacing - UpToDate SUMMARY AND RECOMMENDATIONS Temporary cardiac pacing involves electrical cardiac stimulation to treat bradyarrhythmias and rarely a tachyarrhythmia, until it resolves or until long-term therapy can be initiated. The purpose of temporary pacing is to reestablish circulatory integrity and normal hemodynamics that are acutely compromised by a slow or fast heart rate. (See 'Introduction' above.) Temporary cardiac pacing is most commonly utilized for patients with symptomatic bradyarrhythmias, most frequently due to atrioventricular (AV) nodal block. Temporary cardiac pacing for bradycardia that results from an acute and reversible cause (eg, acute myocardial infarction, electrolyte disturbances, drug toxicities, Lyme disease, etc) will often not require permanent pacing. (See 'Indications' above.) Temporary cardiac pacing can be performed in a variety of ways, most commonly via transvenous endocardial leads designed for temporary pacing, transvenous endocardial leads designed for permanent cardiac pacing if longer-term temporary pacing will be required, or transcutaneous leads. Temporary transvenous pacing is the preferred approach for most patients, although transcutaneous pacing can be initiated more rapidly in an emergency. (See 'Pacing techniques' above.) The preferred access sites for temporary transvenous pacing leads are the left subclavian vein and the right internal jugular vein; this relates primarily to the curvature of the lead and ease of advancing the lead into the heart. A brachial vein approach is not recommended because of the risk of cardiac puncture and instability, while a femoral vein approach is not recommended because of the risks of deep vein thrombosis and infection and the need for the patient to remain continuously supine. (See 'Vascular access' above.) Once central venous access has been secured and the introducer sheath is in place, the transvenous lead is inserted and advanced into the heart. The progress of the advancing lead can be monitored using lead marking, continuous electrocardiographic monitoring, and/or fluoroscopy. (See 'Transvenous lead placement' above.) The temporary pacing rate should be set to whatever rate optimizes the patient's hemodynamics. For a pediatric patient and often for postoperative patients, a faster heart rate (eg, 80 to 100 beats per minute) may be desired. For most other patients, a rate of 60 to 70 beats per minute will likely be adequate. If the patient is pacemaker-dependent, then the temporary pacer can be turned to the least sensitive value (ie, the temporary pacemaker will essentially function in an asynchronous mode). If the patient has an https://www.uptodate.com/contents/temporary-cardiac-pacing/print 14/19 7/6/23, 11:03 AM Temporary cardiac pacing - UpToDate intermittent intrinsic ventricular rhythm, then the sensitivity should be adjusted to allow normal sensing of the intrinsic events. (See 'Pacemaker programming' above.) Immediately following completion of transvenous lead placement, a chest radiograph should be obtained to establish the position of the lead, an immediate postprocedure 12- lead ECG should be recorded during pacing to determine the electrocardiographic appearance of the QRS complex, and a physical examination should be performed to evaluate for any evidence of cardiac tamponade or pneumothorax. (See 'Immediate postprocedural management' above.) Continuous ECG monitoring is mandatory during the entire time the patient has a temporary cardiac pacemaker, and a separate intravenous access is recommended should there be a need for drug therapy. Daily chest radiographs and ECGs are not needed; however, patients with temporary pacemakers require a daily check of pacing thresholds to make certain that there is proper capture. (See 'Management for the duration of temporary pacing' above.) ACKNOWLEDGMENTS The UpToDate editorial staff acknowledges Brian Olshansky, MD, and David L Hayes, MD, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation 2019; 140:e333. 2. Glikson M, Nielsen JC, Kronborg MB, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427. 3. Tjong FVY, de Ruijter UW, Beurskens NEG, Knops RE. A comprehensive scoping review on transvenous temporary pacing therapy. Neth Heart J 2019; 27:462. 4. Sullivan BL, Bartels K, Hamilton N. Insertion and Management of Temporary Pacemakers. Semin Cardiothorac Vasc Anesth 2016; 20:52. https://www.uptodate.com/contents/temporary-cardiac-pacing/print 15/19 7/6/23, 11:03 AM Temporary cardiac pacing - UpToDate 5. Murphy JJ. Current practice and complications of temporary transvenous cardiac pacing. BMJ 1996; 312:1134. 6. Ng ACC, Lau JK, Chow V, et al. Outcomes of 4838 patients requiring temporary transvenous cardiac pacing: A statewide cohort study. Int J Cardiol 2018; 271:98. 7. Metkus TS, Schulman SP, Marine JE, Eid SM. Complications and Outcomes of Temporary Transvenous Pacing: An Analysis of > 360,000 Patients From the National Inpatient Sample. Chest 2019; 155:749. 8. Abd Elaziz ME, Allama AM. Temporary Epicardial Pacing After Valve Replacement: Incidence And Predictors. Heart Surg Forum 2018; 21:E049. 9. 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. 10. 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. 11. Kornberger A, Schmid E, Kalender G, et al. Bridge to recovery or permanent system implantation: an eight-year single-center experience in transvenous semipermanent pacing. Pacing Clin Electrophysiol 2013; 36:1096. 12. Kawata H, Pretorius V, Phan H, et al. Utility and safety of temporary pacing using active fixation leads and externalized re-usable permanent pacemakers after lead extraction. Europace 2013; 15:1287. 13. Bektas F, Soyuncu S. The efficacy of transcutaneous cardiac pacing in ED. Am J Emerg Med 2016; 34:2090. 14. Quast ABE, Beurskens NEG, Ebner A, et al. Feasibility of An Entirely Extracardiac, Minimally Invasive,Temporary Pacing System. Circ Arrhythm Electrophysiol 2019; 12:e007182. 15. Aser R, Orhan C, Niemann B, et al. Temporary epicardial pacemaker wires: significance of position and electrode type. Thorac Cardiovasc Surg 2014; 62:66. 16. Francis GS, Williams SV, Achord JL, et al. Clinical competence in insertion of a temporary transvenous ventricular pacemaker. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology. Circulation 1994; 89:1913. 17. Ezeugwu CO, Oropello JM, Pasik AS, Benjamin E. Position of temporary transvenous pacemaker after insertion. J Cardiothorac Vasc Anesth 1994; 8:367. 18. Goldberger J, Kruse J, Ehlert FA, Kadish A. Temporary transvenous pacemaker placement: what criteria constitute an adequate pacing site? Am Heart J 1993; 126:488. https://www.uptodate.com/contents/temporary-cardiac-pacing/print 16/19 7/6/23, 11:03 AM Temporary cardiac pacing - UpToDate 19. Pinneri F, Frea S, Najd K, et al. Echocardiography-guided versus fluoroscopy-guided temporary pacing in the emergency setting: an observational study. J Cardiovasc Med (Hagerstown) 2013; 14:242. 20. Ferri LA, Farina A, Lenatti L, et al. Emergent transvenous cardiac pacing using ultrasound guidance: a prospective study versus the standard fluoroscopy-guided procedure. Eur Heart J Acute Cardiovasc Care 2016; 5:125. 21. Guo H, Hahn D, Olshansky B. Temporary biventricular pacing in a patient with subacute myocardial infarction, cardiogenic shock, and third-degree atrioventricular block. Heart Rhythm 2005; 2:112. 22. Madershahian N, Scherner M, Weber C, et al. Temporary biventricular pacing improves bypass graft flows in coronary artery bypass graft patients with permanent atrial fibrillation. Interact Cardiovasc Thorac Surg 2015; 21:435. 23. Baciewicz FA Jr, Leighton RF, Davis JT. Use of rapid atrial pacing to induce 2:1 atrioventricular block with marked improvement in hemodynamics. Int J Cardiol 1987; 17:327. 24. Scott WA, Lemler M, Farley L, Zehr R. Evaluation of temporary atrial pacing leads. Pacing Clin Electrophysiol 1993; 16:1789. 25. Takeda M, Furuse A, Kotsuka Y. Use of temporary atrial pacing in management of patients after cardiac surgery. Cardiovasc Surg 1996; 4:623. 26. Ohm OJ, Breivik K, Segadal L, Engedal H. New temporary atrial and ventricular pacing leads for patients after cardiac operations. J Thorac Cardiovasc Surg 1995; 110:1725. 27. Hildick-Smith DJ, Petch MC. Temporary pacing before permanent pacing should be avoided unless essential. BMJ 1998; 317:79. Topic 1005 Version 26.0 https://www.uptodate.com/contents/temporary-cardiac-pacing/print 17/19 7/6/23, 11:03 AM Temporary cardiac pacing - UpToDate GRAPHICS Options for hands-free pacemaker/defibrillator pad positioning Positioning options for hands-free pacemaker/defibrillator pads showing anterior/lateral positioning (left) and anterior/posterior positioning (right). Graphic 103268 Version 2.0 https://www.uptodate.com/contents/temporary-cardiac-pacing/print 18/19 7/6/23, 11:03 AM Temporary cardiac pacing - UpToDate Contributor Disclosures N A Mark Estes, III, MD Consultant/Advisory Boards: Boston Scientific [Arrhythmias]; Medtronic [Arrhythmias]. All of the relevant financial relationships listed have been mitigated. Bradley P Knight, MD, FACC Grant/Research/Clinical Trial Support: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; MDT [Electrophysiology]; Philips [Electrophysiology]. Consultant/Advisory Boards: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; CVRx [Heart failure]; MDT [Electrophysiology]; Philips [Electrophysiology]; Sanofi [Arrhythmias]. Speaker's Bureau: Abbott [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Transeptal catheterization]; BSCI [Electrophysiology]; MDT [Electrophysiology]. All of the relevant financial relationships listed have been mitigated. Todd F Dardas, MD, MS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/temporary-cardiac-pacing/print 19/19