Was thinking about this thread couple of days ago in the OR. Here is my clinical scenario...
Small two cardiac OR hospital that does about 300 hearts per year. Nothing complicated, just usually CABGs, AVRs, LV Leads, and Thorocotomies. However, usually only physicians in house at time of surgery are Anesthesiologist and CT Surgeon. Sometimes occasional EP and a Cardiologist have scheduled cases, but not this day. Doing a Heartport AVR through a mini Anterior Thoracotomy with a sutureless AVR. Standard patient with normal EF, diabetic, and Hypertension. No preexisting conduction abnormalities. I place a Left Subclavian Introducer with a PA Endovent and a 8F double lumen central line at the beginning. Everything proceeds normally with Femoral cannulation. No problems with the new bioprosthesis. Ventricular and Atrial pacing wires placed. I test the wires prior to separating from CPB. Separate easily on low dose Levo. Patient in NSR. Everything looks good so we decannulate after all pump volume in. About 15 minutes later, after all Protamine has been given and hemostasis is achieved, pt starts having junctional rhythm, so I plug in Ventricular leads and getintermittent capture as maximum output. SBP which was in the 100-120 range is now 60-70. Surgeon tries to place new V lead but can't reach RV. A lead captures easily but little conduction. I start some Epi to try to help ventricular capture, but the patient already has a pretty tight LVOT and already appears quite hyperdynamic despite volume replacement. So, I'm left with a couple of options that are all pretty ****ty.
1) Recannulate to go back on CPB and place new Ventricular leads. Possible that we may need to convert to Sternotomy to do this effectively
2) Take down the drapes and have a Cardiologist come in a couple hours to place a Transvenous pacer since surgeon has never done one before. Or, just place it myself.
3) Take out my Subclavian lines and have the surgeon place a PPM. Not optimal for a number of reasons
4) Place a Transvenous pacer from the groin.
To preserve the surgical field, I chose option 4. I had done a couple previously, but never post bypass and never from the Femoral position. Had my tech get a temporary pacing kit from EP. I scrubbed in and placed it under Fluoro and yes I use Fluoro for my Heartports so I know what to look for for final lead position. After several attempts with the lead getting could up in the RAA, I was finally able to place it in the RV and get capture with threshold down to 5. Surgeon sutures in TVP lead, since there is no locking mechanism (I would normally just secure with tegaderms). So, we are able to close and get over to ICU
If this happened after the chest was closed, placing it either from the Subclavian or IJ position would have been tremendously easier. I agree with others that said if you can float a Swan, you should be able to place these if you know how to work a pacer box. Just my opinion, though. I understand others being uncomfortable if you don't do cardiac on a regular basis
