Echocardiography-guided versus fluoroscopy-guided temporary pacing in the emergency setting: an observational study.

BACKGROUND: The insertion of a temporary pacemaker can be a lifesaving procedure in the emergency setting. OBJECTIVES: This is an observational monocentric study comparing echocardiography-guided temporary pacemaker via the right internal jugular vein to standard fluoroscopy-guided temporary pacemaker via the femoral vein; the procedure was tested for noninferiority. METHODS: Patients needing urgent pacing were consecutively enrolled. Primary efficacy endpoints were time to pacing and need for catheter replacement. Primary safety endpoint was a composite outcome of overall complications. RESULTS: One hundred and six patients (77 ± 10 years) were enrolled: 53 underwent echocardiographic-guided and 53 fluoroscopy-guided temporary pacemaker. Baseline characteristics of the two groups of treatment were similar. Time to pacing was shorter in the echocardiography-guided than in the fluoroscopy-guided group (439 ± 179 vs. 716 ± 235 s; P<0.0001; power 100%). During the pacing (54 ± 35 h), there was a higher incidence of pacemaker malfunction in the fluoroscopy-guided group [15 vs. 3 patients; odds ratio (OR) 6.5, confidence interval (CI) 95% 1.9-29.7, P<0.001; power 5.7%] and there was a significantly lower incidence of complications in the echocardiography-guided temporary pacemaker group (6 vs. 22 patients; OR 0.18, CI 95% 0.06-0.49, P<0.001; echocardiography-guided temporary pacemaker events rate 0.1929 vs. fluoroscopy-guided temporary pacemaker events rate 1.398 per 100 person-hours paced, P<0.0001). In the standard group there was one death attributable to a temporary pacemaker complication (sepsis). CONCLUSION: Echocardiography-guided temporary pacemaker is a well-tolerated procedure that could allow reliable insertion of a temporary pacemaker; therefore, it is a well-tolerated option in an emergency setting and in hospitals where fluoroscopy is not available.

Refractory acute decompensated heart failure: an observational study on a noninvasive hemodynamic monitoring system aimed at improving the therapeutic approach.

BACKGROUND: Inotropic agents should only be administered in acute decompensated heart failure (ADHF) refractory to vasodilators at optimal doses because they are associated with adverse outcome. In this setting a noninvasive hemodynamic monitoring system (NHMS) could be useful for optimizing treatment. INCLUSION CRITERIA: advanced chronic heart failure, ejection fraction 30% or less, admission for ADHF with systolic blood pressure 115 mmHg or less and inadequate response at 48 h of therapy. Patients were evaluated with a NHMS: with vascular systemic resistance (VSR) greater than 1500 dyne x s/cm we used vasodilators at increasing doses, with VSR less than 1500 and cardiac index (CI) less than 2.4 l/min per m inotropic agents were used. RESULTS: The study population consisted of 20 patients (mean age 67 + or - 12 years) with ejection fraction 20 + or - 7%. After 48 h of clinical-guided therapy, none of the patients achieved VSR 1500 or less, and 12 patients had a CI less than 2.4 l/min per m. After hemodynamic-guided therapeutic optimization there was a significant reduction of dyspnea at rest (7.7 + or - 1.25 versus 2.44 + or - 1.33 on the 10-point Likert scale, P < 0.001) and 'cold' presentation (12 patients before and 1 patient after, P = 0.0004). Daily urinary volume was higher (1217 + or - 369 versus 2260 + or - 797 ml, P = 0.001) without renal function deterioration (creatinine 1.56 + or - 0.52 versus 1.34 + or - 0.61 mg/dl, P = 0.012).The nitroprusside dosing was increased after NHMS (0.13 + or - 0.19 versus 0.4 + or - 0.310 microg/kg per min, P = 0.044), whereas doses of inotropic agents, diuretics and beta-blockers did not change significantly. CONCLUSIONS: In refractory ADHF a NHMS improves significantly symptoms and renal function, with a better use of vasodilators.

[Temporary emergency cardiac pacing under continuous echocardiographic control. Feasibility and safety of the procedure without using fluoroscopy]. / Posizionamento ecoguidato di elettrostimolatore temporaneo endocavitario in emergenza. Fattibilità e sicurezza della procedura senza impiego di fluoroscopia.

BACKGROUND: Cardiac pacing often turns out to be the only effective treatment of severe brady-arrhythmias. Several invasive and noninvasive temporary pacing procedures are known, whose application is sometimes difficult or time-consuming. An alternative temporary cardiac pacing procedure is described in this article, which is based on echocardiographic control. METHODS: Fifty-four nonconsecutive patients were studied; they all were needing urgent cardiac pacing. A first choice attempt to perform an ultrasound-guided temporary cardiac pacing, by using a right jugular venous approach, was done. The catheter pathway was monitored by means of echocardiography performed by another operator. All data concerning time of execution, pacing parameters, acute or chronic complications and the in situ time duration of the catheter without needing to be repositioned were obtained. RESULTS: Ultrasound-guided cardiac pacing was not feasible in 3 patients (6%), because of a high thoracic acoustic impedance or failing to perform right jugular venous catheterization. Mean execution time was 680 +/- 179 s. Echocardiographic monitoring was performed in 50 patients by a cardiologist, in 1 patient by a non-cardiologist physician, and in 3 patients by a nurse, who had been previously trained to keep the transducer in the right position. No serious complications occurred. On 4 occasions (8%) the catheter had to be repositioned during the following hours. On 25 occasions (46%) permanent cardiac pacing was finally performed. CONCLUSIONS: Temporary ultrasound-guided cardiac pacing seems to be a safe and easy procedure; it can be performed in a broad range of clinical and logistic scenarios and does not require fluoroscopic monitoring. A limited number of human resources is needed, but technical skills in central venous catheterization are required. Further studies are needed to validate this procedure; however it shows several potential benefits as compared to the other temporary cardiac pacing techniques.