Table 2 Suggested protocol for TEE-guided insertion of TVP
From: Transesophageal echocardiography (TEE)-guided transvenous pacing (TVP) in emergency department
Steps | Level and acquisition | Protocol for TEE-guided insertion of TVP |
|---|---|---|
Step 1: Preparation | Place the patient on the monitor, continue transcutaneous pacing. Check the box and batteries | |
Step 2: CVC Cannulation | Obtain central venous access, preferably the right internal jugular vein | |
Step 3: TEE Probe insertion | Mid esophageal level, Bicaval view Transducer Angle: ~ 90–110º | Advance the TEE transducer to bicaval view |
Step 4: Placement of Pacing Wire | Thread the transvenous pacing wire through the central venous line, inflate the balloon at 20 cm, continue advancing the wire until it is visualized in the superior vena cava and then into the right atrium (Fig. 1, Additional file 1: Video S1) | |
Step 5: Visualization of wire in the right heart | Mid esophageal level-RV inflow–outflow view Transducer Angle: ~ 50–70º Refer toa | Reduce the transducer angle to visualize the RV inflow–outflow view (Fig. 2, Additional file 2: Video S2) |
Step 6: Placement in right ventricle | Advanced the transvenous pacing wire through tricuspid valve into the right ventricle (Fig. 3, Additional file 2: Video S2) | |
Step 7: Color Doppler Test | Apply color Doppler over the tricuspid valve. Tricuspid regurgitation is expected if the wire has passed through the valve (Fig. 3) | |
Step 8: Confirmation of the wire tip location | Mid esophageal level, 4 or 5 chamber view Transducer Angle: ~ 0–10º Refer toa | Guide the transvenous pacing wire into position with the tip in the apical right ventricular endocardium (Fig. 4, Additional file 3: Video S3). Confirm the adequate contact of the tip by advancing the probe to visualize the 4 or 5- chamber view |
Step 9: Perform Electrical capture | Connect the pacing wire to pacing box. Set to demand. Turn rate to 30 bpm greater than intrinsic rate. Set output to 4 mA. Confirmation electrical with cardiac monitoring & ECG. Reduce the amperage until the power threshold is obtained and then double it | |
Step 10: Checking complications | Secure the transvenous catheter and screen for post procedural complications such as pneumothorax, perforation resulting in pericardial effusion |