What are the indications for external pacing lead placement during open heart surgery?

Indications for External Pacing Lead Placement During Open Heart Surgery

Routine placement of temporary epicardial pacing wires is recommended for most cardiac surgeries, including isolated coronary artery bypass grafting, aortic valve surgery, surgery for atrial fibrillation, and tricuspid valve surgery. 1

Specific Indications by Procedure Type

Coronary Artery Bypass Grafting (CABG)

• Routine placement is reasonable (Class IIa, Level B-NR) 1
• Particularly indicated in patients with:
  • Older age
  • Female sex
  • Preoperative renal failure
  • Lower ejection fraction
  • Preoperative arrhythmias
  • Preoperative use of calcium channel blockers
  • Longer cross-clamp times 2

Valve Surgery

• Aortic Valve Surgery: Routine placement is recommended (Class I, Level C-LD) 1
• Mitral Valve Surgery: Routine placement is reasonable (Class IIa, Level C-LD) 1
• Tricuspid Valve Surgery: Routine placement is recommended (Class I, Level C-LD) 1

Surgery for Atrial Fibrillation

• Routine placement is recommended (Class I, Level B-NR) 1
• Higher risk of postoperative bradycardia requiring pacing 1

High-Risk Factors for Requiring Temporary Pacing

• Preoperative rhythm abnormalities (especially absence of sinus rhythm)
• Advanced age (>70 years)
• Female gender
• Redo cardiac surgery
• Prolonged aortic cross-clamp time
• Larger volumes of cardioplegic agent used 3
• Multivalve surgery (particularly involving the tricuspid valve) 4
• Preoperative conduction abnormalities (especially RBBB or LBBB)

Special Considerations

Permanent Epicardial Lead Placement

• Consider intraoperative placement of a permanent epicardial left ventricular lead in patients who:
  • Will likely require future cardiac resynchronization therapy (CRT)
  • Will likely require future ventricular pacing
  • Are undergoing CABG, aortic valve, mitral valve, or AF surgery (Class IIb, C-EO) 1

Biventricular Pacing

• Consider biventricular temporary pacing in patients with:
  • Severe left ventricular dysfunction
  • Pre-existing LBBB
  • Anticipated postoperative heart block
  • This approach can improve cardiac output by approximately 22% compared to right ventricular pacing alone 5

Postoperative Management

• In patients who develop new postoperative sinus node dysfunction (SND) or atrioventricular block with persistent symptoms or hemodynamic instability that does not resolve, permanent pacing is recommended before discharge (Class I, B-NR) 1
• Typical timing for permanent pacemaker implantation if needed is 5-7 days after surgery for CABG and 3-5 days for valve surgery 1

Pitfalls and Caveats

• Avoid routine prophylactic temporary transvenous pacing in patients with LBBB who require pulmonary artery catheterization for intraoperative monitoring (Class III: Harm, B-NR) 1
• There is a small risk of bleeding during removal of temporary epicardial wires, but this is generally outweighed by the benefits of having pacing capability when needed 1
• Consider using leads with localized electrodes rather than standard braided wire leads, as they provide lower current and voltage thresholds 6
• Failure to place temporary pacing wires in high-risk patients can lead to adverse outcomes if bradyarrhythmias develop postoperatively 3

By following these evidence-based recommendations, clinicians can optimize the use of temporary epicardial pacing wires during cardiac surgery to improve patient outcomes while minimizing unnecessary procedures.