Of note, securing a venous access is not a minor issue, with a high failure rate reported among studies (average 15%, range 6–40%). Femoral access can be performed with ease however, it can be more difficult to advance the electrodes to the right ventricle, limits patient mobility, has a higher risk of venous thromboembolism, and offers the least stable wire position. Right subclavian/axillary route follows the right IJV and is preferred in patients with hypovolemia, given the ability of these vessels to remain patent even in patients with volume depletion. In general, the right internal jugular vein provides the most direct route to the right ventricle and it is associated with lowest rate of loss of ventricular capture and thus is the recommended route for using in practice. As a general rule, the right-sided veins are preferred over the left because permanent systems are usually inserted on the left side and because it is often technically easier from the right side. Regarding the selection of the route of insertion, this may be guided by several factors, such as the presence of hypovolemia, anticoagulation status, or adequate anatomy. This is the case of the combination of US guidance with intracavitary ECG, which is easy to perform, may lead to a reduction in the time to active pacing and may avoid complications. The combination of guided techniques for the placement of the EC is a valid and useful strategy, with the intention of making the procedure easy, safe, and effective. Since the blind technique is neither safe nor effective most of the times, and considering that fluoroscopy is not usually available at the bedside or patients are commonly unstable to be transferred to the radiology department, ECG and/or real-time ultrasonographic (US) guidance are generally chosen to assist in the procedure at the patient’s bedside. The placement of the EC can be achieved in several ways, including a blind technique as well as a couple of guided techniques, such as intracavitary electrocardiography (ECG), ultrasonographic-guided insertion (US) and fluoroscopy. Giving these facts, a safe method to monitor the EC insertion is desirable. Several complications can result from this critical procedure such as failure to secure venous access, failure to place the lead correctly, sepsis, puncture of arteries, lungs or myocardium and life-threatening arrhythmias. Temporary transvenous pacing consists in inserting a temporary pacing electrode catheter (EC) into the right ventricle and then applying an electric stimulus with the goal of restoring effective cardiac depolarization and heart contraction, resulting in the delivery of an adequate heart rate and cardiac output. Temporary transvenous pacing (TVP) is a lifesaving procedure which is mainly indicated in patients with symptomatic bradyarrhythmias as well as in patients with specific tachyarrhythmias (i.e., overdrive pacing).
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