Transoesophageal echocardiography allows bedside guidance of temporary pacing catheter placement a novel practical approach for the intensive care unit

Transoesophageal echocardiography (TEE) is increasingly used by intensivists as a bedside diagnostic tool for cardiac and haemodynamic assessment. We emphasize the versatility of TEE as an on-site imaging modality in the ICU by demonstrating TEE-guided positioning of a temporary transvenous pacing lead. The case of a haemodynamically unstable, mechanically ventilated patient who suffered a subacute inferior myocardial infarction complicated by interventricular septal rupture is presented. After surgical closure of the defect, the patient had an insufficient underlying rhythm and required urgent cardiac pacing due to failure of the standard temporary epicardial leads. Patient transfer to a fluoroscopy suite for conventional pacing catheter guidance was considered impossible due to the patient's instability. Alternatively, a temporary pacing catheter was introduced transvenously and appropriate positioning in the right ventricular cavity was guided by TEE. By this means, inadvertant lead-related perforation of the infarcted septum or free wall, manipulation of the patch or dislodgement of the pulmonary artery catheter could successfully be avoided. In order to confirm the accuracy of TEE-based visualization of a temporary pacing lead, we performed an in-vitro experiment: an echocardiographic view was generated by installing a TEE probe and pacing lead in a water bath demonstrating excellent differential visibility of the catheter, tip and electrodes.The available literature supports our experience and favours TEE as a rather fast, practical and accurate on-site imaging modality for right ventricular pacing lead placement in the ICU. This novel approach has to the best of our knowledge not been described before and could be incorporated in a goal directed echocardiography training for non-cardiologist intensivists.