Transcutaneous Pacer Pad Placement

Transcutaneous Pacer Pad Placement

Mak Moayedi and Anand Swaminathan

• Although transvenous (TV) pacing is superior to transcutaneous (TC) pacing for efficacy, we often use TC pacing, at least as a temporizing measure.
• There is no high-quality evidence on the optimal positioning of the pads for TC pacing.
• Dr. Moayedi is the lead author on two publications on the issue:
  • Moayedi S et al. Anteroposterior pacer pad position is better than anterolateral for transcutaneous cardiac pacing. Resuscitation 2022 and Moayedi S et al. Anteroposterior pacer pad position is more likely to capture than anterolateral for transcutaneous cardiac pacing. Circulation 2022
• Enrolled patients scheduled for elective cardioversion of atrial fibrillation.

• After conversion, all patients (n = 20) paced with pads both in the anterolateral and anteroposterior position.
• Compared successful capture and threshold output for capture.
• Key findings:
  • Capture rate:
    • Anterolateral: 42%
    • Anteroposterior: 78%
  • Four patients could not be captured at maximal output with either pacer pad placement.
  • Pacing threshold: 33 mA lower in the anteroposterior pad configuration
• Other lessons from the electrophysiology (EP) lab:
  • Cardiologists place the anterior pad slightly higher on the chest when cardioverting supraventricular rhythms like atrial fibrillation to maximize energy across the atria.
  • Many cardiologists will start with the maximal energy setting (200 J) when cardioverting instead of starting with lower dosages of electricity.
  • If cardioversion failed, the cardiologists would apply pressure to the anterior pad to reduce the distance between the anterior and posterior pad and improve the rate of successful cardioversion.
• Critical Point: TC pacing has a low rate of success and should not be relied upon in patients with severe bradycardia.

CorePendium: Cardiac Pacing