INDICATIONSymptomatic bradyarrhythmia with cardiovascular compromise unresponsive to drugs AND transcutaneous pacing — sinus arrest, sick sinus, slow AF, high-grade AV block.
EQUIPMENT
CODE CART / RESUS BAY · TVP KIT
Introducer sheath kit 6–7 Fr (“Cordis”-type) with integral sterile sleeve
Balloon-tipped bipolar pacing catheter 5 Fr — depth-marked every 10 cm
Bridge first: transcutaneous pacing + chronotropes while the kit is set up.
Access: right IJ introducer sheath, sterile ultrasound-guided Seldinger. Site order: R IJ → L subclavian → L IJ → R subclavian. Never through a port of a multi-lumen line.
Test balloon in saline — 1.5 mL air, no leak. Thread the catheter through its sterile sleeve BEFORE insertion; connect to generator — distal terminal = negative.
Set generator before floating: rate 80, output maximal — 20 mA, asynchronous (DOO / sensitivity fully down).
Advance to 15–20 cm (just beyond sheath tip) → inflate balloon gently, lock.
Advance smoothly: electrical capture = wide LBBB-pattern paced QRS. Confirm MECHANICAL capture — pulse-ox waveform, art line, or POCUS. Never trust ECG alone. RV ≈ 30–40 cm from the right IJ.
Capture → STOP. Deflate the balloon passively — unlock and let it empty.
Threshold test: turn output down 20→15→10→5→3→2→1 mA until capture lost — good position captures at <1 mA. Set output 2× threshold; capture must survive a cough.
Sensitivity: switch to VVI/demand, start ~2 mV; set at half the sensing threshold (higher mV = LESS sensitive).
Secure + confirm: lock sleeve, suture sheath, tape a loop, hang the generator. CXR — tip at RV apex over the inferior border; 12-lead — paced LBBB with superior axis.
Balloon UP to advance · DOWN to withdraw. Depth rising with no capture = coiling — deflate, pull back to 20 cm, re-float.