Intracardiac pacing as emergency treatment in Adams-Stokes syndrome.

In most cases of atrioventricular block with Adams-Stokes attacks the application of either an endocardial or an epicardial electrode for artificial pacing can be performed in the operating-theatre with all necessary equipment available. In some cases, however, the situation is more dramatic: electrical pacing may be necessary without any delay, and it may be impossible to transfer the patient to the operating-theatre or an x-ray laboratory with TV equipment. In such emergency cases we have used a technique which renders it possible to introduce an endocardial pacemaker electrode by means of very simple equipment, and the method which we have applied in 27 cases has proved to be safe and reliable. The principle is to use the pacemaker electrode for picking up the electrocardiogram from the heart cavities. As the electrocardiogram from the atrium pacemaking is established. The electric defibrillator and the external pacemaker are held in readiness. Materials From September 1965 to April 1967 indications for intra-cardiac pacing were found in 62 patients. Twenty-seven of these were critically ill with repetitive Adams-Stokes attacks, and the emergency introduction of an endocardial pacemaker electrode by the described technique was therefore attempted (see Table). Fifteen of these had acute myocardial infarction. In 21 the electrode was successfully placed in the right ven-tricle, and effective stimulation of the heart was obtained in all of them. In one patient (Case 1) with sinoatrial block the tip FIG. 1.-A, subcutaneous indifferent electrode. B, soft, flexible intracardiac eletrode. C, external pacemaker (Elema-Sch6nander). as well as from the ventricle is highly characteristic, the electro-cardiographic pattern can easily be used as guide for a correct introduction into the right ventricle without the aid of fluoroscopy. Method Under sterile conditions and after cleansing and draping the area an incision is made over the antecubital or jugular vein. A soft flexible intracardiac electrode (Fig. 1) is introduced into the exposed vein and connected to the V terminal of an electro-cardiograph by means of a clip. The electrode is then advanced to the right atrium under constant monitoring on oscilloscope or electrocardiograph. When characteristic atrial patterns are seen (Fig. 2), the patient is carefully rotated to the left lateral position to facilitate passage of the electrode through the tricuspid valve. The electrocardiographic patterns change suddenly when the electrode passes into the ventricular cavity. The atrial complexes become small, and the ventricular complexes large with the rS or QS appearance. The electrode …