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Journal of Electrocardiology 49 (2016) 530 – 535
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Risk of early mortality after placement of a temporary-

permanent pacemaker
Farah Z. Dawood, MD, MS, a,⁎ Andrew Boerkircher, DO, b Bryon Rubery, MD, a Don Hire, BS, c
Elsayed Z. Soliman, MD, MSc, MS a, d
a
Department of Internal Medicine- Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC
b
Department of Internal Medicine- General Medicine, Wake Forest School of Medicine, Winston-Salem, NC
c
Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
d
Epidemiological Cardiology Research Center (EPICARE), Wake Forest School of Medicine, Winston-Salem, NC

Abstract Background: Temporary-permanent pacemakers [TPPM] are externally placed permanent

generators attached to active fixation transvenous leads. TPPM can be used as an alternative to
standard temporary pacing leads when placement of a permanent pacemaker is contraindicated. We
sought to determine the incidence and risk factors for early (within 6 months) mortality after
placement of a TPPM.
Methods: Electronic medical records were used to extract baseline characteristics for 152 patients
from Wake Forest Baptist Medical Center who had a TPPM placed between the years 2007 and
2012. Multivariable adjusted Cox proportional hazard models were used to estimate hazard ratios
[HR] and 95% confidence intervals [C]) for baseline characteristics [age, sex, race, hypertension,
diabetes, heart failure, coronary artery disease, smoking, dyslipidemia, chronic kidney disease
[CKD], and indication for pacemaker] on early mortality.
Results: Of the 152 patients [mean age 68.9 years; 57.2% female; 86.8% white], 45 [29.6%] died
within the first 6 months after TPPM placement. No deaths occurred as a direct result of TPPM
placement, and only 1 patient experienced documented non-fatal complications. Maximum time to
PPM from the date of insertion of TPPM was 336 days. Using a backward multivariable adjusted
hazard regression model, independent risk factors for early mortality were pre-existing CKD [HR
(95% CI): 2.240 (1.002–5.010) for eGFR 30–59 and 7.645 (3.594–16.263) for eGFR b 30 compared
to eGFR N 60] and history of smoking [HR (95% CI): 2.015 (1.099–3.696)]. Surprisingly,
dyslipidemia was protective of early mortality [HR (95%CI): 0.470 (0.240–0.924)].
Conclusion: TPPM placement is a safe procedure with rare direct complications. CKD and smoking
are predictive of increased risk for early mortality in patients undergoing TPPM placement.
© 2016 Elsevier Inc. All rights reserved.
Keywords: Temporary pacemaker; Heart pacing; Risk of mortality

Introduction another procedure. The efficacy and safety of traditional

temporary transvenous pacing with passive fixation and later
Temporary-permanent transvenous pacing (TPPM) via a
via active fixation leads and an externalized re-usable
permanent external generator attached to active fixation
permanent pacemaker has been previously explored
transvenous leads can be a lifesaving procedure in a variety
[1–11]. Case reports have highlighted complications asso-
of cardiac arrhythmias including sinus node and atrioven-
ciated with temporary pacemaker and TPPM placement
tricular (AV) node dysfunction. It is a well-established
[6–8,12–14] and earlier studies found a low complication
method to restore normal cardiac rhythm when placement of
rate associated with the transvenous pacing [9–11].
a permanent pacemaker is contraindicated for a variety of
Temporary transcutaneous pacemaker is important while
reasons including active infection, transient conduction
bridging to permanent pacemakers in the setting of
abnormalities, perioperative period, or prophylaxis for
hemodynamically significant AV block, the evolving
⁎ Corresponding author at: Department of Internal Medicine, Section on
transcutaneous techniques for cardiac valves replacement
Cardiovascular Medicine, Wake Forest School of Medicine, Medical Center
due to increase in the rate of bundle branch blocks and
Boulevard, Winston-Salem, NC 27157. infection [13,15,16]. Over the years, advances in cardiac
E-mail address: fdawood@wakehealth.edu pacing devices came with greatly improved pacemaker lead
http://dx.doi.org/10.1016/j.jelectrocard.2016.05.004
0022-0736/© 2016 Elsevier Inc. All rights reserved.
 F.Z. Dawood et al. / Journal of Electrocardiology 49 (2016) 530–535
insulation and tip materials. Rastan et al. first reported
utilization of active-fixation leads attached to pacemaker
generators as a bridging therapy and Braun et al. compared
passive vs active fixation leads [16,17] in 2005. The
utilization of active fixation leads during temporary
transcutaneous pacemaker insertion increased the effective-
ness and reliability of temporary pacemakers by avoiding
frequent loss of capture and under-sensing.
Though temporary-permanent transvenous pacing is proven
to be a useful procedure, it is not without risk. Understanding
which population of patients may be at an increased risk for
complications may change clinical management. Given ad-
vances in cardiac pacing devices, improvements in temporary
pacemaker placement, and expanding indications for temporary
pacing, it would be worth revisiting the immediate complication
rate and early mortality rate (within 6 months) in the general
adult population presenting with contraindications to permanent
pacemaker placement.
Methods
Data were collected from the electronic medical records
(EMR, Epic and Carecast) of 152 patients who received a
temporary pacemaker with external generator for any
indication from 2007 to 2012 at Wake Forest Baptist
Medical Center. Records were reviewed for age, sex, race,
pre-existing conditions (diabetes, hypertension, coronary
artery disease, congestive heart failure, smoking history),
temporary pacemaker indication (sinus node disease, AV
node disease defined as type II second degree or third degree
AV block or other high grade block), date of temporary
implant, complication from implant, contraindication to
permanent pacemaker placement, and time to permanent
pacemaker placement (if indicated). Patients discharged
were set up for follow up for device check to assess the need
for PPM according to standard protocol followed by most
US hospitals.
Active fixation leads (Medtronic 5076) and Medtronic
external re-usable permanent pacemaker were used that were
secured with sterile dressing technique. Pacing lead
threshold at implantation was considered acceptable if
1.0 V at a pulse width of 0.5 ms, as were sensing amplitudes
of ≥ 5 mV for the R-wave and ≥ 1 mV for the P-wave.
Wound check, chest X-ray and device interrogation were
performed during the first 24 h after implantation. Patients were
discharged home or to a nursing care facility once clinically
stable with TTPM system until PPM can be implanted.
Time to PPM if indicated or death was recorded and all-cause
mortality data was collected by reviewing the EMR for date of
death and cause (if documented). Mortality was only recorded if
the patient died within one year of receiving a temporary
pacemaker. A small subset (n = 12) was lost to follow up,
therefore date and cause of death were not determined.
Complications related to placement of the temporary
pacemaker were defined as any documented adverse
outcome of the procedure including mechanical damage
caused by placement of the pacing lead, or infection of the
pacing system.
531
Contraindication to placement of a permanent pacemaker
included active infection from any source, emergent placement
due to hemodynamic instability, perioperative period, transient
symptoms (often caused by spinal cord injury), prophylaxis for
transcatheter aortic valve replacement (TAVR), or other
correctable causes including electrolyte abnormalities, respira-
tory failure, drug overdose, or treatable diseases not expected to
require permanent pacing.
Statistical analysis
Baseline characteristics of the patients were tabulated and
compared by survival status within 6 months. Multivariable
adjusted Cox proportional hazard regression models were
used to estimate hazard ratios and 95% confidence intervals
for baseline demographics and clinical factors on early
all-cause mortality. Variables included in the model are age,
sex, race (white vs non-white), hypertension, diabetes,
congestive heart failure, coronary artery disease, smoking
(current or past), dyslipidemia, chronic kidney disease, and
pacing indication (SA node disease, AV node disease,
others). Backward selection multivariable adjusted hazard
regression model was used to identify independent risk
factors for early mortality. Survival probability was
estimated using Kaplan Meier method and compared by
levels of the factors identified by the backward selection
regression model using log-rank test. Statistical significance
for all analyses was p b 0.05. Analyses were conducted
using SAS 9.2 [SAS Institute, Cary, NC].
Results
Of the 152 total patients (mean age 68.9 years ± 16.4;
57.2% female; 86.8% white), 45 (29.6%) died within the first
6 months after TPPM placement. No deaths occurred as a
direct result of pacemaker placement, and only 1 (0.7%)
patient experienced documented non-fatal complication
related to tamponade. Mean and median time to PPM
implantation was 9.7 and 21 days respectively. Maximum
time to PPM, if indicated, from the date of insertion of TPPM
was 336 days. Approximately 35 patients were discharged
with TPPM and 15 patients had the system in place for more
than 30 days. Patients' early mortality was related to
multiple conditions including cardiovascular disease
(CVD), ventricular fibrillation (VF)/pulseless electrical
activity (PEA) arrest, NSTEMI and abdominal aortic
aneurysm (AAA) rupture (10 patients), respiratory failure
(9 patient), neurological related death including stroke and
subdural hematoma (5 patients), sepsis (8 patients), post
bowel surgery complications (2 patients) and unknown for
the remaining 11 patients.
About 30.9% of the participants had diabetes, 64.4% had
hypertension, 38.2% had coronary heart disease, 24.3% had
heart failure, 38.2% had dyslipidemia and 35.5% were
smokers. Table 1 shows the patients characteristics stratified
by occurrence of early mortality. As shown, patients with
early mortality were more likely to have history of chronic
kidney disease and congestive heart failure.
532 F.Z. Dawood et al. / Journal of Electrocardiology 49 (2016) 530–535

Table 1 Table 3
Patients characteristics stratified by early morality. Independent risk factors of early mortality using backward selection
modeling.
Variable [n (%) or Alive at Died before p-value
mean ± SD] 6 months (n = 107) 6 months (n = 45) Variables⁎ Hazard Lower 95% Upper 95% p-value
ratio⁎ Confidence Confidence
Age (years) 68.8 ± 17 69.1 ± 13.5 0.90
interval interval
Female 65 (60.75) 22 (48.89) 0.18
White race/ethnicity 94 (87.85) 38 (84.44) 0.57 Ever smoker 2.015 1.099 3.696 0.024
Hypertension 73 (68.22 25 (55.56) 0.14 Chronic kidney disease
Diabetes 33 (30.84) 14 (31.11) 0.97 Stage III (vs eGFR N=60) 2.240 1.002 5.010 0.049
Dyslipidemia 45 (42.06) 13 (28.89) 0.13 Stage IV (vs eGFR N=60) 7.645 3.594 16.263 b.001
Ever smoker 33 (30.84) 21 (46.67) 0.06 Dyslipidemia 0.470 0.240 0.924 0.028
Congestive heart 20 (18.69) 17 (37.78) 0.01
eGFR = estimated glomerular filtration rate in mL/min/1.73 m2.
failure ⁎ The starting model included all the variables in Table 2.
Coronary artery 39 (36.45) 19 (42.22) 0.50
disease
Chronic Kidney b .01
Disease Table 2 shows the results of multivariable Cox proportional
Stage I and II 64 (59.81) 11 (24.44) hazards analysis in which all patients' characteristics were
(eGFR N 60)
entered in the model. As shown, only smoking and history of
Stage III 30 (28.04) 13 (28.89)
(eGFR 30–59) CKD (eGFR N 30) were predictive of early mortality.
Stage IV 13 (12.15) 21 (46.67) Using a backward multivariable adjusted hazard regression
(eGFR b 30) model, independent risk factors for early mortality were
Indication of 00.52 pre-existing CKD [eGFR 30–59 and eGFR b 30 compared to
pacemaker
eGFR N 60] and history of smoking. Surprisingly, dyslipidemia
AV nodal disease 46 (42.99) 19 (42.22)
SA nodal disease 42 (39.25) 21 (46.67) was protective of early mortality (Table 3). Figs. 1, 2 and 3 show
Others 19 (17.76) 5 (11.11) Kaplan Meier curves for survival probability by chronic kidney
eGFR = estimated glomerular filtration rate in mL/min/1.73 m2.
disease status, smoking status and dyslipidemia.

The most common indications for pacemaker placement

were AV node dysfunction 42.8%, sinus node dysfunction
41.4%, TAVR 6.65%, Mobitz II AV block 4.6%, Mobitz I
AV block 2%, and other 2.6%.
The most common site for insertion was the right internal
jugular vein (43.4%), followed by the right axillary vein
(19.7%), right subclavian vein (17.8%), left axillary vein
(9.2%), left subclavian vein (4.6%), left internal jugular vein
(3.9%), right femoral vein (0.08%), and epicardial (0.08%).
Contraindication to permanent pacemaker placement
included active infection (49.3%, n = 75), emergent place-
ment (23.7%, n = 36), perioperative (8.6%, n = 13), TAVR
(7.9%, n = 12), and other (5.9%, n = 9).
Discussion
The two key findings from this study are 1) placement of
TPPM when a permanent implanted pacemaker is contraindi-
cated is a safe procedure with rare direct complications, and 2)
CKD and smoking are predictive of increased risk of early
mortality in patients undergoing TPPM placement with maxi-
mum length of time to PPM being shorter as eGFR decreases.
Temporary pacing with a conventional external generator
and temporary pacing wires exposes a patient to additional risks
including cardiac perforation, disconnection of wires from the
generator, and lead dislodgement [1]. In addition, nursing
expertise is necessary to properly handle and care for a

Table 2
Patients characteristics and risk of early morality.
Hazard ratio⁎ Lower 95% Confidence interval Upper 95% Confidence interval p-value
Age (per year) 1.004 0.984 1.025 0.698
Female (vs. male) 0.762 0.398 1.459 0.412
White (vs. non-white) 0.678 0.267 1.719 0.413
Hypertension 0.589 0.284 1.221 0.155
Diabetes 0.587 0.276 1.248 0.166
Dyslipidemia 0.549 0.246 1.224 0.143
Ever smoker 1.964 1.006 3.834 0.048
Congestive heart failure 1.797 0.869 3.716 0.114
Coronary artery disease 1.063 0.517 2.188 0.868
Chronic kidney disease
Stage III (vs eGFR N=60) 2.293 0.951 5.528 0.064
Stage IV (vs eGFR N=60) 8.206 3.673 18.332 b.001
Indication of pacemaker
SA nodal disease (vs. AV node disease) 1.216 0.604 2.449 0.584
Others (vs. AV node disease) 0.565 0.198 1.615 0.287
eGFR = estimated glomerular filtration rate in mL/min/1.73 m2 AV = atrioventricular.
⁎ Calculated from multivariable adjusted Cox proportional hazards analysis that included all the variables in the table.
 F.Z. Dawood et al. / Journal of Electrocardiology 49 (2016) 530–535 533

Fig. 1. Kaplan Meier curves for survival probability by chronic kidney disease status.

temporary pacemaker to prevent pacing failure [18,19]. Patient permanent pacemaker for an extended time in the setting of a
mobility is also significantly limited while a conventional pacemaker pocket infection has been shown safe [5,20].
temporary pacing lead is in place. Placement of a temporary Overall, we found morbidity associated with the procedure

Fig. 2. Kaplan Meier curves for survival probability by smoking status.

534 F.Z. Dawood et al. / Journal of Electrocardiology 49 (2016) 530–535
Fig. 3. Kaplan Meier curves for survival probability by dyslipidemia status.
was 1.9% with no deaths directly attributed to placement of the
device. Despite having an external generator, with trained
operators and sterile technique, there appears to be a very low
infection rate. Even among those who were discharged home
with the external device in place, there were no documented
device infections on follow up.
We have shown that patients undergoing placement of a
temporary permanent pacemaker have a high mortality rate
in general, 29.6% at 6 months. Nevertheless, there appears to
be a very low complication rate associated with the
procedure itself. The high mortality rate likely reflects the
complex nature of our patient population with multiple
comorbidities and the degree of illness for which they
initially present. We have shown, however, that there are at
least two predictors of increased risk of early mortality; CKD
and smoking. When evaluating a patient for a TPPM, it may
be prudent to consider CKD and smoking as risk factors for
increased mortality.
Our results should be read in the context of certain limitations
including the relatively small sample size, and mostly white
male population from a single tertiary care center. We have no
evidence that this mortality is a complication related to the
procedure and hence our prediction models may be less useful in
the contest of predicting poor outcomes in those undergoing
TPPM. Nevertheless, since the focus was on early (6-months)
mortality, it is still possible that death could be a
procedure-related complication. These limitations may affect
generalizability of our results. In addition, given that this was a
retrospective study, we were forced to rely on documentation
provided by previous providers therefore its accuracy cannot
be confirmed.
In conclusions, although there is a relatively high early
mortality within 6 months after placement of a temporary-
permanent pacemaker, there appears to be a very low
complication rate associated with the procedure itself. Patients
with a history of CKD and smoking appear to be at a particularly
elevated risk of early mortality. Given these results, placement
of a temporary-permanent pacemaker should be viewed as a safe
and effective procedure but should be used with caution in those
with renal dysfunction or history of smoking.
Disclosures
None.
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