Atrial pacing leads

These are passed through a valved central venous sheath. In emergencies, a soft wire (e.g. a balloon flotation wire) may be used before substitution with a more stable atrial J-wire. The J-wire contains a central stylet which stiffens and straightens the lead to allow passage through the sheath. Further positioning may be guided by fluoroscopy (or internal ECG recording in emergencies). The stylet is slowly withdrawn while the lead is rotated to position the tip inferior to the right atrial appendage. Pulling back on the lead causes it to lodge in the appendage (pointing anteriorly and towards the left shoulder tip). The position is confirmed by lateral radiography. The J should be allowed to flex incompletely on itself, but not open up to an angle of more than 50° to 60°. In difficult cases, the atrium may be paced briefly via the coronary sinus. The optimal atrial pacing threshold is less than 2 mA.

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