Temporary epicardial pacing following cardiac surgery is a common and important practice in postoperative cardiac care.  
 
Purpose 
Temporary epicardial pacing is used to prevent or treat bradyarrhythmias and certain tachyarrhythmias that can occur after cardiac surgery due to: 
Surgical trauma to the conduction system 
Myocardial ischemia or oedema 
Electrolyte imbalances 
Effects of cardioplegia or hypothermia 
 
Indications 

Bradyarrhythmias 
Sinus bradycardia not responsive to drugs 
Junctional escape rhythms 
Complete or high-grade AV block 

Atrial pacing 
To maintain atrial contribution to cardiac output 
To facilitate AV synchrony 

Overdrive pacing 
To suppress atrial or ventricular ectopy 

Haemodynamic optimization 
AV sequential pacing can improve cardiac output, especially in LV dysfunction 
 
Lead Placement 
Epicardial pacing wires are sutured directly onto the epicardial surface of the heart during surgery. 

Usually: 
Right atrial wire(s) → placed on the right atrial appendage 
Right ventricular wire(s) → placed on the RV anterior surface 
Wires are brought out through the skin and connected to an external pacing generator. 
Atrial wires on the Right side of the patient’s chest; ventricular wires on the left (with a typical midline sternotomy). 
 
Pacing Modes 


 
Settings (Typical) 
Rate: 70–90 bpm (adjust for haemodynamics) 
Output (mA): Set at twice the pacing threshold (usually 5–15 mA) 
Sensitivity (mV): Adjust to detect intrinsic activity (typically 1–2 mV atrial, 2–5 mV ventricular) 
 
Duration 
Wires are typically left for 3-4 days postoperatively. 
They are removed once: 
The patient is haemodynamically stable 
No pacing requirement for ≥24 hours 
Coagulation status has been checked and the INR is typically less than 3 (or as documented by the clinician) 
 
Wire Removal 
Ensure no anticoagulation or bleeding risk (INR less than 3 is usual but should be set by clinician) 
Check the operation note that the wires are not sutured internally  
Check ECG 
Record baseline observations 
Patient should be on the bed in semi fowler’s postion 
Remove with gentle traction (if difficult to remove, stop pulling and call a surgeon for help) 
Apply pressure dressing and observe for: 
Bleeding 
Tamponade (rare complication) 
Bed rest for 1 hour post wire removal 
Observations every 15 minutes for the first hour post removal and hourly for 2 hours thereafter; monitor for signs of tamponade 
 
Complications 
Failure to capture or sense (due to dislodgment, fibrosis, ischaemia) 
Infection at exit site 
Cardiac tamponade (rare, after removal) 
Arrhythmias during wire manipulation 
 
Key Points 
Always test thresholds daily and before removal 
Check battery status every shift 
Ensure wires are secured safely 
If pacing dependence persists → a permanent pacemaker may be needed before discharge