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LEFT VENTRICULAR GUIDEWIRE �PACING DURING TAVR

The Leaflet Lounge

Kristina Mack MSN-ED, BSN, RN, CCRN-CMC, CV-BC

September 2026

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DISCLAIMER

THIS PRESENTATION IS FOR EDUCATIONAL USE ONLY. FOR MORE DETAILS AND UPDATES ON THE DEVICES PICTURED OR MENTIONED WITHIN THE TEXT, PLEASE SEE THEIR OFFICIAL WEBSITE.

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WHAT IS LV GUIDEWIRE PACING?

Left ventricular guidewire pacing (LV-GW pacing) is a temporary pacing technique that sends the electrical signals directly through the metal guidewire placing it in the left ventricle of the heart.

This procedure is most used during Transcatheter Aortic Valve Replacement (TAVR) to provide rapid ventricular pacing during valvuloplasty and device deployment.

Instead of having to obtain another access as with traditional transvenous pacing, the physician can use the same access for pacing and for valve support.

(Image from ScienceDirect.com)

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WHY IS RAPID VENTRICULAR PACING USED DURING TAVR?

Rapid ventricular pacing is used during TAVR procedures to temporarily drop cardiac output to stabilize deployment during valve replacement.

Normal cardiac contraction can push against the balloon or the new artificial valve and push it out of position leading to valve embolization.

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ELECTRICAL PACING CIRCUIT

Key Points:

An anode and cathode are the two connections necessary to complete the LV pacing circuit.
When the pacemaker delivers an impulse, electrical energy travels between the two connections and produces ventricular capture.
Verify the pacemaker’s negative and positive labels
Cathode STIMULATES and Anode COMPLETES

Connection	Location	Function
Cathode (-) “Back to Black”	Connected to the external end of the guidewire positioned in the left ventricle. It becomes the temporary pacing electrode. It is the negative connection that delivers the pacing stimulus to the myocardium of the left ventricle.	It is the active pacing electrode. The distal curve of the guidewire contacts the left ventricular myocardium to the deliver the stimulus that causes ventricular depolarization (contraction)
Anode (+) “Red to Ahead”	Connected to a return electrode to complete the circuit. Needle placed in subcutaneous tissue near the femoral access site. Connected to an intravascular wire (J-Wire) placed in the femoral vein. Or connected to a ground pad.	Completes the electrical circuit by providing the return pathway through the patient’s tissue.

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REQUIRED EQUIPMENT

Compatible LV guidewire
Pacing generator
Sterile connecting cable or alligator clip
Return electrode
Continuous ECG and arterial pressure monitoring
Defibrillation pads and capability
Backup pacing plan
Supplies needed for the anode of choice

(Image from Medtronic)

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LV VERSUS RV PACING

Category	LV Guidewire Pacing	RV Transvenous Pacing
Access	Uses the existing arterial access and delivery guidewire positioned in the LV Usually avoids a separate venous access.	Requires separate venous access with a sheath and pacing catheter positioned in the RV.
Pacing location	The LV guidewire acts as the negative electrode (cathode). A cutaneous or subcutaneous electrode acts as the positive return electrode (anode).	A temporary pacing catheter provides electrodes directly within the RV.
Equipment	LV stiff guidewire, external pulse generator, pacing cable or sterile alligator clips, approved return electrode, and an insulating balloon or valve-delivery catheter.	Venous sheath, temporary transvenous pacing catheter, connecting cables, and external pulse generator.
Procedural efficiency	May shorten the procedure and reduce fluoroscopy time, equipment use, and cost by eliminated RV lead placement.	Familiar and reliable, but additional venous access and lead positioning my increase procedural and fluoroscopy time.
Capture characteristics	Capture depends on LV wire contact, insulation, correct polarity, and secure connections. Thresholds may be higher or more variable.	Usually provides predictable capture when the lead has stable contact with the right ventricular myocardium.
Availability after deployment	Only available when the LV leads is in place, has adequate insulation, and the connections are maintained.	Can remain available after deployment and can be secured for continued pacing during recovery and post-procedural monitoring.
Post-TAVR conduction support	Limited because the wire must eventually be removed.	Better suited when continued temporary pacing may be required as it can remain in place.
Access complications	Avoids complications from an additional venous puncture.	Venous bleeding, hematoma, thrombosis, infection, and pneumothorax.
Cardiac complications	Potential LV perforation, pericardial effusion, tamponade, ventricular ectopy/ ventricular arrhythmia, or mitral valve injury due to the procedural proximity to the valve’s sub-valvular apparatus and chordae tendineae.	Potential RV perforation, pericardial effusion, tamponade, ventricular arrhythmia, lead entanglement, or tricuspid valve injury.
Pacing-system complications	High threshold, unreliable capture, incorrect polarity, inadequate insulation, guidewire movement, local muscle stimulation, or needle-related injury at the return electrode.	Lead displacement, lead malfunction, failure to capture, inappropriate sensing, or unstable lead positioning.
Commonly favored when:	Some physicians may prefer a “minimalist” TAVR approach, capture is reliable, and the patient has a low anticipated need for continued pacing.	Baseline conduction disease, RBBB, anticipated high-grade AV block, unreliable LV capture, or likely need for pacing post-artificial valve deployment.

LV GUIDEWIRE PACING VS. RV TRANSVENOUS PACING

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PATIENT AND PROCEDURAL SELECTION

Patients will be evaluated prior to procedure day for:

Baseline EKG rhythm
Pre-existing RBBB
Pre-existing conduction disease
Likelihood of need for post-TAVR pacing
Valve platform
Reliability of alternative bailout pacing

(Image from Edwards Lifesciences)

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PREPARATION AND SAFETY CHECK

Confirmation of guidewire position under fluoroscopy
Confirmation of connections and polarity
Testing of capture threshold
Hemodynamic response with capture
Team roles
Emergency backup before critical procedural steps

(Image from Shutterstock)

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PROCEDURAL WORKFLOW

The physician will position a stiff 0.035” LV support/ delivery guidewire inside the left ventricular apex and myocardial cavity.

Pre-shaped:

Savvy Wire
Safari Small or Extra Small
Confida Wire

Unshaped:

Amplatz Extra-Stiff Wire or Super-Stiff
Lunderquist Wire

A diagnostic catheter or the transcatheter heart valve delivery catheter will remain over the wire to ensure proper electrical insulation and focused current.

(Image from Springer Nature)

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A return path must be established by using either:

A.) A 21 to 23-gauge subcutaneous needle in the femoral region
B.) An intravascular wire placed in the femoral vein (J-wire)
C.) Or a grounding pad placed on the lateral left chest (D.)

The physician will then connect the external pacemaker box using a sterile disposable alligator clamp on the LV wire terminal.

“Red to Ahead” – anode (+) 🡪 connects to grounding pad, subcutaneous needle, or intravascular venous wire
“Black to Back” – cathode (-) 🡪 connects to distal external backend of the LV guidewire

(Blusztein et al., 2023)

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Method	Description	Primary Benefits	Risks
Grounding Pad	Large adhesive conductive pad that is placed directly on the patient’s skin.	Non-invasive Has a large surface area for burn prevention Commonly used	There must be adequate skin contact to prevent malfunction and high impedance Can detach due to fluid or sweat
Subcutaneous Needle	21 to 23-gauge needle that is inserted into the patient’s subcutaneous tissue typically in the femoral region.	Reduced risk of deep vascular injury Ease of placement	Invasive Increased local current density due to the small surface area Risk of local site injury
Intravascular Wire	A dedicated conductive wire that is placed directly inside of the femoral vein (J-wire)	Has the lowest possible electrical impedance Highly stable electrical connection	Most invasive compared to the previous options Increased risk of vascular injury or bleeding Risk of thrombosis

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EFFECTIVE CAPTURE

Test pacing at a slower rate should be performed on each patient to ensure:

Paced ventricular rhythm on ECG
Consistent electrical capture
Expected reduction in arterial pulse pressure

Electrical capture alone does not confirm adequate hemodynamic suppression.

(Blusztein et al., 2023)

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DEPLOYMENT CADENCE

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TROUBLESHOOTING

Troubleshooting typically involves checking the electrical connections, grounding, and wire positioning.

Check alligator clip connections
Inspect settings on the generator to confirm the correct programming
Ensure guidewire optimal apical apposition and contact against the left ventricular endocardium
Confirm that the insulating catheter (i.e., diagnostic catheter, balloon, or valve delivery system) is properly shielded to prevent current shunting
Verify 1:1 capture with hemodynamic changes prior to committing to rapid ventricular pacing

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BENEFITS AND LIMITATIONS

Benefits:

Avoids risks of venous bleeding, vessel damage, and right ventricular perforation
Possible faster procedure time due to not having to obtain a venous access
Reduction in equipment due to combining valve support and pacing into a single line, therefore reducing cost

Limitations:

Risks of loss of capture
Arrythmia
Guidewire movement
LV injury or perforation
Tamponade
Loss of pacing capability after guidewire removal

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POSSIBLE COMPLICATIONS

LV injury or perforation
Pericardial effusion/ tamponade
Loss of pacing capability after guidewire removal
Ventricular ectopy/ arrhythmia
Mitral valve trauma due to the wire being near the sub-valvular apparatus
Thromboembolism and stroke
Unstable wire positioning
Loss of capture

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POST-TAVR RHYTHM MANAGEMENT

LV wire pacing does not replace post-procedure conduction monitoring. The wire must come out and cannot be secured in place.

Prior to the procedure, the heart team will evaluate each patient for their risk of post-procedural abnormal conduction issues and have a back up plan in place.

Post-procedure management includes discussion of telemetry, EKG assessment, criteria for continued temporary pacing, and escalation for high-grade AV block.

(Image from LITFL: Life in the Fastlane)

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RESOURCES:

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RESOURCES CONTINUED:

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THANK YOU!