We wish to congratulate Keituqwa Yáñez et al.1 for publishing the first series on transvenous temporary cardiac pacing using an active-fixation permanent pacemaker electrode via femoral access. The authors confirm the information that–compared to the passive-fixation ones– active-fixation permanent pacemakers minimize one the main complications: electrode displacement.2 The authors say that with femoral access the venous access commonly used can be spared for definitive pacemaker implantation without more infections and with a minimum percentage of puncture related complications.1

Although this study has some limitations due its retrospective nature, here are a few comments on the femoral access:

• 1

  Puncture related complications: the authors describe only 1 complication associated with puncture.1 However, the appearance of these complications largely depends on the technique used rather than the access route.2,3 Ultrasound-guided vascular accesses have simplified the technique and minimized complications. Compared to subclavian access ultrasound-guided internal jugular access facilitates fast catheterizations and reduces pulmonary complications like pneumothorax or hemothorax. Also, it minimizes vascular complications compared to x-ray guided punctures or punctures guided by anatomical references.2,3 Similarly, jugular access would facilitate the access of electrodes to the right ventricle making the entire procedure much easier.

• 2

  Venous access preservation: most permanent pacemakers are often implanted via left subclavian access even in patients who previously require transient pacemakers. Although femoral access would prevent upper extremity thrombosis, the big picture is that the forseeable effect would be marginal as confirmed by the fact that most patients included in the jugular access series would be implanted with a permanent pacemaker.2

• 3

  Infections and thromboembolisms: it is well-known that femoral electrodes are associated with local infection and sepsis, as well as deep vein thrombosis and pulmonary embolism. Authors report on the limited appearance of infections and lack of thrombotic events. Providing information on whether infectious or thromboembolic prophylaxis was used could shed light on how to understand the study much better.4,5

• 4

  Delay until definitive pacemaker implantation: finally, we would like to say that most complications increase the longer the time until definitive pacemaker implantation. Although the cause of bradyarrhythmia can be reversible, most patients will end up being implanted with a definitive pacemaker. In this study, 32 out of a total of 35 patients (91.4%) received a permanent pacemaker with a mean time elapsed until implantation of 4.9 ± 4.6 days. Although the authors say that it is a short waiting time, minimizing these times–in case of forseeable nonreversible bradyarrhythmias–could lead to fewer complications by just generalizing these procedures.

In conclusion, we agree with the authors on the utility of usingactive-fixation electrodes to prevent electrode displacement. However, based on the information currently available, we believe that ultrasound-guided jugular puncture and the early implantation of definitive devices should be considered the strategy of choice.