# Temporary Pacing Simulator: A Training Tool for Clinicians
## 1 Introduction  
Cardiovascular diseases (CVDs) remain a significant global health challenge, accounting for 32% of deaths worldwide, with over 20.5 million fatalities in 2021 and projections indicating a rise to 23 million by 2030 [1]. While advancements in diagnostics, treatment, and public health initiatives have significantly reduced CVD-related mortality in high-income countries like the UK--where deaths have declined by 75% since 1961--CVDs still cause 27% of deaths, with a concerning increase in incidence among younger populations [2]. Temporary cardiac pacing (TP) devices are essential in managing various cardiac conditions, particularly in emergency situations where the heart's natural pacemaker fails to maintain an adequate rhythm. These devices are critical for initiating myocardial contractions and preserving appropriate cardiac output in patients with haemodynamically unstable arrhythmias or following cardiac surgery, serving either as a therapeutic measure or as a bridge to permanent pacemaker (PPM) implantation. By delivering electrical impulses to the heart via leads connected to the myocardium, TP devices provide crucial support in acute cases such as bradycardia or heart block, preventing serious complications including heart failure, syncope, or sudden cardiac arrest. However, unlike PPM devices,which are fully automated and implanted for long-term use, TP devices require manual adjustments, and their effectiveness is highly dependent on the precise configuration of their settings in relation to the patient's condition. Cardiologists and nurses play a critical role in the initial programming and ongoing management of TP devices in the operating theatre and intensive care units (ICUs). Therefore, it is crucial that they have a comprehensive understanding of TP modes, intervals, and the potential complications that can arise following cardiac surgery [3]. Despite the widespread use and significance of TP devices, particularly in the postoperative management of cardiac surgery patients, there is a notable lack of formal guidelines and standardised training programmes for TP setting and patient management, both in the UK and globally [4; 5; 6]. The absence of automated systems for sensitivity and output threshold checks, coupled with the reliance on manual adjustments, increases the risk of complications associated with TP. Such complications can have severe consequences, including life-threatening arrhythmias [3]. Moreover, the lack of clear, standardised guidelines means that TP procedures are often performed by medical staff from various disciplines with varying levels of experience, leading to inconsistencies in care and potentially suboptimal patient outcomes. Studies have shown that the use of TP is associated with worse survival rates and higher risks of complications compared to permanent pacing systems [7; 8]. British research has revealed that complications and issues arise in approximately one-third to half of all cases involving TP, with operator inexperience being a significant contributing factor [9]. These concerns are echoed globally. For instance, [PERSON] et al. [4] highlight that TP is frequently employed in urgent, high-risk situations, yet training for these procedures remains inconsistent. Other studies from Italy [5; 6] further underscore the inconsistencies in the management of TP. Moreover, [PERSON] et al. [10] point out that current recommendations for TP are largely based on clinical consensus rather than robust trial data. The inherent instability of TP, especially given the unpredictable haemodynamic status of patients post-cardiac surgery, requires frequent and precise adjustments to the pacing settings. However, the availability of training to equip medical staff with the necessary skills to optimise TP settings is limited. This training gap is reflected in the declining number of TP procedures being performed and the increasing reliance on haemodynamically suboptimal pacing modes [9]. Recent research highlights the need for a more sophisticated approach to TP management.