Chapter 69: Management of Pacemakers and AICDs

INTRODUCTION

The perioperative period poses a unique challenge in providing care for patients with cardiovascular implantable electronic devices (CIEDs). CIED is a term that encompasses pacemakers for bradyarrhythmia treatment, implantable cardioverter defibrillators (ICDs) for tachyarrhythmia management, and cardiac resynchronization therapy (CRT) devices for systolic dysfunction with conduction delays. Perioperative management should be multidisciplinary and individualized to the patient, the type of CIED and the procedure being performed.

PREOPERATIVE EVALUATION

A focused evaluation should establish whether a patient has a CIED, define the type of device, determine whether a patient is pacemaker-dependent, determine the CIED function, and determine the magnet behavior. This can be accomplished through the following:

1. A focused history including patient interview, review of medical records, available chest X-rays (CXR), electrocardiograms, or available monitor or rhythm strip. Examination of the CXR can immediately provide information about lead configuration, and whether the device is a single- or dual-chamber pacemaker, a biventricular device, or an ICD. Device manufacturer markings may be visible on CXR.

2. A focused physical examination, which includes checking for scars and palpating for a device.

3. Defining the type of device by obtaining manufacturer’s identification card from patient or other source. Refer to supplemental resources (i.e., manufacturer’s databases, cardiologist consultation).

4. Determining the dependence on pacing function of the CIED through verbal history or medical record documentation of the following:

   1. Symptomatic bradyarrhythmia resulting in CIED implantation.

   2. Successful atrioventricular nodal ablation resulting in CIED implantation.

   3. CIED evaluation showing clinically evident hemodynamic compromise when the pacing function is programmed to VVI mode at the lowest programmable rate.

5. Ideally, determining the CIED function by having the device interrogated is preferred. If this is not possible then, determine whether the device will capture when it paces (i.e., produce a mechanical systole with a pacemaker impulse).

6. Contacting the manufacturer for perioperative recommendations may be a consideration.

Preparation and Intraoperative Management

Preparation and intraoperative management for patient safety during the perioperative period includes the following:

1. Determining whether electromagnetic interference (EMI) is likely to occur during the planned procedure.

2. Determining if reprogramming pacing function to asynchronous mode or disabling rate responsive function is advantageous.

3. Suspending antitachyarrhythmia functions if present.

4. Evaluating the possible effects of anesthetic techniques and of the procedure on CIED function and patient–CIED interactions. Anesthetic technique should be dictated by the underlying physiologic disorder and patient comorbidities.

5. Intraoperative monitoring which includes both continuous ECG and continuous peripheral pulse monitoring as per the American Society of Anesthesiologists (ASA) standard. Peripheral pulse can be monitored by palpation of the pulse, auscultation of heart sounds, pulse plethysmography or oximetry, a tracing of arterial waveform, or ultrasound peripheral pulse monitoring.

Management of Potential CIED Dysfunction as a Result of EMI

Management of potential CIED dysfunction as a result of EMI includes the following:

1. Advise the individual performing the ...