Perioperative Management of Patients with Cardiac Implantable Electronic Devices
Publication Date: February 1, 2020
Last Updated: March 14, 2022
Advisory Recommendations
Preoperative Evaluation
- Determine whether a patient has a cardiac implantable electronic device (cardiac implantable electronic device).
- Conduct a focused history (e.g., interview the patient or other source, review medical record, chest x-ray, and electrocardiogram if available).
- Perform a focused physical examination (e.g., check for scars, palpate for device).§§§§§
- Determine the cardiac implantable electronic device type, manufacturer, and primary indication for placement.
- Obtain the manufacturer’s identification card from the patient or other source.
- Review the medical record.
- Obtain and review the most recent cardiac implantable electronic device interrogation report.‖‖‖‖‖
- Refer to supplemental resources (e.g., manufacturer’s databases, cardiac implantable electronic device clinic records)
- Order a chest x-ray if no other data are available.#####
- Determine whether the patient is pacing-dependent.******
- From the focused history and medical record, assess for one or more of the following indicators:
- Bradycardia that caused syncope or other symptoms resulting in cardiac implantable electronic device implantation.
- Successful atrioventricular nodal ablation resulting in cardiac implantable electronic device implantation.
- A cardiac implantable electronic device interrogation showing no evidence of spontaneous ventricular activity. when the cardiac implantable electronic device’s pacing function is temporarily programed to a nontracking mode (i.e., ventricular-only pacing and sensing) at the lowest programmable rate.
- From the focused history and medical record, assess for one or more of the following indicators:
- Determine the cardiac implantable electronic device’s current settings, that it is functioning properly (i.e., by interrogating the cardiac implantable electronic device or obtaining the most recent interrogation report), and that it is optimally programed for the planned procedure.‡‡‡‡‡‡§§§§§§
- Reinterrogate the cardiac implantable electronic device if there is any question of proper function.
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§§§§§ Not all implantable electronic devices are cardiac implantable electronic devices (i.e., deep brain stimulators, spinal cord stimulators, vagal nerve stimulators, gastric stimulators, phrenic nerve stimulators, etc.). Although most cardiac implantable electronic device generators are in a pectoral position, some are in the abdomen or in an alternate position in the thorax (i.e., subcutaneous implantable cardioverter–defibrillator). Some cardiac implantable electronic devices are now implanted entirely within the heart (i.e., leadless pacemaker).
‖‖‖‖‖ Many cardiac implantable electronic devices now have remote interrogation and monitoring capabilities. Thus, the most recent cardiac implantable electronic device interrogation report might be from an in-office interrogation or from a remote transmission (provided the remote transmission contains all needed information).
##### Most cardiac implantable electronic devices have an x-ray code inscribed on the generator that can be used to identify the cardiac implantable electronic device manufacturer.
****** A patient with an absent intrinsic heart rhythm is completely pacing-dependent. A patient with an inadequate intrinsic heart rhythm may be considered relatively or functionally pacing-dependent.
‡‡‡‡‡‡ In many patients, determining proper cardiac implantable electronic device function can be accomplished by accessing the patient’s most recent cardiac implantable electronic device interrogation report. Note that the majority of consultants and ASA members agree that a cardiac implantable electronic device should be interrogated within 3 to 6 months before a procedure.
§§§§§§ A cardiac implantable electronic device specialist might need to be consulted to help determine key information about the cardiac implantable electronic device, whether the patient is pacing-dependent, the cardiac implantable electronic device’s current settings, and that it is functioning properly.
‖‖‖‖‖‖ If electromagnetic interference is unlikely, it may be unnecessary to alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode. Altering the pacing function of a pacemaker to an asynchronous pacing mode may be accomplished by reprogramming or in many cases by applying a magnet. For most pacemakers, magnet application will initiate asynchronous pacing at a fixed pacing rate with a fixed atrioventricular delay. Some pacemakers have a programmable magnet response or no magnet response (i.e., some leadless pacemakers). Altering the pacing function of an implantable cardioverter–defibrillator to an asynchronous pacing mode must always be accomplished by reprogramming, because magnet application will never alter the pacing mode of an implantable cardioverter–defibrillator.
###### If electromagnetic interference is unlikely, it may be unnecessary to suspend the antitachycardia function of an implantable cardioverter–defibrillator. Suspending the antitachycardia function of an implantable cardioverter–defibrillator may be accomplished by reprogramming or in many cases by applying a magnet. A magnet correctly applied to an implantable cardioverter–defibrillator often results in suspension of antitachycardia therapy. For most implantable cardioverter–defibrillators, there is no reliable means to confirm the magnet response. Some implantable cardioverter–defibrillators may have no magnet response. In obese patients or those with a deep cardiac implantable electronic device implant (i.e., subcutaneous implantable cardioverter–defibrillator), magnet application might fail to elicit the magnet response. The antitachycardia function of some older implantable cardioverter–defibrillators can be permanently disabled by magnet application.
******* Note that the majority of consultants disagree and ASA members are equivocal regarding the recommendation to alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient if monopolar electrosurgery (“bovie”) use is planned inferior to the umbilicus,
††††††† Suspending the active rate sensor of a pacemaker may be accomplished by reprogramming or in many cases by magnet application. Suspending the active rate sensor of an implantable cardioverter–defibrillator must always be accomplished by reprogramming.
‡‡‡‡‡‡‡ The term “continuous” means “prolonged without any interruption at any time” (see Standards for Basic Anesthetic Monitoring, American Society of Anesthesiologists; approved by the ASA House of Delegates October 21, 1986; last amended October 28, 2015).
§§§§§§§ The peripheral pulse may be continuously monitored with either pulse oximetry plethysmography or an intraarterial pressure waveform.
‖‖‖‖‖‖‖ For some cases, the electrosurgical dispersive electrode will need to be placed at a site different from the thigh. For example, in head and neck cases, the dispersive electrode may be placed on the posterior superior aspect of the shoulder contralateral to the generator position.
####### An underbody electrosurgery dispersive electrode that is incorporated into a pad and placed directly on the operating table is sometimes used instead of a conventional dispersive electrode. In patients with a cardiac implantable electronic device, there is insufficient evidence to determine the impact of using an underbody dispersive electrode as compared with a conventional dispersive electrode on the risk of electromagnetic interference.
******** An inhibitory effect could occur even when the active electrode of the electrosurgery instrument is not touching the patient.
†††††††† More information about the management of patients with cardiac implantable electronic devices undergoing magnetic resonance imaging or radiation therapy may be found in the 2017 Heart Rhythm Society Expert Consensus Statement on Magnetic Resonance Imaging and Radiation Exposure in Patients with Cardiovascular Implantable Electronic Devices (https://www.hrsonline.org/2017-hrs-expert-consensus-statement-cardiovascular-implantable-electronic-device-lead-management; accessed August 7, 2019).
‡‡‡‡‡‡‡‡ Some cardiac implantable electronic devices are labeled by the Food and Drug Administration as magnetic resonance imaging-conditional. These systems have been approved for magnetic resonance imaging under specific conditions of use. Cardiac implantable electronic devices that do not meet these criteria are non–magnetic resonance imaging-conditional. In many centers, magnetic resonance imaging remains contraindicated in the presence of an non–magnetic resonance imaging-conditional cardiac implantable electronic device; however, some centers have implemented specific protocols allowing patients with a nonconditional cardiac implantable electronic device to undergo magnetic resonance imaging.
§§§§§§§§ Postoperative cardiac implantable electronic device interrogation may not be needed in low-risk situations (e.g., appropriate preoperative cardiac implantable electronic device interrogation, no electromagnetic interference-generating devices used during the procedure, no perioperative reprogramming occurred, and no problems identified during the procedure).
‖‖‖‖‖‖‖‖ In some instances, new settings may be needed.
######## Although the antitachycardia function of some older implantable cardioverter–defibrillators can be permanently disabled by magnet application, these implantable cardioverter–defibrillators are unlikely to still be encountered.
********* If the cardiac implantable electronic device is not interrogated during the immediate postoperative period, an interrogation after the patient is discharged may be warranted. Note that the expert consultants strongly agree and ASA members agree that interrogation should occur within 30 days after a procedure.
††††††††† Preferred reporting items of systematic reviews and meta-analyses.
‡‡‡‡‡‡‡‡‡ All meta-analyses are conducted by the ASA methodology group. Meta-analyses from other sources are reviewed but not included as evidence in this document. A minimum of five independent randomized controlled trials (i.e., sufficient for fitting a random-effects model) is required for meta-analysis.
§§§§§§§§§ Consultants were drawn from the following specialties where perioperative management of cardiac implantable electronic devices are a concern: anesthesiology (85% of respondents) and cardiac electrophysiology (15% of respondents).
‖‖‖‖‖‖‖‖‖ When an equal number of categorically distinct responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. Ties are calculated by a predetermined formula.
######### To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/B983).
‖‖‖‖‖ Many cardiac implantable electronic devices now have remote interrogation and monitoring capabilities. Thus, the most recent cardiac implantable electronic device interrogation report might be from an in-office interrogation or from a remote transmission (provided the remote transmission contains all needed information).
##### Most cardiac implantable electronic devices have an x-ray code inscribed on the generator that can be used to identify the cardiac implantable electronic device manufacturer.
****** A patient with an absent intrinsic heart rhythm is completely pacing-dependent. A patient with an inadequate intrinsic heart rhythm may be considered relatively or functionally pacing-dependent.
‡‡‡‡‡‡ In many patients, determining proper cardiac implantable electronic device function can be accomplished by accessing the patient’s most recent cardiac implantable electronic device interrogation report. Note that the majority of consultants and ASA members agree that a cardiac implantable electronic device should be interrogated within 3 to 6 months before a procedure.
§§§§§§ A cardiac implantable electronic device specialist might need to be consulted to help determine key information about the cardiac implantable electronic device, whether the patient is pacing-dependent, the cardiac implantable electronic device’s current settings, and that it is functioning properly.
‖‖‖‖‖‖ If electromagnetic interference is unlikely, it may be unnecessary to alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode. Altering the pacing function of a pacemaker to an asynchronous pacing mode may be accomplished by reprogramming or in many cases by applying a magnet. For most pacemakers, magnet application will initiate asynchronous pacing at a fixed pacing rate with a fixed atrioventricular delay. Some pacemakers have a programmable magnet response or no magnet response (i.e., some leadless pacemakers). Altering the pacing function of an implantable cardioverter–defibrillator to an asynchronous pacing mode must always be accomplished by reprogramming, because magnet application will never alter the pacing mode of an implantable cardioverter–defibrillator.
###### If electromagnetic interference is unlikely, it may be unnecessary to suspend the antitachycardia function of an implantable cardioverter–defibrillator. Suspending the antitachycardia function of an implantable cardioverter–defibrillator may be accomplished by reprogramming or in many cases by applying a magnet. A magnet correctly applied to an implantable cardioverter–defibrillator often results in suspension of antitachycardia therapy. For most implantable cardioverter–defibrillators, there is no reliable means to confirm the magnet response. Some implantable cardioverter–defibrillators may have no magnet response. In obese patients or those with a deep cardiac implantable electronic device implant (i.e., subcutaneous implantable cardioverter–defibrillator), magnet application might fail to elicit the magnet response. The antitachycardia function of some older implantable cardioverter–defibrillators can be permanently disabled by magnet application.
******* Note that the majority of consultants disagree and ASA members are equivocal regarding the recommendation to alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient if monopolar electrosurgery (“bovie”) use is planned inferior to the umbilicus,
††††††† Suspending the active rate sensor of a pacemaker may be accomplished by reprogramming or in many cases by magnet application. Suspending the active rate sensor of an implantable cardioverter–defibrillator must always be accomplished by reprogramming.
‡‡‡‡‡‡‡ The term “continuous” means “prolonged without any interruption at any time” (see Standards for Basic Anesthetic Monitoring, American Society of Anesthesiologists; approved by the ASA House of Delegates October 21, 1986; last amended October 28, 2015).
§§§§§§§ The peripheral pulse may be continuously monitored with either pulse oximetry plethysmography or an intraarterial pressure waveform.
‖‖‖‖‖‖‖ For some cases, the electrosurgical dispersive electrode will need to be placed at a site different from the thigh. For example, in head and neck cases, the dispersive electrode may be placed on the posterior superior aspect of the shoulder contralateral to the generator position.
####### An underbody electrosurgery dispersive electrode that is incorporated into a pad and placed directly on the operating table is sometimes used instead of a conventional dispersive electrode. In patients with a cardiac implantable electronic device, there is insufficient evidence to determine the impact of using an underbody dispersive electrode as compared with a conventional dispersive electrode on the risk of electromagnetic interference.
******** An inhibitory effect could occur even when the active electrode of the electrosurgery instrument is not touching the patient.
†††††††† More information about the management of patients with cardiac implantable electronic devices undergoing magnetic resonance imaging or radiation therapy may be found in the 2017 Heart Rhythm Society Expert Consensus Statement on Magnetic Resonance Imaging and Radiation Exposure in Patients with Cardiovascular Implantable Electronic Devices (https://www.hrsonline.org/2017-hrs-expert-consensus-statement-cardiovascular-implantable-electronic-device-lead-management; accessed August 7, 2019).
‡‡‡‡‡‡‡‡ Some cardiac implantable electronic devices are labeled by the Food and Drug Administration as magnetic resonance imaging-conditional. These systems have been approved for magnetic resonance imaging under specific conditions of use. Cardiac implantable electronic devices that do not meet these criteria are non–magnetic resonance imaging-conditional. In many centers, magnetic resonance imaging remains contraindicated in the presence of an non–magnetic resonance imaging-conditional cardiac implantable electronic device; however, some centers have implemented specific protocols allowing patients with a nonconditional cardiac implantable electronic device to undergo magnetic resonance imaging.
§§§§§§§§ Postoperative cardiac implantable electronic device interrogation may not be needed in low-risk situations (e.g., appropriate preoperative cardiac implantable electronic device interrogation, no electromagnetic interference-generating devices used during the procedure, no perioperative reprogramming occurred, and no problems identified during the procedure).
‖‖‖‖‖‖‖‖ In some instances, new settings may be needed.
######## Although the antitachycardia function of some older implantable cardioverter–defibrillators can be permanently disabled by magnet application, these implantable cardioverter–defibrillators are unlikely to still be encountered.
********* If the cardiac implantable electronic device is not interrogated during the immediate postoperative period, an interrogation after the patient is discharged may be warranted. Note that the expert consultants strongly agree and ASA members agree that interrogation should occur within 30 days after a procedure.
††††††††† Preferred reporting items of systematic reviews and meta-analyses.
‡‡‡‡‡‡‡‡‡ All meta-analyses are conducted by the ASA methodology group. Meta-analyses from other sources are reviewed but not included as evidence in this document. A minimum of five independent randomized controlled trials (i.e., sufficient for fitting a random-effects model) is required for meta-analysis.
§§§§§§§§§ Consultants were drawn from the following specialties where perioperative management of cardiac implantable electronic devices are a concern: anesthesiology (85% of respondents) and cardiac electrophysiology (15% of respondents).
‖‖‖‖‖‖‖‖‖ When an equal number of categorically distinct responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. Ties are calculated by a predetermined formula.
######### To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/B983).
Overview
Title
Perioperative Management of Patients with Cardiac Implantable Electronic Devices
Authoring Organization
American Society of Anesthesiologists