Perioperative Management of Patients with Cardiac Implantable Electronic Devices

• 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.
• 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.

• Determine whether intraoperative electromagnetic interference is likely to occur.
• If electromagnetic interference is likely to occur (e.g., monopolar electrosurgery [“bovie”] use, or radiofrequency ablation is planned superior to the umbilicus), alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient^{‖‖‖‖‖‖######} and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present.^*******
  • Before suspending the antitachycardia function, ensure that the patient is in a monitored environment.
  • Avoid the indiscriminate use of a magnet over an implantable cardioverter–defibrillator.
  • If needed, consult a specialist to alter the pacing function of a cardiac implantable electronic device or to suspend the antitachycardia function of an implantable cardioverter–defibrillator.
• Ensure that temporary pacing and defibrillation equipment are immediately available before, during, and after all procedures with electromagnetic interference potential.
• Suspend a cardiac implantable electronic device’s active sensor for rate-responsive pacing to prevent undesirable tachycardia.^{†††††††}

• Continuously monitor and display a patient’s electrocardiogram and Spo₂ as required by American Society of Anesthesiologists (ASA) standards from the beginning of anesthesia until the patient is transferred out of the anesthetizing location.^{‡‡‡‡‡‡‡}
• Perform continuous peripheral pulse monitoring for all cardiac implantable electronic device patients receiving anesthesia care.^{§§§§§§§}
• If unanticipated cardiac implantable electronic device interactions occur, temporarily suspend the procedure until the source of interference can be identified and eliminated or managed.

Electrosurgery

• If monopolar electrosurgery is planned superior to the umbilicus, ensure that the pacing function of a cardiac implantable electronic device is altered to an asynchronous pacing mode in the pacing-dependent patient and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present.
• Before suspending the antitachycardia function, ensure that the patient is in a monitored environment.
• Minimize the risk of electromagnetic interference from monopolar electrosurgery.
• Position the electrosurgical instrument and dispersive electrode (“bovie pad”) so the current pathway does not pass through or near the cardiac implantable electronic device generator or leads.^{‖‖‖‖‖‖‖#######}
• Avoid waving the activated electrode over the generator.^********
• Use short, intermittent, and irregular bursts of electrosurgery at the lowest feasible energy levels.
• Use bipolar electrosurgery or an ultrasonic (harmonic) scalpel, if possible.

• If radiofrequency ablation is planned superior to the umbilicus, ensure that the pacing function of a cardiac implantable electronic device is altered to an asynchronous pacing mode in the pacing-dependent patient and suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present.
  • Before suspending the antitachycardia function, ensure that the patient is in a monitored environment.
• Avoid direct contact between the ablation catheter and the generator and leads.
• Keep the radiofrequency’s current path (electrode tip to current return pad) as far away from the generator and leads as possible.

• Do not focus the lithotripsy beam near the generator.

• Ensure that a standardized workflow and/or institutional protocol is in place and followed.
• Move the patient outside of the immediate magnetic resonance imaging area when the use of an external defibrillator/monitor, cardiac implantable electronic device programmer, or any other magnetic resonance imaging-unsafe equipment is required.
• Before the magnetic resonance imaging scan, perform the following:
  • Interrogate the cardiac implantable electronic device.
  • Suspend the antitachycardia function of an implantable cardioverter–defibrillator, if present.
    • For magnetic resonance imaging-conditional cardiac implantable electronic devices, adhere to all product labeling including activating “magnetic resonance imaging mode” to suspend the antitachycardia function of a magnetic resonance imaging-conditional implantable cardioverter–defibrillator.^{‡‡‡‡‡‡‡‡}
    • In the pacing-dependent patient, alter the pacing function of the cardiac implantable electronic device to an asynchronous pacing mode.
• Ensure that an individual capable of performing advanced cardiac life support remains in attendance for the duration of the magnetic resonance imaging scan.
• Ensure that an individual capable of programming the cardiac implantable electronic device is readily available for consultation or remains in attendance for the duration of the magnetic resonance imaging scan whenever dictated by institutional policy.
• After the magnetic resonance imaging scan is completed, reinterrogate the cardiac implantable electronic device and restore its permanent settings.

• Avoid using radiofrequency identification devices in close proximity to the cardiac implantable electronic device, whenever possible.
• Monitor for signs of electromagnetic interference and be prepared to stop using the radiofrequency identification device if interference occurs.

• Alter the pacing function of a cardiac implantable electronic device to an asynchronous pacing mode in the pacing-dependent patient.
• Suspend an implantable cardioverter–defibrillator’s antitachycardia function, if present.
• Monitor for and be prepared to manage postconvulsive sinus tachycardia.
• Monitor for and treat ventricular arrhythmias that may occur secondary to the hemodynamic effects of electroconvulsive therapy.

• Before attempting to emergently externally cardiovert or defibrillate a patient with an implantable cardioverter–defibrillator and magnet-disabled therapies, terminate all sources of electromagnetic interference and remove the magnet to reenable the implantable cardioverter–defibrillator’s antitachycardia therapies.
  • Observe the patient for appropriate antitachycardia therapy from the implantable cardioverter–defibrillator.
  • Determine the need for reenabling an implantable cardioverter–defibrillator’s antitachycardia therapy if it was disabled by programming.
• If the above activities fail to restore the implantable cardioverter’s antitachycardia therapy, or if the antitachycardia therapy cannot be restored expeditiously, proceed with emergency external cardioversion or defibrillation when needed.
  • Follow advanced cardiac life support guidelines for delivered energy level and pad placement.
  • Position the cardioversion and defibrillation pads so they are not directly over the cardiac implantable electronic device generator to minimize the current flowing through the generator and leads.
  • Use a clinically appropriate energy output regardless of the presence of a cardiac implantable electronic device.
  • Interrogate the cardiac implantable electronic device immediately after external cardioversion or defibrillation is performed.

• Continue to monitor and display a patient’s cardiac rate and rhythm throughout the immediate postoperative period as required by ASA standards and as indicated by the patient’s medical condition.
• For a cardiac implantable electronic device that was reprogrammed pre- or intraoperatively:
  • Ensure that back-up pacing and cardioversion–defibrillation equipment are immediately available until the cardiac implantable electronic device’s permanent settings are restored.^{§§§§§§§§}
  • Ensure the patient’s cardiac rate and rhythm are continuously monitored and displayed until the cardiac implantable electronic device’s permanent settings are restored.^{‖‖‖‖‖‖‖‖}
  • Ensure the patient remains in a monitored environment until the cardiac implantable electronic device’s permanent settings are restored (e.g., until the antitachycardia function of an implantable cardioverter–defibrillator is reenabled).
• Perform a postoperative cardiac implantable electronic device interrogation whenever:
  • Emergency surgery occurred without appropriate preoperative cardiac implantable electronic device evaluation.
  • There is suspicion that antitachycardia therapy might have been disabled rather than temporarily suspended with magnet placement.^########
  • The delivery of antitachycardia therapy was observed or suspected.
  • There is concern for cardiac implantable electronic device malfunction (i.e., significant electromagnetic interference occurred in close proximity to the cardiac implantable electronic device, an invasive procedure was performed in close proximity to a cardiac implantable electronic device generator or lead, or large fluid shifts occurred).
• If interrogation determines that the cardiac implantable electronic device settings are inappropriate, reprogram to newly appropriate settings.^*********