In this issue of Anesthesia & Analgesia, Sun et al. (1) describe the correct process for noncardiac radiofrequency ablation in a patient with an implanted cardiac pacemaker. As the authors note, such patients should undergo a comprehensive evaluation of their pacemaker before the procedure. Consideration should be given to appropriate reprogramming of the pacemaker (when indicated). Finally, the pacemaker should be reevaluated after the procedure to ensure that no new issues have arisen either because of electromagnetic interference (EMI) during the procedure or because of changes in the patient’s physiology resulting from the procedure. Such pre- and postoperative pacemaker evaluations are in keeping with perioperative recommendations from the American College of Cardiologists (ACC) (2) and the Heart Rhythm Society (formerly called the North American Society of Pacing and Electrophysiology) (3).
This article is significant—and disturbing—for another reason. For radiofrequency ablation, pacemaker reprogramming to asynchronous mode is often recommended to prevent pacemaker oversensing and inhibition due to EMI. In this case, however, no reprogramming took place because the consulting cardiologist erroneously reported that asynchronous mode was not available in this particular pacemaker. Although this pacemaker was uncommon and the manufacturer (Intermedics, formerly of Angleton, TX) was subsequently purchased by Guidant Corporation (St. Paul, MN), information about the device was readily available. Obtaining a physician’s manual required only a call to Guidant technical support, and a review of this document shows that this pacemaker does, in fact, include asynchronous pacing in single-chamber mode. So why were our colleagues misinformed?
Cardiac pacemaking is complicated. Approximately 26 companies have produced nearly 2000 models of pacemaker generators. Many of these manufacturers no longer exist—assets have been sold or traded—but patients still rely on generators from these companies (as in this case). Furthermore, the likelihood of receiving incorrect information about implanted devices will increase as more complicated devices are developed, as indications for pacemaker (and defibrillator) implantation expand, and as more patients undergo device implantation. Granting of pacemaker privileges by a hospital relies, in general, only on the number of devices implanted; rarely does a hospital require documentation of training for follow-up care of pacemakers or implanted cardioverter-defibrillators. Guidelines from the ACC for training in clinical cardiology specify that only 2 months of curriculum (during the 3-yr fellowship) be devoted to “arrhythmia management, permanent pacemaker management, and electrophysiology” (4). Even the policy statement regarding training issues related to “cardiac implantable electronic devices” published by the North American Society of Pacing and Electrophysiology (the Heart Rhythm Society) does not mention the need for knowledge of the large variety of pacing devices from the various manufacturers (5). Interestingly, in their report on medical errors, the Institute of Medicine did not appear to address the possibility of factual errors in consultant recommendations (6).
Adding to the complicated nature of this subject, much of the literature regarding perioperative care of patients with implanted cardiac devices is based on old, outdated, and sometimes misinterpreted case reports. For example, a discussion published in 1978 about monopolar electrocautery (7), with possibly incorrect conclusions and recommendations, continues to be cited (8) despite a more recent publication (9) that challenges these old findings and is readily found with computerized searches. Also, incorrect statements about magnets continue to be made (8), although some reviews correctly note that not all pacemakers will revert to continuous, asynchronous pacing upon placement of a magnet (10,11).
What should we, as anesthesiologists, do about this situation? First, we should be discussing the perioperative care guidelines from the ACC with our colleagues and risk-management groups at our hospitals and surgery centers. Previous reports (one article and one abstract) suggest that the presence of a pacemaker appears to confer more frequent postoperative morbidity and mortality (12,13), although this subject is not well studied. At my hospital, more than 30% of 172 patients (over 2 yr) who presented for an anesthetic did not meet published guidelines for pacemaker checks, and 15% had serious pacemaker problems. In nine (5.2%) of these patients, our preoperative pacemaker check disclosed the need for generator replacement because of battery depletion (14). There are also significant postoperative issues, as documented by Trankina et al.1 Thus, checking each device before and after surgery seems prudent and might improve patient outcome.
Second, the pacemaker manufacturers should consider standardizing, to the extent possible, the response of a device to magnet placement. Discussions about this issue are under way at the Association for the Advancement of Medical Instrumentation (Washington, DC), although the American Society of Anesthesiologists is not represented at these meetings.
Third, I believe that anesthesiologists (and cardiologists who are unfamiliar with a particular generator brand or model) must be less hesitant about calling the technical support personnel at the manufacturing company’s headquarters. These companies answer the phone 24 h per day, 7 days a week, and their technical support representatives have extensive experience in educating physicians, nurses, and allied professionals. Although these calls might be time-consuming, they will likely reduce the incidence of incorrect reports, and they also might shed light on device recalls and past problems.
Finally, the ultimate solution to this problem is educating, training, and certifying anesthesiologists in the field of perioperative cardiac pacing. Anesthesiologists are, by nature, pioneers in cross-specialty training. We evaluate patients of all ages for many diseases and conditions (such as pregnancy) that affect perioperative physiology. We make adjustments in medications and treatments for both ambulatory and perioperative patients in an attempt to improve patient outcomes. When challenged, we make changes in our own training and education programs. For example, only 20 yr ago, the first use of intraoperative monitoring with transesophageal echocardiography was published (15). Today, in conjunction with the Society of Cardiovascular Anesthesiologists, almost 1500 anesthesiologists have demonstrated, via the National Board of Echocardiography examination, knowledge and skill in the area of perioperative transesophageal echocardiography. Similar certification (Examination of Special Competency in Cardiac Pacing and Cardioversion Defibrillation) exists in the pacing environment under the auspices of the Heart Rhythm Society (http://www.naspexam.org).
In their review of EMI in implanted devices, pacemaker specialists Pinski and Trohman (16) suggest the following: “Ideally, a trained physician and the corresponding programmer should be available within the hospital whenever a patient with an implanted device undergoes electrosurgery.” This case suggests that to continue to provide outstanding care, anesthesiologists might need to become perioperative pacemaker (and implanted cardioverter-defibrillator) experts as well.
1. Sun DA, Martin L, Honey CR. Percutaneous radiofrequency trigeminal rhizotomy in a patient with an implanted cardiac pacemaker. Anesth Analg 2004;99:1585–6.
3. Goldschlager N, Epstein A, Friedman P, et al. Environmental and drug effects on patients with pacemakers and implantable cardioverter/defibrillators: a practical guide to patient treatment. Arch Intern Med 2001;161:649–55.
4. Beller GA, Bonow RO, Fuster V, et al. ACC revised recommendations for training in adult cardiovascular medicine core cardiology training II (COCATS 2). March 2002. Available at: http://www.acc.org/clinical/training/COCATS2.pdf
. Accessed: June 7, 2004.
5. Hayes DL, Naccarelli GV, Furman S, et al. NASPE training requirements for cardiac implantable electronic devices: selection, implantation, and follow-up. Pacing Clin Electrophysiol 2003;26(7 Pt 1):1556–62.
6. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
7. Batra YK, Bali IM. Effect of coagulating and cutting current on a demand pacemaker during transurethral resection of the prostate: a case report. Can Anaesth Soc J 1978;25:65–6.
8. Stone KR, McPherson CA. Assessment and management of patients with pacemakers and implantable cardioverter defibrillators. Crit Care Med 2004;32(4 Suppl):S155–65.
9. Rozner MA. Untitled letter. Pacing Clin Electrophysiol 2003;26:923–5.
10. Pinski SL, Trohman RG. Interference in implanted cardiac devices. I. Pacing Clin Electrophysiol 2002;25:1367–81.
11. Rozner MA, Trankina MF. Intrathoracic gadgets: update on pacemakers and implantable cardioverter defibrillators. In: Schwartz AJ, ed. ASA refresher courses in anesthesiology. 28th ed. Philadelphia: Lippincott Williams & Wilkins, 2000:183–99.
12. Badrinath SS, Bhaskaran S, Sundararaj I, et al. Mortality and morbidity associated with ophthalmic surgery. Ophthalmic Surg Lasers 1995;26:535–41.
13. Samain E, Schauveliege F, Henry C, Marty J. Outcome in patients with a cardiac pacemaker undergoing noncardiac surgery [abstract]. Anesthesiology 2001;95:A142.
14. Rozner MA, Roberson JC, Nguyen AD. Unexpected high incidence of serious pacemaker problems detected by pre-and postoperative interrogations: a two-year experience [abstract]. J Am Coll Cardiol 2004;43:113A.
15. Roizen MF, Beaupre PN, Alpert RA, et al. Monitoring with two-dimensional transesophageal echocardiography: comparison of myocardial function in patients undergoing supraceliac, suprarenal-infraceliac, or infrarenal aortic occlusion. J Vasc Surg 1984;1:300–5.
16. Pinski SL, Trohman RG. Interference in implanted cardiac devices. II. Pacing Clin Electrophysiol 2002;25:1496–509.