We thank Dr. Weiner1 for his interest in the important topic of perioperative cardiovascular implantable electronic device (CIED) management. One of his major concerns was the need for greater education among anesthesiologists, and on this point, we enthusiastically agree.
Concern was also expressed as to whether the anesthesiologist-based program for device management described in our editorial2 provides the level of collaboration among referring cardiologist, anesthesiology, surgeon, and electrophysiologist/cardiology as recommended by the Heart Rhythm Society (HRS)/American Society of Anesthesiologists expert consensus statement.3 In fact our program was designed specifically to be in accord with those guidelines. Dr. Jeanne Poole, the electrophysiologist who was instrumental in the creation of our program, was cochair of the consensus panel of experts that wrote the HRS guidelines. We actually delayed implementing our program to be sure that the structure of the program matched the final version of the HRS guidelines.
Our program began providing clinical care in September 2010 with direct supervision by electrophysiology cardiologists for every case but has evolved to the point that most interrogations are now handled entirely by the anesthesia service. Yet the electrophysiology service is still frequently called on for advice and for clinical follow-up of devices perioperatively. The most common example of our collaboration involves patients who undergo placement of left ventricular assist devices. At the time of surgery, the CIED often suffers adverse changes in lead sensitivity and capture thresholds and subsequent follow up is necessary. This task is deferred to cardiology as we consider such care beyond our level of training. Furthermore, if the anesthesiologist is at any time not comfortable with the interrogation results or the decision-making process regarding suitable device programming, then help is obtained from electrophysiology/cardiology.
We hope this clarifies how our anesthesia-based CIED management program functions. We want to emphasize that our program may not be suitable for all practice settings. Local needs and resources will ultimately determine how CIEDs are best managed in a particular hospital.
Conflicts of Interest: G. Alec Rooke reported a conflict of interest with Medtronic. G. Alec Rooke is an investigator on a study of electromagnetic interference and cardiovascular implantable electronic devices that is funded by Medtronic.
Alec Rooke, MD, PhD
T. Andrew Bowdle, MD, PhD
Department of Anesthesiology
University of Washington School of Medicine
1. Weiner MM. Preoperative evaluation of patients with pacemakers and implanted cardioverter defibrillators. Anesth Analg. 2014;118:1138
2. Rooke GA, Bowdle TA. Perioperative management of pacemakers and implantable cardioverter defibrillators: it’s not just about the magnet. Anesth Analg. 2013;117:292–4
3. . The Heart Rhythm Society Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: Facilities and patient management. Heart Rhythm. 2011;8:1114–52