To the Editor
We agree with Schulman and Rozner1 regarding the importance of preoperative evaluation of Cardiac Implantable Electronic Devices (CIEDs) and wish to share our experience on management of CIEDs pre-, intra-, and postoperatively by anesthesiologists in a tertiary care community hospital. Collaborating with our electrophysiology cardiologists, we provided a 1-day education for anesthesiologists on basic principles and hands-on training with 4 major CIEDs in the United States, that is, Medtronic, Biotronic, St. Jude, and Boston Scientific.
Instruction included turning on/off defibrillator function, identifying pacer dependency, switching pacing mode from/to asynchronous (atrium-paced, no-chamber-sensed, no-sensing-fixed mode; ventricle-paced, no-chamber-sensed, no-sensing-fixed mode; asynchronous pacing; etc.), and changing the pacing rate and printing reports. At the end of the training, each anesthesiologist was asked to perform turning on/off tachycardia therapy, identify pacer dependency, and change pacer mode/rate independently to verify their skills. An education seminar every 6 months is planned. Each company provided their respective CIED programmer, and a CIED cart was assembled with all 4 programmers available. The cart remains in the operating room (OR) area.
A perioperative CIEDs clinic was established to ensure maximal safety for CIED patients undergoing surgery. This clinic was led by a cardiac anesthesiologist, staffed by anesthesiologists, with available consultation from an electrophysiology cardiologist, and supported by CIED manufacture representatives.
When a patient with a CIED presents to the preoperative area, the CIED clinic anesthesiologist will be notified. CIEDs are interrogated in the preoperative area, magnet response is assessed, and settings are changed if necessary (turn on/off tachycardia therapy or change pacemaker mode and rate for patients who are pacer-dependent) in the OR after standard monitors are applied. There must be a magnet in the OR and a defibrillator immediately available.
The anesthesiologist must document the following information in each patient’s chart and communicate to the entire OR/Anesthesia team.
- Date and time device setting is changed.
- Changes made on the device including turning on/off tachycardia therapy or changing pacemaker mode and rate.
- The name and cell phone number of the anesthesiologist who makes the changes.
CIEDs must be restored to the original settings by the CIED anesthesiologist before the patient leaves the OR. The CIED anesthesiologist reports to recovery room physicians and nurses regarding each patient’s CIED status. The CIED manufacturer’s representatives are called to interrogate the device before the patient leaves a cardiac telemetry environment if reprogramming has occurred or if the patient meets one of the criteria listed below.2
- Patients in whom the CIED was reprogrammed before the procedure that left the device nonfunctional such as disabling tachycardia detection.
- Patients with a CIED and who underwent surgery during which hemodynamic instability may have occurred.
- Patients with a CIED and who experienced significant intraoperative events including cardiac arrest requiring temporary pacing or cardiopulmonary resuscitation and those who required external electrical cardioversion.
- Emergent surgery wherein the site of electromagnetic interference exposure was above the umbilicus.
- Cardiothoracic surgery.
- Patients with a CIED and who underwent a procedure (external cardioversion, radiofrequency ablation, and therapeutic radiation) that emits electromagnetic interference with a greater probability of affecting device function.
- Patients with a CIED who have logistical limitations preventing reliable device evaluation within 1 month from their procedure.
All other patients will be scheduled for outpatient evaluation within 1 month of the procedure.
An example of how such expertise was used is represented by the following case: A 58-year-old man with a history of diabetes, morbid obesity (Body Mass Index 39 kg/m2), hypertension, sleep apnea, and gout presented for left ventricular assist device exchange because of pump malfunction. A Medtonic CIED was in place for his ischemic cardiomyopathy. Adhesive defibrillation pads were placed on right shoulder and left lateral chest before draping and connected to a functional external defibrillator. The CIED was interrogated by a CIED cardiac anesthesiologist and determined that ventricular fibrillation and ventricular tachycardia (VT) detection and therapy were functional. The pacing mode was dual mode, dual chamber, and dual sensing 70 bpm. The tachy therapy was then turned off, and the mode changed to asynchronous pacing at 85 beats per minute, and atrial and ventricular capture verified.
The left ventricular assist device was successfully changed through a left subcostal incision during femoral vein to artery cardiopulmonary bypass. The patient was separated from bypass, and when the surgeon used unipolar electrocoagulation (Unipolar Bovie, Bovie Medical Corporation, Clearwater, FL) near the heart to stop bleeding, the cardiac rhythm suddenly deteriorated to VT and then ventricular fibrillation. External transcutaneous defibrillation was performed multiple times without success, presumably from the increased distance between pads and the heart because of his morbid obesity. The mean blood pressure decreased to the low 40s. The subcostal incision/exposure prevented us from using internal defibrillating paddles in the surgical field directly on the heart. Since the external transcutaneous defibrillator was not effective and CIED was turned off, the CIED programmer and the implantable cardioverter defibrillator therapies were turned back on after which the implantable cardioverter defibrillators shocked the heart twice; the rhythm went into VT after the first shock and returned to sinus rhythm after the second shock. Amiodarone infusion was started, and the remainder of the procedure was uneventful.
As described by Schulman and Rozner,1 a magnet alone is inadequate to manage CIEDs perioperatively. Education and establishment of a formal CIED clinic by anesthesiologists are feasible and useful in a community tertiary care hospital.
Jiapeng Huang, MD, PhD
Department of Anesthesiology
Michael Springer, MD
Department of Electrophysiology Cardiology
1. Schulman PM, Rozner MA. Case report: use caution when applying magnets to pacemakers or defibrillators for surgery. Anesth Analg. 2013;117:422–7
2. Crossley GH, Poole JE, Rozner MA, Asirvatham SJ, Cheng A, Chung MK, Ferguson TB Jr, Gallagher JD, Gold MR, Hoyt RH, Irefin S, Kusumoto FM, Moorman LP, Thompson A. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm. 2011;8:1114–54