Current Perioperative Management of the Patient With a Cardiac Rhythm Management Device

Abstract

The safe and effective perioperative management of the patient with a cardiac rhythm management device (ie, pacemaker and/or implantable cardioverter defibrillator) is based entirely on the avoidance of adverse outcomes, including damage to the device, the leads, or the site of lead implantation that might prevent the device from functioning as intended. An important management principle is the potential reprogramming of such a device in the perioperative period to avoid transient interruption of device function or the delivery of inappropriate electrophysiological therapy (eg, unnecessary defibrillation or pacing). Given the large numbers of patients worldwide currently implanted with these devices, the anesthesia practitioner should become electively familiar with the current technology. This article describes the current status of cardiac rhythm management devices and discusses recommended perioperative management.

Society position statement

“…11 Most publications involve case reports, case series, consensus-based guidelines, and industry position statements. 2,7,8,11,12 Because we did not find a single randomized trial comparing different management strategies, the recommendations in this document are based on a Grade C level of evidence.…”

“…While controversy remains relative to the clinical usefulness of universally applied rate-modulated pacing, virtually all pacemakers implanted today have rate modulation functions available. 12,18 A variety of technologies have been investigated and 4 main technologies remain (Table 3). 19 Various intraoperative events may cause interference with the intended interpretation of physiological changes for rate modulation, 20,21 and pacemaker-driven tachycardia is described from different sources.…”

Perioperative management of outpatients with implantable cardioverter defibrillators

“…Boston Scientific, formerly Guidant (Natick, Massachusetts, USA)] have different responses to magnet application [4 ]. If magnet application results in audible tones synchronous with R-waves the device will remain disabled until the magnet remains on the device and if the R-wave synchronous tones become solid tones then the device will be permanently disabled, which can be reactivated by reapplying the magnet for 20-30 s until the R-wave synchronous tones are heard again [4 ]. Of note, some ICDs may be programmed to ignore the placement of a magnet and therefore will continue to deliver therapy even if a magnet is properly positioned over the device.…”

“…It is estimated that approximately 500 000 patients worldwide have an ICD. In the United States around 100 000 ICDs are implanted annually [3,4 ]. It is no surprise that in recent years an increasing number of patients with ICDs are presenting for ambulatory surgery.…”

“…It is no surprise that in recent years an increasing number of patients with ICDs are presenting for ambulatory surgery. However, the literature regarding their perioperative management is sparse and of limited quality [4 ]. Because these patients pose significant challenges and are at an increased risk of perioperative complications, the suitability of ambulatory surgery in this patient population remains controversial [3,4 , 5,6 ,7].…”