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Perioperative cardiac device management
- 2. The perioperative period poses unique challenges to ensure patient safety. ◦ Expanding use of potential sources of electromagnetic interference (EMI) ◦ Great concern for phantom reprogramming ◦ Potential Lead/Device damage ◦ Rapid changes in CRM technology Current complex digital transmission of programming signals. Contradictory advice ◦ Literature ◦ Manufactures Great need for a consistent consensus document. www.theafcenter.com
- 3. Class I 1. Sinus node dysfunction with documented symptomatic bradycardia 2. Symptomatic chronotropic incompetence (failure to increase HR with exercise or increased metabolic demand) 3. 3° and advanced 2° AV block associated with any of the following: Arrhythmias that require drugs resulting in symptomatic bradycardia Sinus pauses > 3 seconds Asymptomatic escape rate < 40bpm while awake 4. Type II 2° AV www.theafcenter.com
- 5. Causes: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005. Failure to Capture Failure to Pace Failure to Sense www.theafcenter.com
- 6. Atrial sensed, ventricular paced Consistent with DDD or VDD www.theafcenter.com
- 7. Atrial paced Consistent with AAI or DDD www.theafcenter.com
- 12. All patients with EF of <36% on good medical therapy Patients who have survived a VT or VF arrest without clear precipitating cause ◦ i.e. – acute MI Patients structural heart disease or genetic conditions at a high risk for SCD. Bi-V ICD for patients with heart failure and LBBB www.theafcenter.com
- 13. Defibrillators – Pacing capabilities ICD patients: ◦ Majority do not have pacing indications VVI 40 No pacing on baseline ECG ◦ Most patients that do have pacing indications will have BiV ICD implanted www.theafcenter.com
- 14. Implantable Defibrillators (1989-2003) 209 cc 120 cc 80 cc 80 cc 72 cc 54 cc 62 cc 49 cc 39.5 cc 39.5 cc 36 cc 83% size reduction since 1989! 38 cc39.5 cc www.theafcenter.com
- 15. NON- Magnet Magnet = VOO Magnet Operation Pacemakers •Asynchronous Pacing •Magnet Response at ERI www.theafcenter.com
- 17. NON- Magnet Magnet Operation ICDs • No changes to Pacing mode • Tachy Therapies are Temporarily Disabled* • Older generation Guidant Devices www.theafcenter.com
- 19. Absolute Functional ◦ Slow baseline rhythms or escape rhythm ◦ Dependent after anesthesia induction ◦ BiV patients asynchronous www.theafcenter.com
- 20. Pacemakers: ◦ Potential deleterious effects of asynchronous pacing Potential pro-arrhythmic effect May have significant impact in patients with depressed LV function and CRT Defibrillators: ◦ Inadvertently leaving tachy therapies OFF www.theafcenter.com
- 22. Effective communication between CIED and operative team Current complex digital transmission of programming signals ◦ EMI/Reset/Phantom reprogramming - no longer a concern. Most patients will not need a de novo preoperative evaluation ◦ If information needed if in the records of the CIED clinic. We strongly support the prior HRS recommendations that industry representatives cannot be placed in a position of medical responsibility ◦ not to say that an IEAP cannot assist with the technical part of that evaluation as long as the IEAP is under the supervision of a physician experienced in CIED management. www.theafcenter.com
- 23. Pacemaker/AICD response to EMI: 1. Temporary or permanent resetting to a backup pacing mode. 2. Temporary or permanent inhibition of pacemaker output. 3. Increase in pacing rate (rate-responsive PMs). 4. AICD inappropriate shock. 5. Myocardial injury at the lead tip: failure to sense or capture. Sources: 1. Electrocautery 2. Radiofrequency ablation 3. MRI (contraindicated!) 4. Radiation therapy 5. ECT www.theafcenter.com
- 24. 1. Cautery tool and current return pad are positioned so the current pathway does not pass through or near the CIED pulse generator and leads; 2. Avoiding proximity of the cautery's electrical field to the pulse generator or leads; 3. Using short, intermittent, and irregular bursts at the lowest feasible energy levels; 4. Using a bipolar electrocautery system or an ultrasonic (harmonic) scalpel if possible. www.theafcenter.com
- 25. • Infrequent • More commonly caused by therapeutic ionizing radiation • Rarely reported after exposure to electrosurgery • Direct application of cautery to pulse generator • Safety backup. www.theafcenter.com
- 30. Pre-op and post-op evaluation/reprogramming for every patient. Ophtalmology Thoracic Neurosurgery Shoulder/arm surgery www.theafcenter.com
- 31. Pacemakers ◦ Dependent patients Below umbilicus: no changes necessary Above umbilicus: Careful use of cautery / patches application Use of magnet ◦ Non-dependent patients No changes: unless close to pulse generator/leads Careful monitoring as patients may become dependent during procedure www.theafcenter.com
- 32. Defibrillators ◦ What is the response to magnets? ◦ Dependency: absolute or functional? ◦ Tachytherapies Disable by using magnet ◦ Brady Program if surgery above umbilicus and patient is dependent www.theafcenter.com