Perioperative cardiac device management

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The number of patients with implantable devices continues to grow. There are important aspects and difficulties in the perioperative management of these patients.

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Perioperative cardiac device management

  1. 1. Jose Osorio, MD www.theafcenter.com
  2. 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. 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
  4. 4. VOO VVI AAI DDD www.theafcenter.com
  5. 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. 6. Atrial sensed, ventricular paced Consistent with DDD or VDD www.theafcenter.com
  7. 7. Atrial paced Consistent with AAI or DDD www.theafcenter.com
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  12. 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. 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. 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. 15. NON- Magnet Magnet = VOO Magnet Operation Pacemakers •Asynchronous Pacing •Magnet Response at ERI www.theafcenter.com
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  17. 17. NON- Magnet Magnet Operation ICDs • No changes to Pacing mode • Tachy Therapies are Temporarily Disabled* • Older generation Guidant Devices www.theafcenter.com
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  19. 19.  Absolute  Functional ◦ Slow baseline rhythms or escape rhythm ◦ Dependent after anesthesia induction ◦ BiV patients  asynchronous www.theafcenter.com
  20. 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
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  22. 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. 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. 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. 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
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  30. 30.  Pre-op and post-op evaluation/reprogramming for every patient.  Ophtalmology  Thoracic  Neurosurgery  Shoulder/arm surgery www.theafcenter.com
  31. 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. 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

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