Anesthesia for patients with Cardiac Implantable Electronic Devices

Anesthesia for patients with
Cardiac Implantable Electronic Device
1amr moustafa kamel

Cardiac implantable electronic devices is a
term that encompasses:
1) cardiac pacemakers for bradyarrythmias
treatment.
2) implantable cardioverter-defibrillators (ICD)
for tachyarrythmias treatment.
3) cardiac resynchronization therapy (CRT)
devices for systolic dysfunction complicating
conduction delays
amr moustafa kamel 2

A permanent pacemaker (PPM)system consists of:
1. a "pulse generator” to generate the electric
impulse
2. Leads and electrodes connecting the generator
to the heart for sensing and pacing
It’s main function is to restore and maintain a
cardiac rhythm and rate sufficient to meet the
metabolic needs of the body, i.e. treatment of
symptomatic bradyarrythmias.

1. At the level of the sinoatrial node: Sick sinus
syndrome is the most common indication for
permanent pacing. Carotid sinus hypersensitivity and
exaggerated vasovagal attacks
2. At the level of tha atria: AF with slow ventricular
response not responding to medical treatment.
3. Symptomatic chronotropic incompetence.
4. Type II second degree AV block with symptoms or
wide QRS (>120 msec)
5. Bifascicular block with symptoms or with type II
second degree heart block or post MI
6. Third degree AV block.
7. Congenital complete heart block or prolonged QT
interval
8. Post cardiac transplantation
9. Drug induced symptomatic bradycardia

The term “symptomatic bradycardia” is
defined as a documented bradyarrhythmia
that is directly responsible for the
development of frank syncope or near-
syncope, transient dizziness or light-
headedness, and confusional states resulting
from cerebral hypo- perfusion attributable to
slow heart rate. Fatigue, exercise
intolerance, and frank congestive heart failure
may also result from bradycardia. Definite
correlation of symptoms with a
bradyarrhythmia is a requirement to fulfill the
criteria of symptomatic bradycardia.

1. Asynchronous mode: pace the heart at a fixed
preset rate independent of any intrinsic cardiac
electrical activity. They can be (AOO), (VOO), or
(DOO). Theoretically they can induce ventricular
fibrillation through the (R on T phenomenon).
2. Single chamber demand pacing: the most
popular type is(VVI)in which the ventricle is only
paced when the intrinsic heart rate drops below
a preset rate. However, it can’t maintain the
atrioventricular synchrony leading to the
“pacemaker syndrome”

Patients with sick sinus syndrome and normal
AV node and conducting system usually
benefit from (AAI) mode.
3. Dual chamber sequential pacing: with 2 leads
, the atrium is stimulated first then after an
adjustable PR interval the ventricle is
stimulated. Thus preserving the AV synchrony.
It’s most common type is (DDD) or (DVI)
which is used in patients with sinoatrial and
conducting system abnormalities .
4. Rate adaptive pacemakers: mainly for
patients with chronotropic incompetence.

It is a small battery-powered electrical impulse
generator that is implanted in patients who are at
risk of sudden cardiac death (SCD) due
to ventricular fibrillation and ventricular
tachycardia. The device is programmed to detect
cardiac tachy-arrhythmias and correct it by
delivering a brief electrical impulse to the heart
within 10-15 sec.
It can also produce anti-bradycardia pacing and
synchronized cardioversion.

1. Survivors of cardiac arrest due to VF/VT not
resulting from reversible causes.
2. Spontaneous sustained VT with structural heart
disease.
3. Syncope of undetermined origin in a patient with
hemodynamically significant sustained VT/VF
induced at electrophysiology study.
4. Ischemic cardiomyopathy with EF<35% at least 40
days post MI.
5. Ischemic and non-ischemic dilated cardiomyopathy
with EF<35% and are NYHA class II or III.
6. Brugada syndrome and HOCM.
7. Arythmogenic right ventricular dysplasia
8. Patients awaiting cardiac transplantation

ICD acts by measuring each cardiac R-R
interval and categorize the rate as normal, too
fast (short R-R interval), or too slow (long R-R
interval). When the device detects a sufficient
number of short R-R intervals within a period
of time it will begin an antitachycardia event.
The internal computer will decide between
antitachycardia pacing (less energy use,
better tolerated by patient) or shock. If shock
is chosen, an internal capacitor is charged.
An ICD with antibradycardia pacing capability
will begin pacing when the R-R interval is too
long

Cardiac resynchronization therapy (CRT) is a
relatively new therapy for patients with
symptomatic heart failure resulting from systolic
dysfunction.
CRT is achieved by simultaneously pacing both
the left and right ventricles.
Theoretically, biventricular pacing resynchronizes
the timing of global left ventricular depolarization
and as a result improves mechanical contractility
and mitral regurgitation.
This therapy has been shown to improve the
symptoms of heart failure and overall quality of life
in certain patients with severe symptoms that
aren't controlled with medication.

1. CRT is indicated for patients who have LVEF
less than or equal to 35%, sinus rhythm, LBBB
with a QRS duration greater than or equal to
150 ms, and NYHA class II, III, or ambulatory IV
symptoms.
2. CRT can be useful for patients who have LVEF
less than or equal to 35%, sinus rhythm, LBBB
with a QRS duration 120 to 149 ms, and NYHA
class II, III, or ambulatory IV symptoms.
3. CRT may be considered for patients who have
LVEF less than or equal to 30%, ischemic
etiology of heart failure, sinus rhythm, LBBB
with a QRS duration of greater than or equal to
150 ms, and NYHA class I symptoms.

In response to abnormal heart rhythms, it may
also provide the following therapies:
1. Pacing therapy for slow heart rhythms
2. Defibrillation therapies for fast or irregular
heart rhythms
There are two types of CRT devices: a CRT
pacemaker (CRT-P) and a CRT defibrillator
(CRT-D). CRT-D devices, like all
defibrillators, have a pacemaker function in
them. Both devices help to coordinate the
heart’s pumping action and deliver pacing
therapy for a slow heart rate. However, the
CRT-D can also treat fast heart rhythms

Once a patient is identified as having a cardiac implantable
electronic device, certain points have to be covered
• the cause (underlying pathology as ISHD, malignant arrhythmia, drug
intake, other co-morbid conditions for preoperative optimization)
• When it was last checked (a comprehensive check by the programmer at
least once yearly for pacemakers and every 6 months for ICD &CRT)
• Cardiological consultation (to determine The type of the device and
program mode, Is it functioning properly ? Battery longevity?)
• Obtain a copy of the cardiological interrogation of the
CIED.
• Consider replacing any CIED near its elective
replacement period in a patient scheduled to undergo
either a major surgery or surgery within25 cm of the
generator.
• Identification and avoidance of any probable sources for
intraoperative electromagnetic interference
• The device response to magnet placement

Preoperative Evaluation
 Establish whether a patient has a cardiac rhythm management device
(CIED).
 Conduct a focused history (patient interview, medical records review, and
review of available chest x-rays, electrocardiograms, or any available monitor
or rhythm strip information).
 Conduct a focused physical examination (check for scars and palpate for
device).
 Define the type of CIED.
 Obtain manufacturer's identification card from patient or other source.
 Order chest x-ray if no other data are available.
 Refer to supplemental resources (e.g., cardiological consultation,
manufacturer's databases).
 Determine the dependence on pacing function of the CIED.
 Patient has history of symptomatic bradyarrhythmia resulting in CIED
implantation.
 Patient has history of successful atrioventricular nodal ablation.
 Patient has inadequate escape ventricular rhythm at lowest programmable
pacing rate with VVI mode.
 Determine CIED function.
 Interrogate device (consultation with a cardiologist or pacemaker-implantable
cardioverter-defibrillator [ICD] service is necessary).
 Determine whether the device will capture when it paces (i.e., produce a
mechanical systole with a pacemaker impulse).

preoperative appropriate reprogramming is the
safest way to avoid intraoperative problems,
especially if monopolar diathermy will be used.
1. Program minute ventilation rate responsiveness off
if present.
2. Program all rate enhancements and modulation
off.
3. Consider increasing the pacing rate to optimize
oxygen delivery to tissues for major cases.
4. Disable anti-tachycardia therapy if a defibrillator by
shifting its mode to “monitor only”
5. In case of central line insertion, Preoperative CXR
for CRT to confirm the position of the coronary
sinus lead and deactivation of ICD.
6. Establish a rapport with the proceduralist to identify
and minimize the intraoperative causes of
electromagnetic interference.

Regarding pacemakers: Reprogramming the pacing mode to
asynchronous, at a rate greater than the patient’s underlying rate,
usually ensures that no over- or under-sensing from EMI will take
place. However, setting a device to asynchronous mode has the
potential to create a malignant rhythm, the “R on T phenomenon”

Placement of a magnet over a generator might
produce no change in pacing since NOT ALL
PACEMAKERS SWITCH TO A CONTINUOUS
ASYNCHRONOUS MODE WHEN A MAGNET IS
PLACED. Also, not all models from a given company
behave the same way. Magnet behavior can be altered or
disabled via programming in many devices. only a magnet
test or interrogation with a programmer can reveal current
settings. Heart rhythm society recommends magnet
placement to create asynchronous pacing when needed
where the magnet behavior is known, appropriate for the
patient, the patient is supine, the magnet can be observed,
and access to the magnet is possible

Preoperative serum potassium level should
be correct in patients with CIED ONCE
DETECTED as hyperkalemia can have
deleterious effects on those patients through
increasing the resting membrane potential to
a more positive value thus increasing pacing
and the risk of VT/VF.

1. Temporary pacing “transcutanuoes and
transvenous”, defibrillation equipment, and resuscitation drugs
should be immediately available.
2. Availability of appropriate cardiac personnel.
3. Continues ECG and peripheral pulse monitoring.(disable the artifact
filter and pacing mode of monitor)
4. Regional anesthesia can be used (caution if anticoagulant is used)
5. Better to avoid drugs that inhibit the SA or the AV nodes like
dexmedetomidine or potent opiates.
6. Etomidate and ketamine can induce myoclonus
7. Succinylcholine could interfere with CEID by either elevating
serum potassium level or inducing fasciculations “myopotentials”
which are misinterpreted as cardiac electrical activity
8. some potent inhalational agents (isoflurane, sevoflurane, and
desflurane) might exacerbate the long Q-T syndrome
9. Avoid N2O in recently implanted pacemakers.
10. Avoid intraoperative hyperventilation

 Assure that the electrosurgical receiving plate is
positioned so the current pathway does not pass
through or near the CIED system.
 Advise the individual performing the procedure to
avoid proximity of the cautery's electrical field to
the pulse generator or leads.
use short, intermittent and irregular bursts at the
lowest feasible energy levels.
reconsider the use of a bipolar electrocautery
system or ultrasonic (harmonic) scalpel in place of
a monopolar electrocautery system if possible.

 Emergency defibrillation or cardioversion For the patient with an ICD and magnet-
disabled therapies:
 Advise the individual performing the procedure to terminate all sources of EMI while the
magnet is removed.
 Remove the magnet to re-enable anti-tachycardiac therapies.
 Observe the patient and the monitors for appropriate CIED therapy for 10 seconds
 If the above activities fail to restore ICD function, proceed with emergency external
defibrillation or cardioversion.
 For the patient with an ICD and programming-disabled therapies:
 Advise the individual performing the procedure to terminate all sources of EMI while the
magnet is removed.
 Re-enable therapies through programming if the programmer is immediately available
and ready to be used.
 Observe the patient and the monitors for appropriate CIED therapy for 10 seconds
 If the above activities fail to restore ICD function, proceed with emergency external
defibrillation or cardioversion.
 For external defibrillation:
 Position defibrillation/cardioversion pads or paddles as far as possible from the pulse
generator.
 Position defibrillation/cardioversion pads or paddles perpendicular to the major axis of
the CIED to the extent possible by placing them in an anterior-posterior location.
 If it is technically impossible to place the pads or paddles in locations that help to protect
the CIED, then defibrillate/cardiovert the patient in the quickest possible way and be
prepared to provide pacing through other routes.

postoperative care should include transferal to
the ICU, avoid postoperative shivering, pain,
and a full telemetric check and
re‐programming back to the original setting if
preoperative re‐programming was required.
Anti‐tachycardia therapies of implantable
defibrillators should obviously be
re‐programmed to their original settings.

Anesthesia for patients with Cardiac Implantable Electronic Devices

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