Science, Medicine, and the Anesthesiologist

Periprocedural management of cardiac implantable electric devices (CIEDs) is challenging given the variety of devices currently in use. The American Heart Association’s guideline recommends preoperative practices, including identifying the type of device (transvenous or leadless pacemaker; transvenous, subcutaneous, or extravascular defibrillator; cardiac resynchronization device; or implantable cardiac monitor); location of the device (right or left infraclavicular, intracardiac, abdominal, or midaxillary region); indication for placement (sick sinus syndrome, atrioventricular block, prevention of sudden death, ventricular tachycardia or fibrillation); pertinent history (heart failure, cause of cardiomyopathy); and whether electromagnetic interference is a possibility. Key information that needs to be obtained preoperatively are battery life, programmed pacing mode, magnet response, magnetic resonance imaging (MRI) compatibility, underlying rhythm, and pacing dependency. The guideline highlights intraoperative risk mitigation strategies such as keeping the current path away from the CIED by placing the return electrode on the contralateral lower limb; using bipolar electrosurgery whenever possible; minimizing monopolar electrosurgery to 5-s bursts or shorter; and avoiding whole-body return electrodes. The guideline provides specific information on the magnet response of various devices by type, manufacturer, and models. Different strategies and workflows for successful periprocedural management of CIEDs are presented. The guideline includes user-friendly graphics.

Take home message: Periprocedural management of CIEDs includes patient-specific factors such as pacemaker dependency and device location; device-specific factors such as device type, settings, and function; and procedure-specific factors including the planned surgery, electrocautery, and positioning.