Management of Cardiac Implanted Electrical devices (CIED)

Management of Cardiac Implanted Electrical devices (CIED)

PERIOPERATIVE MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES (CIED) Paul G. Tarasi M.D. Staff Anesthesiologist Allegheny Health Network Adjunct Clinical Assistant Professor of Anesthesiology Temple University School of Medicine MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Objectives Describe different types of implanted cardiac devices

Describe indications for placement of implanted devices Discuss the pre-operative evaluation/preparation of patients with implanted cardiac devices Discuss the intra-operative management of patients with implanted cardiac devices Discuss the post-operative management and evaluation of patients with implanted cardiac

devices MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 1 True/False: All pacemakers have defibrillation capabilities. A. TRUE B. FALSE MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 2

True/False: All Implanted CardioverterDefibrillators (ICDs) have pacemaking capabilities. A. TRUE B. FALSE MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 3 The second letter in a pacemaker code (ex. DDD, VVI) refers to:

A. B. C. D. Chamber paced Chamber sensed Response to sensing Defibrillation capabilities MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 4 The general response to placing a magnet over a pacemaker is:

A. Deactivates pacemaker function B. Inhibits device sensing of electromagnetic interference C. Changes pacemaker to asynchronous mode D. Nothing MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 5 True/False: Placing a magnet over an ICD will place the pacemaker function (if activated) into asynchronous mode? A. TRUE B. FALSE

MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Types of Devices Pacemakers Implantable Cardioverter-Defibrillator Cardiac Resynchronization Therapy (CRT) - Bi-V MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Indications for Pacemakers

Symptomatic sinus node disease Symptomatic atrioventricular node disease (AV node) Long QT syndrome Hypertrophic Obstructive Cardiomyopathy Dilated Cardiomyopathy (CRT-P) MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES

Indications for ICD Ventricular Tachycardia Ventricular Fibrillation Brugada Syndrome Arrhythmogenic Right Ventricular Dysplasia Hypertrophic cardiomyopathy Cardiomyopathy with EF < 30-35%

MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Pacemaker Code https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=267 https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=267 ht tps ://www. cms.g ov/ me dic are -co verage -d atab as e/d eta ils/ nc a-de cis ion -memo.a spx ?NCAI d= 267 ht tps: //www.c ms .g ov/ med ica re- cov erage -da tab ase /de ta ils/ nca -de cis ion -memo.as px ?NCAId = 267 http s:/ /www.c ms .go v/med ica re-c ov era ge- dat aba se /de tai ls/n ca- dec isi on -me mo .as px? NCAId =2 67 MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES ICD Code

http://anesthesiology.pubs.asahq.org/data/Journals/JASA/931183/27TT2.png MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Pre-operative Evaluation Goals: Establish whether a patient has a CIED Define type of device

Determine is patient is CIED-dependent for anti-bradycardia pacing function Determine device function MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Pre-operative Evaluation 1. Determine if a patient has a CIED HISTORY patient interview review medical records review CXR, EKGs, monitor, rhythm strip PHYSICAL EXAMINATION

palpate device look for surgical scar MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Pre-operative Evaluation 2. Define the type of device Obtain manufacturers ID card from patient Review operative/implantation record Call device manufacturer (if known)

Review CXR MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES PRE-operative Evaluation 2. Define type of device CXR review: Most devices have an X-ray code to identify manufacturer Look for lead characteristics MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES

Pre-operative Evaluation - Chest X-Ray https://uscemeducation.com/2016/03/24/pacemaker-panic/ MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Pre-operative Evaluation 3. Determine whether a patient is dependent on device for antibradycardia pacing function (pacer dependent) Verbal history/medical record History of successful AV Node ablation CIED evaluation that shows no evidence of

spontaneous ventricular activity when pacemaker programmed to VVI at lowest programmable rate MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Pre-operative Evaluation 4. Determining device function Comprehensive device evaluation MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES

Pre-operative Preparation 1. Obtain a pre-procedure evaluation and prescription from the CIED team Advise CIED team about planned procedure: Type, anatomic location, patient position for procedure Potential for electromagnetic interference (EMI) Surgical venue, post-op disposition, unusual circumstances CIED team to provide prescription to the procedure team: Device type/make/model/indication for placement/last interrogation Interrogation: Within 12 months for pacemaker, 6 months for ICD

Plan for pre-/intra-/post-op management Device response to magnet Is patient pacemaker dependent MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Pre-op Preparation 1. Determine if EMI is likely to occur 2. Determine if reprogramming of pacemaker function to asynchronous mode or disabling special algorithms is needed.

3. Suspend antitachyarrhythmia function if present 4. Discuss case with surgeon - minimize EMI 5. Assure availability of temporary pacing and defibrillation equipment 6. Evaluate possible effects of anesthetic techniques on CIED function

MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Table 1 Pre-operative Preparation Action EMI Unlikely (below umbilicus) EMI Likely - PM no special precautions Reprogram to asynchronous mode when indicated Suspend rate-adaptive mode EMI Likely - ICD

Suspend antitachyarrhythmia mode If pacer dependent - modify as indicated above EMI Likely - All Use Bipolar electrocautery or ultrasonic scalpel Have temporary pacing and cardioversion/ defib equipment available MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Intra-operative Management

Monitoring: Continuous electrocardiography Continuous monitoring of peripheral pulse Palpation of pulse Arterial line tracing Pulse plethysmography MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Intra-operative Management Manage potential sources of EMI

Electrocautery Position cautery tool and current return pad so current pathway does not pass through or near the CIED: >6 inches Avoid proximity of cauterys electric field to the pulse generator and leads Use short, intermitted burst of electrocautery and lowest feasible energy levels Use bipolar electrocautery or ultrasound (harmonic) scalpels MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES

Intra-operative Management Electromagnetic Interference: Radiofrequency Ablation: Avoid contact of ablation catheter to generator and leads Keep current pathway as far away as possible Cardioversion Place pads as far away from generator as possible Place pads perpendicular to major axis of generator and leads:

A-P Lithotripsy Possible inappropriate sensing and suppression of pacing Focus lithotripsy beam away from use generator Terminate lithotripsy for arrhythmias Disable atrial pacing if the lithotripsy machine triggers on the R-wave MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Intra-operative Management Therapeutic Radiation Device must be out of target area for radiation

Device evaluation post-treatment ECT Pacemaker: If unipolar sensing - reprogram to asynchronous ICD: disable tachytherapy MRI Generally contraindicated - if must be performed, consult with cardiologist, radiologist, and device manufacturer MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES

Intra-operative Management Special circumstances - EMI Colonoscopy/gastroscopy: No problem unless electrocautery used Tissue Expanders: May have magnets used to direct needle to fill expanders - may activate magnetic switch in device DO NOT USE

TENS/Spinal Cord Stimulators Generally not recommended MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Intro-operative Management DISABLING THERAPY: device reprogramming magnet MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Intra-operative Management

Magnet Response: Pacemaker: generally cause ASYNCHRONOUS PACING ICD: generally inhibits antitachycardia (SHOCK) therapy Not always *****NO effect on pacemaker function!!! Asynchronous pacemaker function needs to be programmed. MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Intra-operative Management

Reprogramming: Advantage: predictable does not rely on proper placement of magnet Disadvantage: Changes not always readily reversible (Vtach, sinus tach/competing heart rhythm) Human error: programming and failure to re-enable tachytherapy Need for continuous ECG monitoring and defibrillation equipment continuously available Need for patient tagging MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES

Intra-operative Management Magnet Advantage: readily available quickly reversible Disadvantage: Not always possible to maintain magnet position Unpredictable magnet response MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES

Post -operative Management Goals: interrogation of device restoration of CIED function MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Post-operative Management ASA Practice Advisory: Cardiac rate and rhythm should be monitored continuously throughout immediate post-op period

Interrogation of device Restoration of antitachytherapy Consider consultation with cardiologist or pacemaker/ICD service MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Post-operative Management

Heart Rhythm Society/ASA Consensus Statement MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Post-operative Management HRS/ASA Consensus Statement Table 9: Indications for interrogation of CIEDs prior to patient discharge or transfer from a cardiac telemetry environment Patients with CIEDs reprogrammed prior to the procedure that left the

device nonfunctional such as disabling tachycardia detention in an ICD Patients with CIEDs who underwent hemodynamically challenging surgery such as cardiac surgery or significant valvular surgery (e.g. AAA repair) Patients with CIEDs who experienced significant intraoperative events including cardiac arrest requiring temporary pacing or CPR and those who required external electrical cardioversion. Post-operative Management MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Table 9: Indications for interrogation of CIEDs prior to patient

discharge or transfer from a cardiac telemetry environment (cont.) Emergent surgery where the site of EMI exposure was above the umbilicus Cardio-thoracic surgery Patients with CIEDs who underwent certain types of procedures (Table 8 previous slide) that emit EMI with a greater probability of affecting device function Patients with CIEDs who have logistical limitations that would prevent reliable device evaluation within one montH from their procedure. MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 1

True/False: All pacemakers have defibrillation capabilities. A. TRUE B. FALSE MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 1 True/False: All pacemakers have defibrillation capabilities. A. TRUE B. FALSE MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES

Question 2 True/False: All Implanted CardioverterDefibrillators (ICDs) have pacemaking capabilities. A. TRUE B. FALSE MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 2 True/False: All Implanted CardioverterDefibrillators (ICDs) have pacemaking capabilities. A. TRUE

B. FALSE MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 3 The second letter in a pacemaker code (ex. DDD, VVI) refers to: A. B. C.

D. Chamber paced Chamber sensed Response to sensing Defibrillation capabilities MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 3 The second letter in a pacemaker code (ex. DDD, VVI) refers to:

A. B. C. D. Chamber paced Chamber sensed Response to sensing Defibrillation capabilities MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 4

The general response to placing a magnet over a pacemaker is: A. Deactivates pacemaker function B. Inhibits device sensing of electromagnetic interference C. Changes pacemaker to asynchronous mode D. Nothing MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 4 The general response to placing a magnet over a pacemaker is:

A. Deactivates pacemaker function B. Inhibits device sensing of electromagnetic interference C. Changes pacemaker to asynchronous mode D. Nothing MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 5 True/False: Placing a magnet over an ICD will place the pacemaker function (if activated) into asynchronous mode? A. TRUE B. FALSE

MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Question 5 True/False: Placing a magnet over an ICD will place the pacemaker function (if activated) into asynchronous mode? A. TRUE B. FALSE MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES Questions?

MANAGEMENT OF CARDIAC IMPLANTED ELECTRICAL DEVICES References: Crossley, GH et. al The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the Preoperative Management of Patients with Implantable Defibrillators, Pacemakers, and Arrhythmia Monitors: Facilities and Patient Management 2011 Practice Advisory for the Preoperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators - An Updated Report by

the American Society of Anesthesiologists Task Force on Preoperative Management of Patients with Cardiac Implantable Electronic Devices. Anesthesiology 2011; 114:247-61 Rozner, MA Cardiac Pacing and Defibrillation.

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