Cardiac implantable electronic devices (CIEDs)

Learning objectives

• Preoperative assessment and precautions for patients with a CIED
• Intraoperative and postoperative management of patients with a CIED

Definition

• Cardiac implantable electronic device (CIED) refers to any permanently implantable cardiac pacemaker or any implantable cardioverter–defibrillator (ICD), as well as any cardiac resynchronization therapy device

Possible perioperative adverse events

Magnet use

• Application of a magnet to a modern pacemaker produces an asynchronous mode of pacing to protect a patient from the effects of electromagnetic interference
• A magnet can be secured over the pulse generator of an ICD to suspend the arrhythmia detection function and prevent discharge. Subsequent removal of the magnet promptly reactivates the ICD

Management

• Preoperative
  • Determine whether the patient has a CIED 
  • Determine the CIED type, manufacturer, and primary indication for placement
  • Determine whether the patient is pacing-dependent
  • Determine the CIED’s current settings and that it is functioning properly by interrogating the cardiac implantable electronic device or obtaining the most recent interrogation report
  • Determine possible sources of electromagnetic interference:
    • Electrosurgery (monopolar > bipolar)
    • Evoked potential monitors 
    • Nerve stimulators (twitch monitors) 
    • Fasciculations 
    • Shivering 
    • Large tidal volumes
    • External defibrillation 
    • Magnetic resonance imaging 
    • Radiofrequency ablation or lesioning 
    • Extracorporeal shock wave lithotripsy
    • Electroconvulsive therapy
  • Determine precautions:

• Intraoperative
  • Continuously monitor and display the electrocardiogram and SpO2 
  • Perform continuous peripheral pulse monitoring for all patients
  • If unanticipated CIED interactions occur, temporarily suspend the procedure until the source of interference can be identified and eliminated or managed
  • Interference source management:
  • Interference source management:

    Electrosurgery	Position the electrode so that the current does not pass through or near the CIED generator and leads
    	Avoid proximity of the electrical current to the generator or leads
    	When possible, use bipolar electrosurgery instead of monopolar
    	When monopolar electrosurgery is necessary, use intermittent and irregular bursts at the lowest feasible energy levels
    	Use an ultrasonic (harmonic) scalpel
    	If monopolar electrosurgery is planned superior to the umbilicus, ensure that the pacing function is altered to an asynchronous pacing mode in pacing-dependent patients and suspend an ICD’s antitachycardia function, if present. Ensure that the patient is in a monitored environment
    Radiofrequency ablation	Keep the radiofrequency current path (electrode tip to current return pad) as far away from the generator and leads as possible
    	If radiofrequency ablation is planned superior to the umbilicus, ensure that the pacing function is altered to an asynchronous pacing mode in pacing-dependent patients and suspend an ICD’s antitachycardia function, if present. Ensure that the patient is in a monitored environment
    Lithotripsy	Avoid focus of the lithotripsy beam near the generator
    Magnetic Resonance Imaging (MRI)	Move the patient outside of the immediate MRI area
    	Interrogate the CIED before the MRI scan
    	Suspend the antitachycardia function of an ICD before the MRI scan
    	Alter the pacing function to an asynchronous pacing mode in pacing-dependent patients before the MRI scan
    	Ensure that someone capable of programming the CIED remains in attendance for the duration of the MRI scan
    	Ensure that someone capable of performing advanced life support remains in attendance for the duration of the MRI scan
    	Reinterrogate the CIED and restore its permanent settings after the MRI is completed
    Radiofrequency identification devices	Avoid the use of these devices in close proximity to the CIED
    	Monitor for signs of electromagnetic interference and be prepared to stop using the radiofrequency identification device if interference occurs
    Electroconvulsive Therapy	Alter the pacing function to an asynchronous pacing mode in pacing-dependent patients
    	Suspend an IDC’s antitachycardia function, if present
    	Monitor for and be prepared to manage postconvulsive sinus tachycardia
    	Monitor for and treat ventricular arrhythmias that may occur secondary to the hemodynamic effects of electroconvulsive therapy

• Postoperative

Suggested reading

• Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators 2020. Apfelbaum JL, Schulman PM, Mahajan A, Connis RT, Agarkar M. Anesthesiology. 2020;132:225–252.
• Stone ME, Salter B, Fischer A. Perioperative management of patients with cardiac implantable electronic devices. British Journal of Anaesthesia. 2011;107:i16-i26.

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