Perioperative Management of Patients with Cardiac Implantable Electronic Devices and Utility of Magnet Application

Abstract

With the demographic evolution of the population, patients undergoing surgery today are older and have an increasing number of sometimes complex comorbidities. Cardiac implantable electronic devices (CIED) are also getting more and more complex with very sophisticated programming algorithms. It may be generally assumed that magnet application reverts pacing to an asynchronous mode in pacemakers and disables tachycardia detection/therapy in internal cardioverter-defibrillators. However, depending on device type, manufacturer and model, the response to magnet application may differ substantially. For these reasons, perioperative management of CIED patients is getting more and more challenging. With this review article we provide an overview of optimal perioperative management of CIED patients with a detailed description of CIED response to magnet application depending on manufacturer and device-type, which may help in providing a safe perioperative management plan for the CIED patient.

Keywords: cardiac implantable electronic device; cardiac resynchronization therapy; implantable cardioverter defibrillator; magnet application; pacemaker; perioperative management.

Figure 1

Radiopaque manufacturer identifier of the most frequently implanted CIEDs. Each manufacturer has a specific radiopaque identifier embedded within the device header which can be visualized by means of an X-ray of the chest. Depending on the model, MRI compatibility, etc., there may be some additional letters, numbers or symbols. # The vast majority of St. Jude Medical CIEDs show three specific letters, i.e., SJM, but additional letters may appear. * Boston Scientific CIEDs are labeled as either BSC or BOS, followed by an additional three-digit numeric code, which can vary according to the model.

Figure 2

Proposed algorithm for perioperative management of patients with PM/CRT-P. First, check if generator is accessible and correct magnet positioning may be guaranteed throughout surgery (PM accessible). Afterwards check if EMI occurrence is likely. Finally, check if patient is pacing dependent. In case of preoperative programming, continuous rhythm monitoring is mandatory until device is reprogrammed. Correct placement of the dispersive electrode is crucial to reduce EMI risk. Consider specific magnet responses of different manufacturers and CIED models. In case invasive blood pressure monitoring is not available, pulsoxymetry should be used, since evaluation of monitor ECG may be difficult due to artefacts caused by electrosurgery. Reprogram device: program asynchronous mode; EMI—electromagnetic interference; PM—pacemaker; PM dependent—pacing dependent; CRT-P—cardiac resynchronization therapy—pacemaker.

Figure 3

Proposed algorithm for perioperative management of patients with ICD/CRT-D. First, check if generator is accessible and correct magnet positioning may be guaranteed throughout surgery (PM accessible). Afterwards check if EMI occurrence is likely. Finally, check if patient is pacing dependent and if rate response is programmed. In case of preoperative programming, continuous rhythm monitoring is mandatory until device is reprogrammed. Correct placement of the dispersive electrode is crucial to reduce EMI risk. Consider specific magnet responses of different manufacturers and CIED models. In case invasive blood pressure monitoring is not available, pulsoxymetry should be used, since evaluation of monitor ECG may be difficult due to artefacts caused by electrosurgery. Reprogram device: deactivate tachycardia detection and therapy if patient is not pacing dependent; program asynchronous mode if patient is pacing dependent (automatically deactivates tachycardia detection and therapy); deactivate rate response, if necessary. EMI—electromagnetic interference; PM—pacemaker; PM dependent—pacing dependent; ICD—internal cardioverter defibrillator; CRT-D—cardiac resynchronization therapy—defibrillator.