Periprocedural Management and Multidisciplinary Care Pathways for Patients With Cardiac Implantable Electronic Devices: A Scientific Statement From the American Heart Association

Abstract

The rapid technological advancements in cardiac implantable electronic devices such as pacemakers, implantable cardioverter defibrillators, and loop recorders, coupled with a rise in the number of patients with these devices, necessitate an updated clinical framework for periprocedural management. The introduction of leadless pacemakers, subcutaneous and extravascular defibrillators, and novel device communication protocols underscores the imperative for clinical updates. This scientific statement provides an inclusive framework for the periprocedural management of patients with these devices, encompassing the planning phase, procedure, and subsequent care coordinated with the primary device managing clinic. Expert contributions from anesthesiologists, cardiac electrophysiologists, and cardiac nurses are consolidated to appraise current evidence, offer patient and health system management strategies, and highlight key areas for future research. The statement, pertinent to a wide range of health care professionals, underscores the importance of quality care pathways for patient safety, optimal device function, and minimization of hemodynamic disturbances or arrhythmias during procedures. Our primary objective is to deliver quality care to the expanding patient cohort with cardiac implanted electronic devices, offering direction in the era of evolving technologies and laying a foundation for sustained education and practice enhancement.

Keywords: AHA Scientific Statements; critical pathways; defibrillators, implantable; delivery of health care; pacemaker, artificial; patient safety; perioperative care.

Figure 1.. Central Illustration: The cycle of periprocedural management of cardiac implantable electronic devices.

Periprocedural management of CIEDs begins with the development of a procedural plan at the CIED care center (cardiology clinic with and without remote monitoring; top left), which is communicated to the surgical/procedural team and implemented before the procedure (top right). The device and patient are monitored during the procedure (bottom right); settings are restored; and events are noted postprocedurally (bottom left) and communicated back to the CIED center. CIED indicates cardiac implantable electronic devices.

Figure 2.. Decision pathway for intraprocedural CIED management.

Decision pathway for CIED planning during medical procedures including surgical site, considerations for the presence of a defibrillator, pacemaker dependence, and requirements for magnet application. All devices with programming changes are usually reverted to preprocedural settings, and defibrillator therapies are re-enabled after the procedure. CIED indicates cardiac implantable electronic devices; ICD, implantable cardioverter defibrillator. *May use a magnet or reprogram the device, depending on pacing dependency, patient positioning, or recommendations from the CIED team. †Pacemaker dependency may be increased under sedation. In nondependent patients, the underlying rhythm/rate may still be inadequate for the operative procedure. ‡Reprogramming is required for defibrillators because the magnet does not affect the pacing mode. AOO, VOO, and DOO are asynchronous pacing of the atrium, ventricle, and both atrium and ventricle, respectively.

Figure 3.. Radiographic appearance of cardiac implantable electronic devices.

A, Side-by-side comparison of the chest x-ray film appearance of a dual-chamber implantable cardioverter defibrillator (ICD; left) and dual-chamber permanent pacemaker (right). The coil on the ICD lead (black arrow) is the hallmark of a defibrillator and helps distinguish it from a pacemaker. B, Anteroposterior (left) and lateral (right) chest x-ray film with Medtronic Micra AV ventricular implant (white arrow). Also shown are the atrial appendage clip (black arrow) and mitral valve replacement (white asterisk). C, Anteroposterior (left) and lateral (right) chest x-ray film with Aveir DR atrial implant (white arrow) and Aveir DR ventricular implant (black arrow). D, Anteroposterior (left) and lateral (right) chest x-ray film with Boston Scientific subcutaneous ICD generator (white arrow) and subcutaneous coil (black arrow). E, Anteroposterior (left) and lateral (right) chest x-ray film with Medtronic Aurora extravascular ICD generator (white arrow) and substernal coil (black arrow). F, Anteroposterior chest x-ray film (left) with loop recorder implant (white arrow). Right, clockwise: Medtronic Linq II, Biotronik Biomonitor 3, Abbott Confirm Rx, and Boston Scientific Lux-DX.

Figure 4.. Proposed workflow and interdisciplinary care of cardiac implantable electronic devices.

Medical center workflow for a patient with a CIED from periprocedural phases from advance outpatient procedure planning, preprocedural preparation, intraprocedural monitoring and emergency response, and postprocedural return to outpatient CIED follow-up. CIED indicates cardiac implantable electronic device; ICD, implantable cardioverter defibrillator; and PPM, permanent pacemaker.