Perioperative Management of Cardiac Implantable Electronic Devices

03/10/2021 - Dr. Justin Roberts

Transcript

1. Perioperative Management of Cardiac Implantable Electronic Devices Justin Roberts, MD Adult Cardiothoracic Fellow, PGY-V Robert Wood Johnson University Hospital March 10th, 2021
2. Objectives • 1) Understand the hardware and software of CIED’s • 2) Understand how EMI affects CIED’s • 3) Learn how to properly manage CIED’s for elective procedures
3. What Is A CIED? • Refers to any permanently implantable cardiac pacemaker, implantable cardioverter-defibrillator or resynchronization device.
4. Recent Practice Advisory From ASA
5. Conduction System of the Heart
6. When Errant Conduction Occurs??? • Your heart simply, needs help
7. Implantable Cardioverter-Defibrillators (ICD) • Indications: Prevention of sudden cardiac death (SCD) due to fatal arrhythmia • Primary prevention • Secondary prevention
8. ICD: Hardware • Electrodes • Pacing/Sensing • Defibrillation • Pulse generator
10. Pacemakers • Indications: • Symptommatic sinus bradycardia (usually <40BPM or frequent sinus pauses • Acquired AV block • Complete AV dissociation • Advanced 2nd degree (two or more consecutive P waves) • Symptommatic 2nd degree AV block, Mobitz 1 and 2 • Mobitz 2 with widened QRS or bifascicular block • Exercise induced second or third degree AV block
11. Pacemakers • Systems • Types • Modes • Related complications
12. Pacemaker Systems • Pulse generators: Battery component of the pacemaker • Trans venous systems: Trans venous electrodes to transmit electrical impulses from the pulse generator to the heart • Epicardial: Direct stimulation through pulse generator attached to the hearts surface • Leadless system: Newer innovation – Medtronic devices
13. Pacemaker Types • Single chamber • Dual chamber • BiVentricular pacer
14. Pacemaker Modes • Follow the NASPE/BPEG classification system
15. Pacemaker Complications • Pacemaker syndrome: represents suboptimal atrioventricular synchrony or AV dyssynchrony, regardless of the pacing mode after pacemaker implantation • Chest pain • Cannon a waves • Palpitations • Pneumothorax • Perforation
16. Peri-Operative Management • Electromagnetic interference: potential disruption of a device when in the presence of an electromagnetic field – externally. • Most common culprit => Electrosurgery unit • Unipolar or Bipolar • True Bipolar or Integrated Bipolar
17. Electromagnetic Interference • Pacing abnormalities • Device injury • Delivered shock to patient • Do not forget, mechanical injury
18. Pre-Operative Assessment • Elective procedures • Pre op assessment • Type of CIED • Manufacturer • Model number • Settings if available • Proper functioning device
19. Pre Operative Assessment (cont) • Device interrogation • Is the patient pacer dependent? • Is the device an ICD? • Will a magnet be appropriate?
20. Pre Operative Assessment (cont) • Physical Exam: • Pulse regularity • Location of generator • Recent EKG • CXR
21. Placing A Magnet • If a magnet is planned the device’s magnet response should be known • Most devices will default into asynchronous pacing at a fixed rate • ICD -> a magnet will suspend the tachyarrhythmia detection and therapy • Avoidance of inappropriate shocks • Should be reprogrammed to an asynchronous mode in pacer dependent patients to avoid oversensing or inhibition • Important to note, a magnet will never change a pacing mode of an ICD and inhibition may still occur
22. Magnet Placement (pacemakers) • Boston Scientific: device will beep continuously to indicate presence of magnet • If there is no beeping then it means device malfunction • Asynchronous pacing at 100BPM • Medtronic: Tone emitted upon device detection of magnet; asynchronous pacing at 85BPM • St Jude: No sound confirmation; Asynchronous at 100BPM • Biotronik: No sound confirmation; asynchronous VOO pacing at 70-90 BPM • Microport/Sorin: Pacing rate to 90, no sound; Asynchronous pacing at 96BPM and then gradually decreasing to 80
23. Magnet Placement (ICD) • Disabling tacchyarrhythmia function and therpy
24. Intraoperative Management • Monitors • Defibrillation capabilities • EMI precaution • Emergency
25. Postoperative Management • If programming took place prior to procedure the patient should be seen by a rep post operatively • Patient should remain on continuous ICU level monitoring until reprogramming takes place • ICD: EKG, pulse ox and defibrillator pads should be kept in place until patient is reprogrammed or seen by rep • If suspicion is high that arrhythmia took place or device malfunction occurred then clinical acumen prevails and patient should be seen. • Air on side of caution -> if there is a question have patient seen.
26. Taking Ownership • ASA: Interrogation of the device does not need to be done unless it was done within the last three to six months and is working well. • When appropriate alter the pacemaker to an asynchronous pacing mode by placing a magnet. Also, for ICD’s remove antitachycardic function. • Prevent current running through generator • Post op interrogation is not needed if no EMI occurred • Interrogate CIED after emergency surgery for all patients with these devices
40. CIED’s having interactions in non hospital environment • Much of the procedures happening in a hospital are outpatient procedures… • Cell phones now have wireless chargers that can alter device generators and affect normal functioning, transcutaneous muscle nerve stimulators • Interrogation studies show about 10% of patients with these devices have outside unintended magnet mode induction events.