Perioperative Interrogation of Boston Scientific Cardiovascular Implantable Electronic Devices: A Guide for Anesthesiologists

[Follow-up of the patient with pacemakers: Interrogation and basic programming]

Permanent pacemakers are a frequently used therapeutic modality. Its use has had a great impact on the morbidity and mortality and quality of life of patients with heart rhythm disturbances, with an exponential increase observed in recent decades. The use of this strategy presents different phases, in which follow-up throughout the useful life of the device is a fundamental and determinant pillar of the efficacy and safety of this therapeutic modality. This review seeks to provide a clear and structured update of the fundamental aspects to consider in the follow-up of all patients with pacemakers. The follow-up of the patient with a pacemaker must follow a complete, systematic and periodic protocol, evaluating aspects and parameters related to the patient and the pacemaker, in order to ensure the proper and safe operation of the device adapted to the person.

Evaluating the magnet response in deep subcutaneous implanted cardioverter defibrillator implants

INTRODUCTION

The manufacturer of subcutaneous implantable cardioverter defibrillators (S-ICDs) acknowledges that 'deep implants' may fail to elicit a magnet response, however, does not define 'deep implant' or recommend a maximum implant depth. This study aims to systematically evaluate the effect of subcutaneous tissue depth and magnet types on evoked magnet response.

METHODS

Sunshine Coast University Hospital's S-ICD cohort underwent magnet response evaluation; where bar and donut magnets were compared and the evoked magnet response was recorded in three separate zones, guided by a template. Ordinal regression (OR) models assessed the relationship between the evoked magnet response and tissue depth (TD), measured via post-implant X-Ray. The patient's ability to hear the magnet response audible tone was recorded.

RESULTS

Patients (n = 39) with measurable TD (n = 30) were analyzed. The bar magnet evoked a magnet response in all zones in 53% of patients, compared with 73% of patients with the donut magnet (p = 0.18). The relationship between bar magnet response and TD showed the odds of an evoked magnet response decreased by 11% every 1 mm increase in TD (OR of 0.89, p < 0.01), whereas the donut magnet decreased by 16% per 1 mm (OR of 0.84, p < 0.01). Directly over the S-ICD was the most effective in evoking magnet response with the bar (85% of patients), and off-centre was most effective for the donut magnet (100%). BMI and Praetorian score were not significantly associated with magnet response. We found 23% of patients were unable to detect the audible tone.

CONCLUSION

We observed a statistically significant association between TD and ability to evoke magnet response. The bar magnet was less reliable than the donut magnet for therapy inhibition in deep implants.

An Unexpected Magnet Response of a Biotronik Pacemaker in Automatic Mode: A Case Report

In patients with cardiovascular implantable electronic devices, asynchronous pacing is necessary for surgeries with a risk of electromagnetic interference. Magnets are often used for asynchronous pacing. In this case report, magnet application to a Biotronik Evia DR-T pacemaker (Biotronik) programmed to a magnet response mode called automatic magnet mode (AUTO) led to a brief period of asynchronous pacing before reverting to prior settings, an unexpected response that was not revealed on the preoperative interrogation report. For Biotronik pacemakers programmed to the AUTO mode, changes in programming are needed for asynchronous pacing.

Pro-Con Debate: Are Patients With a Cardiovascular Implantable Electronic Device Suitable to Receive Care in a Free-Standing Ambulatory Surgery Center?

Migration of surgical and other procedures that require anesthesia care from a hospital to a free-standing ambulatory surgery center (ASC) continues to grow. Patients with cardiac implantable electronic devices (CIED) might benefit from receiving their care in a free-standing ASC setting. However, these patients have cardiovascular comorbidities that can elevate the risk of major adverse cardiovascular events. CIEDs are also complex devices and perioperative management varies between devices marketed by various manufacturers and require consultation and ancillary services, which may not be available in a free-standing ASC. Thus, perioperative care of these patients can be challenging. Therefore, the suitability of this patient population in a free-standing ASC remains highly controversial. Although applicable advisories exist, considerable discussion continues with surgeons and other proceduralists about the concerns of anesthesiologists. In this Pro-Con commentary article, we discuss the arguments for and against scheduling a patient with a CIED in a free-standing ASC.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Perioperative Management of Cardiac Implantable Electronic Devices: A Single-Center Report of 469 Interrogations

OBJECTIVE

Anesthesiologists increasingly are involved in the perioperative management of cardiac implantable electronic devices (CIEDs). The variety of devices available and the ongoing advancements in technology, programming capabilities, and responses to conventional management (eg, magnet application) complicate the management of these devices. As an aid to this clinical challenge, this manuscript reviews 469 interrogations performed by a single cardiac anesthesiologist during a 4.5-year period to derive useful information with which to guide anesthesiologists who have chosen to pursue training in this area of perioperative care.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Single institution, quaternary care hospital.

PARTICIPANTS

Patients with CIEDs presenting for surgery; the quality assurance (QA) reports of 469 interrogations performed between May 2015 and September 2019 were reviewed.

INTERVENTIONS

No intervention.

MEASUREMENT AND MAIN RESULTS

The distributions of surgical procedures, device types, device manufacturers, pacing modes, rate-response sensors, special functions, and performed interventions were reviewed and analyzed. The QA reports were evaluated to identify information or experiences that demonstrated important lessons for anesthesiologists engaging in perioperative CIED management.

CONCLUSIONS

This database review provides general guidance for anesthesiologists managing CIEDs in the perioperative period. Concepts germane to the operating room are emphasized.