Electromagnetic Interference with Protocolized Electrosurgery Dispersive Electrode Positioning in Patients with Implantable Cardioverter Defibrillators

Perioperative Considerations for Modern Leadless Pacemakers

Since their initial approval by the Food and Drug Administration in 2016, leadless pacemakers have become increasingly prevalent. This growth has been driven by an improved adverse effect profile when compared to traditional pacemakers, including lower rates of infection, as well as eliminated risk of pocket hematoma and lead complications. More recently, technology enabling leadless synchronized atrioventricular pacing in patients with atrioventricular block has vastly expanded the indications for these devices. Anesthesiologists will increasingly be relied upon to safely care for patients with leadless pacemakers undergoing non-electrophysiology procedures and surgery. This article provides an overview of the technology, evidence base, current indications, and unique perioperative considerations for leadless pacemakers.

Fundamental Electrophysiology Principles Related to Perioperative Management of Cardiovascular Implantable Electronic Devices

An increasing number of patients undergoing elective or emergency surgery in the United States have a cardiovascular implantable electronic device. Practice advisories and consensus statements have been issued by the American Society of Anesthesiologists and the Heart Rhythm Society, advocating a multidisciplinary approach. Unfortunately, anesthesia providers often find themselves in a situation in which they are left to manage these devices independently. At the University of Washington Medical Center, an anesthesiology-based service to manage these devices has existed for more than a decade. Many problems with devices have been observed, including confusing rhythms, failure of magnets to provide the desired change in device function, and actual device malfunction. With these clinical case examples taken from the authors' collective experience, this article provides an in-depth understanding of some key electrophysiology principles relevant to cardiovascular implantable electronic device function and appropriate perioperative management.

Inappropriate Implantable Cardioverter-Defibrillator Therapy During Total Hip Arthroplasty

Electromagnetic interference (EMI) is a known risk factor for triggering inappropriate therapy from implantable cardioverter-defibrillators (ICDs). Recommendations from the American Society of Anesthesiologists focus on EMI when using monopolar electrocautery for supraumbilical surgeries. Infraumbilical surgeries are not considered high risk for EMI; thus, no magnet must be applied routinely to prevent inappropriate ICD therapy intraoperatively. We describe a case of a 71-year-old woman who presented for left total hip arthroplasty with a history of an ICD. The patient's history was significant for non-ischemic cardiomyopathy. Monopolar electrocautery was used, and the level of the surgery was below the umbilicus. She experienced nine inappropriate ICD therapies intraoperatively with no long-term sequelae. The location of the electrocautery dispersion pad may have contributed to inappropriate therapies. Thus, the dispersion pad location should be considered when deciding whether to suspend anti-tachycardia functions intraoperatively. We present a case of inappropriate therapy from an ICD and make a recommendation for preventing such events.

Understanding the Principles of Electrosurgery for Endoscopic Surgery and Third Space Endoscopy

Electrosurgery is the application of high-frequency electrical alternating current to biologic tissue to cut, coagulate, desiccate, and/or fulgurate. Electrosurgery is commonly used in gastrointestinal endoscopy, with applications including biliary sphincterotomy, polypectomy, hemostasis, the ablation of lesions, and endoscopic surgery. Understanding electrosurgical principles is important in endoscopic surgery to achieve the desired therapeutic effect, optimize procedural outcomes, and minimize risks or adverse events. This article describes fundamental principles that apply to electrosurgical units, operator technique, and practical considerations for achieving desired tissue effects in endoscopic surgery; and provides practical guidance and safety considerations when using electrosurgical units in endoscopic surgery.

Sudden Occurrence of Pacemaker Capture Failure during Irreversible Electroporation Ablation for Prostate Cancer in Post-COVID-19 Patient: A Case Report

Irreversible electroporation (IRE) ablation is a novel treatment option for localized prostate cancer. Here, we present a case of an abrupt and fatal arrhythmia during the IRE procedure in a prostate cancer patient with an implanted permanent pacemaker. A 78-year-old male patient with a pacemaker due to sick sinus syndrome and syncope was scheduled for IRE prostate ablation surgery under general anesthesia. He had a history of recovering from coronavirus disease 2019 (COVID-19) after having been vaccinated against it and recovered without sequalae. Pacemaker interrogation and reprogramming to asynchronous AOO mode was carried out before surgery, however, sinus pause occurred repeatedly during ablation pulse delivery. After the first sinus pause of 2.25 s there was a decrease in continuous arterial blood pressure (ABP). During the delivery of the second and third pulses, identical sinus pauses were observed due to failure to capture. However, the atrial-paced rhythm recovered instantly, and vital signs became acceptable. Although sinus pause recovered gradually, the duration thereof was increased by the delivery of more IRE pulses, with a subsequent abrupt decrease seen in blood pressure. The pacemaker was urgently reprogrammed to DOO mode, after which there were no further pacing failures and no hemodynamic adverse events. For patients with pacemakers, close cardiac monitoring in addition to the interrogation of the pacemaker during the electromagnetic interference (EMI) procedure is recommended, especially in the case of having a disease that may aggravate cardiac vulnerability, such as COVID-19.

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.

Inadvertent Intraoperative Defibrillation Secondary to Electrocautery Grounding Pad Placement

Intraoperative defibrillation secondary to the usage of electrocautery in a patient with a cardiovascular implantable electronic device is a rare occurrence, and below-the-umbilicus electrocautery use causing inadvertent defibrillation is a near-zero risk. Defibrillation secondary to electrodispersive pad (EDP) radiofrequency dispersion has only ever been theorized. In this report, we describe the case of a 67-year-old male with an automatic implantable cardioverter defibrillator (AICD) undergoing a robotic-assisted left anterior total hip arthroplasty for left hip osteoarthritis who experienced inadvertent intraoperative defibrillation concurrent with electrocautery usage. The defibrillations ceased following contralateral EDP repositioning and application of a donut magnet overlying the patient's AICD.

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.

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

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.

Preoperative optimization of patients undergoing interventional procedures: infrastructure, logistics, and evidence-based medicine

PURPOSE OF REVIEW

Patients presenting for non-operating room procedures are often 'too sick' for surgery and require specific anesthesia care in remote areas with logistical and scheduling challenges.

RECENT FINDINGS

Increased complexity and scope of minimally invasive procedures have expanded this practice. In addition, the concept of therapeutic options other than conventional surgery is gaining traction.

SUMMARY

Our review of recent literature confirms the complexity and supports the safety of providing care in non-operating room anesthesia locations. Standard preanesthesia assessments and principles apply to these areas.

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.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Inappropriate Implantable Cardioverter-Defibrillator Therapy With the Use of an Underbody Electrosurgery Dispersive Electrode

Perioperative management of implantable cardioverter-defibrillators is an important part of anesthetic care. Society recommendations and expert consensus statements exist to aid clinicians, and they have identified the umbilicus as an important landmark in decision-making. Implantable cardioverter-defibrillator antitachycardia therapy may not need to be deactivated for infraumbilical surgery because electromagnetic interference is unlikely to occur. The authors present two cases in which inappropriate antitachycardia therapy occurred intraoperatively with use of an underbody dispersive electrode, even though both surgeries were infraumbilical. The authors also present two cadaver models to demonstrate how monopolar electrosurgery below the umbilicus is sensed using both traditional and underbody dispersive electrosurgical return electrodes.

The Year in Electrophysiology: Selected Highlights From 2020

This article is the third in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief Dr. Kaplan, the Associate Editor-in-Chief Dr. Augoustides, and the editorial board for the opportunity to continue this series; namely, the highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This third article focuses on the convergent procedure, His-bundle pacing, a comparison of subcutaneous and transvenous defibrillator therapies, the 2020 practice advisory update for the perioperative management of patients with cardiac implantable electronic devices, and a technology update regarding the Micra AV (Medtronic, Moundsview, MN), the EMPOWER leadless pacemaker (Boston Scientific, Marlborough, MA), WiSE-CRT (EBR Systems, Sunnyvale, CA), the Extravascular Implantable Cardioverter Defibrillator (Medtronic, Moundsview, MN), and the BAROSTIM NEO (CVRx Inc, Minneapolis, MN).

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

A modified algorithm for choosing the most appropriate intraoperative pacemaker mode for patients with permanent pacemaker in non-cardiac surgery

To avoid the risk of R-on-T incident and the unnecessary decrease of cardiac output, we devised an algorithm consisting of six steps for choosing the most appropriate intraoperative pacemaker (PM) mode, which is modified from Heart Rhythm Society and the American Society of Anesthesiologists expert consensus statement. Following this algorithm, we reviewed previous operations at our hospital to evaluate the appropriateness of the choices. Six of 78 cases (7.7%) were unfit to the algorithm because of an inappropriate mode change. The PM mode was changed preoperatively in four patients, even though the surgical site was under the umbilicus. In one case of the two other cases, the PM mode was changed from AAI to VOO. This case could not be avoided by the previous algorithm of the expert clinical statements. In another case, the anesthesiologist did not change PM mode even though the patient underwent parotidectomy and his heart rate depended on PM. Prospective research on this algorithm could clarify its usefulness in the future. Moreover, discussions about this algorithm could help develop this field of study and improve the intraoperative management of PMs.