Use Caution When Applying Magnets to Pacemakers or Defibrillators for Surgery

Safe and effective intraosseous basivertebral nerve radiofrequency neurotomy in a patient with a permanent pacemaker

Introduction

Intraosseous basivertebral nerve radiofrequency neurotomy is a fairly novel technique which is currently considered contraindicated in patients with an implanted pacemaker. Re-evaluation of this restriction is important given the comorbidity of chronic low back pain and cardiac disease.

Case

A 78-year-old male with chronic low back pain (CLBP) that had failed both conservative and operative management with work-up including MRI spine suggestive of vertebrogenic low back pain. Patient agreed to undergo this procedure using a magnet to convert the active pacemaker to asynchronous pacing, resulting in fixed ventricular rate, perioperatively. The procedure was accomplished successfully with sustained improvement of his CLBP at six months follow up.

Conclusion

This is the first published case demonstrating successful intraosseous basivertebral nerve radiofrequency neurotomy in a patient with a permanent pacemaker with appropriate precautions.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

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

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.

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.

Safety and Efficacy of Magnet Use to Temporarily Inhibit Inappropriate Subcutaneous Implantable Cardioverter Defibrillator Therapy in Emergency Situations: A Case Report

Introduction: The subcutaneous implantable cardioverter defibrillator (S-ICD) represents a major advancement in ICD technology. Inappropriate shocks (IAS) occur in more than 3.1% of the population with S-ICD each year and are usually followed by admission to the emergency department (ED). In this setting, the disabling of IAS is mandatory during a pseudo-electrical storm (ES). This report describes the strategies that can be followed in order to temporarily inhibit IAS in critical care settings with the use of magnets.

Case presentation: An S-ICD was implanted more than 6 weeks prior to presentation in a 68-year-old man with hypertrophic cardiomyopathy. In the ED, the patient experienced 3 IAS in the last hour. A Medtronic magnet was applied to stop IAS, as the specific programmer was not available. The maneuver interrupted the IAS. In order to verify the universal magnetic response of the S-ICD, six different magnets and one smartphone with MagSafe technology were tested. All magnet models suspended arrhythmia detection and IAS, while the smartphone did not cause magnet interferences.

Conclusions: This report demonstrates the safety and efficacy of all clinical magnet models in inhibiting IAS. In case of pseudo-ES, any type of magnet allows ED providers to easily and rapidly disable the functionality of the devices when appropriate.

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.

Appropriate Delivery of Antitachyarrhythmia Therapy Despite Magnet Placement Over Implanted Cardioverter-Defibrillator: A Case Report

The fundamental perioperative concern for patients with implantable cardioverter-defibrillators (ICDs) is the potential for electromagnetic interference (EMI) from monopolar electrosurgery. The ICD may interpret electromagnetic signals as a tachyarrhythmia and deliver an inappropriate shock to the patient. Magnet placement is often used to avoid this problem since a magnet will often deactivate an ICD's tachyarrhythmia therapy. We report a case in which magnet placement over an ICD failed to suspend tachyarrhythmia therapy because of imprecise magnet positioning. This case demonstrates the possibility for error when relying on a magnet to suspend tachyarrhythmia therapies.

Patient with an implantable cardiac electrical stimulation device. What should the anesthesiologist know?

Patients with implantable electric stimulation devices are challenging to the anesthesiologist since these cases demand a comprehensive knowledge about how the device operates, the indications for the implant and the implications that must be addressed during the perioperative period . This article is intended to provide the reader with clear and structured information so that the anesthesiologist will be able to safely deal with the situation of a patient with an implantable cardiac stimulation device, who has been programmed for emergent surgery. A search for the scientific evidence available was conducted in Pubmed / Medline, ScienceDirect, OVID, SciELO), for a non-systematic review. The incidence of the use of cardiac electric stimulation devices has been growing. Their operation is increasingly complex, and demands being constantly updated on the knowledge in the area.

Implementation of a Postoperative Electronic Health Record Alert for Cardiac Implantable Electronic Device Patients

PURPOSE

Approximately 2% of surgical patients have an existing cardiac implantable electronic device (CIED). Perioperative device reprogramming requires postoperative care to ensure that device settings are restored. Electronic health record (EHR) alerts have been shown to improve communication between providers and decrease time to necessary interventions in other areas of medicine. The aim of this quality improvement project was to create an EHR alert for postoperative CIED patients who require device reprogramming to help clinicians track, remember, and document the timely and safe restoration of device settings.

DESIGN

This project used a pre-post observational design.

METHODS

This project was conducted at a major academic medical center using a pre-post observational design. To prevent anesthesia providers from closing an encounter in the EHR before postoperative restoration of device settings, an alert was developed and embedded within the intraoperative EHR to track preoperative device reprogramming, and alert anesthesia providers to perform and document postoperative restoration of safe settings.

FINDINGS

The postimplementation group (n = 272) had fewer unknown or undocumented preoperative CIED interventions (12.9% vs 30.9%), a 7.3% shorter device suspension time (median = 165 minutes vs 178 minutes), 6.8% improvement in documentation of postoperative re-enabling of device therapies (78.8% vs 72.0%), and a 72.48% decrease in length of stay (median = 625 hours vs 172 hours) when compared with the preimplementation group (n = 132).

CONCLUSION

Electronic prompts effectively captured patients who received preoperative CIED reprogramming and provided a process for reprogramming devices to safe settings, both significant steps in preventing negative patient outcomes associated with undocumented CIED interventions. Perioperative CIED documentation improved, and length of stay decreased after project implementation.

Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter–Defibrillators 2020

This practice advisory updates the “Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter–Defibrillators: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices,” adopted by the American Society of Anesthesiologists in 2010 and published in 2011. This updated advisory is intended for use by anesthesiologists and all other individuals who deliver or who are responsible for anesthesia care. The update may also serve as a resource for other physicians and healthcare professionals who manage patients with cardiac implantable electronic devices.

Supplemental Digital Content is available in the text.

Comparison of perioperative strategies in ICD patients: The perioperative ICD management study (PIM study)

BACKGROUND

The prevalence of patients with implanted cardioverter defibrillators (ICDs) and the frequency of surgery on these patients are steadily on the rise. Guidelines recommend preoperative ICD reprogramming, although this is sometimes difficult in clinical practice. Placing a magnet on the ICD is a practical alternative and even no inactivation is possible in selected cases.

METHODS

In this prospective observational study, we compared different perioperative ICD management strategies depending on the location of the surgery and the type of electrocautery used. Patients undergoing surgery above the umbilicus with monopolar electrocautery had their ICD therapy inactivated by reprogramming. When surgery below the navel or surgery above the navel with bipolar electrocautery was completed, ICD inactivation was performed using a magnet. No inactivation was performed on patients undergoing lower extremity surgery with bipolar electrocautery. Only ICD patients who were not pacemaker dependent were enrolled. After surgery, the ICDs were assessed regarding documented arrhythmias and parameters.

RESULTS

Out of 101 patients included in this study, the ICD was preoperatively reprogrammed in 42 patients (41.6%), a magnet was used on 45 patients (44.5%), and ICDs were not deactivated at all in 14 patients (13.9%). No intraoperative electromagnetic interference was detected. Postoperative ICD analysis demonstrated no changes of preset parameters.

CONCLUSIONS

All three tested ICD management strategies were proved safe in this study. Keeping the location of surgery and the type of electrocautery in mind, an intraoperative magnet or even no ICD deactivation at all could be feasible alternatives in surgery on patients with ICDs.

Cautery selection for oculofacial plastic surgery in patients with implantable electronic devices

PURPOSE

To discover oculofacial plastic surgeon practice patterns for cautery selection in the setting of implantable electronic devices and present guidelines based on a review of current literature.

METHODS

A 10-Question web-based survey was sent to the email list serve of the American Society of Ophthalmic Plastic and Reconstructive Surgery to determine surgeon cautery preference in the setting of various implantable electronic devices and comfort level with the guidelines for cautery selection in their practice or institution. The relationship between survey questions was assessed for statistical significance using Pearson's Chi-square tests.

RESULTS

Two hundred ninety-three (41% response rate) surveys were completed and included for analysis. Greater than half of respondents either had no policy (36%) or were unaware of a policy (19%) in their practice or institution regarding cautery selection in patients with a cardiac implantable electronic device. Bipolar cautery was favored for use in patients with a cardiac implantable electronic device (79%-80%) and this number dropped in patients with implantable neurostimulators (30%). Overall, one-third of respondents did not feel comfortable with their practice/institution policy.

CONCLUSION

Choices and comfort level among oculofacial plastic surgeons for cautery selection in patients with implantable electronic devices vary considerably, and some choices may increase the risk for interference-related complications. Practice patterns vary significantly in the setting of a neurostimulator or cochlear implant, where interference can cause thermal injury to the brain and implant damage, respectively. Guidelines are proposed for cautery selection in patients with implantable electronic devices undergoing oculofacial plastic surgery.

Asystole during pacemaker magnet application

Pacemaker magnet application during surgery for patients who are pacemaker-dependent is often utilized to avoid perioperative inhibition from electromagnetic interference. We present a case during which such routine magnet use resulted in an unexpected response and discuss the limitations and nuances of this common practice.

Anaesthetic consideration in patients with cardiac implantable electronic devices scheduled for surgery

With advances in cardiology and cardiothoracic surgery, several newer implantable cardiac devices have become common in the surgical population. Multichamber pacemakers, implanted cardiac defibrillators and ventricular assist devices are frequent in current day practice. Many of the newer implantable cardiac electronic devices are targeted at managing heart failure. While managing such patients for non-cardiac surgeries, specific issues related to equipment characteristics and troubleshooting should be a priority for the anaesthesiologists. There is a possibility of malfunction of the devices resulting in catastrophic outcomes. Therefore, it is imperative to understand the pathophysiology, device characteristics and troubleshooting before embarking on anaesthetising patients with implantable cardiac electronic devices.

Interference between surgical magnetic drapes and pacemakers: an observational study comparing commercially available devices and a new magnetically isolated drape

Background

Magnetic fields may potentially interfere with the function of cardiovascular implantable electronic devices. Sterile magnetic drapes used to hold surgical instruments are often placed on the patient’s thorax, and they are likely to interfere with the function of these devices.

Methods

Thirty patients were recruited to compare a new prototype surgical magnetic drape (LT10G™ by Menodys) made with bottom-isolated ferrite magnets to the Covidien magnetic drape we used in a previous study. Twenty additional patients were recruited to compare the prototype drape with four commercially available surgical magnetic drapes.

Results

Magnetic interference was found in 33 of the 50 total patients (70 %) when the Covidien drape was placed over the pacemaker. Of the 20 additional patients, 5 patients (25 %) displayed magnetic interference with a second type of surgical magnetic drape. A third magnetic drape caused interference in one patient (5 %), whereas a larger drape of the same model did not interfere in any patient. No patients demonstrated magnetic interference with the prototype drape.

Conclusion

Bottom isolation of magnets in the prototype magnetic drape (LT10G™) used during surgery prevents magnetic interference in all patients when placed over the pacemaker. Three of the four commercially available magnetic drapes tested demonstrated magnetic interference. Flipping the prototype drape is not recommended as it may expose non-isolated magnets to the cardiovascular implantable electronic device.

Electronic supplementary material

The online version of this article (doi:10.1186/s12938-016-0205-y) contains supplementary material, which is available to authorized users.

Management of Patients With Cardiovascular Implantable Electronic Devices in Dental, Oral, and Maxillofacial Surgery

The prevalence of cardiovascular implantable electronic devices as life-prolonging and life-saving devices has evolved from a treatment of last resort to a first-line therapy for an increasing number of patients. As these devices become more and more popular in the general population, dental providers utilizing instruments and medications should be aware of dental equipment and medications that may affect these devices and understand the management of patients with these devices. This review article will discuss the various types and indications for pacemakers and implantable cardioverter-defibrillators, common drugs and instruments affecting these devices, and management of patients with these devices implanted for cardiac dysrhythmias.

Initial Experience of an Anesthesiology-based Service for Perioperative Management of Pacemakers and Implantable Cardioverter Defibrillators

Background

Management of cardiovascular implantable electronic devices (CIEDs), including pacemakers and implantable cardioverter defibrillators, for surgical procedures is challenging due to the increasing number of patients with CIEDs and limited availability of trained providers. At the authors’ institution, a small group of anesthesiologists were trained to interrogate CIEDs, devise a management plan, and perform preoperative and postoperative programming and device testing whenever necessary.

Methods

Patients undergoing surgery between October 1, 2009 and June 30, 2013 at the University of Washington Medical Center were included in a retrospective chart review to determine the number of devices actively managed by the Electrophysiology/Cardiology Service (EPCS) versus the Anesthesiology Device Service (ADS), changes in workload over time, surgical case delays due to device management, and errors and problems encountered in device programming.

Results

The EPCS managed 254 CIEDs, the ADS managed 548, and 227 by neither service. Over time, the ADS providers managed an increasing percentage of devices with decreasing supervision from the EPCS. Only two CIEDs managed by the ADS required immediate assistance from the EPCS. Patients who were unstable postoperatively were referred to the EPCS. Although numerous issues in programming were encountered, primarily when restoring demand pacing after programming asynchronous pacing for surgery, no patient harm resulted from ADS or EPCS management of CIEDs.

Conclusions

An ADS can provide safe CIED management for surgery, but it requires specialized provider training and strong support from the EPCS. Due to the complexity of CIED management, an ADS will likely only be feasible in high-volume settings.

Development and validation of a novel algorithm based on the ECG magnet response for rapid identification of any unknown pacemaker

BACKGROUND

Pacemaker (PM) interrogation requires correct manufacturer identification. However, an unidentified PM is a frequent occurrence, requiring time-consuming steps to identify the device.

OBJECTIVE

The purpose of this study was to develop and validate a novel algorithm for PM manufacturer identification, using the ECG response to magnet application.

METHODS

Data on the magnet responses of all recent PM models (≤15 years) from the 5 major manufacturers were collected. An algorithm based on the ECG response to magnet application to identify the PM manufacturer was subsequently developed. Patients undergoing ECG during magnet application in various clinical situations were prospectively recruited in 7 centers. The algorithm was applied in the analysis of every ECG by a cardiologist blinded to PM information. A second blinded cardiologist analyzed a sample of randomly selected ECGs in order to assess the reproducibility of the results.

RESULTS

A total of 250 ECGs were analyzed during magnet application. The algorithm led to the correct single manufacturer choice in 242 ECGs (96.8%), whereas 7 (2.8%) could only be narrowed to either 1 of 2 manufacturer possibilities. Only 2 (0.4%) incorrect manufacturer identifications occurred. The algorithm identified Medtronic and Sorin Group PMs with 100% sensitivity and specificity, Biotronik PMs with 100% sensitivity and 99.5% specificity, and St. Jude and Boston Scientific PMs with 92% sensitivity and 100% specificity. The results were reproducible between the 2 blinded cardiologists with 92% concordant findings.

CONCLUSION

Unknown PM manufacturers can be accurately identified by analyzing the ECG magnet response using this newly developed algorithm.

Patients with pacemaker or implantable cardioverter-defibrillator

The preparation of patients with a cardiac implantable electronic device (CIED) for the perioperative period necessitates familiarity with recommendations from the American Society of Anesthesiologists and Heart Rhythm Society. Even clinicians who are not CIED experts should understand the indications for implantation, as well as the basic functions, operations, and limitations of these devices. Before any scheduled procedure, proper CIED function should be verified and a specific CIED prescription obtained. Acquiring the requisite knowledge base and developing the systems to competently manage the CIED patient ensures safe and efficient perioperative care.