Does an 87-year-old male patient with hypertension, chronic Atrial Fibrillation (AFib) on a Watchman device, and a pacemaker require cardiac testing or can he be cleared for a sinus abscess procedure under general anesthesia from a cardiology standpoint?

From the Guidelines

This 87-year-old male patient with hypertension, chronic atrial fibrillation on a Watchman device, and a pacemaker can likely be cleared for a sinus abscess procedure under general anesthesia from a cardiology standpoint without extensive cardiac testing, given the presence of a Watchman device which implies a thorough cardiac evaluation has already been conducted. The patient's pacemaker and Watchman device do require consideration for perioperative management, as noted in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. Key aspects of management include:

• Communication between the surgical team and the clinician following the patient's CIED to plan perioperative management, as recommended by the guideline 1.
• Review of the patient's cardiac rhythm and history of ventricular arrhythmias, considering the underlying cardiac condition for which the device was implanted.
• Potential need for perioperative CIED interrogation or reprogramming to avoid electromagnetic interference during surgery.
• Ensuring the anesthesiologist is informed about the pacemaker and that a magnet is available in the operating room if needed to convert the pacemaker to asynchronous mode. Given the patient's advanced age and cardiac comorbidities, a cautious approach is still warranted, focusing on optimizing perioperative care rather than extensive preoperative testing. The guideline emphasizes individualized perioperative management for patients with CIEDs, suggesting that a one-size-fits-all approach is not appropriate 1. Therefore, a thorough review of the patient's records, including recent pacemaker interrogation and assessment of cardiac function, along with coordination between the cardiology and surgical teams, is crucial for safe perioperative management.

From the Research

Cardiac Evaluation for Sinus Abscess Procedure

The patient's history of hypertension, chronic Atrial Fibrillation (AFib) on a Watchman device, and a pacemaker requires careful consideration from a cardiology standpoint before undergoing a sinus abscess procedure under general anesthesia.

• The patient's cardiac condition and the presence of a Watchman device and pacemaker indicate a need for thorough evaluation to assess the risk of cardiac complications during the procedure.
• According to 2, a thorough history and physical examination are essential to detect most cardiac problems that can affect perioperative management or outcome.
• The patient's history of chronic AFib and the presence of a Watchman device suggest a higher risk of thrombotic events, and the management of anticoagulation is crucial, as discussed in 3 and 4.
• The use of anticoagulants after WATCHMAN implantation in patients with high bleeding risks has been a source of debate, and the current evidence suggests that antithrombotic therapy with aspirin and clopidogrel for six months followed by daily aspirin indefinitely may be feasible for patients with an absolute contraindication to oral anticoagulation, as mentioned in 3.
• Studies such as 5 and 6 provide insights into the safety and efficacy of WATCHMAN implantation in patients with a history of atrial fibrillation and intracranial hemorrhage, but the specific situation of an 87-year-old patient with hypertension, chronic AFib on a Watchman device, and a pacemaker undergoing a sinus abscess procedure under general anesthesia requires individualized assessment.

Testing and Clearance

• Based on the available evidence, it is essential to conduct a thorough cardiac evaluation, including a review of the patient's medical history, physical examination, and possibly additional diagnostic tests, such as an electrocardiogram or chest radiograph, as indicated by the history and physical examination, to assess the patient's cardiac risk and determine the need for further testing or clearance for the procedure.
• The decision to clear the patient for the sinus abscess procedure under general anesthesia should be made in consultation with a cardiologist, taking into account the patient's individual risk factors and the current evidence on the management of patients with WATCHMAN devices and pacemakers, as discussed in 2, 3, 5, 4, and 6.