Perioperative Management of Patients with Pacemakers Undergoing Surgery
For patients with pacemakers undergoing surgery, a management plan must be developed before surgery if electromagnetic interference (EMI) is anticipated, including identification of the type of cardiac implantable electronic device (CIED), manufacturer, and model. 1
Preoperative Assessment
- Identify patients with CIEDs before surgery through patient interview, medical records review, chest x-rays, ECG review, and physical examination (checking for scars, palpating for device) 2
- Determine the type of device (pacemaker, ICD, implantable monitor), manufacturer, and model by obtaining the manufacturer's identification card or reviewing medical records 1, 2
- Assess whether the patient is pacemaker-dependent by reviewing medical history for bradyarrhythmias causing syncope or other symptoms requiring pacemaker implantation 1, 2
- Evaluate device function within 3-6 months before significant surgical procedures, particularly for pacemaker-dependent patients 1
- Determine device programmed settings and battery status 1
Risk Assessment for EMI
- The risk of EMI is influenced by:
- Distance between electrosurgery unit and the pulse generator/leads (risk decreases with distance) 1
- Type of surgery (procedures involving chest or abdomen pose higher risk) 1
- Type of electrocautery (bipolar poses less risk than unipolar) 1
- Whether the patient is pacemaker-dependent 1
- Whether the pacemaker has unipolar or bipolar leads 1
Preoperative Management
- For pacemaker-dependent patients undergoing surgery above the umbilicus with anticipated EMI:
- Reprogram the pacemaker to an asynchronous mode (VOO or DOO) or place a magnet over the generator to provide asynchronous pacing 1
- For patients with ICDs:
- For patients with leadless pacemakers who are pacemaker-dependent: reprogram to an asynchronous mode if EMI is anticipated above the umbilicus 1
- For patients with subcutaneous ICDs undergoing surgery above the groin: reprogram the device or use a magnet to temporarily disable tachytherapies 1
Intraoperative Management
- Implement continuous ECG and pulse monitoring during surgery, as electrocautery may interfere with ECG monitoring 1
- Minimize EMI by:
- Using bipolar electrocautery when possible 1
- Using short and intermittent bursts of electrocautery at the lowest possible energy levels 1
- Maximizing distance between electrocautery and the device 1
- If unipolar cautery must be used, place the ground patch to minimize current flow through the pacemaker or ICD 1
- For emergency cardioversion, place paddles as far from the implanted device as possible, preferably in an anterior-posterior position 1
Postoperative Management
- Restore device functioning before hospital discharge for patients who had devices reprogrammed to asynchronous pacing or had tachytherapies programmed off 1
- Assess pacemaker function after surgery, particularly if the device was reprogrammed before surgery 1
Common Pitfalls and Caveats
- Failure to identify pacemaker dependency status can lead to adverse outcomes including asystole 2
- Magnets should not be relied upon without pre-operative confirmation of their effects on CIEDs, as some devices have programmable magnet responses with effects other than forcing asynchronous pacing 1, 3
- Rate-responsive pacemakers should have rate adaptive modes disabled before surgery to prevent inappropriate heart rate changes during surgery 3
- While modern devices are more resistant to EMI than older models, inappropriate sensing can still occur when unipolar electrocautery is used in close proximity (<8 cm) to the pacemaker generator 4
- Patients with CIEDs frequently have underlying cardiac diseases that require evaluation, including arrhythmias, structural heart disease, and heart failure 1