What is the management plan for a patient with an Implantable Cardioverter-Defibrillator (ICD)?

Management of Patients with Implantable Cardioverter-Defibrillators (ICDs)

All patients with ICDs require systematic preoperative evaluation, continuous intraoperative monitoring with peripheral pulse assessment, and immediate availability of external defibrillation equipment, with specific attention to electromagnetic interference management and device interrogation before and after any procedure. 1

Preoperative Evaluation and Preparation

Device Identification and Assessment

• Confirm ICD presence through focused history, medical record review, chest x-ray examination, physical examination checking for scars, and palpation for the device 1
• Obtain the manufacturer's identification card from the patient or access manufacturer databases 1
• Define the specific type of cardiac implantable electronic device (CIED) present 1

Determine Pacing Dependence

Critical assessment includes three specific criteria: 1

• History of symptomatic bradyarrhythmia that led to device implantation
• History of successful atrioventricular nodal ablation
• Inadequate escape rhythm at the lowest programmable pacing rate

Device Interrogation

• Interrogate the device preoperatively, consulting with a cardiologist or pacemaker-ICD service as necessary 1
• Verify that the device captures appropriately when pacing (produces mechanical systole with pacemaker impulse) 1
• Contact the manufacturer for specific perioperative recommendations 1

Electromagnetic Interference (EMI) Risk Assessment

Determine if EMI is likely during the planned procedure, as this dictates all subsequent management decisions 1

Procedures with high EMI risk include: 1

• Electrocautery (most common)
• Radiofrequency ablation
• Magnetic resonance imaging (MRI)
• Lithotripsy (variable risk)
• Radiation therapy (variable risk)

Preoperative Device Modifications

If EMI is anticipated: 1

• Suspend all antitachyarrhythmia functions in the ICD (this is mandatory, not optional)
• For pacemaker-dependent patients: reprogram pacing function to asynchronous mode (DOO, VOO) or apply a magnet when applicable
• Disable rate-responsive functions and special algorithms
• Caution: Do NOT routinely place magnets over ICDs - magnet response varies by manufacturer, may permanently disable some devices, and provides no reliable confirmation of proper placement 1

Ensure immediate availability of: 1

• Temporary external pacing equipment
• External defibrillation equipment
• These must be present before, during, and after the procedure

Intraoperative Management

Continuous Monitoring Requirements

Two simultaneous monitoring modalities are mandatory: 1

1. Continuous electrocardiographic monitoring (per ASA standards from anesthesia start until patient transfer)
2. Continuous peripheral pulse monitoring using one of:
   • Manual pulse palpation
   • Pulse oximeter plethysmogram
   • Arterial line waveform
   • Ultrasound peripheral pulse monitoring
   • Auscultation of heart sounds

This dual monitoring is critical because ECG alone may show pacing spikes without confirming mechanical capture 1

EMI Mitigation Strategies

Electrocautery management (most common source of interference): 1

• Position the electrosurgical receiving plate so current pathway does NOT pass through or near the ICD system - for head/neck cases, place on superior posterior shoulder contralateral to the generator, not the standard thigh position
• Maintain maximum distance between cautery tip and pulse generator/leads
• Use short, intermittent, and irregular bursts at the lowest feasible energy levels
• Strongly consider bipolar electrocautery or ultrasonic (harmonic) scalpel instead of monopolar systems

Radiofrequency ablation: 1

• Avoid direct contact between ablation catheter and pulse generator/leads
• Keep RF current path as far from the pulse generator and lead system as possible

Lithotripsy: 1

• Avoid focusing the lithotripsy beam near the pulse generator

Emergency Defibrillation Protocol for ICD Patients

For patients with magnet-disabled ICD therapies: 1, 2

1. Terminate all sources of EMI immediately
2. Remove the magnet to re-enable antitachycardia therapies
3. Observe patient and monitors for appropriate ICD therapy (allow 30-60 seconds for ICD treatment cycle) 2
4. If ICD function fails to restore, proceed immediately with external defibrillation

For patients with programming-disabled therapies: 1

1. Terminate all EMI sources
2. Re-enable therapies through programming if programmer is immediately available
3. Observe for appropriate ICD therapy
4. If unsuccessful, proceed with external defibrillation

External defibrillation technique in ICD patients: 2

• Position defibrillation pads/paddles at least 8 cm away from the pulse generator
• Use anterior-posterior positioning perpendicular to the ICD's major axis whenever possible
• Avoid placing pads directly over the ICD device
• Do NOT delay defibrillation if optimal pad placement is impossible - defibrillate immediately and prepare alternative pacing routes
• Use standard adult-sized electrode pads (8-12 cm diameter)
• Use clinically appropriate energy output regardless of ICD presence

Postoperative Management

Immediate Post-Procedure Actions

After any procedure involving EMI or device manipulation: 2

• Interrogate the ICD as soon as possible to assess for damage or programming changes
• Restore all antitachyarrhythmia therapies that were suspended
• Continue cardiac rate and rhythm monitoring
• Maintain immediate availability of backup pacing and defibrillation equipment
• Consult with cardiologist or pacemaker-ICD service to confirm proper device function

Long-Term Follow-Up

• Minimum monitoring frequency: once per year for all patients with CIEDs 1
• More frequent monitoring for patients with recent device therapies or complications 3
• Standard follow-up visits can be managed by general cardiologists (71% of visits), but emergency presentations or clinical problems require electrophysiologist expertise (60% of emergency visits need specialist involvement) 3

Special Clinical Scenarios

Goals of Care and Device Deactivation

For patients in skilled nursing facilities or with advanced disease: 1

• SNF intake forms must include ICD/pacemaker history and physical examination for device identification
• Discuss patient wishes for ICD deactivation as part of routine goals of care conversations
• Identify appropriate timing for future deactivation
• Consult with attending cardiologist to evaluate implications of deactivation
• ICD deactivation prevents unnecessary suffering from repeated shocks at end of life and can be done at any time consistent with patient goals 4

Psychological Considerations

Assessment and treatment of psychological distress is mandatory, not optional: 1

• Anxiety occurs in 8-63% of ICD patients, depression in 5-41%
• Highest risk: patients experiencing inappropriate shocks or >5 shocks
• Screen for post-traumatic stress disorder, particularly in patients with prior shock therapy
• Pre-implantation distress predicts post-implant problems
• Address impact on driving, intimate relations, sleep, body image, and sports participation

Management of Recurrent Shocks

Stepwise pharmacologic and interventional approach: 4

1. Beta-blockers as first-line therapy (uptitrate to maximally tolerated doses)
2. Add amiodarone for refractory cases (combination more effective than either alone)
3. Urgent catheter ablation for electrical storm (multiple shocks despite amiodarone plus beta-blocker) - Class I indication
4. Correct electrolyte abnormalities immediately (potassium, magnesium)

Critical Pitfalls to Avoid

• Never delay life-saving defibrillation due to concerns about the ICD - the presence of an ICD does not contraindicate external defibrillation 2
• Never assume the ICD will automatically treat all arrhythmias, especially if disabled or malfunctioning 2
• Never routinely use magnets on ICDs - response is unpredictable and may cause permanent disabling 1
• Never place electrocautery receiving plates in standard positions without considering current pathway - this causes most EMI-related complications 1
• Be aware that unipolar pacing spikes may confuse AED software and prevent proper VF detection 2