Version June 2024
| Preoperative recommendation | Intraoperative magnet use | ESU dispersive electrode placement | Postoperative recommendation | Emergency procedures | ||
| Pacemaker (PM) | Implantable cardioverter-defibrillator (ICD) | |||||
| ASA | De novo interrogation likely not needed provided CIED was interrogated within prior three to six months and shown to be functioning properly. | When appropriate, altering the pacing function of a PM to an asynchronous pacing mode may be accomplished by applying a magnet. When appropriate, suspending the antitachycardia function of an ICD may be accomplished by applying a magnet; however indiscriminate magnet use over an ICD discouraged. | Prevent presumed current pathway from passing through or near the CIED system. Insufficient evidence to determine impact of using an underbody dispersive electrode as compared with a conventional dispersive electrode on the risk of EMI. | Postoperative interrogation may not be needed in low-risk situations (eg, appropriate preoperative interrogation, no EMI-generating devices used during procedure, no perioperative reprogramming occurred, and no problems identified during the procedure). Interrogation should occur within 30 days after surgery if not performed during the immediate postoperative period. | Interrogate CIED after emergency surgery if preoperative interrogation was not performed. | |
| HRS | PM interrogation within 12 months, ICD interrogation within six months, and CRT interrogation within three to six months. CIED physician must provide prescription for perioperative care. | Magnet use suggested to produce asynchronous pacing (where needed in PM patients) and disabling ICD high-energy therapy, provided that patient position does not interfere with magnet access or observation. | Prevent presumed current path from crossing the chest/CIED system. | For most cases involving EMI (especially those inferior to the umbilicus and where no preoperative reprogramming was performed), interrogation can take place within one month as an ambulatory procedure. For reprogrammed CIEDs, hemodynamically challenging cases, cardiothoracic surgery, RFA, and external cardioversion, interrogation prior to transfer from cardiac telemetry. | Use 12-lead ECG to identify pacing need; presume dependence if 100% pacing. Cardiac monitoring until postoperative interrogation. | |
| Use magnet to produce asynchronous pacing to prevent pacing inhibition. | Use magnet to suspend ICD tachyarrhythmia therapy. | |||||
| CAS-CCS | De-novo interrogation likely not needed, but CIED physician must provide prescription for perioperative care. | Where reasonable, magnet use suggested for asynchronous pacing (where needed in PM patients) and disabling ICD high-energy therapy. | No mention. | Clear plan for postoperative care established prior to elective case. | Use 12-lead ECG to identify pacing need; assume pacing dependence if 100% paced; careful monitoring to determine if magnet application to a PM (notICD) produces asynchronous pacing with an acceptable hemodynamic profile; asynchronous pacing might be indicated in a pacing-dependent patient (PM or ICD) if ESU interference is observed (a magnet does not produce asynchronous pacing in an ICD). If a reprogramming machine cannot be employed before or during surgery in such emergencies, EMI may be minimized by use of bipolar instead of monopolar ESU, with short, intermittent bursts at the lowest feasible energy levels. | |
| MHRA* | Preoperative contact with the pacemaker/ICD follow-up clinic for evaluation and perioperative recommendations. | Caution advised since magnet behavior can be affected by programming. | "Ensure that the return electrode is anatomically positioned so that the current pathway between the diathermy electrode and return electrode is as far away from the pacemaker/defibrillator (and leads) as possible." | Follow-up clinic to prescribe postoperative follow-up. | Attempt to follow routine steps; postoperative interrogation as soon as possible. | |
| Magnet might create asynchronous pacing. | Magnet might prevent inappropriate discharge. | |||||
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