Preoperative evaluation for patients with a cardiac implantable electronic device (CIED)

A: CIED information needed at time of preoperative evaluation

Manufacturer
CIED type (transvenous or intracardiac PM, transvenous or subcutaneous ICD)
Remaining battery longevity
Programmed values
- Modes
  - Pacing (PM and ICD)
  - High-energy (ICD) modes
- Pacing basic rate
- Maximum (upper) tracking rate if dual-chamber tracking mode (VDD, DDD)
- For ICDs
  - First treatment (ATP or shock)
  - If ATP, will ATP delay shock?
  - HR for first treatment
  - Does programming permit treatment delay (eg, therapy hold for presumed supraventricular tachycardia)?
- Enhancements that might masquerade as pacing system malfunction (pseudo-malfunction)
  - Hysteresis rate (promotes intrinsic cardiac activity by allowing the intrinsic heart rate to fall below the LRL of the CIED before pacing is initiated [Note: The LRL determines the rate at which the CIED will pace the heart in the absence of intrinsic activity.])
  - Sleep rate (allows pacing at a rate lower than the programmed LRL of the CIED during presumed sleep hours)
  - Rate drop response (high-rate pacing – typically 100 bpm for 1 to 10 minutes – instigated by a falling native HR to prevent neurocardiogenic syncope)
  - RV pacing avoidance algorithms
    - Allowing prolonged AV delay (to 450 msec)
      - Biotronik "Vp suppression mode"
      - St. Jude Medical "ventricular intrinsic preference"
    - Allowing dropped QRS events
      - Boston Scientific "RYTHMIQ"
      - Medtronic "managed ventricular pacing"
      - Sorin "AAI-SafeR"
Magnet behavior (pacing mode, rate, and AV delay) and setting (on, off)
- The following CIEDs have programmable magnet behavior:
  - Biotronik PMs (default is NO asynchronous pacing)
  - Boston Scientific PMs and ICDs
  - St Jude Medical PMs and ICDs
Rate responsiveness
- Maximum (upper) sensor rate
- Sensor type
  - Mechanical sensor
  - Minute ventilation sensor (consider programming off)

B: Patient information

Indication for implant
Underlying native cardiac rhythm and rate to determine pacing dependency
Date of last comprehensive check, which includes pacing threshold determination(s)
History of arrhythmias and pharmacologic as well as ICD treatment (if ICD)
History of manufacturer alerts necessitating special care
- Device alerts with possible need for temporary transvenous pacing backup
- Lead alerts

C: Procedure information

Facility where procedure will occur
Nature of procedure
Anatomic site(s) of procedure
Patient position during the procedure
Need for radiofrequency energy device(s)
- Monopolar ESU (commonly known as cautery or the "Bovie")
- Radiofrequency ablative instruments
- Lithotripsy
Anticipated high-risk event
- Significant blood loss
- Need for cardioversion or defibrillation
- Difficult or no access to device

For further explanation of terms, refer to UpToDate topics on modes of cardiac pacing and cardiac pacing nomenclature.

CIED: cardiac implantable electronic device; PM: pacemaker; ICD: implantable cardioverter-defibrillator; VDD: ventricular chamber paced, atrial and ventricular chambers sensed, atrial and ventricular chambers triggered and inhibited; DDD: atrial and ventricular chambers paced, atrial and ventricular chambers sensed, atrial and ventricular chambers triggered and inhibited; ATP: antitachycardia pacing; LRL: lower rate limit; bpm: beats per minute; HR: heart rate: RV: right ventricular; msec: millisecond; AV: atrioventricular; Vp: ventricular pacing; AAI: atrial chamber pacing, atrial chamber sensing, atrial chamber inhibited; ESU: electrosurgery.

Adapted from: Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm 2011; 8:1114.

Graphic 105464 Version 5.0

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Preoperative evaluation for patients with a cardiac implantable electronic device (CIED)