Pacemakers & ICDs

 

 

Considerations

 

  • Indications for the device:

    • Pacemaker: SA node disease, AV block, CRTD, MI, HOCM, dilated cardiomyopathy 

    • AICD: VT, VF, cardiomyopathy with EF<35%

  • Determine dependency & history of use 

  • Strategies to minimize risk & prepare for potential PM/AICD interference & failure:

    • Strategies to minimize EMI (electromagnetic interference):

      • Bipolar cautery

      • Short bursts of cautery (<5sec), distance, “cut” better than “coag” or “blend"

      • Have magnet available

    • Device interrogation pre & post op:

      • Reprogram to asynchronous (pacemaker) or disable anti-tachycardia therapy (ICD)

    • Alternate pacing/defibrillation strategies:

      • Sympathomimetics (epinephrine, dopamine, isoproterenol)

      • Transvenous/transcutaneous pacing

      • External defibrillator device

  • Co-existing Disease:

    • Associated CAD, cardiomyopathy with low EF

    • Hypertension, renal failure, diabetes 

  • Perioperative medication management

 

 

Goals

 

  • Optimization of underlying cardiac status

  • Knowledge of device settings & response to magnet

  • Anticipate & prevent failure or interference with appropriate backups

  • Avoid inappropriate inhibition (asystole) or triggering of device (shocks) by EMI

  • Prevent damage to device

 

 

Causes of Intra-operative Pacemaker Failure 

 

  • Generator failure (e.g. battery, malfunction) 

  • Lead failure (e.g. dislodgement) 

  • Failure to capture

  • Acid-base imbalance 

  • Electrolyte abnormality 

  • Ischemia/infarction 

  • Antiarrhytmics (overdose or withdrawal) 

 

 

Pacemaker Insertion Complications 

 

  • Pneumothorax

  • Arterial puncture

  • Arrhythmia

  • Venous air embolism

  • Cardiac perforation/tamponade

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