Review Article
Update on Cardiovascular Implantable Electronic Devices for Anesthesiologists

https://doi.org/10.1053/j.jvca.2017.09.007Get rights and content

With the advent of “wireless” endocardial pacing, the subcutaneous implantable cardioverter defibrillator, and leadless pacemakers comes an added layer of complexity to the perioperative management of cardiovascular implantable electronic devices (CIED). Since no formal recommendations currently exist for these new CIED technologies, preoperative identification of these devices, understanding their functionality, and developing an individualized perioperative management plan are imperative for the anesthesiologist. The following review is intended to provide the background information required to devise a successful perioperative management strategy for newer CIEDs.

Section snippets

Permanent Transvenous Pacemakers

Improvements in technology have resulted in smaller and more sophisticated devices since permanent pacemakers initially were implanted more than 6 decades ago. These advancements, the improvement in quality of life, and reduction in mortality in specific patient populations have led to approximately 250,000 devices being implanted in the United States annually.1 Even though a detailed description of all the devices and programming options available would be impractical, a review of a few

Transvenous Implantable Cardioverter Defibrillators

A transvenous ICD is a CIED that is able to sense, detect, and treat malignant ventricular tachyarrhythmias with antitachycardia pacing (ATP) or defibrillator shock via shock coils in the RV and occasionally in the superior vena cava. Treatment of identified ventricular tachyarrhythmias via overdrive pacing (ie, ATP) or defibrillation depends on the diagnosis of either ventricular tachycardia or ventricular fibrillation. ATP, or overdrive pacing, typically occurs at lower rates (ie, ventricular

Device Recognition

Important device information can be obtained from a wallet card provided by the patient, patient history and medical records, or the manufacturing company. Other approaches such as trialing programmers from all 5 device companies to determine the manufacturer, assuming the device is functional, or calling all 5 companies are time consuming and may not yield useful information. Alternatively, magnet application to a pacemaker can narrow the field of potential manufacturers by the magnet mode

Current Recommendations

Current recommendations from the ASA and HRS focus on an individualized, multidisciplinary approach with less reliance on direction from industry-employed allied health professionals and increased involvement of the primary CIED management team.17, 37 Alternative protocols for device management, such as the PACED-OP protocol, advocate for more selective criteria for CIED reprogramming in an effort to operate within the confines of restricted resources and to avoid reprogramming errors (Table 5).

Cardiovascular Implantable Electronic Device Milestones

Since the first pacemaker was implanted in 1958, there have been many improvements in the programming, leads, battery life, and sizing of CIEDs.44 However, reliance on the transvenous placement of leads has persisted through the development and implantation of the ICD and CRT. Even though slight deviations from the transvenous model have occurred (eg, epicardial pacing) since its introduction, it has taken nearly 50 years for the leadless pacemaker to come to market (Fig 7).1 The production of

Indication and Features

The S-ICD system (Boston Scientific) consists of a single subcutaneous electrode and a pulse generator and has emerged as an excellent alternative to conventional transvenous ICD systems for the prevention of sudden cardiac death. The S-ICD provides sensing, detection, and defibrillation therapy (synchronous, biphasic shock energy of 80 J) of malignant ventricular tachyarrhythmias in patients who have no need for ATP or bradycardia pacing and avoids complications associated with chronic

Conclusions

CIED technology is evolving rapidly and presents challenges to anesthesiologists. This evolution has led to newer devices that are implanted in the myocardium or extrathoracically and have different functionality from traditional transvenous CIEDs. Similarly, there is room for the role of the anesthesiologist in CIED management to expand and evolve. Progress already is under way at some large academic centers where comprehensive perioperative CIED services are staffed by anesthesiologists.67, 68

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