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: executive summary 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)

Wireless Interrogation During Cardiac Surgery For a Patient With Aveir Leadless Pacemaker: A Case Report

Intraoperative wireless interrogation is a useful monitoring method for the leadless pacemaker (LP); however, there are few reports on this technique. A 60-year-old woman underwent cardiac surgery 24 days after Aveir LP implantation. Considering the risk of intraoperative device dislodgment and pacemaker malfunction due to electromagnetic interference, the LP was monitored by wireless interrogation via body-surface electrodes, and no device dislodgement or pacemaker malfunction was observed during surgery. Our findings suggest that wireless interrogation using body-surface electrodes on the chest is a practical and valuable monitoring technique in open-heart surgery, which lends additional safety to anesthetic management.

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Economic Evaluation of Anesthesiology-Led Cardiac Implantable Electronic Device Service

BACKGROUND

Implementation of an anesthesiology-led cardiac implantable electronic device (CIED) service can be viewed to have economic and efficiency challenges. This study evaluates the cost savings of an anesthesiology-led CIED service.

METHODS

A total of 830 patients presented in the pre-implementation period from 1 March 2016 to 31 December 2017, and 1981 patients presented in the post-implementation period from 1 January 2018 to 31 October 2021. Interrupted time-series analysis for single-group comparisons was used to evaluate the cost savings resulting from reduction in operating room (OR) start delays for patients with CIEDs.

RESULTS

OR start-time delay was reduced by 10.6 min (95%CI: -20.5 to -0.83), comparing pre- to post-implementation. For an OR cost of USD 45/min, we estimated the direct cost to the department to be USD 1.68/min. The intervention translated into a total cost reduction during the intervention period of USD 250,000 (USD 18,000 to USD 470,000) per year for the institution and USD 9800 (USD 730 to USD 17,000) per year for the department. The yearly cost of employing a full-time team of CIED specialists would have been USD 135,456. The service triggered electrophysiology consultation on 13 device malfunctions.

CONCLUSIONS

An anesthesiology-led CIED service resulted in substantial cost savings, increased OR efficiency and patient safety.

ACR Appropriateness Criteria® Routine Chest Imaging

Routine chest imaging has been used to identify unknown or subclinical cardiothoracic abnormalities in the absence of symptoms. Various imaging modalities have been suggested for routine chest imaging. We review the evidence for or against the use of routine chest imaging in different clinical scenarios. This document aims to determine guidelines for the use of routine chest imaging as initial imaging for hospital admission, initial imaging prior to noncardiothoracic surgery, and surveillance imaging for chronic cardiopulmonary disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Electroconvulsive Therapy in Patients With Cardiac Implantable Electronic Devices: A Case Report and Systematic Review of Published Cases

OBJECTIVE

The aims of the study were to report the case of a 54-year-old man with recurrent depressive disorder with multiple medical comorbidities having a dual-chamber pacemaker, treated successfully with 11 sessions of electroconvulsive therapy, and to conduct a systematic review of published cases documenting the use of electroconvulsive therapy (ECT) in patients with cardiac implantable electronic devices (CIEDs) for treating major psychiatric disorders.

METHODS

We searched electronic databases (MEDLINE, PubMed, Google Scholar, Embase, Cochrane Library, PsycINFO, and Crossref) and included studies reporting on the use of electroconvulsive therapy in patients with CIEDs.

RESULTS

Thirty-five publications across 53 years (1967-2021) reported on 76 patients (including current report) who received a pooled total of 979 modified ECT sessions. The most common adverse events were premature ventricular contraction and hypertension. There have been no reports of serious adverse effects that necessitated the cessation of ECT.

CONCLUSIONS

Electroconvulsive therapy is a safe and efficacious treatment for major psychiatric disorders, and the presence of CIEDs should not delay or deter the use of ECT in these patients.

Endodiathermal Tautening of Floppy or Irregular Iris in Endothelial Keratoplasty (Iridodiathermy)

ABSTRACT

Floppy or irregular irides may be seen during endothelial keratoplasty in complex cases or in eyes with damaged irides and may cause uneven air fill, retro-pupillary air escape, anterior bowing of iris, forward movement of lens-iris diaphragm, shallowing of anterior chamber (AC), bellowing and floppiness of iris, uneven AC depth, difficulty in inserting and opening graft, iris trauma, intraoperative bleeding, and iridodialysis. We present a technique of iridodiathermy for tautening and flattening such irides. With continuous irrigation using AC maintainer, the bipolar endodiathermy probe tip is applied in localized spots to midperipheral iris in the affected area with power and duration adjusted to induce mild localized shrinkage and tightening of iris stroma. Such iris tautening decreases its floppiness and prevents anterior bowing, excessive mobility, irido-corneal touch, and peripheral anterior synechiae formation. It provides a stable AC with regular depth and improved, uniform, and nonmigratory air fill, thus decreasing intraoperative challenges.

An Unexpected Magnet Response of a Biotronik Pacemaker in Automatic Mode: A Case Report

In patients with cardiovascular implantable electronic devices, asynchronous pacing is necessary for surgeries with a risk of electromagnetic interference. Magnets are often used for asynchronous pacing. In this case report, magnet application to a Biotronik Evia DR-T pacemaker (Biotronik) programmed to a magnet response mode called automatic magnet mode (AUTO) led to a brief period of asynchronous pacing before reverting to prior settings, an unexpected response that was not revealed on the preoperative interrogation report. For Biotronik pacemakers programmed to the AUTO mode, changes in programming are needed for asynchronous pacing.

Effects of medically generated electromagnetic interference from medical devices on cardiac implantable electronic devices: A review

As cardiac implantable electronic devices (CIED) become more prevalent, it is important to acknowledge potential electromagnetic interference (EMI) from other sources, such as internal and external electronic devices and procedures and its effect on these devices. EMI from other sources can potentially inhibit pacing and trigger shocks in permanent pacemakers (PPM) and implantable cardioverter defibrillators (ICD), respectively. This review analyzes potential EMI amongst CIED and left ventricular assist device, deep brain stimulators, spinal cord stimulators, transcutaneous electrical nerve stimulators, and throughout an array of procedures, such as endoscopy, bronchoscopy, and procedures involving electrocautery. Although there is evidence to support EMI from internal and external devices and during procedures, there is a lack of large multicenter studies, and, as a result, current management guidelines are based primarily on expert opinion and anecdotal experience. We aim to provide a general overview of PPM/ICD function, review documented EMI effect on these devices, and acknowledge current management of CIED interference.

Success of extracorporeal shock wave lithotripsy and ERCP in symptomatic pancreatic duct stones: a systematic review and meta-analysis

Background and study aims  Pain is the most frequent and dominant symptom of chronic pancreatitis. Currently, these patients are treated using a step-up approach, including analgesics and lifestyle adjustments, endoscopic, and eventually surgical treatment. Extracorporeal shock wave lithotripsy (ESWL) is indicated after failure of the first step in patients with symptomatic intraductal stones larger than 5 mm in the head or body of the pancreas. To assess the complete ductal clearance rate and pain relief after ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones, a systematic review and meta-analysis was performed. Patients and methods  A systematic literature search from January 2000 to December 2018 was performed in PubMed, the Cochrane Library, and EMBASE for studies on ductal clearance rate of ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones. Results  After screening 486 studies, 22 studies with 3868 patients with chronic pancreatitis undergoing ESWL for pancreatic duct stones were included. The pooled proportion of patients with complete ductal clearance was 69.8 % (95 % CI 63.8-75.5). The pooled proportion of complete absence of pain during follow-up was 64.2 % (95 % CI 57.5-70.6). Complete stone fragmentation was 86.3 % (95 % CI 76.0-94.0). Post-procedural pancreatitis and cholangitis occurred in 4.0 % (95 % CI 2.5-5.8) and 0.5 % (95 % CI 0.2-0.9), respectively. Conclusion  Treatment with ESWL results in complete ductal clearance rate in a majority of patients, resulting in absence of pain during follow up in over half of patients with symptomatic chronic pancreatitis caused by obstructing pancreatic duct stones.

Anesthesia teams managing pacemakers and ICDs for the perioperative period: enhanced patient safety and improved workflows

PURPOSE OF REVIEW

There have been both technological and philosophical advances over the last decade regarding pacemakers and implanted cardioverter defibrillators (ICDs). Collectively, these devices are currently referred to as cardiac implantable electronic devices (CIEDs). Technological advances include the introduction of leadless pacemakers, subcutaneous defibrillators and cardiac event recorders, enhancements regarding compatibility of CIEDs for MRI scanning, the ability to interrogate devices remotely, and improved programming modes that preserve battery life. Philosophical advances have been mainly in the area of perioperative management of CIED patients.

RECENT FINDINGS

Current practice recommendations now acknowledge that not every patient requires a formal interrogation of their CIED before and after surgery (as was previously recommended). The response to magnet application is standardized across manufacturer's platforms, and it is known that sources of electromagnetic interference remote from the CIED and its leads do not usually cause any interference with device function.

SUMMARY

Educated anesthesia teams can independently manage the vast majority of CIED patients perioperatively with magnet application alone. Furthermore, this portends enhanced patient safety and improved workflows in the perioperative period.

Anesthesia for Ambulatory and Office-Based Ear, Nose, and Throat Surgery

With today's technological advances in outpatient surgery, anesthetic technique does not differ significantly between inpatient and outpatient settings. It is important to decide which setting is most appropriate for the patient based on the surgeon's ability, the patient's comorbidities, the facility resources, and the staff who will provide care for the patient. Matching all of the above can lead to good outcomes, less complications, and a good patient experience.

Transvenous Lead Extractions: Current Approaches and Future Trends

The use of cardiac implantable electronic devices (CIEDs) has continued to rise along with indications for their removal. When confronted with challenging clinical scenarios such as device infection, malfunction or vessel occlusion, patients often require the prompt removal of CIED hardware, including associated leads. Recent advancements in percutaneous methods have enabled physicians to face a myriad of complex lead extractions with efficiency and safety. Looking ahead, emerging technologies hold great promise in making extractions safer and more accessible for patients worldwide. This review will provide the most up-to-date indications and procedural approaches for lead extractions and insight on the future trends in this novel field.

Cautery selection for oculofacial plastic surgery in patients with implantable electronic devices

PURPOSE

To discover oculofacial plastic surgeon practice patterns for cautery selection in the setting of implantable electronic devices and present guidelines based on a review of current literature.

METHODS

A 10-Question web-based survey was sent to the email list serve of the American Society of Ophthalmic Plastic and Reconstructive Surgery to determine surgeon cautery preference in the setting of various implantable electronic devices and comfort level with the guidelines for cautery selection in their practice or institution. The relationship between survey questions was assessed for statistical significance using Pearson's Chi-square tests.

RESULTS

Two hundred ninety-three (41% response rate) surveys were completed and included for analysis. Greater than half of respondents either had no policy (36%) or were unaware of a policy (19%) in their practice or institution regarding cautery selection in patients with a cardiac implantable electronic device. Bipolar cautery was favored for use in patients with a cardiac implantable electronic device (79%-80%) and this number dropped in patients with implantable neurostimulators (30%). Overall, one-third of respondents did not feel comfortable with their practice/institution policy.

CONCLUSION

Choices and comfort level among oculofacial plastic surgeons for cautery selection in patients with implantable electronic devices vary considerably, and some choices may increase the risk for interference-related complications. Practice patterns vary significantly in the setting of a neurostimulator or cochlear implant, where interference can cause thermal injury to the brain and implant damage, respectively. Guidelines are proposed for cautery selection in patients with implantable electronic devices undergoing oculofacial plastic surgery.

A practical approach to perioperative management of cardiac implantable electronic devices

With the increased use of cardiac implantable electronic devices (CIEDs), it is increasingly important to recognise the unique challenges involved in the management of patients with CIEDs who are undergoing surgery. Practice advisories and consensus statements have been issued by the American Society of Anesthesiologists and the Heart Rhythm Society, advocating a multidisciplinary approach. This review discusses and presents a practical approach to perioperative CIED management in the Singapore context.

Management of Patients With Cardiovascular Implantable Electronic Devices in Dental, Oral, and Maxillofacial Surgery

The prevalence of cardiovascular implantable electronic devices as life-prolonging and life-saving devices has evolved from a treatment of last resort to a first-line therapy for an increasing number of patients. As these devices become more and more popular in the general population, dental providers utilizing instruments and medications should be aware of dental equipment and medications that may affect these devices and understand the management of patients with these devices. This review article will discuss the various types and indications for pacemakers and implantable cardioverter-defibrillators, common drugs and instruments affecting these devices, and management of patients with these devices implanted for cardiac dysrhythmias.

Radiotherapy in patients with pacemakers and implantable cardioverter defibrillators: a literature review

An increasing number of patients with implantable cardiac rhythm devices undergo radiotherapy (RT) for cancer and are thereby exposed to the risk of device failure. Current safety recommendations seem to have limitations by not accounting for the risk of pacemakers and implantable cardioverter defibrillators malfunctioning at low radiation doses. Besides scant knowledge about optimal safety measures, only little is known about the exact prevalence of patients with devices undergoing RT. In this review, we provide a short overview of the principles of RT and present the current evidence on the predictors and mechanisms of device malfunctions during RT. We also summarize practical recommendations from recent publications and from the industry. Strongly associated with beam energy of photon RT, device malfunctions occur at ∼3% of RT courses, posing a substantial issue in clinical practice. Malfunctions described in the literature typically consist of transient software disturbances and only seldom manifest as a permanent damage of the device. Through close cooperation between cardiologists and oncologists, a tailored individualized approach might be necessary in this patient group in waiting time for updated international guidelines in the field.

Perioperative evaluation and management of cardiac disease in the ambulatory surgery setting

Preoperative cardiac evaluation focuses on risk assessment and reduction. Diagnostic testing and interventions are used only when the risk of adverse outcomes is high and intervention will lower the risk. The evaluation is performed in a stepwise fashion according to guidelines in the literature.

Regional anaesthesia with sedation protocol to safely debride sacral pressure ulcers

A treatment challenge for patients with sacral pressure ulcers is balancing the need for adequate surgical debridement with appropriate anaesthesia management. We are functioning under the hypothesis that regional anaesthesia has advantages over general anaesthesia. We describe our regional anaesthesia protocol for perioperative and postoperative management.

Electromagnetic interference and implanted cardiac devices: the medical environment (part II)

Electromagnetic interference produced by medical equipment can interact with implanted cardiac devices such as pacemakers and implantable cardioverter-defibrillators. The most commonly observed interaction is in the operating room with electrosurgery. The risk of interactions can often be mitigated by close communication between the cardiac-device specialist and the anesthesiology/surgical team to develop a patient-specific strategy that accounts for factors such as type of device, type of surgery, and whether the patient is pacemaker dependent. Although magnetic resonance imaging should generally not be used in patients with implanted cardiac devices, several published guidelines provide strategies and recommendations for managing risks if magnetic resonance imaging is required with no suitable diagnostic alternatives. Other common sources of electromagnetic interference in the medical environment are ionizing radiation and left ventricular assist devices.

Electromagnetic interference and implanted cardiac devices: the nonmedical environment (part I)

The number of patients with cardiovascular implantable electronic devices (CIEDs), such as permanent pacemakers and implantable cardioverter-defibrillators, is dramatically rising due to an aging population and recent clinical trials showing benefits in mortality and morbidity. Coupled with this increase in the number of patients with CIEDs is the proliferation of technology that emits electromagnetic signals, which can potentially interfere with CIED function through electromagnetic interference (EMI). Despite continuous efforts of manufacturers to create "EMI-proof" CIEDs, adverse events from EMI still occur. Physicians caring for patients with CIEDs should be aware of potential sources of EMI and appropriate management options. This 2-part review aims to provide a contemporary overview of the current knowledge regarding risks attributable to EMI interactions from the most common nonmedical (Part I) and medical (Part II) sources.