R-on-T and cardiac arrest from dual-chamber pacing without an atrial lead

Temporary Epicardial Pacing After Cardiac Surgery

Temporary epicardial pacing frequently is employed after cardiac surgery, and can have a significant impact on a patient's hemodynamics, arrhythmias, and valvulopathies. Given that anesthesiologists often are involved intimately in the initial programming and subsequent management of epicardial pacing in the operating room and intensive care unit, it is important for practitioners to have a detailed understanding of the modes, modifiable intervals, and potential complications that can occur after cardiac surgery. Because this topic has not been reviewed recently in anesthesia literature, the authors attempted to review relevant epicardial pacemaker specifics, discuss modes and parameters that apply to the perioperative period, present an algorithm for mode selection, describe the potential effects of epicardial pacing on valvulopathies and hemodynamics, and, finally, discuss some postoperative considerations.

Hemodynamic response and safety of vasodilator stress cardiovascular magnetic resonance in patients with permanent pacemakers or implantable cardioverter-defibrillators

INTRODUCTION

Vasodilator stress cardiovascular magnetic resonance (CMR) is a powerful diagnostic modality, but data toward its use in patients with permanent pacemakers (PPMs) or implantable cardioverter-defibrillators (ICDs) is limited.

METHODS AND RESULTS

Patients with ICDs (>1% pacing) or PPMs who underwent regadenoson single photon emission computed tomography (SPECT) and all patients with ICDs or PPMs who underwent stress CMR were retrospectively identified. SPECT tests were analyzed for hemodynamic responses and new pacing requirements; CMR studies were examined for safety, device characteristics and programming, hemodynamic responses, and image quality. Changes from baseline were evaluated with the Related-Samples Wilcoxon Signed Rank Test. Of 67 patients (median age 65 [IQR 58-72] years, 31 [46%] female, 31 [46%] Black), 47 underwent SPECT and 20 CMR. With regadenoson SPECT, 89% of patients experienced tachycardic responses above resting heart rates (+19 [13-32] beats per minute, p < .01). During stress CMR, 10 (50%) devices were asynchronously paced approximately 10 beats per minute above resting rates, and the remaining were temporarily deactivated. Those with asynchronous pacing had no changes in heart rates, whereas patients with deactivated devices had near uniform heart rate accelerations. Image quality was diagnostic in the majority of stress CMR sequences, with nonconditional ICDs contributing 40 of 57 (70%) of nondiagnostic segments.

CONCLUSION

This data supports the safety of vasodilator stress CMR with promising diagnostic quality images in patients with CMR conditional ICDs and PPMs. Despite a near uniform tachycardic response to regadenoson in the SPECT environment, high rates of asynchronous pacing during vasodilator stress CMR did not result in competitive pacing or adverse arrhythmic events. Further studies are needed to validate these findings and confirm the diagnostic and prognostic performance of stress CMR in these individuals.

Perioperative Management of Cardiac Implantable Electronic Devices: A Single-Center Report of 469 Interrogations

OBJECTIVE

Anesthesiologists increasingly are involved in the perioperative management of cardiac implantable electronic devices (CIEDs). The variety of devices available and the ongoing advancements in technology, programming capabilities, and responses to conventional management (eg, magnet application) complicate the management of these devices. As an aid to this clinical challenge, this manuscript reviews 469 interrogations performed by a single cardiac anesthesiologist during a 4.5-year period to derive useful information with which to guide anesthesiologists who have chosen to pursue training in this area of perioperative care.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Single institution, quaternary care hospital.

PARTICIPANTS

Patients with CIEDs presenting for surgery; the quality assurance (QA) reports of 469 interrogations performed between May 2015 and September 2019 were reviewed.

INTERVENTIONS

No intervention.

MEASUREMENT AND MAIN RESULTS

The distributions of surgical procedures, device types, device manufacturers, pacing modes, rate-response sensors, special functions, and performed interventions were reviewed and analyzed. The QA reports were evaluated to identify information or experiences that demonstrated important lessons for anesthesiologists engaging in perioperative CIED management.

CONCLUSIONS

This database review provides general guidance for anesthesiologists managing CIEDs in the perioperative period. Concepts germane to the operating room are emphasized.

Patients with pacemaker or implantable cardioverter-defibrillator

The preparation of patients with a cardiac implantable electronic device (CIED) for the perioperative period necessitates familiarity with recommendations from the American Society of Anesthesiologists and Heart Rhythm Society. Even clinicians who are not CIED experts should understand the indications for implantation, as well as the basic functions, operations, and limitations of these devices. Before any scheduled procedure, proper CIED function should be verified and a specific CIED prescription obtained. Acquiring the requisite knowledge base and developing the systems to competently manage the CIED patient ensures safe and efficient perioperative care.