Perioperative Interrogation of St. Jude Cardiovascular Implantable Electronic Devices: A Guide for Anesthesiologists

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.

A generalized framework for pacing artifact removal using a Hampel filter

Cardiac pacing is a clinical therapy widely used for treating irregular heart rhythms. Equivalent techniques for the treatment of gastric functional motility disorders hold great potential. Accurate analysis of pacing studies is often hindered by the stimulus artifacts which are superimposed on the recorded signals. This paper presents a semi-automated artifact detection method using a Hampel filter accompanied by 2 separate artifact reconstruction methods: (i) an auto-regressive model, and (ii) weighted mean to estimate the underlying signal. The developed framework was validated on synthetic and experimental signals containing large periodic pacing artifacts alongside evoked bioelectrical events. The performance of the proposed algorithms was quantified for gastric and cardiac pacing data collected in vivo. A lower mean RMS difference was achieved by the artifact segment reconstructed using the auto-regression ([Formula: see text]), method compared to the weighted mean ([Formula: see text]) method. Therefore, a more accurate artifact reconstruction was provided by the auto-regression approach. Clinical Relevance- The ability to efficiently and accurately isolate evoked bioelectrical events by eliminating large artifacts is a critical advancement for the analysis of paced recordings. The developed framework allows more efficient analysis of preclinical pacing data and thereby contributes to the advancement of pacing as a clinical therapy.

Pro-Con Debate: Are Patients With a Cardiovascular Implantable Electronic Device Suitable to Receive Care in a Free-Standing Ambulatory Surgery Center?

Migration of surgical and other procedures that require anesthesia care from a hospital to a free-standing ambulatory surgery center (ASC) continues to grow. Patients with cardiac implantable electronic devices (CIED) might benefit from receiving their care in a free-standing ASC setting. However, these patients have cardiovascular comorbidities that can elevate the risk of major adverse cardiovascular events. CIEDs are also complex devices and perioperative management varies between devices marketed by various manufacturers and require consultation and ancillary services, which may not be available in a free-standing ASC. Thus, perioperative care of these patients can be challenging. Therefore, the suitability of this patient population in a free-standing ASC remains highly controversial. Although applicable advisories exist, considerable discussion continues with surgeons and other proceduralists about the concerns of anesthesiologists. In this Pro-Con commentary article, we discuss the arguments for and against scheduling a patient with a CIED in a free-standing ASC.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

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.

Comparison of perioperative strategies in ICD patients: The perioperative ICD management study (PIM study)

BACKGROUND

The prevalence of patients with implanted cardioverter defibrillators (ICDs) and the frequency of surgery on these patients are steadily on the rise. Guidelines recommend preoperative ICD reprogramming, although this is sometimes difficult in clinical practice. Placing a magnet on the ICD is a practical alternative and even no inactivation is possible in selected cases.

METHODS

In this prospective observational study, we compared different perioperative ICD management strategies depending on the location of the surgery and the type of electrocautery used. Patients undergoing surgery above the umbilicus with monopolar electrocautery had their ICD therapy inactivated by reprogramming. When surgery below the navel or surgery above the navel with bipolar electrocautery was completed, ICD inactivation was performed using a magnet. No inactivation was performed on patients undergoing lower extremity surgery with bipolar electrocautery. Only ICD patients who were not pacemaker dependent were enrolled. After surgery, the ICDs were assessed regarding documented arrhythmias and parameters.

RESULTS

Out of 101 patients included in this study, the ICD was preoperatively reprogrammed in 42 patients (41.6%), a magnet was used on 45 patients (44.5%), and ICDs were not deactivated at all in 14 patients (13.9%). No intraoperative electromagnetic interference was detected. Postoperative ICD analysis demonstrated no changes of preset parameters.

CONCLUSIONS

All three tested ICD management strategies were proved safe in this study. Keeping the location of surgery and the type of electrocautery in mind, an intraoperative magnet or even no ICD deactivation at all could be feasible alternatives in surgery on patients with ICDs.