Anesthesia Alert: Should You Take Cardiac Device Patients?

The pros and cons of ASCs handling patients with CIEDs.

With ASCs increasingly taking on more complex surgical cases, there is a growing movement for surgery centers to take on patients who have traditionally been relegated to hospital-only care — especially those with cardiac implanted devices such as pacemakers.

A cardiac implantable electronic device (CIED) has traditionally referred to either an implanted transvenous pacemaker or an implantable cardioverter-defibrillator (ICD), but novel devices like leadless pacemakers have recently been introduced, as well. The suitability of including this high-risk patient population in freestanding ASCs remains controversial — due to the limited resources both in terms of the proper equipment and adequate trained personnel — surgery centers may have available to handle postoperative complications. But careful appropriate patient selection can impact postoperative outcomes, efficiency and safety in ASCs. Here’s a closer look at the arguments for and against scheduling these patients in an ASC.

The pros

Generally, most patients with CIEDs are suitable for an ASC if adequate functioning of the device is confirmed prior to surgery. Interrogation reports of the CIED provide critical information about the device like indication for implantation, battery life, magnet responses, number of tachyarrhythmia events and number of shocks delivered. In the past, an in-person cardiology office visit for the CIED interrogation was needed for the physician to check the programming of the CIED and confirm it was functioning properly. Now, however, remote monitoring is transforming how we care for patients with CIEDs. Remote interrogation — the transmission of stored CIED information from the device directly to the healthcare provider — combined with telemedicine cardiologist consultation allows for identification and management of any issues with the device, eliminating the need for patients to schedule in-person cardiology office visits for CIED interrogation.

Another factor to consider: With an ICD, the application of a magnet would result in suspension of the antitachyarrhythmia function but not the conversion to asynchronous mode. Therefore, preoperatively programming the device may be necessary in patients who are pacemaker dependent. This programming may also be facilitated through remote consultation.

There is a concern of device malfunction from electromagnetic interference (EMI) generated during the procedure but modern CIEDs are resistant to EMI and more than half of all procedures performed in an ambulatory setting have a low risk of EMI generation. About 40% of outpatient procedures do not require the use of electrocautery and another 15% are located below the umbilicus, or at least six inches (15 cm) from the CIED generator and leads, and therefore at low risk of EMI.

These low risk procedures can be safely performed at an ASC even if monopolar electrocautery or radiofrequency ablation is used. In many other procedures, bipolar electrocautery or an ultrasound (harmonic) scalpel can be used to minimize the risk of EMI. If monopolar electrocautery must be used, adequate precautions can prevent the adverse effects of EMI by placing the return pad as close to the surgical site as possible.

Postoperatively, is there a fear these cases will lead to delayed discharge due to the need for postoperative CIED assessment? Not if they’re done efficiently. If a magnet was used intraoperatively or the CIED was programed prior to surgery, the device must be interrogated to ensure proper functioning and reprogrammed if necessary. Still, this should not delay patient discharge since interrogation usually takes only a few minutes with assistance from a CIED team member or a telemedicine cardiologist consultation.

The cons

Of course, there are several justifiable risks. By definition, CIED implantation suggests that a patient has a high cardiac comorbidity burden. As preoperative evaluation is typically performed on the day of the procedure, comorbidities may not be fully realized prior to surgery. Despite adequate optimization, patients may be frail from their underlying cardiac disease. ASC may not be equipped to manage potential perioperative complications such as arrhythmias or hemodynamic compromise due to inadequate resources and timely availability of consultants and ancillary services.

There is also increased variability in the capability of delivering anti-arrhythmic therapy or pacing with even the most sophisticated CIED technology. For instance, cardiac resynchronization therapy (CRT) devices may or may not have defibrillation functions, while leadless intracardiac pacemakers only have rate modulation and pacemaker capabilities. Moreover, the response to magnets and the requirements for reprogramming also vary between manufacturers.

Remote monitoring is transforming how we care for patients with CIEDs.

Intraoperatively, even during minimally invasive procedures, the risk from EMI generation exists. Using a magnet involves several challenges. Some devices are programed to ignore the magnet effect (mode “off”), while others don’t provide a signal (beeping tones) to confirm that anti-arrhythmic therapy has been turned off. Depending on the location of the procedure, the magnet needs to be reliably secured over the CIED generator in a way that doesn’t interfere with the surgical field.

Reprogramming might be necessary for patients who are pacemaker-dependent because, with most ICDs, the magnet will deactivate the antitachyarrhythmia functions but won’t affect the pacing mode. Reprogramming before the procedure requires the intervention of a CIED team, which may not be logistically feasible in a free-standing ASC.

Postoperatively, patients must be closely monitored until the device is reinterrogated and reprogrammed, as there is the potential for delay in not only the start time of the procedure but also in discharge home, which can decrease ASC efficiency.

Case-by-case basis

Overall, the approach to accepting CIED patients should be individualized. Not all patients are suitable candidates and caution must be exercised when scheduling patients for these procedures. In addition to careful preoperative evaluation and optimization of comorbidities, it’s critical to evaluate CIED function, including battery life and appropriateness of magnet use. Potential intraoperative EMI generation should also be determined and followed with proper risk mitigation steps. Finally, whenever your ASC does accept a CIED patient, you must be prepared with all the necessary resources to manage complications. OSM