Dysrhythmia / Cardiovascular Implantable Devices (CIEDs)

ASSESSMENT

Data Gathering

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History

  • Previous cardiovascular disease

  • Previous cardiac testing (stress tests, cardiac catheterization, echocardiography, CT coronary angiography)

  • Previous electrophysiology testing (EP studies, cardiac monitor reports)

  • CIED interrogation reports (ASA practice advisoryACC/AHA guideline)

    • Within 6 months for biventricular (BiV) pacemaker or implanted cardiodefibrillator (ICD)​

    • Within 12 months for standard single-/dual-chamber pacemaker

    • Need following information from these:

      • Device type and function

      • Abnormal rhythms detected

      • Recent automatic interventions (ie, defibrillation or overdrive pacing)

      • Is patient pacemaker-dependent?

      • Battery life

      • Response to magnet

Symptoms

  • Palpitations

  • Diaphoresis

  • Fatigue

  • Syncope

  • Orthopnea/nocturnal dyspnea

  • Chest pain

  • Exertional dyspnea

  • Lightheadedness

Risk Stratification

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Diagnostic Studies

  • BMP within 4 months for non-low risk surgery (author opinion due to potential for dysrhythmia exacerbation from electrolyte disturbances)

  • ECG - within 1-3 months for non-low risk surgery (ACC/AHA guideline)​

  • Digoxin level (if on digoxin)

  • TSH within 12 months (if on amiodarone)

Prediction of Postop AFib after Noncardiac Surgery (Stronati et al)
HART.jpg

Consider postoperative telemetry for patients at increased risk for postop AFib

General Considerations

  • Premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) are risk factors for intraoperative and postoperative arrhythmias but not perioperative MI or mortality (ACC/AHA guideline)​

  • Patients with CIEDs and known dysrhythmias rarely require further evaluation or changes in management (HRS consensus statement)

  • Patients with ICDs who are pacemaker-dependent may need device reprogramming prior to and after surgery because a magnet turns off defibrillator function but does not alter pacemaker function (ie, sensing function remains active so electrocautery is interpreted as intrinsic cardiac activity and no pacing is given)

  • New dysrhythmias should be evaluated as indicated in non-perioperative setting and as the surgical timeframe allows (ACC/AHA guideline)​

  • Intraventricular conduction delays, including bundle branch blocks, usually don’t result in perioperative complete heart block (ACC/AHA guideline)​

  • For patients with severe bradycardia, determine potential for increased vagal tone due to operative factors (eg, ocular manipulation, severe head-down positioning with robotic pelvic surgery) & communicate with surgeon/ anesthesiology

MANAGEMENT

Indications for Surgical Delay

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  • New ventricular arrhythmia

  • Supraventricular arrhythmia with HR >110 or with structural/ischemic heart disease

  • Significant dysrhythmias on interrogation

  • CIED battery near end-of-life

Medication Management

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  • Continue all dysrhythmics uninterrupted but discuss possible dose adjustment with cardiology if significant perioperative change in renal function

  • If prolonged postoperative NPO state anticipated, discuss plan for possible conversion of anti-arrhythmics to parenteral form

Anticoagulation for AFib/AFlutter (ACC Expert Consensus Pathway)

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  1. Determine if anticoagulation interruption is required

    • If no bleeding risk factors plus low bleeding risk surgery & on warfarin or very low​ bleeding risk surgery & on DOAC, do not interrupt anticoagulation

      • Bleeding Risk Factors:

        • Major bleed or ICH within 3 mo

        • Thrombocytopenia

        • Platelet dysfunction (including antiplatelet use)

        • Supratherapeutic INR

        • Bleeding with previous bridging or similar procedure

      • Low Bleeding Risk Procedures:​

        • Very Low: Cataract, Arthrocentesis

        • Low: Carpal tunnel release, Hysteroscopy, Ureteroscopy, CIED placement

  2. Determine if bridging anticoagulation required if anticoagulation interrupted - indications:

    • WARFARIN:

      • Any mechanical heart valve plus AFib (2019 ACC/AHA AFib guideline)

      • CHA2DS2VASc >6  or thromboembolism (TE) within 3 months plus NO patient risk factors for bleeding ("definitely bridge")

      • CHA2DS2VASc >6  or TE within 3 months plus patient risk factors for bleeding BUT no ICH within 3 months ("likely bridge")

      • Any prior TE plus NO patient risk factors for bleeding ("likely bridge")

    • PERIOP 2 trial (published after latest guidelines) found no benefit from postoperative bridging anticoagulation in AFib patients but provided preoperative bridging to all patients (Kovacs et al​)

    • DOACs: DO NOT BRIDGE (stop and restart medication per instructions in Medication Management)

  3. If bridging required, follow this protocol:

    • Last dose of warfarin 5 days before surgery​ if INR 2-3 (3-4 days before if INR <2 and ≥5 days if INR >3) 

    • Start LMWH 1 mg/kg twice daily or therapeutic IV UFH once INR subtherapeutic (60 hours after last warfarin dose)

    • Provide last dose of therapeutic LMWH 24 hours before surgery and neuraxial/regional anesthesia; stop UFH 4-6 hours before surgery and neuraxial/regional anesthesia

    • Resume warfarin 12-24 hours after surgery

    • Resume therapeutic LMWH/UFH no early than 24 hours after low bleeding risk surgery and 48-72 hours after non-low bleeding risk surgery (always confirm with surgeon before resumption)

Other Perioperative Management

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  • Whenever possible get specific perioperative management recommendations from electrophysiology

  • Arrange for electrophysiology to provide preoperative CIED reprogramming as necessary

  • Assure availability of temporary pacing and defibrillation equipment

Postoperative

  • Cardiac telemetry may be beneficial for patients with chronic arrhythmias (AFib/AFlutter) plus decreased reserve such as LV dysfunction and end-organ dysfunction (eg, CKD, cerebrovascular disease)

  • Arrange for electrophysiology to provider postoperative CIED reprogramming as necessary

COUNSELING & COMMUNICATION

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  • Collaborate with patients' cardiologists and electrophysiologists

  • Share with patients that current risk estimation tools do not necessarily accurately account for the risks related to dysrhythmias and CIEDs