
Dysrhythmia / Cardiovascular Implantable Devices (CIEDs)
ASSESSMENT
Data Gathering
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History
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Previous cardiovascular disease
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Previous cardiac testing (stress tests, cardiac catheterization, echocardiography, CT coronary angiography)
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Previous electrophysiology testing (EP studies, cardiac monitor reports)
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CIED interrogation reports (ASA practice advisory, ACC/AHA guideline)
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Within 6 months for biventricular (BiV) pacemaker or implanted cardiodefibrillator (ICD)​
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Within 12 months for standard single-/dual-chamber pacemaker
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Need following information from these:
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Device type and function
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Abnormal rhythms detected
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Recent automatic interventions (ie, defibrillation or overdrive pacing)
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Is patient pacemaker-dependent?
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Battery life
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Response to magnet
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Symptoms
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Palpitations
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Diaphoresis
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Fatigue
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Syncope
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Orthopnea/nocturnal dyspnea
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Chest pain
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Exertional dyspnea
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Lightheadedness
Risk Stratification
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Diagnostic Studies
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BMP within 4 months for non-low risk surgery (author opinion due to potential for dysrhythmia exacerbation from electrolyte disturbances)
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ECG - within 1-3 months for non-low risk surgery (ACC/AHA guideline)​
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Digoxin level (if on digoxin)
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TSH within 12 months (if on amiodarone)
Prediction of Postop AFib after Noncardiac Surgery (Stronati et al)

Consider postoperative telemetry for patients at increased risk for postop AFib
General Considerations
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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)​
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Patients with CIEDs and known dysrhythmias rarely require further evaluation or changes in management (HRS consensus statement)
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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)
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New dysrhythmias should be evaluated as indicated in non-perioperative setting and as the surgical timeframe allows (ACC/AHA guideline)​
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Intraventricular conduction delays, including bundle branch blocks, usually don’t result in perioperative complete heart block (ACC/AHA guideline)​
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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
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Supraventricular arrhythmia with HR >110 or with structural/ischemic heart disease
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Significant dysrhythmias on interrogation
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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
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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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Determine if anticoagulation interruption is required
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If no bleeding risk factors plus low bleeding risk surgery & on warfarin or very low​ bleeding risk surgery & on DOAC, do not interrupt anticoagulation
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Bleeding Risk Factors:
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Major bleed or ICH within 3 mo
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Thrombocytopenia
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Platelet dysfunction (including antiplatelet use)
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Supratherapeutic INR
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Bleeding with previous bridging or similar procedure
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Low Bleeding Risk Procedures:​
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Very Low: Cataract, Arthrocentesis
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Low: Carpal tunnel release, Hysteroscopy, Ureteroscopy, CIED placement
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Determine if bridging anticoagulation required if anticoagulation interrupted - indications:
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WARFARIN:
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Any mechanical heart valve plus AFib (2019 ACC/AHA AFib guideline)
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CHA2DS2VASc >6 or thromboembolism (TE) within 3 months plus NO patient risk factors for bleeding ("definitely bridge")
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CHA2DS2VASc >6 or TE within 3 months plus patient risk factors for bleeding BUT no ICH within 3 months ("likely bridge")
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Any prior TE plus NO patient risk factors for bleeding ("likely bridge")
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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​)
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DOACs: DO NOT BRIDGE (stop and restart medication per instructions in Medication Management)
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If bridging required, follow this protocol:
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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)
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Start LMWH 1 mg/kg twice daily or therapeutic IV UFH once INR subtherapeutic (60 hours after last warfarin dose)
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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
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Resume warfarin 12-24 hours after surgery
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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)
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Other Perioperative Management
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Preoperative (ACC/AHA guideline, HRS consensus statement)
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Whenever possible get specific perioperative management recommendations from electrophysiology
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Arrange for electrophysiology to provide preoperative CIED reprogramming as necessary
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Assure availability of temporary pacing and defibrillation equipment
Postoperative
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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)
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Arrange for electrophysiology to provider postoperative CIED reprogramming as necessary
COUNSELING & COMMUNICATION
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Collaborate with patients' cardiologists and electrophysiologists
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Share with patients that current risk estimation tools do not necessarily accurately account for the risks related to dysrhythmias and CIEDs