Dysrhythmia / Cardiovascular Implantable Devices (CIEDs)
ASSESSMENT
Data Gathering
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
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
Go to Anticoagulation Management​
Other Perioperative Management
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