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Dysrhythmia / Cardiovascular Implantable Devices (CIEDs)


Data Gathering


  • 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 advisory, ACC/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


  • Palpitations

  • Diaphoresis

  • Fatigue

  • Syncope

  • Orthopnea/nocturnal dyspnea

  • Chest pain

  • Exertional dyspnea

  • Lightheadedness

Risk Stratification

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)

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


Indications for Surgical Delay

  • 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

  • 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 

Other Perioperative Management

  • 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


  • 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


  • 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

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