© 2018 Kurt Pfeifer.

Dysrhythmia / Cardiovascular Implantable Devices (CIEDs)

ASSESSMENT

Data Gathering

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 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

Symptoms

  • 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)

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

  • 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 (ACC Expert Consensus Pathway)

  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")

    • 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 or therapeutic IV UFH once INR subtherapeutic (36-48 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

  • 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

  • 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