Bandar Al Ghamdi, MD,FACC,FHRS,CCDS.

Bandar Al Ghamdi, MD,FACC,FHRS,CCDS.
Perioperative Management of Patients with Cardiac Implantable Electronic Devices (CIEDs) Bandar Al Ghamdi, MD,FACC,FHRS,CCDS.

Introduction The perioperative period for patients with CIEDs represents a unique challenge to ensure a high degree of patient safety Perioperative management of CIEDs can be complex due to: - Rapid changes in CIED technology - The expanding use of potential sources of electromagnetic interference (EMI) There are limited data and recommendations depend mainly on case reports and case series

There are no new management recommendations in the 2011 Advisory compared with the one published in But what is encouragingly ‘new’ (as outlined in the consensus statement) is the emphasis now being placed on an individualized approach to patient management, effective multidisciplinary communication before the procedure, a team approach throughout the perioperative period, and a reduced reliance on representatives from industry [Industry Employed Allied Health Professionals (IEAPs)] to independently manage CIED patients in the absence of physician direction. These documents provide recommendations that promote safe management of patients with CIEDs throughout the perioperative period and reduce the likelihood of adverse outcomes.

General principles of perioperative CIED management
• The perioperative management of CIEDs must be individualized to: - the patient the type of CIED the procedure • It involves CIED team/ Surgical or procedural team • Communication between the two teams: - the type of procedure and likely risk of EMI - prescription for the perioperative management A single recommendation for all CIED patients is not appropriate A small percentage of patients may require consultation from CIED specialists if the information is not available • The perioperative management of CIEDs must be individualized to the patient, the type of CIED and the procedure being performed • A CIED team is defined as the physicians and physician extenders who monitor the CIED function of the patient • The surgical or procedural team should communicate with the CIED team to identify the type of procedure and likely risk of EMI • The CIED team should communicate with the procedure team to deliver a prescription for the perioperative management of patients with CIEDs • For most patients, the prescription can be made from a review of the records of the CIED clinic • It is inappropriate to have industry employed allied health professionals independently develop this prescription Crossley GH. Heart Rhythm 2011; 8: e1–18.

Pacemakers: Basics The most common indications for pacing currently include: - Symptomatic bradycardia (e.g. sinus node dysfunction) - Atrioventricular (AV) conduction block ( e.g. Congenital, post-op, or after catheter ablation of the AV node or junction) Pacing can be provided in several ways: application of external pacing pads urgent insertion of a transvenous pacing lead via central venous access implantation of permanent intracardiac leads along with a pulse generator PhilippN

Pacemakers: Basics Pacing can be delivered to a single chamber (atrium or ventricle only), dual chambers (atrium and ventricle), or multiple chambers (in biventricular pacing) can use either unipolar or bipolar leads Over the last 15 yr, bipolar leads have been predominantly used. With a bipolar lead, both the cathode and anode are present on the lead itself and thus the distance between them is much smaller than with a unipolar lead (where the pulse generator functions as the anode). The advantage of the bipolar configuration is reduced susceptibility to electromagnetic interference (EMI)

Uipolar and Bipolar pacing
The modern pacemaker leads are bipolar leads : they consists of two electrical channels encased in an insulating material. One channel conducts the electrical impulse towards the lead tip and the other channel completes the circuit back to the pacemaker. In older systems, the lead consisted only of one channel which would deliver the impulse and the circuit is completed by the chest wall tissues which are in in contact with the pacemaker body (metal can) – this was referred to as unipolar pacing.

Pacemaker mode coding Position I Position II Position III Position IV
Position V Pacing chamber Sensing chamber Response to sensing Rate Modulation Multisite pacing 0=None A=Atrium T=Triggered R=Rate modulation V=Ventricle I=Inhibited D=dual (atrium and ventricle) D=Dual (atrium and ventricle) D=Dual (Triggered and Inhibited) VVI or VVIR DDD or DDDR Modified The North American Pacing and Electrophysiology/British Pacing and Electrophysiology Group (NASPE/BPEG) pacemaker codes.

Implantable cardioverter defibrillators(ICDs)
ICDs are devices capable of detecting a ventricular arrhythmia and delivering a defibrillatory shock The current-generation ICDs can terminate VF in 98% of episodes VT/VF therapy with: - antitachycardia pacing (ATP) - Cardiovresion or shock Primary prophylaxis: patients at high risk for malignant ventricular arrhythmias Secondary prophylaxis: patients who have survived a malignant arrhythmia Gregoratos G. J Cardiovasc Electrophysiol 2002; 13: 1183–99 ICDs have become a definitive therapy for patients at high risk for malignant ventricular arrhythmias (primary prophylaxis) and are also implanted in patients who have survived a malignant arrhythmia (secondary prophylaxis)

Pacemaker leads are generally placed in the right atrial (RA) appendage, right ventricle (RV), or, in a dual-chamber device, both (Fig. 1). Depending on device programming, in a single-chamber mode, the device can sense intrinsic electrical activity in the chamber where the lead is placed to either inhibit or trigger pacing in that chamber. The lower rate or escape interval is programmed based on the desired heart rate and underlying condition of the patient. If no spontaneous depolarization of the chamber is sensed within the programmed limits, the device will deliver a pacing stimulus. If a spontaneous chamber depolarization occurs and is sensed, the device will inhibit the delivery of a pacing stimulus and wait for a subsequent depolarization during the next pre-set time interval. A dual-chamber pacing mode allows for both sensing and subsequent triggering or inhibition of pacing in one or both chambers. This ‘physiological’ mode of pacing maintains AV synchrony because atrial systole immediately precedes ventricular systole, and the atrial rate is the same as the ventricular rate. These factors optimize left ventricular (LV) filling, AV valve function, and ultimately cardiac output. Physiological pacing modes also minimize the AV valvular insufficiency that occurs with isolated ventricular pacing and retrograde atrial depolarization. More than doubling of cardiac output has been demonstrated with atrial pacing for the treatment of AV junctional rhythm in patients with ischaemic cardiomyopathy J Am Coll Cardiol. 2015;65(15): J Am Coll Cardiol. 2015;66(10):

Combination of devices
Al-Ghamdi B, Shafquat A, Mallawi Y (2016). J Cardiovasc Med Cardiol 3(1):

Perioperative management of patients with CIEDs
Assess the potential perioperative risks Plan a perioperative care: - Preoperative - Intraoperative - postoperative

Potential perioperative risks
The main concern is oversensing due to electromagnetic interference (EMI) in a patient with a CIED: - It may inhibit pacing in a pacemaker-dependent patient or - It may cause inappropriate antitachycardia pacing (ATP) or shock therapy in an ICD patient Christian Sticherling. CARDIOVASCULAR MEDICINE 2016;19(1):13–18

VVIR pacemaker with a lower rate of 70 beats/min
Electrocardiographic tracings. Patient with a VVIR pacemaker with a lower rate of 70 beats/min. After an initial paced ventricular beat, there is a pause of approximately 2.8 seconds with significant baseline artifact. After two additional paced beats, another pause of approximately 2.8 seconds occurs. This patient had a pacemaker programmed to a unipolar sensing configuration. Sensing of myopotentials led to symptomatic pauses, and reprogramming the pacemaker to a bipolar sensing configuration prevented subsequent myopotential oversensing. VVIR pacemaker with a lower rate of 70 beats/min Zipes: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed. 2005

Rev Esp Cardiol. 2010;63:735-9 - Vol. 63 Num.06
1) Atrial and ventricular electrocardiogram during the magnetic resonance imaging scan in a patient with an implantable cardioverterdefibrillator. A noise signal is observed in both channels, interpreted as ventricular fibrillation (VF) while the patient remained in stable sinus rhythm. The device did not apply any therapy as antitachycardia therapies had been deactivated beforehand. 2) Inappropriate therapy will at some point get its own post but in its simplest terms it is treatment delivered by the ICD (a shock or ATP) that is actually not needed. That person is not in a potentially fatal arrhythmia and therefor receives an unnecessary and painful electric shock. This is explained better by the image below that shows the pacemaker getting confused by the interference and then eventually deciding that the heart is in Ventricular Tachycardia (VT Detected – circled) when it isn’t. JP: Cellular phone antennas and health.

Electromagnetic interference (EMI)
Any apparatus that emits radiofrequency waves between 0 and 109 Hz can generate EMI and therefore interfere with proper device function Higher frequency waves (e.g. X-rays, g-rays, infrared, and ultraviolet light) are unlikely to cause interference with CIED function Note: though repeated and/or prolonged exposure to certain types of radiation can cause deterioration of insulation within the device with resultant short-circuiting or other electrical problems. Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)

Potential sources of EMI
Electrocautery (monopolar....bipolar) External defibrillation Magnetic resonance imaging Radio frequency ablation or lesioning Extracorporeal shock wave lithotripsy Evoked potential monitors Electroconvulsive therapy (ECT) Nerve stimulators (twitch monitors) Fasciculations Shivering Large tidal volumes A list of factors associated with the generation of EMI commonly encountered in the perioperative setting. Reporting the anticipated presence of any/all such factors to the CIED team may help them devise appropriate recommendations Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)

Adverse outcomes to be avoided in patients with CIEDs
Failure to deliver pacing Inappropriate delivery of a defibrillatory shock (if an ICD is present) Inadvertent electrical reset to backup pacing modes/ noise reversion mode Damage to the device, the leads, or site of lead implantation Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)

Potential perioperative risks
1. Site of surgery Sensing electromagnetic interference (EMI) is more likely if surgery is performed <15 cm away from the device, i.e., above the umbilicus 2. Underlying cardiac rhythm Only a minority of pacemaker patients are completely pacemaker-dependent (short periods of EMI e.g. cautery <5 seconds) will not result in asystole even if they temporarily inhibit pacing) 3. Type and programming of the device EMI is more likely in patients with unipolar leads (which have become very rare) and those with a very high programmed sensitivity 4. Type of cautery utilized EMI is more likely to occur with unipolar cautery 3. Inappropriately rapid pacing can be caused by manipulation in the vicinity of the generator (“activity sensors”) or by mechanical ventilation or monitoring of respiratory rate in patients with rate-modulation technology (minute ventilation sensors) 4. The grounding pad of the coagulation system should therefore be positioned away from the device (e.g., upper thigh). Bipolar cautery should be preferred over uni polar cautery, with bursts lasting <5 seconds with 5-second pauses between bursts. When using an argon beam coagulation system, reprogramming of the pacemaker in a dependent patient should be considered, since experience is still limited. As outlined in the consensus statement, there are experience and data suggesting that the likelihood of adverse EMI–CIED interactions decreases with the distance from the EMI source to the pulse generator (a critical distance of 6 in. (15 CM) is mentioned) With modern subpectoral devices and electrosurgical cautery units, it is currently believed that the potential for interactions is markedly reduced when the surgery is below the umbilicus and the cautery dispersal pad is placed so as to direct the current away from the pulse generator. Fiek M. Pacing Clin Electrophysiol 2004; 27: 293–8 Christian Sticherling. CARDIOVASCULAR MEDICINE 2016;19(1):13–18

Preoperative Evaluation: Patient factors
a. Establish presence of CIED i. History and Physical ii. ECG iii. CXR b. Define type of CIED i. Manufacturer’s ID card from the patient or chart ii. Manufacturer’s database iii. Cardiologist consultation (recent interrogation) thorough patient interview and relevant physical exam focused interview regarding the CIED and a review of all available medical records, ECGs, and chest X-rays Occasionally, detailed information regarding the type of device, the indication for its implantation, and current settings will be in the patient’s chart or device card If one can identify the device manufacturer (either by asking the patient or by markings on the device visible on CXR), then one can also attempt to get the requisite Before operation Determining that a CIED is present and defining the functionality of the device (e.g. pacemaker or ICD) Determining whether significant EMI will be present during the planned procedure that might affect the programmed behaviour of the CIED Determining whether the patient is dependent on antibradycardia pacing and whether or not reprogramming of the pacemaker mode is required If an ICD is present, deciding the manner in which the antitachycardia therapies shall be suspended (e.g. by a programming device or by temporarily applying a magnet to the device) Determining that the device is functioning as intended

Chest X-ray of pacemakers
A= atrium (RA) V= ventricle (RV) CS= coronary sinus coil in the RV

Chest X-ray of ICDs HV= a high-voltage defibrillation coil in the RV
Pow-Li Chia.Singapore Med J Oct; 56(10): 538–541. Christian Sticherling. CARDIOVASCULAR MEDICINE 2016;19(1):13–18

Chest X-ray of new devices

Preoperative Evaluation
c. Determine whether the patient is pacemaker-dependent: I. History ii. Patient medical records iii. ECG with paced rhythm iv. History of AV nodal ablation resulting in CIED implantation v. CIED evaluation with no spontaneous activity when placed on VVI mode d. Determine the CIED function i. Confirm pacing impulses (if present) ii. Confirm the effect of magnet placement on CIED function (i.e. asynchronous pacing, turning off ICD) (on chart or call representative) iii. Determine that the pacemaker captures when it paces (interrogation) iv. Interrogate the pacemaker/Contact PM clinic for perioperative evaluation

Preoperative Management: Procedure
a. Determine if electromagnetic interference (EMI) is anticipated during the case i. Electrocautery ii. Radiofrequency ablation (RFA) iii. Magnetic Resonance Imaging (MRI) iv. Radiation Therapy v. Extracorporeal Shock Wave Lithotripsy (ESWL) b. Determine if reprogramming the CIED to asynchronous pacing mode is needed. i. CIED team representative should be available on the operative day as discussed during the preoperative visit. ii. Magnet when applicable iii. CIED team representative can reprogram 1. Determine optimal rate given the patient’s medical comorbidities (i.e. HR bpm in cardiac patient instead of default HR of 100bpm)

Preoperative Management
c. Suspending any antitachyarrhythmia/cardioverter-defibrillation functions present - Turn off the ICD portion d. Consider using bipolar electrocautery or harmonic scalpel to minimize potential adverse events e. Assure the availability of temporary pacing and defibrillation equipment - Place trancutaneous pacing/defibrillator pads when necessary/indicated . Evaluate the possible effects of anesthetic techniques and of the procedure on CIED function and interactions - Anesthetic induced physiologic changes may induce unexpected CIED responses or adversely affect the CIED-patient interactions

Intraoperative Management
a. Intraoperative ECG b. Monitoring peripheral pulse (i.e. pulse oximetry) Any unexpected interactions should postpone/discontinue case until source of interaction is elucidated The patient with a CIED is at high risk of dysrhythmias and potentially interference from EMI Thus, the cardiac rate and rhythm must be carefully monitored, and the peripheral pulse must be continuously assessed (by the pulse oximeter, by direct palpation, or by observation of an arterial waveform if invasive arterial pressure monitoring is in use) due to the risk of pulseless electrical activity in this high-risk population Any changes in electrical activity or sudden hemodynamic instability that seems temporally related to EMI should prompt one to ask the surgeon to temporarily stop using cautery until hemodynamic conditions are stabilized If adverse pacing behavior (or inhibition of pacing) is manifest, application of a magnet to the pulse generator should produce an asynchronous mode as long as an ICD is not present Precautionary measures that should also be used include: placing the cautery dispersal plate as distal as possible with respect to the site of device implantation, suggesting the limitation of cautery use to short, irregular bursts and using more ‘cutting’ than ‘coagulating’ current recommend the use of a bipolar cautery unit If the patient develops a malignant ventricular tachyarrhythmia, one should rapidly cardiovert or defibrillate the patient (in accordance with standard ACLS protocols) while attempting to minimize the current that might flow through the pulse generator and leads by positioning the external pads or hand-held paddles as far as possible from the pulse generator Where feasible, an anterior–posterior position is preferred Intra-operatively Ensuring the availability of a backup source of pacing, defibrillation, or both Maintaining vigilance and monitoring in accordance with ASA standards so as to rapidly detect any haemodynamic compromise as a result of interference with CIED function Management of EMI Rapid implementation of the backup source of pacing, defibrillation, or both as required.

Recommendations for specific procedures
Electrocautery: Manage potential sources of EMI i. Assure that the electrocautery receiving pad is positioned so that the pathway does not pass through or near the CIED system ii. Advise the operative surgeon: 1. avoid proximity of the cautery’s electrical field to the pulse generator and leads 2. use short, intermittent, and irregular bursts at the lowest feasible energy levels 3. consider use of bipolar electrocautery or harmonic (ultrasound) scalpel in place of monopolar electrocautery

Radiofrequency Ablation (RFA) 1. Should keep the RF current path as far away from the pulse generator and lead system as possible. 2. Avoid direct contact between ablation catheter and the CIED and leads 3. an ICD should be disabled, a pacemaker should be reprogrammed to an asynchronous mode in dependent patients Lithotripsy (ESWL) Overall, the risk to the CIED system is low 1. Avoid focusing the lithotripsy beam near the pulse generator 2. terminating lithotripsy for arrhythmias, using a magnet only if inhibition occurs and interrogation in the case of complications 3. atrial sensing/pacing disabled if the lithotripter triggers on the R-wave For radiofrequency ablation, an ICD should be disabled, a pacemaker should be reprogrammed to an asynchronous mode in dependent patients, and ablation currents should be kept as far away as possible from the pulse generator and leads because current can be conducted down the leads to their point of contact with the myocardium. Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011) For extracorporeal shock wave lithotripsy, the ICD should be disabled, and atrial sensing/pacing disabled if the lithotripter triggers on the R-wave Note that lithotriptor shocks delivered in the proximity of a CIED can potentially loosen semiconductor components and lead

MRI 1. Generally contraindicated in old (non-MRI compatible) devices 2. If must be performed, consult with cardiologist, ordering physician, radiologist, and CIED manufacturer 3. Several manufacturers that have MRI safe pacemakers/ ICDs Radiation Therapy 1. Can be safely performed in patients with CIEDs unless in the field of radiation 2. ionizing radiation is the most likely cause of electrical resets because ionizing radiation can cause cumulative damage to the insulation of the leads and the semiconductor circuitry within the pulse generator 3. Consider appropriate shielding 4. The recommendation is to consider relocating the generator if it cannot be adequately shielded from the radiation field Recommendations for specific procedures Magnetic resonance imaging (MRI) has previously been contraindicated in patients with a CIED due to concerns surrounding the generation of heat, effects on pacing function, and the possibility that magnetic fields will induce current down the leads. Currently, there are several manufacturers that have MRI safe pacemakers. In the USA, Medtronic has recently released an FDA-approved device, but in Europe, in addition to Medtronic, St Jude Medical and Biotronik also have MRI safe pacemakers. The specific recommendations for scanning patients with these devices can be obtained from the manufacturer. It is critical to understand that it is not just the pulse generator that must be MRI safe, but the leads themselves have special designs and must be MRI safe as well. There are many centres, however, that perform limited MRI scanning using specific protocols in patients with current CIEDs. Despite this, having a CIED, present is generally considered a contraindication to MRI scanning.(Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)) Radiation therapy is not associated with EMI; however, as outlined in the HRS consensus statement, ionizing radiation is the most likely cause of electrical resets because ionizing radiation can cause cumulative damage to the insulation of the leads and the semiconductor circuitry within the pulse generator. Radiation therapy is not contraindicated in patients with CIEDs, assuming that appropriate shielding is used. The recommendation is to consider relocating the generator if it cannot be adequately shielded from the radiation field

Electroconvulsive Therapy (ECT) 1. May have associated transient or long-term myocardial and nervous system effects 2. If ECT must be performed, consult with the ordering physician and cardiologist to plan for the first and subsequent ECTs 3. All CIEDs should undergo a comprehensive interrogation before and after the procedure 4. ICD functions should be disabled for the shock therapy during ECT 5. CIED-dependent patients may require temporary transcutatneous pacemaker to preserve rate and rhythm during shock therapy 6. CIED may require programming to asynchronous activity to avoid myopotential inhibition of the device in pacemaker-dependent patients In electroconvulsive therapy (ECT), an electric current is delivered to the brain, triggering a brief seizure. This has been associated with abnormal CIED function. For electroconvulsive therapy, disable the ICD and have the CIED interrogated following the therapy to assure the appropriateness of all settings Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)

Emergency Defibrillation If emergency defibrillation is needed: 1. Reenable antitachycardia therapies by a. Removing magnet to turn on antitachycardia function b. Reprogram to turn on the ICD c. Place defibrillator/cardioverter pads in an anteroposterior placement as far away from the pulse generator

Postoperative Management
Continuously monitor cardiac rate and rhythm b. Have backup pacing and defibrillation equipment immediately available in the postoperative period c. Interrogate and restore CIED function in the immediate postoperative period d. Restore all antitachyarrhythmic therapies in the ICDs After operation, the patient needs to remain appropriately monitored with the immediate availability of an external source of backup pacing and defibrillation until CIED settings are restored to baseline (particularly until the ICD is reactivated) One of the more controversial aspects of the Practice Advisory is the recommendation that all devices be interrogated for the appropriateness of all settings before transfer from the recovery unit (or intensive care unit) to a non-monitored setting After operation Maintenance of appropriate vigilance and monitoring with the immediate availability of backup pacing, defibrillation, or both until all CIED settings are restored Formal interrogation of the CIED as appropriate (Table 4 and discussion below)

Magnet application

Magnet use Pacemakers Application of a magnet to a modern pacemaker produces an asynchronous mode of pacing to protect a patient from the effects of EMI The asynchronous rate obtained depends on the programming of the device, the remaining battery life, and defaults that vary by manufacturer The specific mode of asynchronous pacing (e.g. AOO, VOO, and DOO) depends on the programming configuration of the device Once the magnet is applied, asynchronous pacing persists for as long as the magnet remains in place over the pulse generator Removal of the magnet results in reversion to baseline device programming Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)

Specific responses of different pacemakers on magnet application
Christian Sticherling. CARDIOVASCULAR MEDICINE – KARDIOVASKULÄRE MEDIZIN – MÉDECINE CARDIOVASCULAIRE 2016;19(1):13–18

Magnet use Implantable cardioverter defibrillators
While there are no specific recommendations, a magnet can be secured over the pulse generator of an ICD to suspend the arrhythmia detection function of the ICD and prevent discharge Subsequent removal of the magnet promptly reactivates the ICD The main caveat to the routine use of magnets to temporarily deactivate an ICD revolves around whether or not there is a possibility that the magnet response of the ICD is programmed to ignore magnet application Even when the ICD has been deactivated by a magnet, pacemaker function of an ICD is not affected Medtronic devices do not have such an option, and magnet application should reliably deactivate the device. Removal of the magnet should reliably reactivate the device. Some Boston Scientific and St Jude devices do have the option of programming the magnet response to off, which underscores the need to know how an implanted device is programmed (and illustrates why a false sense of security can result from the prevailing attitude of ‘just stick a magnet on it’). If the patient has a Boston Scientific/ Guidant Contak Renewal (a specific model of ICD that was subject to recall), a consultant should formally deactivate the device with a programmer. Unlike Medtronic, St Jude, and devices from other manufacturers, Boston Scientific ICDs produce audible R-wave synchronous tones to let one know that the device has successfully deactivated. As long as one hears these tones, arrhythmia detection is suspended. Removal of the magnet reactivates detection and the tones will cease. If the position of the magnet shifts from the device (e.g. during positioning), the tones will cease, indicating reactivation of the device. The annunciation of a continuous tone indicates that the Boston Scientific device is programmed to off, and should prompt consultation with a knowledgeable colleague to interrogate the device. Failure to hear tones at all with magnet application suggests either that the magnet is not properly positioned, that the device is programmed to ignore magnet application, or that the device is not manufactured by Boston Scientific. Medtronic devices also produce audible tones (similar to a European police siren) upon magnet application that indicate an alert is present, but which do not specifically indicate the status of antitachyarrhythmia detection or therapies. St Jude devices do not annunciate tones upon magnet application. One should always remember that all ICDs have backup pacing function. Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)

Manufacturer-specific implantable cardioverter defibrillator responses to magnet application
Christian Sticherling. CARDIOVASCULAR MEDICINE 2016;19(1):13–18

Perioperative management of patients with a pacemaker/ ICD
Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)

Stone, M.E. British Journal of Anaesthesia 107 (S1): i16–i26 (2011)

Conclusions The perioperative management of patients with CIEDs include a multidisciplinary team It must be individualized based on patient and procedure specific needs The majority of patients with a CIED may undergo surgery/ procedure without significant side effects The challenge is to identify CIED patients who are at higher risk including: - pacemaker-dependent patients - ICD patients

Conclusions In high risk patients patient magnet use or device reprogramming before and after surgery is needed There is a need for RCTs to have an evidence-based recommendations

Bandar Al Ghamdi, MD,FACC,FHRS,CCDS.

Similar presentations

Presentation on theme: "Bandar Al Ghamdi, MD,FACC,FHRS,CCDS."— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Bandar Al Ghamdi, MD,FACC,FHRS,CCDS.

Similar presentations

Presentation on theme: "Bandar Al Ghamdi, MD,FACC,FHRS,CCDS."— Presentation transcript:

Similar presentations

About project

Feedback