CARDIAC PACEMAKER AND IT’S

ANAESTHETIC IMPLICATIONS

PRESENTED BY: Dr. Smrutirekha Sahoo , PGT 2

GUIDE : Prof. Dr. Debaprasad Mohanty ( prof.)

: Dr. Ambika Prasad Panda (Asst. Prof.)
: Dr. Trishna Sahu (Asst. Prof.)

Dept. Of Anaesthesiology And Critical Care, SCBMCH

INTRODUCTION
Term cardiac implantable electronic device (CIED) includes :
a. Pacemaker
b. ICD (Implantable cardioverter defibrillator)

What is a pacemaker ?
It is a medical device which generates electrical impulses
and delivers by electrodes contracting the heart muscles
to regulate the beating of heart.

COMPONENTS OF PACEMAKER
Pulse Generator - Containing batteries and electrical circuit.
Electrodes - Exposed metal connected to heart ( may be endo /epi/myocardial ).
- Electrodes are either unipolar or bipolar.

UNIPOLAR BIPOLAR
Cathode electrode inside the Cathode is distal within the
heart heart
Anode on the case of pulse Anode is shortly proximal on
generator the same lead in the heart
Larger pathway exposes the Smaller pathway ….less EMI
deice to more EMI

PACING THRESHOLD
- Minimum amount of energy required to consistently cause depolarization and therefore
contraction of the heart.
- Pacing threshold is measured in terms of both amplitude and duration for which it is applied
to the myocardium.
FACTORS AFFECTING PACING THRESHOLD
INCREASES DECREASES
THRESHOLD THRESHOLD
Hyperkalemia Stress, Anxiety
Hypothyroidism Hyperthyroidism
Hypothermia Sympathomimetic Drugs
Severe Hypoxia Anticholinergics
MI Hypermetabolic States
Anti Arrythemic Drugs Glucocorticoids
1-4 weeks after insertion

R WAVE SENSITIVITY
- Measure of minimal voltage of intrinsic R wave necessary to activate the sensing circuit of
the pulse generator and thus inhibit or trigger the pacing circuit.
TYPES OF PACING
1. Temporary
2. Permanent

TEMPORARY PACING
- External, battery powered, pulse generators with exteriorized electrode produce
electrical cardiac stimulation to treat a brady or tachy arrhythmia until it resolves or until
long term therapy can be initiated.
- Used for less than 3 days.
1. Trans venous
2. Trans thoracic
3. Trans cutaneous
4. Trans esophageal

PERMANENT PACING
- Implantable pulse generators with endo or myocardial electrodes for permanent use.
- Implanted with long batteries of mercuric zinc (3 years) or lithium (10 years)
TECHNIQUE OF PERMANENT PACING
- Leads placed through - subclavian or cephalic vein.
- Leads positioned in the right atrial appendage - for atrial pacing
in right ventricular apex - for ventricular pacing.
- The pulse generator lies in the subcutaneous pocket below the clavicle.
- Epicardial lead placement is used when no trans venous or if the chest is open.
- To understand the language of pacemakers coding system was developed originally by the
international conference on heart disease.
I II III IV V
CHAMBER CHAMBER MODE OF PROGRAMMABILITY ANTICARDIAC
PACED SENSED RESPONSE FUNCTIONS

0 = none 0 = none 0 = none 0 = none 0 = none

A = atrium A = atrium T = triggered P = simple programmable P = pacing
V = ventricle V = ventricle I = inhibited M = multi programmable S = shock
D = dual (A+V) D = (A+V) D = dual(T+I) R = rate responsive D = dual(P+S)
TYPES OF PACEMAKER MODE
1. Asynchronous / fixed rate
2. Synchronous / demand
3. Single / dual chamber sequential (A&V)
4. Programmable /nonprogrammable

ASYNCHRONOUS MODE (AOO, VOO, DOO)

- Simplest form of fixed rate pacemaker which discharges at a preset rate irrespective of the
inherent HR.
- Can be used in case of no ventricular activity.
- Disadvantage - It competes with the patients intrinsic rhythm and results in induction of
tachy arrythmias.
- Continuous pacing wastes energy and also decreases the half life of the
battery.
 SINGLE CHAMBER ATRIAL PACING ( AAI, AAT )
- Atrium is paced and the impulse passes down the conducting pathways thus
maintaining atrio-ventricular synchrony.
- A single pacing lead with electrode is positioned in the right atrial appendage
which senses the intrinsic P wave and causes inhibition or triggering of the
pacemaker.
- Useful in patients with sinus arrest and sinus bradycardia provided atrio
ventricular conduction is adequate.
- Inappropriate for chronic atrial fibrillation and long ventricular pauses.
 SINGLE CHAMBER VENTRICULAR PACING (VVI ,VVT)
- VVI is the most widely used form of pacing in which ventricle is sensed and
paced.
- It senses the intrinsic R wave and thus inhibits the pacemaker function.
- Indication- Complete heart block with chronic atrial flutter, atrial fibrillation
and long ventricular pauses.
- Single chamber ventricular pacing is not recommended for patients with sinus
node disease as these patients are more likely to develop the pacemaker
syndrome.
 DUAL CHAMBER AV SEQUNTIAL PACING (DDD, DVI, DDI, VDD)
- Two leads used-unipolar or bipolar one for the right atrial appendage and the
other for right ventricular apex.
- The atrium is stimulated first to contract, then after an adjustable PR interval
ventricle is stimulated to contract.
- They preserve the normal atrio ventricular contraction sequence and are
indicated in patients with AV block , carotid sinus syncope and sinus node
disease.
- Advantage - They are similar to sinus rhythm and are beneficial in patients
where atrial contraction is important for ventricular filling ( e.g -aortic
stenosis).
- Disadvantage - Pacemaker mediated tachycardia (PMT) due to VA conduction
in which ventricular conduction is conducted back to the atrium and sensed by
the atrial circuit which triggers a ventricular depolarization leading to PMT.
- This problem can be overcome by careful programming of the
pacemaker.
PROGRAMMABLE PACEMAKER
- Pacemakers which not only sense the atrial or ventricular activity but also
sense various other stimuli and thus increase the pacemaker rate.
- The various factors which can be programmed are pacing rate, pulse duration,
voltage output, R wave sensitivity, refractory periods, PR interval, mode of
pacing, hysteresis and atrial tracking rate.
- Various types of sensors have been designed which respond to the parameters
such as vibration, acceleration, minute ventilation, RR, CVP, central venous pH,
QT interval, pre ejection period, RV stroke volume, mixed venous oxygen
saturation and RA pressure.
 PROBLEMS ASSOCIATED WITH CIED
- Related to placement
- Battery failure
- Arrythmias induction
- Myopotential interference
- Pacemaker syndrome
- Micro shock hazards
- Related to electrode placement or traction
- EMI interference
PACEMAKER SYNDROME
- Some individuals particularly those with intact retrograde VA conduction may
not tolerate ventricular pacing and may develop a variety of clinical signs and
symptoms resulting from deleterious hemodynamic induced by ventricular
pacing.
- Includes hypotension, syncope, vertigo, lightheadedness, fatigue, exercise
intolerance, malaise, weakness, lethargy, dyspnea and even CHF.
INDICATIONS FOR PACEMAKER
1. Sinoatrial - SSS, tachy - brady arrhythmia, symptomatic sinus
bradycardia, hypertensive carotid sinus syndrome or vaso vagal
syncope.
2. 2nd degree AV block
3. 3rd degree AV block
4. RBBB
5. Long Q-T syndrome
6. Cardiomyopathy
PRE OPERATIVE ASSESMENT
HISTORY:
1. Cause and date of insertion and maintenance
2. ID card and recommendations
3. Specialists evaluation report
4. Battery and proper function
5. Anticoagulation
6. Pain over pulse generator
7. Comorbidities and medications
INVESTIGATIONS:
12 lead ECG: - Pacing rate to compare with ID CARD
- Absence of electrical spike
- Spike not followed by QRS or P wave
- Paced chambers
Chest X ray : - Lead position
- Paced position
- Type of CIED

- Determining that a CIED is present and defining the functionality of the device(e.g
pacemaker or ICD).
- Whether significant EMI will be present during the planned procedure that might
affect the programmed behavior of the CIED.
- Whether the patient is dependant on pacing and whether or not reprogramming of
- Identification of the manufacturer , type and mode of CIED.
- Have it interrogated by a specialist with a documented written report.
- Determination of patients underlying rhythm/ rate for back up pacing
support.
- If present all rate and anti tachycardia response should be turned off.
- Increasing pacemaker rate to optimize oxygen delivery in major cases.
- Correction of any electrolyte abnormality prior to elective surgery.
- Emergency drugs should be readily available.
- Confirmation of magnet response if it is planned.
IMPORTANT INFORMATION GIVEN TO CIED TEAM
- Intended surgical procedure
- Location of the pulse generator
- Patient position during the procedure
- Types of electro cautery to be used
- Other sources of EMI likely to be present
- Whether cardio version or defibrillation will be necessary
INTRA OPERATIVE
- Ensuring the availibility of a back up source of pacing , defibrillation or
both.
- Maintaining vigilance and monitoring in accordance with ASA
standards so as to rapidly detect any hemodynamic compromise as a
result of interference with CIED function.
- Management of EMI.
- Rapid implementation of the back up source of pacing , defibrillation
or both as required.
MONITORING
- Frequent palpation of patients pulse or arterial waveform in monitor.
- ECG.
- CVC and PAC ; better avoided if CIED recently inserted <2 weeks as they cause lead
dislodgement and arrhythmia during placemant ; safe after 6 week as fibrosis around leads
makes it more stable.
- ETCO2, NIBP, temperature, pulse oximeter.

CONDUCT OF ANAESTHEISA
RA:- Considered safe
- anticoagulants used, coagulation profile to be checked and guidelines to be followed.
GA:- Etomidate and ketamine can cause myopotential interference.
- Succinylcholine is better avoided ( cause myopotential interference)
- A complete array of drugs and equipment must be immediately
available for cardiopulmonary resuscitation.
MAINTENANCE
- Drugs and situation that can increase pacing threshold should be avoided.
- Drugs avoided - Dexmedetomidine (supresses SA and AV node )
- N2O is avoided in a patient with newly implanted pacemaker as it causes an expansion of
gas in the pocket which leads to loss of anodal contact and pacing system malfunction.

MAGNETIC RESPONSE
- Application of magnet is not an advisable practice in all CIED.
- Each CIED has specific response to magnet: - Asynchronous mode
- Turn off transiently
- Turn off permanently
- Reprogramming
FACTORS ASSOCIATED WITH EMI GENERATION
1. Electrocautery
2. Nerve stimulator
3. Evoked potential monitor
4. Fasciculation
5. Shivering
6. Large tidal volumes
7. Radiofrequency ablation
8. ESWL
9. ECT

ADVERSE EVENTS INTERACTION WITH EMI AND PACEMAKER

- Damage to the device , the leads or sites of lead implantation.
- Failure to deliver pacing , defibrillation or both.
- Changes in pacing behavior.
- Inappropriate delivery of a defibrillatory shock.
ELECTRO CAUTERY / DIATHERMY
- Electrocautery remains one of the mcc of EMI; It uses radio frequency current to cut or
coagulate tissues and is usually applied in a unipolar configuration between the handheld
instrument (cathode) and the anode plate attached to the patient’s skin
- The radio frequency is usually between 300 and 500khz.

MEASURES TO DECREASE THE POSSIBILITY OF ADVERSE EFFECTS DUE TO

ELECTROCAUTERY
- Bipolar cautery
- Electro cautery should not be used within 15cm of pacemaker.
- Mode to be changed to asynchronous mode.
- Provision of alternative temporary pacing.
- Drugs( atropine).
- Careful with defibrillation if required( away paddles, lowest energy required).
SPECIFIC PERIOPERATIVE CONSIDERATIONS

TURP AND UTERINE HYSTEROSCOPY :

- Coagulation current used during TURP procedures has no effect but the
cutting current at high frequencies upto 2500 kc/sec can suppress the
output of a bipolar demand ventricular pacemaker.
- During application of cutting current there was a pulsatile arterial flow
which returned with intrerruption of ESU.
- Thus when ESU is anticipated reprogramming of pacemaker preoperatively
to the asynchronous ( fixed rate) mode should be performed.
 ECT :
- ECT appears safe for patients with pacemaker and little current flow
within heart because of the high impedance of body tissue.
- If therapy is going to be short (<5 sec), unlikely hemodynamically
significant oversensing will occur.
- But the seizure may generate myopotentials may inhibit the
pacemaker.
- Thus ECG monitoring is essential and pacemakers should be changed
to nonsensing asynchronous mode( fixed mode).
POST OPERATIVE CARE
- Complete check of pacemaker with technician.
- Re-programming back to the original setting.
- Anti arrhythmic therapies of implantable defibrillators should obviously be re programmed
to their original settings.
- Cardiac rate and rhythm monitoring continuously.
- Shivering and fasciculation should be avoided.
SUMMARY
- Functional capabilities of pacemaker and ICD should be known.
- Magnet application over pacemaker devices converts it into an asynchronous mode most of
the time.
- The greatest threat during surgery is EMI from electro cautery.
- MRI is contraindicated in patients with CIED.
- Primary principles to avoid EMI during surgery should be known and followed in the operating
room. Harmonic scalpel or bipolar electro cautery should be used when possible.
- ECG and peripheral pulse should be continuously monitored intra operatively and post
operatively.
- Facilities for emergency defibrillation should be available in the operating room.
- Before delivering an external defibrillator shock removal of magnet and observation for
inherent tachy arrythmia function of ICD should be observed.
REFERENCES
- STOELTINGS ANESTHESIA AND CO EXISTING DISEASE (8TH EDITION)
- GOLDBERGERS CLINICAL ELECTROCARDIOGRAPHY (9TH EDITION)
- HARRISONS PRINCIPLE OF INTERNAL MEDICINE(21ST EDITION)
- MILLERS ANESTHESIA 9TH EDITION
THANK YOU