Ayman M.

Kamaly, MD
Professor of Anesthesiology
kamaly3@hotmail.com

Anesthesiologists

Do it while you sleep !!

Overview:
1958: 1st Battery operated pacing devices. 1980: Implantable Cardioverterdefibrillator (ICDs). Today: > 2000 pacemaker models, produced by 26 companies.

Epidemiology:
No reliable Egyptian data.
USA data: > 250,000 adults & children are undergoing Cardiac Rhythm Management Device (CRMD) implantation annually. Aging, advances in CRMD technology & expanding indications for pacing, will lead to growing numbers of patients with CRMD.

This will increase the chances to be confronted with patients having CRMD (not uncommon).
Those patients often have significant comorbid diseases and need procedures of varying complexities. Our ability to care for these patients requires attention to their primary medical problems, as well as understanding these devices.

Permanent Pacemaker Indications:

Symptomatic Sinus Bradycardia. S A Node Disease. Symptomatic A V Node Disease. Hypertrophic Obstructive Cardiomyopathy (HOCM). Dilated Cardiomyopathy (DCM). Long Q T Syndrome.

Bryce et al, Ann Intern Med. 2001; 134:1130-41.

Cardiac Rhythm Management Devices (CRMD) basic components

Impulse generator
(1/2 life 5-10 yrs)

Lead: Unipolar, Bipolar, Multiplolar.

How CRMD Works?!

Basic: Track the native electrical rhythm. When doesn't sense a heart beat within a normal beat-to-beat time, it stimulates the ventricle. More complex: Sense &/or stimulate both; atrium and ventricle.

Much More Complex: Rate Modulation

Rate Modulation Sensors

Available
Body activity (vibration) Respiratory rate Minute ventilation Right ventricular stroke volume Right atrial pressure Systolic time intervals Blood temperature

Under Investigation
QT interval Mixed venous oxygen saturation Atrial rate Blood PH Evoked pressure Paced depolarization integral

Generic Pacemaker Code (NASPE/ BPEG, Revised 2002)

Position I: Paced Chamber(s) O = None A = Atrium V = Ventricle Position II: Sensed Chamber(s) O = None A = Atrium V = Ventricle Position III: Response(s) to Sensing O = None I = Inhibited T = Triggered Position IV: Programmability O = None R = Rate Modulation Position V: Multisite Pacing * O = None A = Atrium V = Ventricle

D = Dual (A + V)

D = Dual (A + V)

D = Dual (T + I)

D = Dual (A + V)
* = When 2 atria or 2 ventricles are paced.

NASPE: North American Society of Pacing & Electrophysiology, BPEG: British Pacing & Electrophysiology Group.

Examples and Types of Pacing Modes:

Asynchronous: (AOO, VOO, & DOO)

Fixed (preset rate) rate pacemaker. Discharges irrespective of the native heart rate. Hazard: Competes with the native intrinsic rhythm arrhythmias induction.

Single Chamber Atrial Pacing (AAI, AAT)

Atrium is paced and the impulse passes down the conducting pathways, thus maintaining A-V synchrony. A single lead in the Rt. Atr., which senses the intrinsic P wave and causes inhibition or triggering of the pacemaker. Useful in sinus arrest & sinus bradycardia (adequate AV-conduction) Inappropriate for chronic AF & long ventricular pauses.

Single Chamber Ventricular Pacing (VVI, VVT)

VVI: The most widely used pacing mode.
ventricle is sensed & paced. It senses the intrinsic R wave and thus inhibits the pacemaker function. Indications: Complete HB with chronic AF, Af, & long ventricular pauses.

Dual Chamber AV Sequential Pacing (DDD, DVI, DDI, and VDD)

Using 2 leads (Rt. Atr. & Rt. vent.) 1st: atrium is stimulated to contract, After an adjustable PR interval, ventricle is stimulated (preserve normal AV contraction sequence), indications: AV block, SA node disease. In DDD system, both the atrium and ventricle can be sensed and paced. Advantages: mimic SR, so beneficial when atrial contraction is important for ventricular filling (e.g. A.S.)

Factors Influencing CRMD Pacing Threshold

Effect Drugs Other Factors

Flecainide, Propafenone, Encainide, Sotalol, -Blockers*, Lidocaine*, Verapamile*, Quinidine*, Procainamide*. Atropine, Catecholamines, Glucocorticoids. Amiodarone, Anesthetic drugs (both; inhalational & intravenous)

Increase Threshold

Possibly Decrease Threshold

Myocardial ischemia/infarction Hyperkalaemia Severe Acidosis or Alkalosis Hypothyrodism* Hyperglycemia* Pheochromocytoma Hyperthyroid Hypermetabolic states

No Proven Effect

* Possibly

Atlee, 1999

Effect of the Magnet Application on Pacemaker Function.

Magnet-activated switches were incorporated into pacemakers to produce pacing behavior that demonstrates remaining battery life. Never intended to treat pacemaker emergencies or prevent EMI effects

Thus, magnets can be used to protect the pacemakerdependent patient during EMI, (diathermy/cautery).
Magnet application results in a non-sensing asynchronous mode with a fixed pacing rate (magnet rate).

Use of magnet during surgery is not without risk. Asynchronous pacing may trigger malignant rhythm.

N o t A l l Pa ce m a ke r s Sw i t c h e s t o a Co n t i n u o u s A s y n c h ro n o u s Mo d e W h e n a Magnet is Applied. In programmable pacemakers, in the presence of EMI, generator may unpredictably reprogrammed with a new surprise programme. Most current devices should be considered programmable unless known otherwise.

Anesthesiologists

You Sleep .. We Care !!

How to Deal with a Patient with CRMD

Stepwise Approach Patient with a CRMD:

I. Preoperative Evaluation:
1. Routine preoperative evaluation: CAD (50%) HTN (20%) & DM (10%), Assess: (1) severity, (2) current functional, status (3) medication.

CXR, (continuity of leads) ECG, (Spike) Bioch (s. K+)

Preoperative Evaluation (Cont.):

2. Confirm whether a patient has a CRMD: Focused history: interview, medical records, CXR, ECG. Inquire about the initial indication for the pacemaker & pre-implantation symptoms (dizziness, fainting).

Focused physical examination (check for scars, palpate for device).

Preoperative Evaluation (Cont.):

3. Define the type of CRMD.

Obtain manufacturers I D c a rd from patient. If no other data is available: CXR (X - Ra y c o d e ).

4. Determine patient dependency on CRMD pacing.

No spontaneous ventricular activity when programmed to VVI mode at the lowest programmable rate.

Preoperative Evaluation (Cont.):

5.

Evaluation of CRMD function.

Get the device I N T E R RO G AT E D (by Cardiologist) & get a copy !!

Preoperative Evaluation (Cont.):

5. Evaluation of CRMD function (Cont.)

Ensure that the electrical pacing impulse creates a mechanical systole (preph. pulse) !! If VVI mode: if intrinsic HR is > set rate, slow down HR (carotid massage or Valsalva manoeuvre), while ECG is monitored.

II. Preoperative Preparation

1. If

Intraop. E M I is likely to occur :

Reprogram to Asynchronous mode. Deactivate all Rate Responsive !!

Activity rate responsive: shivering and fasciculations Minute ventilation rate responsive: (RR & Vt) should be kept controlled Temperature rate responsive Temp kept constant.

Disable Antitachyarrhythmia functions if present

(if CRMD is ICD).

Temporary pacing and defibrillation equipment

should be immediately available (all CRMD).

II. Preoperative Preparation (Cont.)

2. Evaluate the possible effects of anesthetic techniques

on CRMD function.

CXR to document the position of the Coronary Sinus

lead, if CVL placement is planned, (CS lead displacement).

III. Intraoperative Management

1. Monitor

CRMD operation.

ECG: Ability to detect pacemaker discharge (disable artifact filter ). Preferably with Respiratory Rate monitoring. Monitor peripheral pulse: Manual palpation, Waveform Display: pulse oximeter, A. line).

III. Intraoperative Management (Cont.)

2.

Anesthetic Technique:
Should be dictated by patients underlying physiology &/or procedure. Agents suppresses AV or SA node (potent opiates or dexmedetomidine) may render patient truly pacemaker dependant. Myoclonic movements, can inhibit or trigger stimulation, (according to programmed pacing modes): Succ. Ch.: fasciculation, Etomidate & ketamine: myoclonic movements. Nitrous Oxide ??!

III. Intraoperative Management (Cont.)

3.

EMIInduced CRMD Potential Dysfunction

Avoid Unipolar ( ). Use Bipolar or ultrasonic (harmonic) ()

A. Electrocautery:

If unipolar used:

Grounding plate: as far as possible from the pacemaker site, Assure that the current does not pass through or near the CRMD Distance: Not within 15 cm of pacemaker. Frequency: 1-second every 10 seconds (to prevent repeated asystolic periods). Pure cut is better than Coag. Asynchronous Mode (magnet or programmer). Emergency Tools: Temporary pacing (transvenous, trans cutaneous), Atropine, Isupril should be ready.

III.Intraoperative Management (Cont.) 3. EMIInduced CRMD Potential Dysfunction (Cont.)

B. Nature of Procedure:

Lithotripsy (ESWL): Avoid beam focusing near the generator. If triggers on the R-wave, disable atrial pacing.

Radiology:

Plain X-ray & CT: Do Not affect pacemaker function

MRI:

Contraindicated Generally

III.Intraoperative Management (Cont.) 3. EMIInduced CRMD Potential Dysfunction (Cont.) B. Nature of Procedure (Cont.):
Radio-therapy:

Safe (Surgically relocate CRMD outside radiation field

ECT:

ECT itself safe (little current flows within the heart) Succinylcholine and seizure (!!!) Reprogram to asynchronous mode.

External pacemaker should be available.

IV. Emergency Defibrillation or Cardioversion.

Follow existing ACLS guidelines (energy level & paddle

placement). Minimize the current flow through the generator & lead system by positioning the paddles :
1. As far as possible from the pulse generator, 2. Perpendicular to the major axis of the generator and leads to the extent possible by placing them in an anteriorposterior location.

V. Postoperative Management

ICU Setup (Continuous ECG monitor, backup pacing

& defibrillation). Assure that all CRMD settings are restored:

Interrogate CRMD; (cardiologist/manufacturer)

Thanks for your Attention !!