Anaesthetic Considerations

for patients with Cardiac

Pacemakers
Presenter: Nisha Thakur, PGY II
Moderator: Dr. Arjun Gurung
Department of Cardiothoracic and Vascular Anaesthesia, MCVTC

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Objectives
• To review the conduction system of heart
• To learn about indications, types, components, modes of pacemakers
• To discuss the perioperative management of patients with pacemaker
• To learn about indications and methods of temporary pacing

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Conduction system of Heart

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Cardiac implantable electrical
devices (CIED)
• Battery powered medical devices to treat cardiac conduction
disorders
• 3 types
1. Pacemakers
2. Implantable cardiac defibrillators (ICD)
3. Cardiac resynchronization therapy (CRT)

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Pacemaker
• Devices that deliver electrical
energy and treat
bradyarrhythmias

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Indications
1. Third degree AV block
• Bradycardia with symptoms
• After drug treatment that cause symptomatic bradycardia
• Escape rhythm < 40 bpm or asystole > 3s

2. Second degree AV block

• Symptomatic bradycardia

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Indications contd..
3. After Myocardial infarction:
• Persistent second degree or third degree block
• Infranodal AV block with left bundle branch block (LBBB)
• Symptomatic second or third degree block

4. Bifascicular or Trifascicular block:

• Intermittent complete heart block with symptoms
• Type II second degree AV block
• Alternating bundle branch block

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Indications contd..
5. Sinus node dysfunction:
• Sinus node dysfunction with symptoms as a result of long-term drug therapy
• Symptomatic chronotropic incompetence

6. Hypertensive carotid sinus and neurocardiac syndromes:

• Recurrent syncope associated with carotid sinus stimulation
• Asystole of > 3s duration in absence of any medication

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 Types
1. Temporary pacemakers:
- External, battery-powered, pulse generators with exteriorized
electrodes produce electrical cardiac stimulation

2. Permanent pacemakers:
- Implantable pulse generators with endocardial or myocardial
electrodes for long term or permanent use

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Types contd..
Based on method of insertion
1. Transvenous
2. Transcutaneous
3. Epicardial
4. Transesophgeal

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Types contd..

Based on number of chamber paced

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Components of Pacemaker:

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Components contd..
1. Pulse Generator
• Energy source (battery) and electric circuits for pacing and sensory
function
• Mercury-Zinc batteries: short life (2–3 years); Lithium-iodide batteries:
longer life (5–10 years)

2. Leads: Insulated wires connecting pulse generator and electrodes

3. Electrode: Exposed metal end of lead in contact with endocardium or

epicardium
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Important Terms
• PACING:
Regular output of electrical current, for depolarizing the cardiac tissue

• SENSING:
Response of a pacemaker to intrinsic heartbeats

• PACING THRESHOLD:
Minimum amount of energy pacemaker sends down the lead to initiate heart
beat

• CAPTURE:
 Cardiac depolarization and resultant contraction (atrial or ventricular)
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• RATE RESPONSE:
Analyse patient’s activity and adjust rate

• TRIGGERED PACING:
Dual chamber pacemakers - sense activity in one chamber (atrium) and deliver
pacing stimulus in other chamber (ventricle ) after certain time delay

• INHIBITION OF OUTPUT:
Inhibit pacing if senses intrinsic activity, or ignore intrinsic activity and deliver a
pacing stimulus anyway

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PACEMAKER MODE
NASPE/ BPEG Pacemaker generic codes(2002)
Position I Position II Position III Position IV Position V

Pacing Chamber (s) Sensing Chamber (s) Response (s) to Programmability Multisite Pacing
Sensing

0 = None 0 = None O = None O = None 0 = None

A = Atrium A = Atrium T= Triggered R = Rate modulation A = Atrium

V = Ventricle V = Ventricle I = Inhibited V = Ventricle

D= Dual ( A + V) D= Dual ( A + V) D= Dual ( T + I) D= Dual ( A + V)

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Modes of pacemaker
1. Asynchronous or fixed-rate modes:
- AOO / VOO / DOO
- Do not provide sensing
- Pace at a preset rate that is independent of native cardiac activity
- Magnet Mode

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Modes contd..
2. Single chamber demand pacing:
- AAI / VVI
- Paces at a preset rate only when spontaneous heart rate drops below
preset rate

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Modes contd..

a. AAI mode:
- Atrium: paced and sensed
- Native atrial activity sensed -- pacing inhibited
- No native activity sensed for pre-determined time -- atrial pacing
initiated
- Used in sinus node dysfunction with intact AV conduction
- Also termed atrial demand mode

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Modes contd..

b. VVI Mode:
- Ventricle: paced and sensed
- Similar to AAI mode
- Used in patients with chronic atrial impairment e.g. atrial fibrillation
or flutter

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Modes contd..
3. Dual- chamber AV sequential Pacing (DDD mode)
- Commonest pacing mode
- Atrial pacing occurs if no native atrial activity for set time
- Ventricular pacing occurs if no native ventricle activity for set time
following atrial activity

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Paced ECG: Electrocardiographic
Features
• Appearance of the ECG depends on:
i. pacing mode
ii. placement of pacing leads
iii. device pacing thresholds
iv. presence of native electrical activity

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Paced ECG contd..
1. Pacing spikes
• Vertical spikes of short duration( 2 ms)
• Bipolar leads smaller pacing spike than unipolar leads
• Epicardially placed leads smaller pacing spikes than endocardially
placed leads

2. Atrial Pacing
• Pacing spike precedes the p wave

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Paced ECG contd..
3. Ventricular Pacing
• Pacing spike precedes the QRS complex

4. Dual Chamber Pacing

• Pacing spikes may precede only p wave, only QRS complex, or both

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Pacemaker dependent
• Absent of a perfusing rhythm without pacing
• Patients
a. With ICD device
b. Who develops symptoms if pacing rate is decreased
c. Who has no intrinsic activity despite decreasing the pacing rate below
45 b/m

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Implantable cardiac
defibrillation
• Consists of pulse generator and leads that can sense VF and Vtach and
deliver a shock to restore sinus rhythm
• Treats tachyarrhythmias
• Functions
1. Synchronised cardioversion
2. Defibrillation
3. Antitachycardia pacing

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Indications of ICD
1. Secondary prevention of Sudden Cardiac Death (SCD) in previous
cardiac arrest (VT/VF)
• Patients with coronary artery disease (CAD) who survived one cardiac arrest
(if >48 h after an acute MI)
• Arrhythmogenic right ventricular (RV) dysplasia
• Genetic proarrhythmic syndromes with one prior episode of VT/VF
• Syncope with inducible sustained VT

2. Primary prevention of SCD

• All subgroups from secondary prevention considered high risk but did not yet
have an episode of VT/VF

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Preoperative evaluation
1. Detailed evaluation of underlying cardiovascular disease responsible
for insertion of pacemaker
2. Associated medical problems: Coronary artery disease (50%),
hypertension (20%) and diabetes (10%)
3. Communication with the CIED team about
a. Type of device
b. Battery life
c. Pacemaker dependence
d. Magnet response

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Investigations
1. Routine biochemical and
hematological investigations

2. Measurement of serum
electrolytes (especially K+)

3. A 12 lead electrocardiogram

4. X-ray chest (for visualization of

continuity of leads)
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Electromagnetic Interference
(EMI)
• Unwanted noise or interference in an electrical path or circuit caused
by an outside source
• Effect of EMI in pacemaker
1. Inhibition of pacemaker
2. Inappropriate delivery of antitachycardia therapy - ICD

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EMI contd..
3. Changes in lead parameters:
• Atrial mode switching
• Inappropriate ventricular sensing
• Electrical reset
• Increase in ventricular thresholds

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EMI contd..
4. Pacemaker failure after direct contact with electrocautery and cardioversion

5. Conversion from asynchronous mode back to backup mode (reprogramming)

6. Transient or permanent loss of capture

7. Dislodgement of leads during atrial fibrillation ablation procedures

8. Rate adaptive pacing (interaction of minute ventilation sensor with

ECG/plethysmography)

9. Oversensing and inhibition

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Sources of EMI
1. Monopolar electrocautery
2. External Cardioversion
3. Radiofrequency Ablation
4. Lithotripsy
5. Radiation
6. Electroconvulsive Therapy

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Reduction of EMI risk
• Distance between EMI source and pacemaker : >15cm (below
umbilicus)
• Bipolar electrocautery
• Monopolar:
- Placement of grounding pad below umblicus
- Use lowest effective current amplitude and deliver current in short bursts
(<5secs)

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Magnets
• Prevents pacemaker from EMI during surgery

• Converts the pacemaker to a fixed rate asynchronous mode

• Most pacemakers -- built-in magnetic reed switches -- depends on

type of manufacturer
• Magnet application to ICD deactivates tachyarrhythmia therapy --
need reprogramming to set in asynchronous mode

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Magnets contd..

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Magnets contd..

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Magnets contd..
Causes of magnet failure
1. A depleted pacemaker battery
2. The pacemaker is programmed to ignore the magnet
3. The magnetic field does not reach the device (obese patients)
4. End of Life or lower battery life

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Intraoperative management
• Monitoring – ASA standard II monitoring - especially
Plethysmographic pulse oximetry

• Invasive monitoring – Arterial line

• Central venous catheterisation: Insertion with caution

- Avoid direct contact between the transvenous leads and CVC guide wires
- Can cause dislodgement of the leads
- Can cause thrombus dislodgement or dissemination of bacterial infection
from the transvenous leads of the pacemaker

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Intraoperative management contd..
• Pacemaker-dependent & monopolar electrocautery within 15 cm of
generator
device reprogrammed or placement of a magnet

• Patients with ICDs

tachyarrhythmia therapies disabled

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CIED pathway for nonemergent
surgery

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CIED pathway for nonemergent surgery contd..

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Impact of Anesthetic Drugs
• Narcotic can be used successfully

• Inhalational gas - Nitrous oxide:

expansion of gas in the pocket – loss of anodal contact and pacing
system malfunction

• Inducing agents - Ketamine and Etomidate - avoided; myoclonic

movements

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Anaesthetic drugs contd..
• Muscle relaxants - Succinylcholine:
- Increase in stimulation threshold
- Contraction of skeletal muscle groups(myopotentials) could inhibit the
pacemaker

NOTE - Anaesthetic agents do not alter current and voltage threshold

of pacemakers

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Anaesthetic management contd..
• Regional anesthesia and pacemaker
- No guidelines favoring or contradicting
- Spinal anesthesia: cautious; preferably avoided in cases of anticipated
blood loss or fluid shift

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Factors that Alter the Pacing Threshold
Increased Threshold Decreased Threshold
1-4 weeks of insertion Stress, Anxiety
Hyperkalemia Sympathomimetics
Hypothyroidism Anti-cholinergics
Hypothermia Glucocorticoids
Severe Hypoxia Hyperthyroidism
Alkalosis/Acidosis Hypermetabolic states
Myocardial Ischemia or Infarction
Antiarrythmic Drugs

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Postoperative Management:
• Continuous monitoring of Cardiac rate and rhythm

• Immediate availability of back up pacing capability and cardioversion-

defibrillation equipment

• Consultation with Pacemaker technician for resuming pacemaker

activity

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Management of pacemaker patient
during emergency surgery

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CIED pathway for emergency
surgery

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CIED pathway for emergency
surgery

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Pacemaker failure
• Causes:
1. Failure of capture
2. Lead failure
3. Generator failure

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Treatment of pacemaker failure
• Rate adequate to maintain blood pressure
1. Oxygen, airway control
2. Place magnet over pacemaker
3. Atropine if sinus bradycardia

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Treatment of pacemaker failure
contd..
• Severe bradycardia and hypotension
1. Oxygen, airway control
2. Place magnet over pacemaker
3. Other types of pacing if magnet does not activate pacemaker
(transcutaneous, transvenous, or esophageal)
4. Atropine if sinus bradycardia
5. Isoproterenol to increase ventricular rate

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Treatment of pacemaker failure
contd..
• No escape rhythm
1. Cardiopulmonary resuscitation
2. Place magnet over pacemaker
3. Other types of pacing if magnet does not activate pacemaker
(transcutaneous, transvenous, or esophageal)
4. Isoproterenol to increase ventricular rate

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Temporary pacing: Indications
1. Acute myocardial infarction
• Symptomatic bradycardia
• Medically refractory New bundle branch block with transient complete heart block
• Complete heart block
• Postoperative complete heart block
• Symptomatic congenital heart block
• Mobitz II with AMI
• New bifascicular block
• Bilateral bundle branch block and first-degree AV block
• Symptomatic alternating Wenckebach block
• Symptomatic alternating bundle branch block

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Temporary pacing indications
contd..
2. Tachycardia treatment or prevention
• Bradycardia-dependent VT
• Torsade de pointes
• Long QT syndrome
• Recurrent supraventricular tachycardia or VT

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Temporary pacing indications
contd..
3. Prophylactic
• Pulmonary artery catheter placement with left bundle branch block
(controversial)
• New AV block or bundle branch block in acute endocarditis
• Cardioversion with sick sinus syndrome
• Postdefibrillation bradycardia
• Counteract perioperative pharmacologic treatment causing hemodynamically
significant bradycardia
• AF prophylaxis postcardiac surgery
• Postorthotopic heart transplantation

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Techniques of Temporary Pacing
1. Transcutaneous
• Right ventricle
• Simple, rapid and safe
• Variable capture, chest wall movement, patient discomfort
• Arrest, intraoperative, prophylactic

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Techniques contd..
2. Transesophageal
• Left atrium
• Reliable atrial capture, safe, simple
• Requires special generator
• Prophylactic atrial pacing, overdrive pacing for SVTs

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Techniques contd..
3. Transvenous
• Right ventricle
• Invasive
• Arrest, intraoperative, prophylactic, maintenance

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Techniques contd..
4. Pacing pulmonary artery catheter (PAC)
• Atrium and/or ventricle
• Reliable ventricular capture, well-tolerated
• Specific PAC must be placed first
• Arrest, intraoperative, prophylactic, maintenance

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Techniques contd..
5. Epicardial pacing wires
• Atrium and/or ventricle
• Reliable short-term
• Postoperative only, early lead failure
• Arrest, prophylactic, maintenance

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Optimization of pacing after
CPB
1. Lead placement
2. Rate
3. AV delay
4. Pacing mode
5. Biventricular pacing

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References
• Miller’s Anesthesia, 9th edition; 2019
• Barash PG. Clinical anesthesia, 8th edition; 2017.
• Kaplan’s cardiac anesthesia, 7th edition; 2017.
• Hensley’s Practical Approach to Cardiothoracic Anesthesia, 6th edition;
2013.

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Thank you!

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