Periprocedural Management and Multidisciplinary Care Pathways for Patients With Cardiac Implantable Electronic Devices

Authors, Journal, Affiliations, Type, DOI

• Authors: Elaine Y. Wan, Albert J. Rogers, Michael Lavelle, Mason Marcus, Sarah A. Stone, Linda Ottoboni, Uma Srivatsa, Miguel A. Leal, Andrea M. Russo, Larry R. Jackson II, George H. Crossley; on behalf of AHA Electrocardiography and Arrhythmias Committee
• Journal: Circulation, 2024;150:e183–e196
• Affiliations: Stanford, Columbia, Emory, Duke, Cooper Medical School, UC Davis, Vanderbilt
• Type: AHA Scientific Statement
• DOI: 10.1161/CIR.0000000000001264

Overview

This 2024 AHA Scientific Statement updates the framework for periprocedural management of all cardiac implantable electronic devices (CIEDs), incorporating newer device types including leadless pacemakers, subcutaneous ICDs (S-ICDs), and extravascular ICDs (EV-ICDs). It provides a structured three-phase approach: preprocedural screening and planning, intraprocedural monitoring and EMI management, and postprocedural device restoration. Key advances over prior guidance include device-specific magnet response differences (Medtronic Micra has no magnet response; Abbott AVEIR does), special precautions for S-ICD/EV-ICD systems, and MRI-conditional considerations for modern CIEDs. Failure to re-enable ICD therapies post-procedure has been associated with patient deaths.

Keywords

AHA Scientific Statements, critical pathways, defibrillators implantable, delivery of health care, pacemaker artificial, patient safety, perioperative care

Key Takeaways

Preprocedural Screening

• Patient screening should identify: CIED type and location, device indication, pacing dependency, sources of EMI, and extracardiac conditions affecting safety
• Device interrogation within 3 months: assess pacing burden, battery life, thresholds, sensing parameters, magnet response
• Physical examination: assess for heart failure symptoms, arrhythmia burden on interrogation; high VA burden or recent ICD therapy may warrant evaluation before elective procedure
• Identify manufacturer via patient card, mobile identification app, chest X-ray, or device company medical records
• Chest X-ray distinguishes ICD (radiopaque coil on lead) from pacemaker; identifies subcutaneous vs extravascular ICD location; shows leadless device position (RA + RV = dual-chamber leadless PM)

Electromagnetic Interference (EMI)

• Unipolar cautery is the principal EMI source; true bipolar cautery is safe and produces no EMI
• Surgery below the umbilicus with return pad also below umbilicus → low EMI risk
• Surgery above the umbilicus (or with abdominal CIED generator) → higher risk; reprogramming may be needed
• EMI effects on pacemakers: oversensing → pacing inhibition; on ICDs: false tachytherapy detection → inappropriate shock or ATP
• Device reset is infrequent with electrosurgery; pulse generator damage is uncommon unless energy applied near generator
• Low battery voltage increases susceptibility to EMI intrusion (protection circuitry is battery current-dependent)
• Risk mitigation: use bipolar cautery; place return electrode on contralateral lower limb; monopolar bursts ≤5 s; avoid whole-body return electrodes
• Additional high-risk EMI sources: RF catheter ablation (high risk with prolonged current and lead proximity), therapeutic radiation (most likely to cause device reset), GI electrosurgery, argon plasma coagulation, LVAD (common — can cause reset/inappropriate shocks/pacing inhibition), cardiac contractility management devices

Pacemaker Dependency and Asynchronous Pacing

• Pacing dependency may increase under anesthesia (autonomic changes, pharmacological agents)
• Non-pacemaker-dependent patients may still have inadequate intrinsic rate for hemodynamic demands of the procedure
• 12-lead ECG confirms intrinsic vs paced rhythm; pacing burden on interrogation informs pre-procedure planning
• Magnet application to transvenous pacemaker → asynchronous pacing at proprietary rate (manufacturer- and battery-specific)
• For pacing-dependent patients with anticipated EMI above umbilicus: reprogram to asynchronous mode (AOO/VOO/DOO)

Device-Specific Magnet Responses

*Asynchronous pacing rate is manufacturer-specific and battery-status dependent.

Transvenous Devices

• Unipolar sensing configuration more susceptible to EMI than bipolar configuration
• Avoid ipsilateral central venous access (risk: venous stenosis, infection, lead dislodgement)
• Guide wires near dual-coil ICD leads risk inducing VA or high-voltage shorting of ICD circuitry
• Surgical intervention near CIED pocket → risk of infection, device damage, lead dislodgement; consult CIED team if unavoidable
• RF ablation: check sensing, impedance, thresholds after procedure
• Conduction system pacing leads: HBP sites have higher risk of elevated thresholds or microdislodgement vs RV apical or LBBP sites

Leadless Devices

• Cannot be palpated; identified on chest X-ray by characteristic markings and intracardiac location
• Two commercially available systems (US): Medtronic Micra and Abbott AVEIR
• Micra VR/AV: no magnet response; AV synchrony via atrial mechanical sensing (accelerometer); rate response via accelerometer
• AVEIR VR/DR: magnet response available but may be difficult to activate by body habitus; AVEIR DR is the only commercially available dual-chamber leadless PM (separate RA + RV devices communicating locally)
• Leadless pacemakers can be programmed "off" (unlike most transvenous pacemakers)
• AVEIR rate response mechanism: blood temperature returning to heart (vs Micra accelerometer)

Subcutaneous and Extravascular ICDs

• S-ICD (Boston Scientific): generator along left midaxillary line; shock coil superficial to sternum; widely spaced sensing → more EMI-susceptible than transvenous bipolar
  • No long-term bradycardia pacing; post-shock pacing only
  • Emergency bradycardia pacing NOT possible through subcutaneous system
• EV-ICD (Medtronic): shock coil deep to (substernal) sternum; also along left midaxillary line
  • No long-term bradycardia pacing; post-shock pacing + ATP + pause prevention pacing (40 bpm, pauses >5 s, programmable to 15 s)
  • Emergency bradycardia pacing is possible
• Both: keep cautery current path away from generator and defibrillation electrode
• Devices combining leadless pacemakers communicating with S-ICD under investigation

Implantable Loop Recorders

• EMI (cautery, defibrillation, RF ablation, lithotripsy, nerve stimulators) → inappropriate episode storage or inhibition
• Extract pre-procedural data to avoid loss of symptomatic events; record accurate procedure date/time
• Consider ILR removal if within planned surgical incision
• MRI: minimal device risk but imaging artifacts near ILR

ICD Management

• Inhibit ICD detection and therapy for procedures above umbilicus (magnet or reprogram "off")
• Continuous external defibrillation pads while ICD therapies are deactivated
• Critical: re-enable ICD therapies before patient discharged from monitored setting — patient deaths reported after failure to re-enable post-elective procedures
• Emergency magnet use: suppress inappropriate shocks (hemodynamically stable arrhythmias, EMI, lead fracture) as bridge to reprogramming; can also increase heart rate to magnet response rate if pacemaker

Medical Center Workflow (Three Phases)

• Advance outpatient planning: CIED team generates periprocedural plan; communicate to surgical and anaesthesia teams; plan addresses EMI sources, surgical site, reprogramming needs
• Day of procedure (pre-procedural): review recommendations; test magnet response in monitored environment; external defibrillator and transcutaneous pacing immediately available; programming by physician only (industry-employed allied professionals may assist logistically but NOT make perioperative recommendations per HRS 2023)
• Intraprocedural: continuous telemetry; arterial BP or plethysmography as alternative monitor if EMI degrades telemetry; note that pacing spike display on telemetry is algorithmic and may be absent at low pacing output
• Postprocedural: verify device returned to pre-procedure settings; interrogate if major events (cardiac arrest, ICD therapy, external defibrillation, suspected device reset); document all reprogramming in EHR; return to routine outpatient CIED follow-up

MRI with CIEDs

• Most contemporary CIEDs are MRI-conditional: FDA-labeled for performance under MRI conditions provided specific conditions met (monitoring, programming as indicated)
• Entire system must be MRI-conditional: abandoned leads or non-conditional components invalidate conditional status
• Institution-specific MRI-CIED protocols required

Limitations of the Document

• Evidence base largely expert consensus/narrative review; limited high-quality RCTs on specific workflow elements
• Research on optimal periprocedural workflows is sparse; remote programming not yet available for most devices
• Workflows are often institution-specific and must be adapted to local resources and CIED team availability
• Statement does not provide guidance on all possible specific device models; direct CIED team consultation always required

Key Concepts Mentioned

• concepts/Periprocedural-CIED-Management — core concept covered by this source
• concepts/Perioperative-Cardiovascular-Assessment — complementary AHA 2024 perioperative framework
• concepts/Conduction-System-Pacing — HBP/LBBP perioperative threshold and dislodgement considerations

Key Entities Mentioned

• entities/Atrial-Fibrillation — supraventricular arrhythmias as trigger for inappropriate ICD therapy periprocedurally
• entities/Heart-Failure — CRT device management; ICD indications
• entities/DCM — ICD/CRT implantation indication
• entities/HCM — ICD implantation indication

Wiki Pages Updated

• wiki/sources/periop-cied-aha-2024.md — created
• wiki/concepts/Periprocedural-CIED-Management.md — created
• wiki/concepts/Perioperative-Cardiovascular-Assessment.md — updated (CIED section + connection added)
• wiki/concepts/Conduction-System-Pacing.md — updated (perioperative note added)
• wiki/wikiindex.md — updated
• wiki/sourceindex.md — updated