The following are key points to remember from a scientific statement on periprocedural management and multidisciplinary care pathways for patients with cardiac implantable electronic devices (CIED):

1. The rapid technological advancements in CIED, coupled with a rise in the number of patients with these devices, necessitate an updated clinical framework for periprocedural management. Furthermore, the introduction of leadless pacemakers, subcutaneous and extravascular defibrillators, and novel device communication protocols highlights the need for clinical updates.
2. This scientific statement provides an inclusive framework for the periprocedural management of patients with these devices, encompassing the planning phase, procedure, and subsequent care coordinated with the primary device managing clinic.
3. The statement, pertinent to a wide range of health care professionals, underscores the importance of quality care pathways for patient safety, optimal device function, and minimization of hemodynamic disturbances or arrhythmias during procedures.
4. Essential elements of patient screening for perioperative CIED management include:
   • Presence of a CIED and its location (right/left infraclavicular, abdominal, and midaxillary region);
   • Type of device (transvenous or leadless pacemaker; transvenous, subcutaneous, or extravascular defibrillator; cardiac resynchronization device; or implantable cardiac monitor);
   • Indication (sick sinus syndrome, atrioventricular block, primary or secondary prevention of sudden cardiac death, ventricular tachycardia, or ventricular fibrillation) and pertinent arrhythmic history (e.g., sinus node dysfunction, tachy-brady syndrome, supraventricular tachycardia, atrial fibrillation or ventricular tachycardia, and cause of cardiomyopathy);
   • Physical examination (jugular venous pressure, pulmonary auscultation, lower extremity edema, and condition of CIED pocket if applicable);
   • Sources of electromagnetic interference (EMI) (e.g., nerve stimulators, cochlear implants, programmable hydrocephalus shunts, left ventricular assist devices, and cardiac contractility management devices);
   • Assessment of new cardiac arrhythmia events recorded by device; and
   • Assessment of extracardiac conditions that may affect intraprocedural safety, including chronic or acute kidney dysfunction, hepatic failure, acute or subacute neural impairment, pulmonary insufficiency, and impediments to vascular access.
5. Specific elements of the device interrogation during procedural planning include:
   • Cardiac rhythm status, including underlying rhythm, baseline heart rate, and dependency on pacing support;
   • Battery life, threshold, impedances, sensing parameters, and history of prior arrhythmias;
   • Whether the device is magnetic resonance imaging conditional and at what magnet strength; and
   • Testing and confirmation of magnet response.
6. For pacemaker-dependent patients, clinicans need to be aware that electrocautery can cause EMI, which leads to oversensing of nonphysiological signals and inhibition of pacing, particularly when surgery is performed above the umbilicus, except for patients with CIED generators in the abdomen, which may require reprogramming because of proximity to the generator. To prevent this, the pacemaker may be programmed to an asynchronous mode (DOO, AOO, or VOO), or a magnet can be placed over the device during the procedure, assuming that a stable magnet position can be maintained and the pulse generator is not ocated within the sterile surgical field. It can be noted the application of a magnet to an implantable cardioverter-defibrillator (ICD) has no effect on the pacing function.
7. For patients with ICDs, to prevent inappropriate therapies from a defibrillator due to EMI, tachyarrhythmia detection should be programmed “off.” If a programmer is not available, one may place a magnet over the pulse generator during the procedure. It is essential to re-enable detection of tachyarrhythmias before discharge from a monitored setting.
8. It should be noted that, unlike transvenous pacemakers, the Micra leadless pacemaker does not have a programmed response to a magnet. Therefore, if a patient is pacemaker dependent and a procedure will involve EMI above the umbilicus, the device may be programmed in a VOO asynchronous pacing mode before the use of electrocautery. Although some leadless pacemakers do have an asynchronous magnet response, the magnet mode may be limited by patient body habitus, and testing before entering the operating room may be considered. If this positioning cannot be consistently maintained, the device can be reprogrammed to an asynchronous mode before the use of electrocautery.
9. In addition to the magnet mode programming described previously, magnets may be useful in certain emergency scenarios, including avoiding inappropriate shocks due to hemodynamically stable rhythms, EMI, or ICD lead fracture or increasing the heart rate to the pacemaker magnet response rate before a device programmer is available.
10. Before the procedure, notifying the device team about the upcoming procedure may facilitate generation of a periprocedural plan for the CIED. Postprocedural communication with the device team about any device changes or reprogramming would also ensure patient safety and safe continuity of care. The primary objective is to deliver quality care to the expanding patient cohort with CIEDs, offering direction in the era of evolving technologies and laying a foundation for sustained education and practice enhancement.

Clinical Topics: Arrhythmias and Clinical EP

Keywords: Implantable Devices

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