Perioperative Management of Pacemaker-Dependent Patients

Preoperative Evaluation

The American College of Cardiology recommends determining pacemaker dependency by reviewing history of syncope or symptoms requiring pacemaker implantation, checking for history of atrioventricular nodal ablation, and evaluating for absence of spontaneous ventricular activity 1
The American College of Cardiology suggests obtaining device information, including manufacturer and model, current programming settings, date of last interrogation, and battery status 1

For pacemaker-dependent patients with complete heart block, the American College of Cardiology recommends reprogramming the device to an asynchronous mode (VOO or DOO) during surgery, or placing a magnet over the device 1
The American Society of Anesthesiologists recommends maintaining continuous ECG and pulse monitoring throughout the procedure 2
The American Society of Anesthesiologists suggests having temporary pacing and defibrillation equipment immediately available 2

The American College of Cardiology recommends using bipolar electrocautery when possible, keeping electrocautery bursts short and intermittent at lowest possible energy, positioning the grounding pad to minimize current flow through the pacemaker, and maximizing distance between electrocautery and the device 1
The American Society of Anesthesiologists suggests considering using ultrasonic (harmonic) scalpel as an alternative to electrocautery for procedures involving the chest or abdomen 2
Electrocautery during surgery poses significant risks, including reprogramming to backup modes, temporary or permanent inhibition of pacemaker output, and increase in pacing rate, according to the American Heart Association, and precautions include using bipolar electrocautery, keeping cautery bursts short, and positioning the ground plate away from the pacemaker 3, 4, 5
Cardioversion/Defibrillation requires positioning paddles as far as possible from the generator, using an anterior-posterior configuration, and device interrogation before and after the procedure, as recommended by the American College of Cardiology 6

The American Society of Anesthesiologists recommends continuing cardiac rhythm monitoring throughout the immediate postoperative period 2
The American College of Cardiology and the American Society of Anesthesiologists recommend restoring original pacemaker settings if reprogrammed preoperatively 1, 2
Pacemaker interrogation after surgery is necessary if significant electromagnetic interference occurred, patient is pacemaker-dependent, or underlying rhythm is unreliable, according to the European Society of Cardiology 4

Patients with pacemakers must follow specific precautions regarding electromagnetic interference, physical activities, and medical procedures to ensure proper device function and prevent complications, as recommended by the European Heart Journal and other guidelines 7, 3, 8
Patients should avoid contact sports that could damage the device or dislodge leads, avoid activities with risk of chest trauma, and avoid extreme arm movements on the implant side for the first 4-6 weeks, as recommended by the American College of Cardiology 8
Driving restrictions apply, including avoiding driving for at least 7 days after implantation for primary prevention ICD and 6 months after the last arrhythmic event for secondary prevention ICD, according to the American Heart Association and the American College of Cardiology 8, 9
Regular device checks are mandatory, with initial follow-up within 2-4 weeks of implantation and subsequent checks every 3-6 months, as recommended by the American College of Cardiology and the Heart Rhythm Society 8, 9
Remote monitoring may supplement but not replace in-person visits, and patients should receive comprehensive education about device function and limitations, as advised by the American College of Cardiology 8

The American College of Cardiology suggests considering right internal jugular venous access for temporary pacing if needed 10
Asymptomatic bifascicular block is not an indication for temporary pacing, according to the American Heart Association 11
Standard monitoring, including ECG, pulse oximetry, and blood pressure, is sufficient, and continuous cardiac monitoring throughout the procedure is recommended by the American College of Cardiology 12
Ensuring the surgical team is aware of the pacemaker and designating a responsible person for device management is key, as recommended by the European Society of Cardiology 4

Household appliances are generally safe when in good working condition, but patients should avoid lingering near security systems and keep cell phones at least 6 inches away from the device, as advised by the American College of Cardiology and the Heart Rhythm Society 8, 9
Strong electromagnetic fields, such as those from MRI machines, can interfere with pacemaker function, causing temporary inhibition of pacemaker output, resetting to backup/safety mode, inappropriate rate increases, or potential device damage in extreme cases, according to the American Heart Association guidelines 13
Physical impact to the device or leads, particularly in pacemaker-dependent patients, is a primary safety concern, emphasizing the importance of careful handling and protection of the device, as noted by the American Heart Association 14
Hydrogen water consumption poses no risk to pacemaker function due to its lack of electromagnetic properties and electrical conductivity concerns, making it safe for patients with pacemakers, according to the American College of Cardiology 13, 15 and the American Heart Association 14
Reporting any unusual symptoms to their healthcare provider is also crucial, although such symptoms would not be expected from hydrogen water consumption, as noted by the American College of Cardiology 13, 15