围手术期间心脏植入装置的管理 专家共识

围手术期间心脏植入装置的管理专家共识第一页，共五十页，编辑于2023年，星期二

CommitteeStaff

8AHA/ACC/4ASA/1STSNashville,TN；Seattle,WA；Houston；TX,Rochester,MNBaltimore；Cleveland,OHGreenville,NC；Hanover,NHCharleston,SC；WestDesMoines,IACleveland,OH；Jacksonville,FLCharlottesville,VA；Nashville,TNEngineersfrom：第二页，共五十页，编辑于2023年，星期二

概要介绍医疗操作期间可能出现的问题ProblemsthatcanoccurduringmedicalproceduresPreoperativeevaluationofapatientwitha心脏植入性电子装置（CIED）患者术前评估心脏植入性电子装置（CIED）患者手术中管理与思考Intraoperativemanagementandconsiderations心脏植入性电子装置术中的评估IntraoperativeevaluationofCIEDs第三页，共五十页，编辑于2023年，星期二AbbreviationsCIED：CardiovascularimplantableelectronicdevicesEMI

：

ElectromagneticinterferenceECT：

ElectroconvulsivetherapyCIEDteam：Physician,nurse,andtechniciansPerioperativeteam：Anesthesiologist,surgeon，physician,nurse第四页，共五十页，编辑于2023年，星期二

Morethan3,000,000deviceswereimplantedintheglobe全球约有三百万以上患者心脏植入装置700,000deviceswasimplantedin20092009年有700,000患者心脏植入装置Increasingattherateof15%everyyear每年以15%速度递增Introduction第五页，共五十页，编辑于2023年，星期二EnsurepatientswithdevicessafeinperioperativeperiodNeedforaconsistentstatement1、RapidchangesinCIEDtechnology2、ExpandinguseofEMI3、ConfusingrecommendationsIntroduction第六页，共五十页，编辑于2023年，星期二ProblemsthatcanoccurduringmedicalproceduresEMIElectrosurgicalenergy第七页，共五十页，编辑于2023年，星期二EMIandCIEDsElectrosurgicalenergy

IdentificationofproblemsspecifictopatientswithCIEDduringmedicalproceduresOversensingRateresponsivealgorithmsResetPulsegeneratordamageLead-tissueinterfacedamage第八页，共五十页，编辑于2023年，星期二EMIandCIEDsTransienteffectionsuchas：PacinginhibitionInappropriatetrackingofelectricalnoiseDamageatthelead-tissueinterfacePulsegeneratordamageElectricalresetmodeRateresponsivealgorithms第九页，共五十页，编辑于2023年，星期二Extentofabnormalbehaviordependson：StrengthDurationParticulartypeofinterferenceClinicalimpactdependson：Patient’sintrinsicrateandrhythmPacingmodeFunctioningofprotectivecircuitryengineeredtofilteroutextraneouselectricalcurrentsEMIandCIEDs第十页，共五十页，编辑于2023年，星期二ElectrosurgicalenergyBipolarelectrosurgery

：(e.g.electricalforceps）UsedfarlesscommonlyonlyforcoagulationandnotdissectionMonopolarelectrosurgeryUtilizedformostsurgicalproceduresElectrode：“Penorstylus”totheoperativesiteReturnelectrode：patient’sbody第十一页，共五十页，编辑于2023年，星期二InteractionswithCIEDsincluding

：InhibitionTriggeringunneededtachyarrhythmiatherapyElectricalresetOversensing

Electrosurgicalenergy第十二页，共五十页，编辑于2023年，星期二DirectlytothepulsegeneratororsystemelectrodePermanentdamageoftheCIEDpulsegeneratorDamagetothelead-myocardialinterfacecausinganincreaseofpacingthresholdsNodamageifthedistanceis

>

6inches

Electrosurgicalenergy第十三页，共五十页，编辑于2023年，星期二Determineconsequencesofoversensing：

DurationofexposurePathofthecurrentPatient’sunderlyingrhythmOversensinginICDsresultsin：inhibitionofpacingATP

therapyICDshocks

Oversensing第十四页，共五十页，编辑于2023年，星期二ICDrequireacertaindurationofcontinuoushigh-ratesensingtofulfillarrhythmiadetectioncriteriaAnapproachthatlimitselectrosurgeryusagetoshortburstsmaybeasaferapproachtopatient-CIEDmanagementthaneitherreprogrammingtheCIEDorplacementofamagnetoverthepulsegenerator

Oversensing第十五页，共五十页，编辑于2023年，星期二CIEDusesaminute-ventilationsensorforrateresponseRateresponsivealgorithmsoccursbecausetheimpedancemeasurementismiscalculatedduetothecurrentfromtheelectrosurgery.AlsoinsomeCIEDs,themagneticswitchcanbeactivatedbyelectrosurgery,causingrapidpacing

Rateresponsivealgorithms第十六页，共五十页，编辑于2023年，星期二Deviceresetismore

causedbytherapeuticionizingradiationthanEMIcorruptionofthememoryinthecircuitry(2)asurgeofenergycoursingthroughthepulsegeneratorthatsimulatestheinitialconnectionofthepowersourceWerecommendcontactingthetechnicalsupportserviceofthemanufacturer

Reset第十七页，共五十页，编辑于2023年，星期二

Pacingandantitachycardiatherapyparametersareuniquetoeachmanufacturer

第十八页，共五十页，编辑于2023年，星期二SomenewerBostonScientificICDshaveSafetyCoreSafetyCoreisaback-upmodeintendedformajorhardwarefailuresthatprovideshigh-voltagetherapywithasimpleunipolarVVIpacing

Reset第十九页，共五十页，编辑于2023年，星期二Electricalenergycanenterthepulsegenerator：BreachofleadinsulationCorruptionofthesealingringswithconductivefluidbridgetotheleadconnector

Pulsegeneratordamage第二十页，共五十页，编辑于2023年，星期二SurgeriesclosetotheCIEDshouldbedonewithbipolarratherthanmonopolarelectrosurgery（e.g.

breast,shoulder,headandneck,pulsegeneratorreplacement,orcarotidprocedures）Surgeryontheipsilateralhand,thereturnelectrodeshouldbeontheipsilateralarm1

Pulsegeneratordamage第二十一页，共五十页，编辑于2023年，星期二

LeadtissueinterfacedamageElectrosurgicalcollateraldamagetothelead-myocardialinterfaceResultingin：IncreaseinpacingthresholdLossofcaptureInductionofarrhythmias第二十二页，共五十页，编辑于2023年，星期二

Howtomitigatetherisk（1）

KeepingthecurrentpathawayfromCIEDdiminishesthepotentialforadverseinteractionwiththeCIED

Forexample：belowtheumbilicusislesslikelytocauseinterferencethanabovetheumbilicusUsingbipolarelectrosurgerywheneverpossibleMinimizingthelengthofmonopolarelectrosurgeryburststo5secondsorless第二十三页，共五十页，编辑于2023年，星期二CardioversionCatheterablationforcardiacarrhythmiasDiagnosticradiationTherapeuticradiationElectroconvulsiveTherapyTransurethralneedleablation(TUNA)Transurethralresectionoftheprostate(TURP)GastroenterologyproceduresTissueexpandersStimulatorsRadiofrequencyidentificationdevices(RFID)OtherwirelesstechnologyLithotripsyIontophoresisPhotodynamictherapyDentalprocedures

Specialsituations第二十四页，共五十页，编辑于2023年，星期二

CardioversionExternalcardioversionwasassociatedwithtransientdysfunctionofolderCIEDs,particularlyusedunipolarleadsusingananterior-lateralelectrodeposition：transientlossofcaptureandelectricalresetInarecentclinicalstudy，44patientswithCIEDsUsingananterior-posteriorelectrode，positionedwith8cmbetweentheanteriorelectrodeandtheCIEDNoCIEDmalfunction第二十五页，共五十页，编辑于2023年，星期二Inacase-seriesofthreepatients,highpacingthresholdsafterthecardioversionExperienceofseveralcommitteemembers：pulsegeneratorreset

Cardioversion第二十六页，共五十页，编辑于2023年，星期二RadiofrequencyenergydeliverynearCIEDsmayresultin：ElectricalresetReprogrammingOversensingInappropriateinhibitionUndersensingInappropriatearrhythmiadetection（ICD）

pulsegeneratormalfunction

Catheterablationforcardiacarrhythmias第二十七页，共五十页，编辑于2023年，星期二HouseholdmicrowaveenergyhasnosignificantimpactonpacemakersandICDsNospecificstudiesareavailableintermsofmicrowaveablation,whethertheenergyisdeliveredtotheepicardiumorendocardium

Catheterablationforcardiacarrhythmias第二十八页，共五十页，编辑于2023年，星期二DiagnosticradiationDiagnosticradiationgenerallydoesnothaveanysignificantadverseeffectonCIEDsWiththenewestgenerationofmultislicecomputedtomographymachinesthatusehigherradiationdoses,transienteffectsonCIEDsduetooversensing第二十九页，共五十页，编辑于2023年，星期二TherapeuticradiationcandamageCIEDfunctionModernCIEDsutilizemetaloxidesemiconductorsintheintegratedcircuitryWhenthesemiconductorsareexposedtoionizingradiation,damageoccurstothesiliconandthesiliconoxideinsulatorswithinthesemiconductorSuddenoutputfailureorrunawaypacinghasbeenreported

Therapeuticradiation第三十页，共五十页，编辑于2023年，星期二DirectradiationofpacemakersandICDsshouldbestrictlyavoidedandaccumulateddoses<5GyScatterneutronmayoccurelectricalresetImportantly,theuseofconventionalx-rayshieldingduringradiotherapydoesnotprotectthepulsegeneratorfromtheeffectsofthescatteredneutronsIfthephotonbeamenergyexceeds10MV,evaluationofCIEDfunctionimmediately

Therapeuticradiation第三十一页，共五十页，编辑于2023年，星期二InECT,anelectriccurrentisdeliveredtothebrain,triggeringabriefseizureDamageto

CIEDfunction：NoisereversionmodeMyopotentialoversensingBradycardiaInappropriateICDshocks

Electroconvulsivetherapy（ECT）第三十二页，共五十页，编辑于2023年，星期二ThephysicianneedstoknowtheICDtachycardiadetectionrateandshouldhaveamagnethandyincasethesinusrategetsnearthatratePretreatmentwithshort-actingbeta-blockersmightalsobeconsideredinsuchpatients

Electroconvulsivetherapy第三十三页，共五十页，编辑于2023年，星期二Transurethralresectionoftheprostate(TURP)PlacingthepatientreturnelectrodeonalegLimitingapplicationsofTURP-relatedelectrosurgeryto1to2secondsevery10secondsReducetheriskofinhibitioninindividualswhoarepacemakerdependentAvoidICDinappropriatedetections第三十四页，共五十页，编辑于2023年，星期二Colonoscopy、gastrocopyandCapsuleendoscopy：Noreportingcause

interferenceTissueexpanders：DevicescalledtissueexpandersareusedbyplasticsurgeonstoprepareforreconstructivebreastsurgeryReceivetissueexpanderswithoutmagneticaimingguides第三十五页，共五十页，编辑于2023年，星期二Radiofrequencyidentificationdevices(RFID)：

avoidplacingidentificationtagsclosetothepulsegeneratorOtherwirelesstechnology：

SeveralstudieshaveevaluatedinteractionofGSMwithCIEDsandfoundinterferencewhenthewirelessdeviceiscloserthan10cmtotheCIEDpocket第三十六页，共五十页，编辑于2023年，星期二Transurethralneedleablation(TUNA)Electromyelograms(EMGs)andnerveconductiontestingIontophoresisPhotodynamictherapyDentalprocedures

TherearenoreportsofthistechnologyinalteringCIEDfunctionality第三十七页，共五十页，编辑于2023年，星期二PreoperativeevaluationofapatientwithaCIEDTimely,thoroughpreoperativeevaluationisessentialforthesafeperioperativemanagementofpatientswithCIEDsandshouldincludeamultidisciplinaryandsystematicapproachCIEDteamANDperioperativeteamThemosteffectiveprescriptionfortheperioperativecareofapatientwithaCIED第三十八页，共五十页，编辑于2023年，星期二

PreoperativerecommendationsTheProcedureteammustadvisetheCIEDteamaboutthenatureoftheplannedprocedureGeneralprinciplesguidinginclude:InactivationofICDdetectionisnotauniversalrequirementforallprocedures.RenderingPMsasynchronousinpacemaker-dependentpatientsisnotauniversal第三十九页，共五十页，编辑于2023年，星期二Pacemakersthatneedtobeprotectedfrominhibitionmaybemadeasynchronousbyprogrammingorbyplacementofamagnetappliedoverthepulsegenerator,providedthepulsegeneratorisaccessible.

ICDarrhythmiadetectioncanbesuspendedbyplacementofamagnetoverthepulsegeneratorAmagnetplacedoveranICDgeneratorwillnotrenderpacemakerfunctioninanICDasynchronous.

Preoperativerecommendations第四十页，共五十页，编辑于2023年，星期二RenderingaPMasynchronousinaPM-dependentpatientispreferableformostproceduresabovetheumbilicus.Inpacemakerpatients,noreprogrammingisusuallyneededifbelowtheleveloftheumbilicus.Patientswithpacemakersundergoingelectivesurgeryshouldhavehadadevicecheckaspartofroutinecarewithinthepast12monthspatientswithICDsundergoingelectivesurgeryshouldhavehadadevicecheckaspartofroutinecarewithinthepast6months

Preoperativerecommendations第四十一页，共五十页，编辑于2023年，星期二

PreoperativeevaluationofapatientwithaCIED

Essentialelementsoftheinformationgiventothe

CIEDphysicianEssentialelementsofthepreoperativeCIEDevaluation第四十二页，共五十页，编辑于2023年，星期二Essentialelementsoftheinformationgiventothe

CIEDphysician第四十三页，共五十页，编辑于2023年，星期二EssentialelementsofthepreoperativeCIED

evaluationtobeprovidedtotheoperativeteam第四十四页，共五十页，编辑于2023年，星期二EssentialelementsofthepreoperativeCIED

evaluationtobeprovidedtotheoperativeteam第四十五页，共五十页，编辑于2023年，星期二Approachtoemergentprocedures1、Identifythetypeofdevice

EvaluatethemedicalrecordExaminethepatientregistrationcardTelephonethecompanytoclarifydevicetypeExaminethechestradiograph2、DetermineifthepatientispacingObtaina12-leadECGorrhythmstripdocumentationIftherearepacemakerspikesinfrontofallormostPwaveand/orQRScomplexes,assumepacemakerdependency第四十六页，共五十页，编辑于2023年，星期二Approachtoemergentprocedures3、

Pacemakerdependent?

Yes:pacemaker(notICD)，Useshortelectrosurgicalbursts,placemagnetoverdeviceforproceduresaboveumbilicusorextensiveelectrosurgery,havemagnetimmediatelyavailableforproceduresbelowumbilicusMonitorpatientwithplethysmograp