Effective Date: ® Administrative Manual Policy #:

˛ Cardiovascular Clinic Manual

August 2003 ® Other _______________

X Original Page 1 Title: Management of Pacemaker/ICD

Revision of 4 Devices in Surgical Setting

PURPOSE

To establish a process for the safe management of patients’ pacemaker/ICD devices during surgical
procedures.

POLICY

All preoperative patients with an implanted cardiac generator (pacemaker/ICD device), in addition to
consulting an anesthesiologist and/or the Preoperative Anesthesiology Clinic, must have an assessment of
and decision regarding the management of their device during surgery.

GENERAL INFORMATION

NASPE/BPEG Generic Pacemaker Code (NBG)

Position I Position II Position III Position IV Position V
Pacing Sensing Response Programmability Antitachy Fcn
O = None O = None O = None O = None O = None
A = Atrium A = Atrium I = Inhibited P = Programmable P = Pacing
V = Ventricle V = Ventricle T = Triggered M = Multiprogram S = Shock
D = Dual (A+V) D = Dual (A+V) D = Dual (I+T) C = Communicating D = Dual (P+S)
R = Rate Modulation*
* Rate Modulation takes precedence over other position IV modes

Not all pacemakers switch to a continuous asynchronous mode when a magnet is placed. For elective
procedures, placing a magnet on what is assumed to be a pacemaker, without knowledge of the way in which
the device will respond, or a ready means to reprogram the device is wrong. Below are some of the ways
these devices can respond to a magnet:
1. Asynchronous pacing without rate responsiveness, using fixed parameters (most common).
2. No change in rhythm or rate.
3. Asynchronous pacing for 10 – 64 beats, then reversion to program mode and values.
4. Continuous or transient loss of pacing.
5. An ICD may be inactivated while the magnet is on, or it may simply disable sensing, thereby
inhibiting therapy (some CPI models).

Patients with pacemakers/leads should generally avoid MRI examinations.

When using electrocautery, please follow these guidelines:

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• Keep the current path (electrode tip to ground plate) as far away as possible from the pulse
generator. Do not perform within 6 inches of the pulse generator.
• Set the electrocautery at the lowest possible clinically effective setting.
• Do not apply electrocautery directly on or over the pulse generator.
• Electrocautery on or near the lead tip may cause burning of the lead-tissue interface.
• If the pulse generator is continually inhibited by frequent bursts of electrocautery, a magnet may be
placed on the pulse generator, which would result in asynchronous pacing (pacemakers only). This
should only be done if the pacemaker has been previously determined to be of the make, model, and
programming set that produces this result.
• Deactivate ICD devices.

PROCEDURE

1) For all preoperative patients with a pacemaker/ICD:

The Cardiology Clinic staff will obtain:
• a record of the indication for device placement
• a record of the specific make and model of the device
• a record of the last battery check and function check
• a history of device events
• a copy of the report from the patients’ last device clinic appointment (if patient is followed in
the UWHC Device Clinic the last clinic note is available in the patients’ medical record)

The department initiating surgery should contact the Cardiology Clinic at 263-1530 with the name and MR#
of the patient and date and type of surgery/procedure. The above information will be obtained by the
Cardiology Clinic CA staff and will be provided to the Cardiology Device Clinic staff and/or the device
manufacturer representative involved in the preoperative care of the patient.

2) Programmable devices should usually be interrogated preoperatively, according to guidelines by the ACC.
The interrogation should be done by UWHC Device Clinic staff, Cardiology Fellow or device manufacturer
representative (names and contact information are listed on page 3 and 4). This is especially recommended
as follows:
• if there is any question of function
• if there is any question of battery life
• if there is a lack of definite knowledge of magnet effect on the device
• if there is a plan to switch operational modes
Interrogation/reprogramming is recommended for:
• rate responsive devices using a minute ventilation sensor (if mechanical ventilation is planned)
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• patients with hypertrophic obstructive cardiomyopathy (HOCM), dilated cardiomyopathy

(DCM) or pediatric patients
• pacemaker dependent patients
• procedures in the chest or abdomen
• Guidant ICD’s
• SW Lithotripsy – no atrial pacing should be used
• TUR/hysteroscopy or ECT procedures

To schedule a preoperative interrogation please contact the Cardiology Clinic at 263-1530. A device clinic
nurse or a device manufacturer representative will be scheduled to perform the interrogation. For
unscheduled emergent situations outside of clinic hours (8:00 am – 4:30 pm), please contact the Cardiology
fellow or device manufacturer representative (names and contact information listed on page 3 and 4).
The nurse, fellow, or manufacturer representative who interrogates or makes changes to the device must
record the changes and the time on the medical record progress sheet, as well as his/her name and contact
information.
3) The anesthesiologist, surgeon or cardiologist must make a decision at the time of surgery to either leave
the pacer on its usual mode or to reprogram. If the pacemaker is switched to asynchronous mode, monitor
carefully for “competition” by a native rhythm. “R on T” risk always exists. Reprogramming to original
values should occur in the PACU. Most manufacturers recommend interrogating the device to reconfirm
settings and battery life after monopolar electrosurgical unit use.

4) Any Guidant defibrillator MUST be turned OFF for the O.R., except in certain circumstances. It must
then be reactivated in the PACU. Adhesive defibrillator pads should be placed on the chest and connected
to a back up external defibrillator, should a malignant ventricular arrhythmia occur perioperatively.

5) Any patient with a deactivated defibrillator must have adhesive defibrillation pads in place and be
connected to an external defibrillator. All patients with a deactivated device must be under continuous
monitoring.

6) Patients with a Medtronic ICD may have a Smart-Magnet™ placed over their device during
surgery/electrocautery, which will disable sensing for the duration of magnet application. If an arrhythmia
occurs during surgery, the Smart-Magnet™ can simply be removed from the ICD site, allowing normal
detection and therapy to occur. This device is usable as long as it doesn’t interfere with the surgical site
(e.g., abdominal surgery, peripheral vascular surgery, etc.).

7) Any patient with a pacemaker implanted for hypertrophic obstructive cardiomyopathy (HOCM) or a
biventricular device for heart failure must have cardiology coordination preoperatively. The department
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initiating surgery must coordinate with the cardiologist. The patients’ device will be programmed according
to the cardiologist’s recommendation preoperatively.

Cardiology Electrophysiology/Device Clinic Contact Information

Adults –
Adult EP Consult Service – (8 am – 5 pm M – F) pager 5607
Cardiology Fellow on call – (after hours) 262-2122
Susan Jones, RN 263-1530 pager 9911
Shannon (Coco) Schauff, RN 263-1530 pager 8428
Magda Valdes, RN 263-1530 pager 6043
Douglas Kopp, MD 265-4188 pager 9808
Jan Moore, PA 263-8005 pager 4711
Peds –
Peds Cardiologist (M – F 8:00 – 4:30) 263-8535
Peds Cardiologist (after hours) 262-2122
Kathleen Maginot, MD 263-9005 pager 9302
Jayme Frank, PNP 263-8776 pager 8742

Device Manufacturer and Representative Contact Information

Company Representative Phone

Biotronic Keith Bergen 1-800-547-0394

ELA Medical Don Martiny 1-800-352-6466

Guidant Joel Marino 1-800-227-3422

(Intermedics)

Medtronic Craig Schneider 1-800-633-8766

St. Jude Medical Jeff Caprini 1-800-722-3423

(Pacesetter,
Teletronics)

Vitatron 1-800-848-287