Perioperative management of patients with cardiac implantable electronic devices | Revista Española de Anestesiología y Reanimación (English Edition)

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Monedero, D. Paz-Martín, J. Cardona-Pereto, F. Barturen, L. Fernández-Quero, L. Aguilera-Celorrio, J. Canet, J.I. Gómez-Herreras, R. Peyró, C. Sánchez, J.C. Valía" "autores" => array:11 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Monedero" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Paz-Martín" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Cardona-Pereto" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Barturen" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Fernández-Quero" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Aguilera-Celorrio" ] 6 => array:2 [ "nombre" => "J." "apellidos" => "Canet" ] 7 => array:2 [ "nombre" => "J.I." "apellidos" => "Gómez-Herreras" ] 8 => array:2 [ "nombre" => "R." "apellidos" => "Peyró" ] 9 => array:2 [ "nombre" => "C." "apellidos" => "Sánchez" ] 10 => array:2 [ "nombre" => "J.C." 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Poveda-Jaramillo, H.D. Castro-Arias, C. Vallejo-Zarate, L.F. Ramos-Hurtado" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Poveda-Jaramillo" "email" => array:1 [ 0 => "ricardopovedamd@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "H.D." "apellidos" => "Castro-Arias" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Vallejo-Zarate" ] 3 => array:2 [ "nombre" => "L.F." "apellidos" => "Ramos-Hurtado" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Anestesia Cardiovascular, Universidad CES, Medellín, Antioquia, Colombia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo perioperatorio de los pacientes con dispositivos cardíacos electrónicos implantables" ] ] "textoCompleto" => "IntroductionIn these days of outstanding technological breakthroughs, medicine is increasingly joining forces with other branches of science to produce new advances. Cardiovascular implantable electronic devices (CIED) were developed as a solution for patients whose intrinsic heart rate was unable to meet the metabolic needs of their body. As humans age, they become more prone to rhythm disorders, and the implantation of devices that stimulate the heart is now a routine procedure. As a result, surgical teams need to be prepared to deal with patients with implanted biotechnology devices. In 2009, more than one million pacemakers and more than 300,000 defibrillators were implanted worldwide. In 2011, an average of 140 cardiac resynchronization devices per million population were implanted in Western and Central Europe.<a class="elsevierStyleCrossRef" href="#bib0170">1</a> The perioperative management of these devices calls for an understanding of their essential characteristics and each patient's associated risks, underlying comorbidities, and metabolism.<a class="elsevierStyleCrossRef" href="#bib0175">2</a>Given the abundance of published studies, this review will deal only with standard implantable electronic cardiac devices. Other implantable devices (wireless pacemakers, subcutaneous defibrillators, neurostimulators) will be addressed by other authors.HistoryThe legendary Hippocrates (460–375 BC) said that “those who suffer from frequent and strong faints without any manifest cause, die suddenly”. In ancient China (280 BC), Wang Shu devoted 10 books to describing the characteristics of the pulse. Since then, our understanding of the association between the electrical activity of the heart and the physiological pulse has substantially improved. In 1951, the Boston-based (Massachusetts) cardiologist Paul Zoll created the first transcutaneous pacemaker. In 1957, University of Minnesota cardiac surgeon Clarence Walton Lillehei implanted the first pacemaker in a 3-year-old girl who presented third-degree atrioventricular block after undergoing surgery for tetralogy of Fallot: the myocardium was paced by a stainless steel wire, the other end of which was brought through the surgical wound and attached to an external stimulator. An indifferent electrode was buried under the skin to complete the circuit. This pacemaker was connected directly to the hospital's power supply. On 31st October of that year, after a 3-hour power outage caused the death of a newborn in the hospital where he worked, Lillehei asked Earl E. Bakken, founder of Medtronic, to create the first portable pacemaker battery. Two metal handles were attached to the prototype to enable it to be strapped to the patient's body. Finally, on 8 October 1958, in Sweden, surgeon Ake Senning and medical inventor Rune Elmqvist succeeded in implanting the first portable, independent, miniature subcutaneous pacemaker in a 43-year-old engineer, Arne Larsson, who eventually outlived both Senning and Elmqvist. The technique for transvenous insertion of permanent bipolar pacing electrodes was developed in 1962 by Victor Parsonnet (in the USA) and Ekstrom (in Sweden).<a class="elsevierStyleCrossRefs" href="#bib0180">3,4</a>PhysiologyThe movement of electric charges is called electric current, and its intensity is measured in amperes. The process by which an electric current passes through matter is called electric conduction, and varies with the nature of the charged particles and the material they travel through. Electric fields exist whenever electric charges are present, i.e., whenever electricity or electrical equipment is in use. Materials that conduct electricity are classified according to their opposition or resistance to the passage of electrons. Electricity has a tendency to propagate as evenly as possible on a conductive surface, and the passage of current through a nonconductive or resistive surface causes localized heating. The electrical stimulus generated by the pacemaker is conducted through the pacing leads, which are made of low resistivity material.<a class="elsevierStyleCrossRef" href="#bib0190">5</a>The mechanisms underlying the electrical stimulation of myocardial cells are determined by the membrane. The myocardial cell responds to a suitable stimulus by generating a depolarization wave. This stimulation generates an electric field which reduces the basal membrane potential. As a result, more sodium channels open until the threshold potential is reached and cell depolarization starts. The minimum amount of energy required for this process is called the stimulation threshold, which depends on the electrode surface, resistivity, the alignment of myocardial fibres in the electric field, the distance to excitable tissue, and the polarization current. The average threshold for stimulation of an area of 3.5mm2 is about 0.6V.<a class="elsevierStyleCrossRef" href="#bib0195">6</a>Anatomy of the deviceCIEDs are medical devices that rely on electrodes to deliver electrical impulses to regulate the heartbeat. The primary purpose of a pacemaker is to enable the heart to eject blood from the atria and ventricles at the rate needed to meet the metabolic needs of the individual. A pacemaker consists of a pulse generator and an electrode that sends electrical impulses to the heart. The electrode is formed of a pacing lead coated with an insulating material known as diamond-like carbon, which terminates in a titanium head at the distal end. The surface area of the electrode head is formed by an electrically conductive material coated with insulating material, forming a stimulation surface. The generator has a battery that provides sufficient electrical current to stimulate the myocardial fibres. Modern pacemakers use lithium batteries, which have a life of 10–15 years, and are therefore suitable for most clinical situations. They also include an oscillator that controls the duration and frequency of the electrical stimulus according to a pre-established programme (Figure 1, material available online).<a class="elsevierStyleCrossRefs" href="#bib0200">7,8</a>The leads may have 1 (unipolar), 2 (bipolar) or multiple (multipolar) electrodes. In unipolar pacing, the electrode is placed in the endocardium, while the generator case, which is located in the chest wall, closes the circuit. In bipolar pacing, the leads are also made of low resistance material; however, here the distance travelled by the electrical stimulation delivered to the tissue is minimal, because the electrodes are placed only a few millimetres apart. Pacemakers are either single- or dual chamber, depending on whether they sense/pace a single heart chamber, or an atrium and ventricle simultaneously (Figure 2, material available online).An implantable cardioverter defibrillator (ICD), on the other hand, consists of three elements: pacing/sensing electrodes, defibrillation electrodes, and a pulse generator. They usually have two electrodes on the ventricular lead for sensing and pacing, with the distal electrode positioned in the right ventricular apical endocardium. The defibrillation electrodes are relatively large and are positioned to maximize current through the myocardium. Modern systems use a “spiral” or coil along the ventricular lead containing the sensing and pacing electrode. The coil functions as a passive component of the electrical circuit, which stores energy in the form of a magnetic field and transfers it to the primary defibrillation electrode. As a result, a single transvenous lead can perform all the functions of pacing, sensing and defibrillation. Additional electrodes improve defibrillation efficacy and reduce its threshold. A second coil can be located proximal to the first. The metal case of the ICD, which contains the sensing circuits, high voltage capacitors and battery, can serve as a discharge electrode.<a class="elsevierStyleCrossRef" href="#bib0210">9</a>Cardiac resynchronization therapy stimulates 2 ventricles synchronously in patients with heart failure refractory to pharmacological treatment and interventricular asynchrony. According to the American Society of Heart Failure, it is indicated in patients with: (1) NYHA II–III; (2) LVEF≤35%; (3) sinus rhythm, and (4) wide QRS complex (>150ms) not caused by right bundle branch block. The European Society of Cardiology also suggests these pacemakers in NYHA IV ambulatory patients.<a class="elsevierStyleCrossRef" href="#bib0215">10</a> The electrodes are placed in the right ventricular apex and the left ventricular epicardial vein through the coronary sinus.<a class="elsevierStyleCrossRefs" href="#bib0220">11,12</a> Transvenous left ventricular pacing is integrated into a conventional pacemaker or ICD.<a class="elsevierStyleCrossRef" href="#bib0230">13</a>CIEDs are typically implanted in the left subclavian prepectoral region, although they can also be place in the right prepectoral area or, if necessary, in the abdomen or lateral chest wall.<a class="elsevierStyleCrossRef" href="#bib0235">14</a>CodingIn 1987, the Heart Rhythm Society, formerly known as the NASPE, and the British Pacing and Electrophysiology Group developed a generic pacemaker programming code for all types of pacemaker. The first three positions (i, ii and iii) describe the chamber paced, the chamber sensed and the response to the sensed event. Two new positions were added in 2002 to describe the rate modulation (iv) and multisite pacing within the atria or ventricles (v) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0220">11</a> Multisite pacing is usually used in biventricular pacing to treat heart failure.<a class="elsevierStyleCrossRef" href="#bib0225">12</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Rate modulation technologies (position iv) were developed in the 1970s to mimic the heart's response to exercise. Most pacemakers implanted today include this function. Several technologies have been developed, but only 4 are still valid today: (1) activity sensor, which measures the mechanical tension of a piezoelectric crystal as a result of motion acceleration; (2) minute ventilation sensor, which measures the change in transthoracic impedance between the lead and the pulse generator; (3) QT interval sensor, which measures changes in the QT interval as an estimate of adrenergic tone, and (4) contractility sensor, which measures the peak endocardial acceleration as an estimate the contractility and overall left ventricular function.Preoperative assessmentThe aim of the preoperative assessment is to anticipate risk by gaining detailed knowledge of the conditions surrounding the surgical procedure planned for CIED patients scheduled for noncardiac surgery. The anaesthetist and the perioperative team should understand the nature of the procedure, the clinical status (electrolytes and fluids) of the patient, the type of device and the indications for implantation, the patient's dependence on the device, potential sources of electromagnetic interference (EMI) and the availability of telemetry during the perioperative period.<a class="elsevierStyleCrossRef" href="#bib0175">2</a>The patient's medical history and a targeted physical examination will usually show the type of device implanted. If the patient is unable to provide details, there are various other sources that can be checked: (1) manufacturer's identification card; (2) last recorded reprogramming of the device; (3) manufacturer's databases, and (4) X-rays. Bipolar electrodes can often be identified on chest radiography by the presence of a 1–3cm electrode proximal to the tip of the lead. ICDs can be distinguished from conventional pacemakers by the presence of a coil in the right ventricular lead, and by thicker and more radiopaque leads.<a class="elsevierStyleCrossRefs" href="#bib0240">15,16</a>Pacemaker dependency can be determined from the clinical history, such as a history bradyarrhythmias causing syncope, history of successful nodal ablation, or pacemaker assessments showing no spontaneous ventricular activity (when programmed to VVI mode at the lowest programmable rate). If dependence is high, the pacemaker should be converted to asynchronous mode during surgery by applying a magnet or reprogramming (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Electromagnetic interferenceEMI refers to the interruption in the operation of an electronic device due to its proximity to an electromagnetic field generated by an external source. An electromagnetic field is produced when electrical current flows in a conductor with magnetic field lines perpendicular to the current flow. EMI can occur as a result of conducted or radiated electromagnetic energy.<a class="elsevierStyleCrossRef" href="#bib0190">5</a> Most surgical electronic devices emit a radiofrequency that can be transmitted directly to other devices.<a class="elsevierStyleCrossRef" href="#bib0250">17</a>EMI is important during the surgical procedure because it can inhibit the generation of electrical current during inhibited pacing modes (AAI, VVI, or DDI) and induce bradycardia or asystole. Whereas while in tracking mode (DDD), preferential sensing of EMI in the atrial channel (which often occurs due to higher programmed sensitivity) could result in increased rate ventricular pacing or atrial arrhythmia detection and a “mode-switch” to inhibited pacing (AAI, VVI, or DDI). In patients with an ICD, electrocautery can be sensed as intrinsic cardiac activity, and can induce inappropriate or antitachycardia pacing. Activation of the magnet response by EMI may lead to asynchronous pacing in pacemakers and disabling of tachycardia therapies in certain ICD systems.<a class="elsevierStyleCrossRef" href="#bib0190">5</a>The main sources of EMI are: electrosurgical units, radiofrequency ablation, and magnetic resonance. Paniccia et al. classified electrical surgical devices as low risk (<0.2mV), intermediate risk (0.2–1.0mV) and high risk (>1.0mV), based on the amount of EMI transmitted to the CIED.<a class="elsevierStyleCrossRef" href="#bib0250">17</a> These authors found that both traditional and advanced bipolar electrosurgical units and harmonic scalpels belong in the first group. Unipolar electrosurgical units without a dispersive electrode and unipolar electrosurgical units in cutting and coagulation mode pose an intermediate risk. Finally, argon plasma coagulation and electrocautery belong in the high risk group. Generally speaking, the higher the voltage the higher the EMI, and the higher the EMI the greater the probability of CIED failure (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>ICDs usually need several seconds to detect high frequencies and trigger anti-tachycardia therapy, and for this reason electrocautery should be applied in short bursts (<5s) separated by long intervals (>5s).In patients with a CIED, any surgery performed above the navel heightens the risk of EMI. The dispersive electrode pad (which closes the circuit in unipolar electrocautery) should be placed in such a way as to ensure that the CIED does not form part of the electrical circuit. Using the electrosurgery device at a distance of less than 15cm from the CIED increases the likelihood of interference, and can permanently damage its electrical circuit. The programming mode of the CIED should be checked after an electrosurgery unit has been used.Highly pacemaker-dependent patients with a unipolar pacemaker undergoing surgery with a high risk of pneumothorax, are more likely to develop asystole due to the sudden increase in electrical impedance. Bipolar pacemakers, however, are less sensitive to EMI because the electrodes are placed closer together.<a class="elsevierStyleCrossRef" href="#bib0255">18</a>MagnetsCardiac devices may malfunction in response to an EMI; this can be prevented by appropriate programming. However, programming CIEDs is a complex procedure that must be undertaken by highly trained specialists, such as technicians trained by the manufacturer or a cardiac electrophysiologist, and as such poses a logistical challenge. To overcome this, CIEDs incorporate switches that allow basic functions to be controlled by clinical magnets. These magnets are readily available and can be used without special training.<a class="elsevierStyleCrossRef" href="#bib0260">19</a>Most pacemakers and ICDs have built-in magnetic “reed switches” that are designed to switch circuitry on and off in response to magnets. A reed switch consists of 2 metal strips made of magnetic material in a glass capsule. Although several configurations are possible, the most common one involves separation of the strips (open switch) by their stiffness and a cantilever attachment to the ends of the capsule. Application of an adequate external magnetic field causes the strips to come in contact (closed switch), which leads to a sudden change in voltage sensed by a sensing amplifier. This amplifier triggers the pulse generator to switch to perform programmed functions such as the asynchronous pacing mode in pacemakers and the suspension of anti-tachycardia therapies in ICDs<a class="elsevierStyleCrossRef" href="#bib0260">19</a> (Figure 3, material available online).Clinical magnets are made of ferrous alloy and come in various shapes (ring or doughnut, horseshoe, and rectangle or bar) to facilitate placement over the CIED implantation site. The magnetic field effect of the clinical magnet is directly proportional to the strength of the magnet and inversely proportional to the distance of the magnet from the CIED. The strength of the magnet is measured in Gauss: a magnetic field effect of ≥10Gauss is required to activate the magnetic switch and alter the device function. Available clinical magnets usually have a strength of ≥90Gauss. Medtronic has introduced a smart magnet with a light indicator to guide appropriate placement; however, the indicator illuminates only with Medtronic devices.<a class="elsevierStyleCrossRef" href="#bib0260">19</a>The site of magnet placement is important, since a poorly positioned magnet may not produce the desired effect. Magnets are usually placed directly on top of the CIED, although there are two exceptions; in St. Jude ICDs, the curve of the magnet should be placed over the bottom or top end of the ICD, and, in Sorin ICDs, the curve of the doughnut magnet should be placed so that it avoids the header on the top end of the device.<a class="elsevierStyleCrossRef" href="#bib0260">19</a>Magnets can change pacing to an asynchronous mode, in other words, the device will pace at a given frequency that will not change in response to external stimuli. This means that a pacemaker programmed to DDD paces as DOO, VVI as VOO, and AAI as AOO. Magnets applied to ICDs prevent over-sensing, deactivate the anti-tachycardia function, and leave the anti-bradycardia function intact. ICDs emit an auditory or vibratory signal to confirm deactivation of anti-bradycardia therapy (only Medtronic and Boston Scientific emit an auditory signal).<a class="elsevierStyleCrossRefs" href="#bib0245">16,19</a> If the patient has an ICD and is also pacer dependent, then reprogramming is mandatory, since placement of a magnet will not cause it to switch to asynchronous pacing, and EMI can cause asystole.<a class="elsevierStyleCrossRefs" href="#bib0240">15,18</a>Placing a magnet on an ICD will deactivate its shock function and suspend biventricular pacing, thus pacing only the right ventricle. It is important to bear this in mind, as the loss of biventricular pacing can cause haemodynamic abnormalities.<a class="elsevierStyleCrossRef" href="#bib0265">20</a>Clinical magnets do not alter heart rate-adaptive functions in ICDs, and reprogramming is necessary when this function needs to be inhibited. Inappropriate tachycardia secondary to mechanical ventilation or to myoclonus has been reported. This is in contrast to those pacemakers wherein magnet application disables any rate responsiveness.<a class="elsevierStyleCrossRef" href="#bib0255">18</a>Failure to produce any response on the surface ECG after magnet placement may be due to any of the following reasons: (1) a depleted battery; (2) the pacemaker is programmed to ignore the magnet (St. Jude, Boston Scientific, and Biotronik synchronous mode) and (3) the magnetic field does not reach the device, as in the case of those with deeper implants or in very obese patients.Magnets cause asynchronous pacing, but the rate will vary according to the battery life and manufacturer. Similarly, not all pacemakers change to asynchronous mode: Biotronik and Intermedics pacemakers (most models are now owned by Boston Scientific) automatically revert to the programmed mode. After 10 asynchronous beat at 90ppm, Biotronik pacemakers with BOL (beginning of life) status switch to the previously programmed pacing mode; in ERI (elective replacement indicator) status, after 10 beat at 80ppm they revert to a rate 11% slower than the programmed rate. Intermedics revert to the previous programming mode after temporary pacing at 64ppm (Figures 4 and 5, material available online).Boston Scientific ICDs usually disable tachycardia therapies if the magnet is held on the generator for 30s. The change is signalled by a continuous, high-pitched tone, and the device does not revert to original programming after removal of the magnet. Reactivation is achieved by placing the magnet on the generator for 30s, and the change is signalled by a return to R-wave synchronous tones. ICDs from other manufacturers remain disabled as long as the magnet is placed over the generator.<a class="elsevierStyleCrossRef" href="#bib0235">14</a> Boston Scientific and St. Jude Medical ICDs may be programmed to ignore the magnet, in which case reprogramming is mandatory.Although removal of the magnet should cause the device to return to the programmed mode or, in the case of ICDs, reactivate tachycardia therapy, in some older ICDs from Guidant/Boston Scientific, the antitachycardia mode remains on “OFF” after the removal of the magnet. For this reason, the device should be interrogated at the earliest opportunity after surgery to detect programming changes that may have occurred. This will avoid leaving the patient unprotected for any longer than necessary.<a class="elsevierStyleCrossRef" href="#bib0260">19</a>ReprogrammingAs already he discussed above, if the patient has an ICD, is pacer dependent, and extensive EMI is likely, then reprogramming is mandatory. Reprogramming is also indicated after argon coagulation, due to the high risk of prolonged EMI.Deactivating tachycardia therapy in ICDs is also essential in surgeries where patient movement can be disastrous (ocular surgery).<a class="elsevierStyleCrossRef" href="#bib0270">21</a> However, this is not necessary in low-risk situations (no EMI). The Canadian guidelines recommend magnet application over reprogramming whenever feasible. However, reprogramming is preferable over magnet placement in specific circumstances, such as prone or lateral patient positioning, or when the device is incidentally within the surgical field (less than 15cm from the cardiac device).Reprogramming is also necessary if the patient has an implanted cardiac resynchronization device, for two reasons: to disable the antitachycardia pacing (as most are coupled with a defibrillator<a class="elsevierStyleCrossRef" href="#bib0225">12</a>), and to set the device to asynchronous pacing, such as VOO or DOO pacing in pacemaker dependent patients.<a class="elsevierStyleCrossRef" href="#bib0275">22</a>The pacing rate assigned by the device when the battery status is BOL (100, 85, 98.6, 100, 96) are at the upper limits of normal, and may not be appropriate for all patients, especially those with coronary disease, valvular heart disease, or some forms of cardiomyopathy.<a class="elsevierStyleCrossRef" href="#bib0240">15</a> In these cases, the device must be reprogrammed to a lower pacing rate suitable for the patient's comorbidities.Intraoperative managementMonitoringECG monitoring should be started before surgery in order to adjust the monitor to recognized the CIED pacing peaks. “Diagnostic” mode is preferable to “monitor” or “filter” modes because it gives a clear picture of high frequency signals, including pacing peaks.<a class="elsevierStyleCrossRef" href="#bib0230">13</a> All patients will require plethysmography to confirm that electrical capture is converted into mechanical systole. The presence of a pacemaker is a contraindication for Swan-Ganz catheter and central venous lines. Should a central line be unavoidable, tachycardia pacing should be disabled in patients with an ICD, while in pacemaker-dependent patients, reprogramming to asynchronous mode is required.<a class="elsevierStyleCrossRefs" href="#bib0175">2,13,23</a>During surgeryAn external defibrillator should be on hand at all times during surgery. The defibrillator pads must be placed before surgery in high-risk patients whose position on the operating table would prevent rapid application of the electrodes in case of emergency. Remind the surgeon that a bipolar electrosurgery device or harmonic scalpel are preferable. If these are not suitable or not available, the unipolar electrosurgery device should be used in short (<5s) bursts, allowing >5s between bursts, and using the lowest possible cutting and coagulation parameters. The electrosurgery device must never come into contact with the CIED. The recommended distance from the ICD is 15cm. If this is not feasible, the ICD should be reprogrammed to asynchronous modes before the procedure (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<a class="elsevierStyleCrossRefs" href="#bib0170">1,24</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Physical and chemical considerationsMany physical and chemical factors can affect the performance of a CIED. Situations such as hyperkalaemia, hyperglycaemia, acidosis, hypoxaemia, hypercapnia and hyperthyroidism can undermine the efficiency of the CIED by increasing the pacing threshold. Shivering and twitching can generate myopotentials that can be interpreted as cardiac ectopy.<a class="elsevierStyleCrossRef" href="#bib0175">2</a>Pharmacological considerationsDrugs that can cause twitching, such as succinylcholines, ketamine or etomidate, should be avoided during surgery, because the electrical activity associated with myogenic twitches can cause EMI.<a class="elsevierStyleCrossRefs" href="#bib0175">2,25,26</a> Biventricular pacing may prolong the QT interval; therefore, high doses of halogenated, haloperidol and methadone (which also prolong the QT segment) should be avoided, thus reducing the risk of torsades de pointes.<a class="elsevierStyleCrossRefs" href="#bib0300">27–30</a> High doses of vagotonic aesthetics (dexmedetomidine or fentanyl) should be avoided in patients with bradycardia due to a theoretical risk of inducing pacemaker dependence.<a class="elsevierStyleCrossRefs" href="#bib0255">18,31</a>As mentioned above, in unipolar pacing and defibrillation, the generator case must remain in contact with the tissue because it serves as an electrode. When nitrous oxide is used, the gas tends to accumulate in the pacemaker pocket and cover the CIED, causing loss of anodal contact and preventing it from functioning as an electrode.<a class="elsevierStyleCrossRefs" href="#bib0245">16,32</a>Emergency defibrillation/cardioversionThe need for defibrillation/cardioversion can arise during surgery, particularly when the tachycardia pacing function of an ICD has been deactivated. Guidelines recommend this be carried out as soon as possible, using the standard procedure, but not before all sources of EMI have been shut down and the magnet removed. The pads should be placed as far as possible from the CIED generator (at least 10cm), placing one in front of the other on the chest, and selecting the standard electric charge. Reanimation protocols remain the same.Postoperative managementDuring the immediate postoperative period, continuous monitoring of heart rate and rhythm is advisable. A defibrillator should also be on hand. It is usually necessary to increase ventricular pacing voltage because the stimulation threshold is also increased due to postoperative hyperkalaemia, acidosis, hypoxaemia or hypercapnia. In highly pacemaker-dependent patients, heart rate will not increase automatically when required by situations such as hypovolaemia, sepsis, etc. In these cases, it is best to programme a pacing rate suitable for the patient's underlying haemodynamic conditions. This can be achieved by reprogramming or by application of a magnet, in which case a rate of at least 85ppm must be achieved. If the device has in-built acceleration sensors, small repeated blows can accelerate the pacing rate to between 110 and 130ppm. Adaptive functions (ventilation sensors) should also be inactivated in patients that are transferred to the intensive care unit for invasive mechanical ventilation. This is because mechanical hyperventilation can initiate rapid pacing.<a class="elsevierStyleCrossRef" href="#bib0330">33</a>Whether by removing the magnet or reprogramming, the CIED functions must be restored as soon as possible after surgery: it is imperative to restart tachycardia/defibrillation therapy in ICDs because an unnecessary delay will expose the patient to an unacceptable risk of fatal arrhythmia. The doctor that ordered reprogramming is responsible for ensuring the device returns to its original setting.<a class="elsevierStyleCrossRef" href="#bib0250">17</a>Based on the sources consulted, we present an algorithm that may be of use in guiding the initial approach to patients with a CIED undergoing elective non-cardiac surgery (Figure 6, material available online). We hope this will contribute to improving the well-being of your patients.ConclusionsModern CIEDs are safe, reliable devices at the cutting edge of technology. They are indispensable in delivering electrical stimulation for sequential, rhythmic contraction of the heart.All CIEDs (pacemakers, and ICDs) use the same coding system.Modern cardioverter defibrillators can function as pacemakers.During surgery, the performance of the CIED can be affected by EMI, usually associated with the use of an electrosurgery unit. Unipolar CIEDs are more susceptible to EMI.In most pacemakers, placing a magnet over the device will initiate asynchronous pacing at a fixed rate and AV delay. In ICDs, the magnet will suspend tachycardia detection and therapy, but will not change the pacing mode: inhibition can still occur.Transcutaneous defibrillation electrodes are placed before or shortly after ICD tachycardia therapy has been disabled.Anaesthetic agents do not affect the performance of the CIED.Ethical responsibilitiesProtection of people and animalsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that no patient data appears in this article.Right to privacy and informed consentThe authors declare that no patient data appears in this article.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres833140" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec829044" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres833139" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec829045" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "History" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Physiology" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Anatomy of the device" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Coding" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Preoperative assessment" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Electromagnetic interference" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Magnets" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Reprogramming" ] ] ] 10 => array:3 [ "identificador" => "sec0050" "titulo" => "Intraoperative management" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Monitoring" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "During surgery" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Physical and chemical considerations" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Pharmacological considerations" ] 4 => array:2 [ "identificador" => "sec0075" "titulo" => "Emergency defibrillation/cardioversion" ] ] ] 11 => array:2 [ "identificador" => "sec0080" "titulo" => "Postoperative management" ] 12 => array:2 [ "identificador" => "sec0085" "titulo" => "Conclusions" ] 13 => array:3 [ "identificador" => "sec0090" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0105" "titulo" => "Right to privacy and informed consent" ] ] ] 14 => array:2 [ "identificador" => "sec0110" "titulo" => "Conflict of interests" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-06-08" "fechaAceptado" => "2016-10-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec829044" "palabras" => array:4 [ 0 => "Artificial pacemaker" 1 => "Implantable cardioverter-defibrillators" 2 => "Cardiac resynchronization therapy devices" 3 => "Anaesthesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec829045" "palabras" => array:4 [ 0 => "Marcapasos artificial" 1 => "Desfibriladores implantables" 2 => "Dispositivos de terapia de resincronización cardíaca" 3 => "Anestesia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The use of implantable cardiac devices in people of all ages is increasing, especially in the elderly population: patients with pacemakers, cardioverter-defibrillators or cardiac resynchronization therapy devices regularly present for surgery for non-cardiac causes. This review was made in order to collect and analyze the latest evidence for the proper management of implantable cardiac devices in the perioperative period. Through a detailed exploration of PubMed, Academic Search Complete (EBSCO), ClinicalKey, Cochrane (Ovid), the search software UpToDate, textbooks and patents freely available to the public on Google, we selected 33 monographs, which matched the objectives of this publication." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Es cada vez más frecuente el uso de dispositivos cardíacos implantables en personas de todas las edades, siendo superlativo en la población adulta mayor, y favoreciendo que cada vez sea más frecuente encontrar pacientes con marcapasos, cardiodesfibriladores o resincronizadores en cirugía por causas no cardíacas. Esta revisión se hizo con el fin de seleccionar y analizar la más actualizada evidencia para el manejo apropiado de los dispositivos cardíacos implantables en el perioperatorio. A través de una exploración detallada en las bases de datos PubMed, Academic Search Complete (EBSCO), ClinicalKey, Cochrane (Ovid), el software de búsqueda UpToDate, libros de texto y patentes de libre acceso al público en Google, seleccionamos 33 monografías que se ajustaban a los objetivos de esta publicación." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Poveda-Jaramillo R, Castro-Arias HD, Vallejo-Zarate C, Ramos-Hurtado LF. Manejo perioperatorio de los pacientes con dispositivos cardíacos electrónicos implantables. Rev Esp Anestesiol Reanim. 2017;64:286–293." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: www.elsevier.es/redar" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following is the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0120" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">I \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">II \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">III \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">V \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paced chamber \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensed chamber \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Response to sensing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rate modulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multisite pacing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">O=None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">O=None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">O=None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">O=None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">O=None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A=Atrium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A=Atrium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T=Triggered \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">R=Rate modulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">A=Atrium \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">V=Ventricle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">V=Ventricle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">I=Inhibited \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">V=Ventricle \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D=Dual (A+V) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D=Dual (A+V) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D=Dual (A+V) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">D=Dual (A+V) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1403347.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pacemaker codes." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exact nature of the procedure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical status: electrolyte and fluids \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CIED model \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Indication for CIED \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Date implanted and date of last follow-up \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CIED dependency: percentage stimulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Possible sources of electromagnetic interference \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Availability of telemetry during surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Response of device to magnet placement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Expected response after removing the magnet \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1403346.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Issues to consider in the preoperative assessment." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Argon coagulation (Argon Beam Coagulator; ConMed) and plasma blades (Peak PlasmaBlade; Medtronic) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unipolar electrocautery with (Force FX, Covidien) and without (Hyfrecator; ConMed) dispersive electrode \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Device with unipolar or bipolar leads programmed in unipolar mode or with very high sensitivity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgeries performed above the navel or within 15cm of the device \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Electrocautery using long (>5s) bursts at short (<5s) intervals \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1403348.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Devices producing significant electromagnetic interference." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Make sure a magnet is on hand for all patients with ICDs. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preferably use bipolar electrosurgical units or harmonic scalpels. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Using unipolar electrocautery in short bursts (<5s) with >5s between bursts. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Never allow the electrocautery device to come into contact with the CIED. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">When using electrocautery, choose low cutting and coagulation parameters. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Make sure all equipment needed for transcutaneous pacing/defibrillation is on hand. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prepare isoproterenol and atropine. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1403345.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for intraoperative pacemaker management." ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 12147608 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0170" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical management of electromagnetic interferences in patients with pacemakers and implantable cardioverter-defibrillators: review of the literature and focus on magnetic resonance conditional devices" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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Perioperative management of patients with cardiac implantable electronic devices

Manejo perioperatorio de los pacientes con dispositivos cardíacos electrónicos implantables

R. Poveda-Jaramillo

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ricardopovedamd@yahoo.com

Corresponding author.

, H.D. Castro-Arias, C. Vallejo-Zarate, L.F. Ramos-Hurtado

Anestesia Cardiovascular, Universidad CES, Medellín, Antioquia, Colombia

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    "titulo" => "Perioperative management of patients with cardiac implantable electronic devices"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In these days of outstanding technological breakthroughs&#44; medicine is increasingly joining forces with other branches of science to produce new advances&#46; Cardiovascular implantable electronic devices &#40;CIED&#41; were developed as a solution for patients whose intrinsic heart rate was unable to meet the metabolic needs of their body&#46; As humans age&#44; they become more prone to rhythm disorders&#44; and the implantation of devices that stimulate the heart is now a routine procedure&#46; As a result&#44; surgical teams need to be prepared to deal with patients with implanted biotechnology devices&#46; In 2009&#44; more than one million pacemakers and more than 300&#44;000 defibrillators were implanted worldwide&#46; In 2011&#44; an average of 140 cardiac resynchronization devices per million population were implanted in Western and Central Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> The perioperative management of these devices calls for an understanding of their essential characteristics and each patient&#39;s associated risks&#44; underlying comorbidities&#44; and metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given the abundance of published studies&#44; this review will deal only with standard implantable electronic cardiac devices&#46; Other implantable devices &#40;wireless pacemakers&#44; subcutaneous defibrillators&#44; neurostimulators&#41; will be addressed by other authors&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">History</span><p id="par0015" class="elsevierStylePara elsevierViewall">The legendary Hippocrates &#40;460&#8211;375 BC&#41; said that &#8220;those who suffer from frequent and strong faints without any manifest cause&#44; die suddenly&#8221;&#46; In ancient China &#40;280 BC&#41;&#44; Wang Shu devoted 10 books to describing the characteristics of the pulse&#46; Since then&#44; our understanding of the association between the electrical activity of the heart and the physiological pulse has substantially improved&#46; In 1951&#44; the Boston-based &#40;Massachusetts&#41; cardiologist Paul Zoll created the first transcutaneous pacemaker&#46; In 1957&#44; University of Minnesota cardiac surgeon Clarence Walton Lillehei implanted the first pacemaker in a 3-year-old girl who presented third-degree atrioventricular block after undergoing surgery for tetralogy of Fallot&#58; the myocardium was paced by a stainless steel wire&#44; the other end of which was brought through the surgical wound and attached to an external stimulator&#46; An indifferent electrode was buried under the skin to complete the circuit&#46; This pacemaker was connected directly to the hospital&#39;s power supply&#46; On 31st October of that year&#44; after a 3-hour power outage caused the death of a newborn in the hospital where he worked&#44; Lillehei asked Earl E&#46; Bakken&#44; founder of Medtronic&#44; to create the first portable pacemaker battery&#46; Two metal handles were attached to the prototype to enable it to be strapped to the patient&#39;s body&#46; Finally&#44; on 8 October 1958&#44; in Sweden&#44; surgeon Ake Senning and medical inventor Rune Elmqvist succeeded in implanting the first portable&#44; independent&#44; miniature subcutaneous pacemaker in a 43-year-old engineer&#44; Arne Larsson&#44; who eventually outlived both Senning and Elmqvist&#46; The technique for transvenous insertion of permanent bipolar pacing electrodes was developed in 1962 by Victor Parsonnet &#40;in the USA&#41; and Ekstrom &#40;in Sweden&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;4</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Physiology</span><p id="par0020" class="elsevierStylePara elsevierViewall">The movement of electric charges is called electric current&#44; and its intensity is measured in amperes&#46; The process by which an electric current passes through matter is called electric conduction&#44; and varies with the nature of the charged particles and the material they travel through&#46; Electric fields exist whenever electric charges are present&#44; i&#46;e&#46;&#44; whenever electricity or electrical equipment is in use&#46; Materials that conduct electricity are classified according to their opposition or resistance to the passage of electrons&#46; Electricity has a tendency to propagate as evenly as possible on a conductive surface&#44; and the passage of current through a nonconductive or resistive surface causes localized heating&#46; The electrical stimulus generated by the pacemaker is conducted through the pacing leads&#44; which are made of low resistivity material&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The mechanisms underlying the electrical stimulation of myocardial cells are determined by the membrane&#46; The myocardial cell responds to a suitable stimulus by generating a depolarization wave&#46; This stimulation generates an electric field which reduces the basal membrane potential&#46; As a result&#44; more sodium channels open until the threshold potential is reached and cell depolarization starts&#46; The minimum amount of energy required for this process is called the stimulation threshold&#44; which depends on the electrode surface&#44; resistivity&#44; the alignment of myocardial fibres in the electric field&#44; the distance to excitable tissue&#44; and the polarization current&#46; The average threshold for stimulation of an area of 3&#46;5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> is about 0&#46;6<span class="elsevierStyleHsp" style=""></span>V&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Anatomy of the device</span><p id="par0030" class="elsevierStylePara elsevierViewall">CIEDs are medical devices that rely on electrodes to deliver electrical impulses to regulate the heartbeat&#46; The primary purpose of a pacemaker is to enable the heart to eject blood from the atria and ventricles at the rate needed to meet the metabolic needs of the individual&#46; A pacemaker consists of a pulse generator and an electrode that sends electrical impulses to the heart&#46; The electrode is formed of a pacing lead coated with an insulating material known as diamond-like carbon&#44; which terminates in a titanium head at the distal end&#46; The surface area of the electrode head is formed by an electrically conductive material coated with insulating material&#44; forming a stimulation surface&#46; The generator has a battery that provides sufficient electrical current to stimulate the myocardial fibres&#46; Modern pacemakers use lithium batteries&#44; which have a life of 10&#8211;15 years&#44; and are therefore suitable for most clinical situations&#46; They also include an oscillator that controls the duration and frequency of the electrical stimulus according to a pre-established programme &#40;Figure 1&#44; material available online&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The leads may have 1 &#40;unipolar&#41;&#44; 2 &#40;bipolar&#41; or multiple &#40;multipolar&#41; electrodes&#46; In unipolar pacing&#44; the electrode is placed in the endocardium&#44; while the generator case&#44; which is located in the chest wall&#44; closes the circuit&#46; In bipolar pacing&#44; the leads are also made of low resistance material&#59; however&#44; here the distance travelled by the electrical stimulation delivered to the tissue is minimal&#44; because the electrodes are placed only a few millimetres apart&#46; Pacemakers are either single- or dual chamber&#44; depending on whether they sense&#47;pace a single heart chamber&#44; or an atrium and ventricle simultaneously &#40;Figure 2&#44; material available online&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">An implantable cardioverter defibrillator &#40;ICD&#41;&#44; on the other hand&#44; consists of three elements&#58; pacing&#47;sensing electrodes&#44; defibrillation electrodes&#44; and a pulse generator&#46; They usually have two electrodes on the ventricular lead for sensing and pacing&#44; with the distal electrode positioned in the right ventricular apical endocardium&#46; The defibrillation electrodes are relatively large and are positioned to maximize current through the myocardium&#46; Modern systems use a &#8220;spiral&#8221; or coil along the ventricular lead containing the sensing and pacing electrode&#46; The coil functions as a passive component of the electrical circuit&#44; which stores energy in the form of a magnetic field and transfers it to the primary defibrillation electrode&#46; As a result&#44; a single transvenous lead can perform all the functions of pacing&#44; sensing and defibrillation&#46; Additional electrodes improve defibrillation efficacy and reduce its threshold&#46; A second coil can be located proximal to the first&#46; The metal case of the ICD&#44; which contains the sensing circuits&#44; high voltage capacitors and battery&#44; can serve as a discharge electrode&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Cardiac resynchronization therapy stimulates 2 ventricles synchronously in patients with heart failure refractory to pharmacological treatment and interventricular asynchrony&#46; According to the American Society of Heart Failure&#44; it is indicated in patients with&#58; &#40;1&#41; NYHA II&#8211;III&#59; &#40;2&#41; LVEF<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>35&#37;&#59; &#40;3&#41; sinus rhythm&#44; and &#40;4&#41; wide QRS complex &#40;&#62;150<span class="elsevierStyleHsp" style=""></span>ms&#41; not caused by right bundle branch block&#46; The European Society of Cardiology also suggests these pacemakers in NYHA IV ambulatory patients&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> The electrodes are placed in the right ventricular apex and the left ventricular epicardial vein through the coronary sinus&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#44;12</span></a> Transvenous left ventricular pacing is integrated into a conventional pacemaker or ICD&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">CIEDs are typically implanted in the left subclavian prepectoral region&#44; although they can also be place in the right prepectoral area or&#44; if necessary&#44; in the abdomen or lateral chest wall&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Coding</span><p id="par0055" class="elsevierStylePara elsevierViewall">In 1987&#44; the Heart Rhythm Society&#44; formerly known as the NASPE&#44; and the British Pacing and Electrophysiology Group developed a generic pacemaker programming code for all types of pacemaker&#46; The first three positions &#40;i&#44; ii and iii&#41; describe the chamber paced&#44; the chamber sensed and the response to the sensed event&#46; Two new positions were added in 2002 to describe the rate modulation &#40;iv&#41; and multisite pacing within the atria or ventricles &#40;v&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a> Multisite pacing is usually used in biventricular pacing to treat heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Rate modulation technologies &#40;position iv&#41; were developed in the 1970s to mimic the heart&#39;s response to exercise&#46; Most pacemakers implanted today include this function&#46; Several technologies have been developed&#44; but only 4 are still valid today&#58; &#40;1&#41; activity sensor&#44; which measures the mechanical tension of a piezoelectric crystal as a result of motion acceleration&#59; &#40;2&#41; minute ventilation sensor&#44; which measures the change in transthoracic impedance between the lead and the pulse generator&#59; &#40;3&#41; QT interval sensor&#44; which measures changes in the QT interval as an estimate of adrenergic tone&#44; and &#40;4&#41; contractility sensor&#44; which measures the peak endocardial acceleration as an estimate the contractility and overall left ventricular function&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Preoperative assessment</span><p id="par0065" class="elsevierStylePara elsevierViewall">The aim of the preoperative assessment is to anticipate risk by gaining detailed knowledge of the conditions surrounding the surgical procedure planned for CIED patients scheduled for noncardiac surgery&#46; The anaesthetist and the perioperative team should understand the nature of the procedure&#44; the clinical status &#40;electrolytes and fluids&#41; of the patient&#44; the type of device and the indications for implantation&#44; the patient&#39;s dependence on the device&#44; potential sources of electromagnetic interference &#40;EMI&#41; and the availability of telemetry during the perioperative period&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The patient&#39;s medical history and a targeted physical examination will usually show the type of device implanted&#46; If the patient is unable to provide details&#44; there are various other sources that can be checked&#58; &#40;1&#41; manufacturer&#39;s identification card&#59; &#40;2&#41; last recorded reprogramming of the device&#59; &#40;3&#41; manufacturer&#39;s databases&#44; and &#40;4&#41; X-rays&#46; Bipolar electrodes can often be identified on chest radiography by the presence of a 1&#8211;3<span class="elsevierStyleHsp" style=""></span>cm electrode proximal to the tip of the lead&#46; ICDs can be distinguished from conventional pacemakers by the presence of a coil in the right ventricular lead&#44; and by thicker and more radiopaque leads&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Pacemaker dependency can be determined from the clinical history&#44; such as a history bradyarrhythmias causing syncope&#44; history of successful nodal ablation&#44; or pacemaker assessments showing no spontaneous ventricular activity &#40;when programmed to VVI mode at the lowest programmable rate&#41;&#46; If dependence is high&#44; the pacemaker should be converted to asynchronous mode during surgery by applying a magnet or reprogramming &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Electromagnetic interference</span><p id="par0080" class="elsevierStylePara elsevierViewall">EMI refers to the interruption in the operation of an electronic device due to its proximity to an electromagnetic field generated by an external source&#46; An electromagnetic field is produced when electrical current flows in a conductor with magnetic field lines perpendicular to the current flow&#46; EMI can occur as a result of conducted or radiated electromagnetic energy&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> Most surgical electronic devices emit a radiofrequency that can be transmitted directly to other devices&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">EMI is important during the surgical procedure because it can inhibit the generation of electrical current during inhibited pacing modes &#40;AAI&#44; VVI&#44; or DDI&#41; and induce bradycardia or asystole&#46; Whereas while in tracking mode &#40;DDD&#41;&#44; preferential sensing of EMI in the atrial channel &#40;which often occurs due to higher programmed sensitivity&#41; could result in increased rate ventricular pacing or atrial arrhythmia detection and a &#8220;mode-switch&#8221; to inhibited pacing &#40;AAI&#44; VVI&#44; or DDI&#41;&#46; In patients with an ICD&#44; electrocautery can be sensed as intrinsic cardiac activity&#44; and can induce inappropriate or antitachycardia pacing&#46; Activation of the magnet response by EMI may lead to asynchronous pacing in pacemakers and disabling of tachycardia therapies in certain ICD systems&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The main sources of EMI are&#58; electrosurgical units&#44; radiofrequency ablation&#44; and magnetic resonance&#46; Paniccia et al&#46; classified electrical surgical devices as low risk &#40;&#60;0&#46;2<span class="elsevierStyleHsp" style=""></span>mV&#41;&#44; intermediate risk &#40;0&#46;2&#8211;1&#46;0<span class="elsevierStyleHsp" style=""></span>mV&#41; and high risk &#40;&#62;1&#46;0<span class="elsevierStyleHsp" style=""></span>mV&#41;&#44; based on the amount of EMI transmitted to the CIED&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a> These authors found that both traditional and advanced bipolar electrosurgical units and harmonic scalpels belong in the first group&#46; Unipolar electrosurgical units without a dispersive electrode and unipolar electrosurgical units in cutting and coagulation mode pose an intermediate risk&#46; Finally&#44; argon plasma coagulation and electrocautery belong in the high risk group&#46; Generally speaking&#44; the higher the voltage the higher the EMI&#44; and the higher the EMI the greater the probability of CIED failure &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">ICDs usually need several seconds to detect high frequencies and trigger anti-tachycardia therapy&#44; and for this reason electrocautery should be applied in short bursts &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>s&#41; separated by long intervals &#40;&#62;5<span class="elsevierStyleHsp" style=""></span>s&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In patients with a CIED&#44; any surgery performed above the navel heightens the risk of EMI&#46; The dispersive electrode pad &#40;which closes the circuit in unipolar electrocautery&#41; should be placed in such a way as to ensure that the CIED does not form part of the electrical circuit&#46; Using the electrosurgery device at a distance of less than 15<span class="elsevierStyleHsp" style=""></span>cm from the CIED increases the likelihood of interference&#44; and can permanently damage its electrical circuit&#46; The programming mode of the CIED should be checked after an electrosurgery unit has been used&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Highly pacemaker-dependent patients with a unipolar pacemaker undergoing surgery with a high risk of pneumothorax&#44; are more likely to develop asystole due to the sudden increase in electrical impedance&#46; Bipolar pacemakers&#44; however&#44; are less sensitive to EMI because the electrodes are placed closer together&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Magnets</span><p id="par0110" class="elsevierStylePara elsevierViewall">Cardiac devices may malfunction in response to an EMI&#59; this can be prevented by appropriate programming&#46; However&#44; programming CIEDs is a complex procedure that must be undertaken by highly trained specialists&#44; such as technicians trained by the manufacturer or a cardiac electrophysiologist&#44; and as such poses a logistical challenge&#46; To overcome this&#44; CIEDs incorporate switches that allow basic functions to be controlled by clinical magnets&#46; These magnets are readily available and can be used without special training&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Most pacemakers and ICDs have built-in magnetic &#8220;reed switches&#8221; that are designed to switch circuitry on and off in response to magnets&#46; A reed switch consists of 2 metal strips made of magnetic material in a glass capsule&#46; Although several configurations are possible&#44; the most common one involves separation of the strips &#40;open switch&#41; by their stiffness and a cantilever attachment to the ends of the capsule&#46; Application of an adequate external magnetic field causes the strips to come in contact &#40;closed switch&#41;&#44; which leads to a sudden change in voltage sensed by a sensing amplifier&#46; This amplifier triggers the pulse generator to switch to perform programmed functions such as the asynchronous pacing mode in pacemakers and the suspension of anti-tachycardia therapies in ICDs<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a> &#40;Figure 3&#44; material available online&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Clinical magnets are made of ferrous alloy and come in various shapes &#40;ring or doughnut&#44; horseshoe&#44; and rectangle or bar&#41; to facilitate placement over the CIED implantation site&#46; The magnetic field effect of the clinical magnet is directly proportional to the strength of the magnet and inversely proportional to the distance of the magnet from the CIED&#46; The strength of the magnet is measured in Gauss&#58; a magnetic field effect of &#8805;10<span class="elsevierStyleHsp" style=""></span>Gauss is required to activate the magnetic switch and alter the device function&#46; Available clinical magnets usually have a strength of &#8805;90<span class="elsevierStyleHsp" style=""></span>Gauss&#46; Medtronic has introduced a smart magnet with a light indicator to guide appropriate placement&#59; however&#44; the indicator illuminates only with Medtronic devices&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The site of magnet placement is important&#44; since a poorly positioned magnet may not produce the desired effect&#46; Magnets are usually placed directly on top of the CIED&#44; although there are two exceptions&#59; in St&#46; Jude ICDs&#44; the curve of the magnet should be placed over the bottom or top end of the ICD&#44; and&#44; in Sorin ICDs&#44; the curve of the doughnut magnet should be placed so that it avoids the header on the top end of the device&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Magnets can change pacing to an asynchronous mode&#44; in other words&#44; the device will pace at a given frequency that will not change in response to external stimuli&#46; This means that a pacemaker programmed to DDD paces as DOO&#44; VVI as VOO&#44; and AAI as AOO&#46; Magnets applied to ICDs prevent over-sensing&#44; deactivate the anti-tachycardia function&#44; and leave the anti-bradycardia function intact&#46; ICDs emit an auditory or vibratory signal to confirm deactivation of anti-bradycardia therapy &#40;only Medtronic and Boston Scientific emit an auditory signal&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;19</span></a> If the patient has an ICD and is also pacer dependent&#44; then reprogramming is mandatory&#44; since placement of a magnet will not cause it to switch to asynchronous pacing&#44; and EMI can cause asystole&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">15&#44;18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Placing a magnet on an ICD will deactivate its shock function and suspend biventricular pacing&#44; thus pacing only the right ventricle&#46; It is important to bear this in mind&#44; as the loss of biventricular pacing can cause haemodynamic abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Clinical magnets do not alter heart rate-adaptive functions in ICDs&#44; and reprogramming is necessary when this function needs to be inhibited&#46; Inappropriate tachycardia secondary to mechanical ventilation or to myoclonus has been reported&#46; This is in contrast to those pacemakers wherein magnet application disables any rate responsiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Failure to produce any response on the surface ECG after magnet placement may be due to any of the following reasons&#58; &#40;1&#41; a depleted battery&#59; &#40;2&#41; the pacemaker is programmed to ignore the magnet &#40;St&#46; Jude&#44; Boston Scientific&#44; and Biotronik synchronous mode&#41; and &#40;3&#41; the magnetic field does not reach the device&#44; as in the case of those with deeper implants or in very obese patients&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Magnets cause asynchronous pacing&#44; but the rate will vary according to the battery life and manufacturer&#46; Similarly&#44; not all pacemakers change to asynchronous mode&#58; Biotronik and Intermedics pacemakers &#40;most models are now owned by Boston Scientific&#41; automatically revert to the programmed mode&#46; After 10 asynchronous beat at 90<span class="elsevierStyleHsp" style=""></span>ppm&#44; Biotronik pacemakers with BOL &#40;beginning of life&#41; status switch to the previously programmed pacing mode&#59; in ERI &#40;elective replacement indicator&#41; status&#44; after 10 beat at 80<span class="elsevierStyleHsp" style=""></span>ppm they revert to a rate 11&#37; slower than the programmed rate&#46; Intermedics revert to the previous programming mode after temporary pacing at 64<span class="elsevierStyleHsp" style=""></span>ppm &#40;Figures 4 and 5&#44; material available online&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Boston Scientific ICDs usually disable tachycardia therapies if the magnet is held on the generator for 30<span class="elsevierStyleHsp" style=""></span>s&#46; The change is signalled by a continuous&#44; high-pitched tone&#44; and the device does not revert to original programming after removal of the magnet&#46; Reactivation is achieved by placing the magnet on the generator for 30<span class="elsevierStyleHsp" style=""></span>s&#44; and the change is signalled by a return to R-wave synchronous tones&#46; ICDs from other manufacturers remain disabled as long as the magnet is placed over the generator&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a> Boston Scientific and St&#46; Jude Medical ICDs may be programmed to ignore the magnet&#44; in which case reprogramming is mandatory&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Although removal of the magnet should cause the device to return to the programmed mode or&#44; in the case of ICDs&#44; reactivate tachycardia therapy&#44; in some older ICDs from Guidant&#47;Boston Scientific&#44; the antitachycardia mode remains on &#8220;OFF&#8221; after the removal of the magnet&#46; For this reason&#44; the device should be interrogated at the earliest opportunity after surgery to detect programming changes that may have occurred&#46; This will avoid leaving the patient unprotected for any longer than necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Reprogramming</span><p id="par0165" class="elsevierStylePara elsevierViewall">As already he discussed above&#44; if the patient has an ICD&#44; is pacer dependent&#44; and extensive EMI is likely&#44; then reprogramming is mandatory&#46; Reprogramming is also indicated after argon coagulation&#44; due to the high risk of prolonged EMI&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Deactivating tachycardia therapy in ICDs is also essential in surgeries where patient movement can be disastrous &#40;ocular surgery&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a> However&#44; this is not necessary in low-risk situations &#40;no EMI&#41;&#46; The Canadian guidelines recommend magnet application over reprogramming whenever feasible&#46; However&#44; reprogramming is preferable over magnet placement in specific circumstances&#44; such as prone or lateral patient positioning&#44; or when the device is incidentally within the surgical field &#40;less than 15<span class="elsevierStyleHsp" style=""></span>cm from the cardiac device&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Reprogramming is also necessary if the patient has an implanted cardiac resynchronization device&#44; for two reasons&#58; to disable the antitachycardia pacing &#40;as most are coupled with a defibrillator<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a>&#41;&#44; and to set the device to asynchronous pacing&#44; such as VOO or DOO pacing in pacemaker dependent patients&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The pacing rate assigned by the device when the battery status is BOL &#40;100&#44; 85&#44; 98&#46;6&#44; 100&#44; 96&#41; are at the upper limits of normal&#44; and may not be appropriate for all patients&#44; especially those with coronary disease&#44; valvular heart disease&#44; or some forms of cardiomyopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> In these cases&#44; the device must be reprogrammed to a lower pacing rate suitable for the patient&#39;s comorbidities&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Intraoperative management</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Monitoring</span><p id="par0185" class="elsevierStylePara elsevierViewall">ECG monitoring should be started before surgery in order to adjust the monitor to recognized the CIED pacing peaks&#46; &#8220;Diagnostic&#8221; mode is preferable to &#8220;monitor&#8221; or &#8220;filter&#8221; modes because it gives a clear picture of high frequency signals&#44; including pacing peaks&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> All patients will require plethysmography to confirm that electrical capture is converted into mechanical systole&#46; The presence of a pacemaker is a contraindication for Swan-Ganz catheter and central venous lines&#46; Should a central line be unavoidable&#44; tachycardia pacing should be disabled in patients with an ICD&#44; while in pacemaker-dependent patients&#44; reprogramming to asynchronous mode is required&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;13&#44;23</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">During surgery</span><p id="par0190" class="elsevierStylePara elsevierViewall">An external defibrillator should be on hand at all times during surgery&#46; The defibrillator pads must be placed before surgery in high-risk patients whose position on the operating table would prevent rapid application of the electrodes in case of emergency&#46; Remind the surgeon that a bipolar electrosurgery device or harmonic scalpel are preferable&#46; If these are not suitable or not available&#44; the unipolar electrosurgery device should be used in short &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>s&#41; bursts&#44; allowing &#62;5<span class="elsevierStyleHsp" style=""></span>s between bursts&#44; and using the lowest possible cutting and coagulation parameters&#46; The electrosurgery device must never come into contact with the CIED&#46; The recommended distance from the ICD is 15<span class="elsevierStyleHsp" style=""></span>cm&#46; If this is not feasible&#44; the ICD should be reprogrammed to asynchronous modes before the procedure &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;24</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Physical and chemical considerations</span><p id="par0195" class="elsevierStylePara elsevierViewall">Many physical and chemical factors can affect the performance of a CIED&#46; Situations such as hyperkalaemia&#44; hyperglycaemia&#44; acidosis&#44; hypoxaemia&#44; hypercapnia and hyperthyroidism can undermine the efficiency of the CIED by increasing the pacing threshold&#46; Shivering and twitching can generate myopotentials that can be interpreted as cardiac ectopy&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Pharmacological considerations</span><p id="par0200" class="elsevierStylePara elsevierViewall">Drugs that can cause twitching&#44; such as succinylcholines&#44; ketamine or etomidate&#44; should be avoided during surgery&#44; because the electrical activity associated with myogenic twitches can cause EMI&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">2&#44;25&#44;26</span></a> Biventricular pacing may prolong the QT interval&#59; therefore&#44; high doses of halogenated&#44; haloperidol and methadone &#40;which also prolong the QT segment&#41; should be avoided&#44; thus reducing the risk of torsades de pointes&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">27&#8211;30</span></a> High doses of vagotonic aesthetics &#40;dexmedetomidine or fentanyl&#41; should be avoided in patients with bradycardia due to a theoretical risk of inducing pacemaker dependence&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">18&#44;31</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">As mentioned above&#44; in unipolar pacing and defibrillation&#44; the generator case must remain in contact with the tissue because it serves as an electrode&#46; When nitrous oxide is used&#44; the gas tends to accumulate in the pacemaker pocket and cover the CIED&#44; causing loss of anodal contact and preventing it from functioning as an electrode&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;32</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Emergency defibrillation&#47;cardioversion</span><p id="par0210" class="elsevierStylePara elsevierViewall">The need for defibrillation&#47;cardioversion can arise during surgery&#44; particularly when the tachycardia pacing function of an ICD has been deactivated&#46; Guidelines recommend this be carried out as soon as possible&#44; using the standard procedure&#44; but not before all sources of EMI have been shut down and the magnet removed&#46; The pads should be placed as far as possible from the CIED generator &#40;at least 10<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; placing one in front of the other on the chest&#44; and selecting the standard electric charge&#46; Reanimation protocols remain the same&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Postoperative management</span><p id="par0215" class="elsevierStylePara elsevierViewall">During the immediate postoperative period&#44; continuous monitoring of heart rate and rhythm is advisable&#46; A defibrillator should also be on hand&#46; It is usually necessary to increase ventricular pacing voltage because the stimulation threshold is also increased due to postoperative hyperkalaemia&#44; acidosis&#44; hypoxaemia or hypercapnia&#46; In highly pacemaker-dependent patients&#44; heart rate will not increase automatically when required by situations such as hypovolaemia&#44; sepsis&#44; etc&#46; In these cases&#44; it is best to programme a pacing rate suitable for the patient&#39;s underlying haemodynamic conditions&#46; This can be achieved by reprogramming or by application of a magnet&#44; in which case a rate of at least 85<span class="elsevierStyleHsp" style=""></span>ppm must be achieved&#46; If the device has in-built acceleration sensors&#44; small repeated blows can accelerate the pacing rate to between 110 and 130<span class="elsevierStyleHsp" style=""></span>ppm&#46; Adaptive functions &#40;ventilation sensors&#41; should also be inactivated in patients that are transferred to the intensive care unit for invasive mechanical ventilation&#46; This is because mechanical hyperventilation can initiate rapid pacing&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Whether by removing the magnet or reprogramming&#44; the CIED functions must be restored as soon as possible after surgery&#58; it is imperative to restart tachycardia&#47;defibrillation therapy in ICDs because an unnecessary delay will expose the patient to an unacceptable risk of fatal arrhythmia&#46; The doctor that ordered reprogramming is responsible for ensuring the device returns to its original setting&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Based on the sources consulted&#44; we present an algorithm that may be of use in guiding the initial approach to patients with a CIED undergoing elective non-cardiac surgery &#40;Figure 6&#44; material available online&#41;&#46; We hope this will contribute to improving the well-being of your patients&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0230" class="elsevierStylePara elsevierViewall">Modern CIEDs are safe&#44; reliable devices at the cutting edge of technology&#46; They are indispensable in delivering electrical stimulation for sequential&#44; rhythmic contraction of the heart&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">All CIEDs &#40;pacemakers&#44; and ICDs&#41; use the same coding system&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Modern cardioverter defibrillators can function as pacemakers&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">During surgery&#44; the performance of the CIED can be affected by EMI&#44; usually associated with the use of an electrosurgery unit&#46; Unipolar CIEDs are more susceptible to EMI&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">In most pacemakers&#44; placing a magnet over the device will initiate asynchronous pacing at a fixed rate and AV delay&#46; In ICDs&#44; the magnet will suspend tachycardia detection and therapy&#44; but will not change the pacing mode&#58; inhibition can still occur&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Transcutaneous defibrillation electrodes are placed before or shortly after ICD tachycardia therapy has been disabled&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Anaesthetic agents do not affect the performance of the CIED&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical responsibilities</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of people and animals</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0275" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interests</span><p id="par0280" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "History"
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          "titulo" => "Anatomy of the device"
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          "clase" => "keyword"
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            0 => "Artificial pacemaker"
            1 => "Implantable cardioverter-defibrillators"
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            0 => "Marcapasos artificial"
            1 => "Desfibriladores implantables"
            2 => "Dispositivos de terapia de resincronizaci&#243;n card&#237;aca"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The use of implantable cardiac devices in people of all ages is increasing&#44; especially in the elderly population&#58; patients with pacemakers&#44; cardioverter-defibrillators or cardiac resynchronization therapy devices regularly present for surgery for non-cardiac causes&#46; This review was made in order to collect and analyze the latest evidence for the proper management of implantable cardiac devices in the perioperative period&#46; Through a detailed exploration of PubMed&#44; Academic Search Complete &#40;EBSCO&#41;&#44; ClinicalKey&#44; Cochrane &#40;Ovid&#41;&#44; the search software UpToDate&#44; textbooks and patents freely available to the public on Google&#44; we selected 33 monographs&#44; which matched the objectives of this publication&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Es cada vez m&#225;s frecuente el uso de dispositivos card&#237;acos implantables en personas de todas las edades&#44; siendo superlativo en la poblaci&#243;n adulta mayor&#44; y favoreciendo que cada vez sea m&#225;s frecuente encontrar pacientes con marcapasos&#44; cardiodesfibriladores o resincronizadores en cirug&#237;a por causas no card&#237;acas&#46; Esta revisi&#243;n se hizo con el fin de seleccionar y analizar la m&#225;s actualizada evidencia para el manejo apropiado de los dispositivos card&#237;acos implantables en el perioperatorio&#46; A trav&#233;s de una exploraci&#243;n detallada en las bases de datos PubMed&#44; Academic Search Complete &#40;EBSCO&#41;&#44; ClinicalKey&#44; Cochrane &#40;Ovid&#41;&#44; el software de b&#250;squeda UpToDate&#44; libros de texto y patentes de libre acceso al p&#250;blico en Google&#44; seleccionamos 33 monograf&#237;as que se ajustaban a los objetivos de esta publicaci&#243;n&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Poveda-Jaramillo R&#44; Castro-Arias HD&#44; Vallejo-Zarate C&#44; Ramos-Hurtado LF&#46; Manejo perioperatorio de los pacientes con dispositivos card&#237;acos electr&#243;nicos implantables&#46; Rev Esp Anestesiol Reanim&#46; 2017&#59;64&#58;286&#8211;293&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar1005">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program&#46; An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page&#58; <span class="elsevierStyleInterRef" id="intr0005" href="http://www.elsevier.es/redar">www&#46;elsevier&#46;es&#47;redar</span></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paced chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sensed chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Response to sensing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rate modulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multisite pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">O<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">O<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">O<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">O<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">O<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Atrium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Atrium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Triggered&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Rate modulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Atrium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">V<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Ventricle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Ventricle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Inhibited&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">V<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Ventricle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Dual &#40;A<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Dual &#40;A<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Dual &#40;A<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Dual &#40;A<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pacemaker codes&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exact nature of the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical status&#58; electrolyte and fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CIED model&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Indication for CIED&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Date implanted and date of last follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CIED dependency&#58; percentage stimulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Possible sources of electromagnetic interference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Availability of telemetry during surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Response of device to magnet placement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Expected response after removing the magnet&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Issues to consider in the preoperative assessment&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Argon coagulation &#40;Argon Beam Coagulator&#59; ConMed&#41; and plasma blades &#40;Peak PlasmaBlade&#59; Medtronic&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unipolar electrocautery with &#40;Force FX&#44; Covidien&#41; and without &#40;Hyfrecator&#59; ConMed&#41; dispersive electrode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Device with unipolar or bipolar leads programmed in unipolar mode or with very high sensitivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgeries performed above the navel or within 15<span class="elsevierStyleHsp" style=""></span>cm of the device&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Electrocautery using long &#40;&#62;5<span class="elsevierStyleHsp" style=""></span>s&#41; bursts at short &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>s&#41; intervals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Devices producing significant electromagnetic interference&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Make sure a magnet is on hand for all patients with ICDs&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preferably use bipolar electrosurgical units or harmonic scalpels&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Using unipolar electrocautery in short bursts &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>s&#41; with &#62;5<span class="elsevierStyleHsp" style=""></span>s between bursts&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Never allow the electrocautery device to come into contact with the CIED&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">When using electrocautery&#44; choose low cutting and coagulation parameters&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Make sure all equipment needed for transcutaneous pacing&#47;defibrillation is on hand&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prepare isoproterenol and atropine&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Recommendations for intraoperative pacemaker management&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:33 [
            0 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical management of electromagnetic interferences in patients with pacemakers and implantable cardioverter-defibrillators&#58; review of the literature and focus on magnetic resonance conditional devices"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Corzani"
                            1 => "M&#46; Ziacchi"
                            2 => "M&#46; Biffi"
                            3 => "L&#46; Allaria"
                            4 => "I&#46; Diemberger"
                            5 => "C&#46; Martignani"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Cardiovasc Med &#40;Hagerstown&#41;"
                        "fecha" => "2015"
                        "volumen" => "16"
                        "paginaInicial" => "704"
                        "paginaFinal" => "713"
                      ]
                    ]
                  ]
                ]
              ]
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            1 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implantable devices&#58; assessment and perioperative management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Costa"
                            1 => "D&#46;C&#46; Richman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.anclin.2015.10.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiol Clin"
                        "fecha" => "2016"
                        "volumen" => "34"
                        "paginaInicial" => "185"
                        "paginaFinal" => "199"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26927747"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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            2 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "S24&#46; History of pacemakers and anesthesia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46; Tsai"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.janh.2015.07.025"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Anesth Hist"
                        "fecha" => "2015"
                        "volumen" => "1"
                        "paginaInicial" => "97"
                        "paginaFinal" => "98"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26930105"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A brief history of cardiac pacing"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "O&#46; Aquilina"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Images Paediatr Cardiol"
                        "fecha" => "2006"
                        "volumen" => "8"
                        "paginaInicial" => "17"
                        "paginaFinal" => "81"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22368662"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of external electrical and magnetic fields on pacemakers and defibrillators&#58; from engineering principles to clinical practice"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46; Beinart"
                            1 => "S&#46; Nazarian"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.113.005697"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2013"
                        "volumen" => "128"
                        "paginaInicial" => "2799"
                        "paginaFinal" => "2809"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24366589"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Basics of electrical cardiac stimulation&#93; German"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "W&#46; Koglek"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s003990170015"
                      "Revista" => array:6 [
                        "tituloSerie" => "Herzschrittmacherther Elektrophysiol"
                        "fecha" => "2001"
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