ANESTHETIC MANAGEMENT OF

PATIENT WITH PACEMAKER

Presented by- Dr Kirtee M. Gurung

2nd year resident
Department of Anesthesia
Moderator – Dr. Abhisesh Shrestha
 Contents

1. Conducting system and blood supply of heart

2. Types of heart blocks
3. Pacemaker – definition and types
4. Components of pacemaker
5. Different modes of pacemaker
6. Perioperative management of patient with
pacemaker
7. Emergency management of patient with
pacemaker
Conducting system of heart
Blood supply of heart
 Heart blocks
• Abnormalities that occur at any part of the
conduction system

TYPES
1. 1st degree block
• prolongation of PR interval (>0.2s)
2. 2nd degree
a. Mobitz type I (Wenckebach) block
• progressive lengthening of PR interval with eventual
dropped ventricular conduction
b. 2nd degree Mobitz type II block
• intermittent dropping of ventricular conduction

3. 3rd degree block (complete heart block)

• complete dissociation between atria and ventricular
4. Right bundle branch block (RBBB)
• RSR in V1 (‘M’), and ‘W’ in V6 (MARROW), normal axis

5. Left bundle branch block (LBBB)

• septal depolarisation reversed so there is a change in
initial direction of QRS (WILLIAM), normal axis
6. Bifascicular block
• RBBB + block of either left anterior or posterior
fascicle
• RBBB + left anterior fascicle block -> LAD
• RBBB + left posterior fascicle block -> RAD
7. Trifascicular block– 3 types:
• Prolonged PR interval + RBBB + LAD
• LBBB + RAD
• AF + RBBB + LAD
 Cardiac implantable electrical devices
(CIED)
• Battery powered medical devices used to treat
a variety of cardiac conduction disorders
• 3 types
1. Pacemakers
2. Implantable cardiac defibrillators(ICD)
3. Cardiac resynchronization therapy(CRT)
 Pacemaker
• Devices that deliver electrical energy and treat
the bradyarrhythmias
 Indications
1. Third degree AV block
• Bradycardia with symptoms
• After drug treatment that cause symptomatic
bradycardia
• Escape rhythm < 40 bpm or asystole > 3s

2. Second degree AV block

• Symptomatic bradycardia
3. After Myocardial infarction:
• Persistent second degree or third degree block
• Infranodal AV block with left bundle branch block (LBBB)
• Symptomatic second or third degree block

4. Bifascicular or Trifascicular block:

• Intermittent complete heart block with symptoms
• Type II second degree AV block
• Alternating bundle branch block
5. Sinus node dysfunction:
• Sinus node dysfunction with symptoms as a result of
long-term drug therapy
• Symptomatic chronotropic incompetence

6. Hypertensive carotid sinus and neurocardiac

syndromes:
• Recurrent syncope associated with carotid sinus
stimulation
• Asystole of > 3s duration in absence of any
medication
 TYPES:
1. Temporary pacemakers:
- External, battery-powered, pulse generators with
exteriorized electrodes produce electrical cardiac
stimulation

2. Permanent pacemakers:
- Implantable pulse generators with endocardial or
myocardial electrodes for long term or permanent
use
 Types :
Based on method of insertion
1. Transvenous
2. Transcutaneous
3. Epicardial
4. Transesophgeal
 Types :
Based on number of chamber paced
Components of Pacemaker:
1. Pulse Generator
• includes the energy source (battery) and electric
circuits for pacing and sensory function
• Mercury–Zinc batteries - short life (2–3 years)
Lithium-iodide batteries- longer life (5–10 years)

2. Leads: Insulated wires connecting pulse generator

and electrodes

3. Electrode: An exposed metal end of the lead in

contact with the endocardium or epicardium
 IMPORTANT TERMS:
• PACING:
 Regular output of electrical current, for depolarizing the cardiac
tissue

• SENSING:
 Response of a pacemaker to intrinsic heartbeats

• PACING THRESHOLD:
Minimum amount of energy the pacemaker sends down the lead
to initiate a heart beat

• CAPTURE:
 Cardiac depolarization and resultant contraction (atrial or
ventricular)
• RATE RESPONSE:
 analyse patient’s activity and adjust the rate

• TRIGGERED PACING:
 Dual chamber pacemakers can be programmed to sense
activity in one chamber(atrium) and deliver a pacing stimulus
in the other chamber(ventricle ) after a certain time delay

• INHIBITION OF OUTPUT:
 Pacemaker can be programmed to inhibit pacing if it senses
intrinsic activity, or it can be programmed to ignore intrinsic
activity and deliver a pacing stimulus anyway
 PACEMAKER MODE CODES
NASPE/ BPEG Pacemaker codes(2002)

LETTER 1 LETTER 2 LETTER 3 LETTER 4 LETTER 5

Chamber PACED Chamber Mode of Programmability Multisite Pacing
SENSED Response to Rate Modulation
Sensing
0 = None 0 = None O = None O = None 0 = None
A = Atrium A = Atrium T= Triggered R = Rate A = Atrium
modulation
V = Ventricle V = Ventricle I = Inhibited V = Ventricle
D= Dual ( A + V) D= Dual ( A + V) D= Dual ( T + I) D= Dual ( A + V)
• Position I: Chambers Paced
– Refers to chambers paced

• Position II: Chambers Sensed

– Refers to the location where the pacemaker senses
native cardiac electrical activity

• Position III: Response to Sensing

– Refers to pacemakers response to sensed native
cardiac activity
– T = Sensed activity results in triggering of paced
activity
– I = Sensed activity results in inhibition of pacing activity
• Position IV: Rate Modulation
– Indicates ability for rate modulation designed to
altered heart appropriately to meet physiological
needs e.g. physical activity

• Position V: Multisite Pacing

– Allows indication of multiple stimulation sites
within one anatomical area e.g. more than one
pacing site within the atria or biatrial pacing
 Modes of pacemaker
1. Asynchronous or fixed-rate modes:
- AOO / VOO / DOO
- Do not provide sensing
- Pace at a preset rate that is independent of the native cardiac
activity
- Also known as Magnet Mode

2. Single chamber demand pacing:

- AAI/VVI
- Paces at a preset rate only when the spontaneous heart rate
drops below the preset rate
 a. AAI mode:
• Atrium : paced and Atrium: sensed

• If native atrial activity sensed - pacing is inhibited

• If no native activity sensed for pre-determined time -

atrial pacing initiated

• Used in sinus node dysfunction with intact AV

conduction

• Also termed atrial demand mode

 b. VVI Mode:

• Ventricle is the chamber for both paced and sensed

• Similar to AAI mode but involving ventricles instead

of the atrium

• Used in patients with chronic atrial impairment e.g.

atrial fibrillation or flutter
 3. Dual- chamber AV sequential Pacing( DDD mode)

• Commonest pacing mode

• Atrial pacing occurs if no native atrial activity for set

time

• Ventricular pacing occurs if no native ventricle

activity for set time following atrial activity
 Paced ECG – Electrocardiographic Features

• The appearance of the ECG depends on

i. pacing mode
ii. placement of pacing leads
iii. device pacing thresholds
iv. the presence of native electrical activity
1. Pacing spikes
• Vertical spikes of short duration( 2 ms)
• Bipolar leads smaller pacing spike than unipolar
leads
• Epicardially placed leads smaller pacing spikes than
endocardially placed leads

2. Atrial Pacing
• Pacing spike precedes the p wave
3. Ventricular Pacing
• Pacing spike precedes the QRS complex

4. Dual Chamber Pacing

• Pacing spikes may precede only p wave, only QRS
complex, or both
 Pacemaker dependent
• Absent of a perfusing rhythm without pacing
• Patients
a. With ICD device
b. Who develops symptoms if pacing rate is decreased
c. Who has no intrinsic activity despite decreasing the
pacing rate below 45b/m
 Implantable cardiac defibrillation
• CIED that consists of pulse generator and leads that
can sense VF and Vtach and deliver a shock to
restore sinus rhythm

• Treats tachyarrhythmias

• Functions
1. Synchronised cardioversion
2. Defibrillation
3. Antitachycardia pacing
• Indications
1. Secondary prevention of Sudden Cardiac Death (SCD)
patients with a previous (VT/VF) cardiac arrest
• Patients with coronary artery disease (CAD) who
survived one cardiac arrest (if >48 h after an acute MI)

• Arrhythmogenic right ventricular (RV) dysplasia

• Genetic proarrhythmic syndromes with one prior

episode of VT/VF - long and short QT syndrome
- Brugada syndrome
- catecholaminergic polymorphic VT
- idiopathic VF
.
• Syncope with inducible sustained VT

2. Primary prevention of SCD

• Includes all the subgroups from the secondary
prevention that are considered high risk but did not
yet have an episode of VT/VF
 Preoperative evaluation
1. Detailed evaluation of the underlying cardiovascular
disease responsible for the insertion of pacemaker

2. Associated medical problems: Coronary artery disease

(50%), hypertension (20%) and diabetes (10%)

3. Communication with the CIED team about

a. Type of device
b. Battery life
c. Pacemaker dependence
d. Magnet response
 Investigations
1. Routine biochemical and
hematological investigations

2. Measurement of serum
electrolytes (especially K+)

3. A 12 lead electrocardiogram

4. X-ray chest-(for visualization of

continuity of leads)
 Electromagnetic Interference
• unwanted noise or interference in an electrical path or circuit
caused by an outside source

• Effect of EMI in pacemaker

1. Inhibition of pacemaker

2. Inappropriate delivery of antitachycardia therapy - ICD

3. Changes in lead parameters:

• Atrial mode switching
• Inappropriate ventricular sensing
• Electrical reset
• Increase in ventricular thresholds
4. Pacemaker failure after direct contact with
electrocautery and cardioversion

5. Conversion from asynchronous mode back to backup

mode (reprogramming)

6. Transient or permanent loss of capture

7. Dislodgement of leads during atrial fibrillation ablation

procedures
8. Rate adaptive pacing (interaction of minute
ventilation sensor with ECG/plethysmography)

9. Oversensing and inhibition

• Sources of EMI
1. Monopolar electrocautery
2. External Cardioversion
3. Radiofrequency Ablation
4. Lithotripsy
5. Radiation
6. Electroconvulsive Therapy
 Reduction of EMI risk
• Distance between the EMI source and pacemaker-
>15cm( below umbilicus ) – doesn’t hamper pacemaker
function- doesn’t need magnet application to the device or
reprogramming

• Bipolar electrocautery does not cause EMI of CIEDs unless it

is applied directly to a CIED

• If monopolar used
- Placement of grounding pad below umblicus
- Use lowest effective current amplitude and deliver the
current in short bursts ( <5secs)
 Magnets
• Prevents pacemaker from EMI during surgery

• Converts the pacemaker to a fixed rate asynchronous mode

• Most pacemakers - built-in magnetic reed switches

designed to switch ‘ON’ or ‘OFF’ in response to magnets –
depends on the type of manufacturer

• Magnet application to ICD will not make the device

asynchronous but deactivate tachyarrhythmia therapy -
ICD needs reprogramming to set in asynchronous mode
• Causes of magnet failure- no response on the surface
ECG pacing rate or mode
(i) A depleted pacemaker battery
(ii) The pacemaker is programmed to ignore the
magnet
(iii) The magnetic field does not reach the device
(obese patients)
(iv) End of Life or lower battery life
 Intraoperative management
• Monitoring – ASA standard II monitoring- especially
Plethysmographic pulse oximetry

• Invasive monitoring – Arterial line

• Central venous catheterisation: Insertion with caution

- Avoid direct contact between the transvenous leads and CVC
guide wires

- Can cause dislodgement of the leads

- Can cause thrombus dislodgement or dissemination of bacterial

infection from the transvenous leads of the pacemaker
• Pacemaker-dependent patient having surgery with
monopolar electrocautery within 15 cm of the
generator- device reprogrammed or placement of a
magnet over a pacemaker to avoid oversensing of
electrocautery as intrinsic cardiac function

• Patients with ICDs- tachyarrhythmia therapies

disabled by either reprogramming or magnet
application
 Impact of Anesthetic Drugs
• Narcotic can be used successfully

• Inhalational gas - Nitrous oxide:

expansion of gas in the pocket – loss of anodal contact
and pacing system malfunction

• Inducing agents- Ketamine and Etomidate - avoided-

myoclonic movements
• Muscle relaxants - Succinylcholine:
- Increase in stimulation threshold
- Contraction of skeletal muscle groups(myopotentials)
could inhibit the pacemaker

NOTE - Anesthetic agents do not alter current and

voltage threshold of pacemakers
• Regional anesthesia and pacemaker
- No guidelines favoring or contradicting

- Spinal anesthesia used cautiously and preferably

avoided in cases of anticipated blood loss or fluid
shift - paced heart cannot compensate for
hypotension by tachycardia
 Factors That Alter The
Pacing Threshold
INCREASES THRESHOLD DECREASES
THRESHOLD
1-4 weeks of insertion Stress, Anxiety

Hyperkalemia Sympathomimetics

Hypothyroidism Anti-cholinergics

Hypothermia Glucocorticoids

Severe Hypoxia Hyperthyroidism

Alkalosis/Acidosis
Hypermetabolic states
Myocardial Ischemia or Infarction

Antiarrythmic Drugs
 Postoperative Management:
• Continuous monitoring of Cardiac rate and rhythm

• Immediate availability of back up pacing capability

and cardioversion-defibrillation equipment

• Consultation with Pacemaker technician for

resuming pacemaker activity
Management of pacemaker patient during
emergency surgery
 Trends and Profile of Permanent Pacemaker Implantation in
Nepal

• Experience From Tertiary Cardiac Center (SGNHC) From

2001 to 2020

• Retrospective cross sectional study done at Shahid

Gangalal National Heart Centre (SGNHC)

• The data of the patient who underwent PPI from 2001

November to 2020 August were reviewed- 3,631
pacemaker implantation

• Increasing trend since 2010

 References
• Miller’s anesthesia( 9th edition)
• Clinical Anesthesia – Paul G. Barash ( 8th
edition)
• Life in fast lane (LIFL)
• Medscape
• Up to date
• https://doi.org/10.3126/njh.v18i1.36778
Thankyou !!