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Perioperative Management of Pacemakers and ICDs

More than three million people in the United States have a conventional pacemaker and more than 300,000 have an implantable cardioverter-defibrillator (ICD) with pacing capabilities (1). Pacemakers and ICDs are becoming more common as technology improves, and are typically used by patients who already require more surgical and interventional procedures (2). Therefore, it is imperative to understand the perioperative management of these devices, which is carefully outlined by ASA (American Society for Anesthesiologists). 

The first step of perioperative management is preoperative management, which involves determining the current settings of the cardiac implantable electronic device (CIED) and confirming that the device is functioning properly. It is necessary to determine the CIED type, manufacturer, and primary indication for placement; whether the patient is pacing-dependent; and whether the CIED is optimally programmed for the planned procedure (3). 

Preoperative preparation involves a safety review of the planned procedure and the procedure environment. Some of these preparatory actions include determining the sources of electromagnetic interference, preoperative reprogramming of the cardiac implantable electronic device’s pacing function to an asynchronous pacing mode or disabling any special algorithms, suspending the anti-tachyarrhythmia functions for an implantable cardioverter-defibrillator, and ensuring the availability of temporary pacing and defibrillation equipment (3). 

In terms of intraoperative management, it is recommended that providers continuously monitor three main indicators. First, it is important to continuously monitor and display a patient’s electrocardiogram and SPO2 as required by ASA standards from the beginning of anesthesia until the patient is transferred out of the anesthetizing location. Second, it is necessary to perform continuous peripheral pulse monitoring for all cardiac implantable electronic device patients receiving anesthesia care. Lastly, if unanticipated cardiac implantable electronic device interactions occur, the procedure should be discontinued until the source of interference can be eliminated (3).  

Electronic interference can occur during an operation, and it is crucial to manage any potential sources of interference. Some of the sources are electroconvulsive therapy, radio frequency identification devices, magnetic resonance imaging, and electrosurgery (3). 

It is necessary to continue monitoring and displaying a patient’s cardiac rate and rhythm throughout the immediate postoperative period as indicated by the patient’s medical condition. In addition, the patient’s CIED programming must be restored to its original state. In the case that a malfunction, emergency surgery, or antitachycardia occurred, it is appropriate to conduct a postoperative CIED interrogation as well (3). 


  1. Pokorney SD, Miller AL, Chen AY, et al. Implantable Cardioverter-Defibrillator Use Among Medicare Patients With Low Ejection Fraction After Acute Myocardial Infarction. JAMA. 2015;313(24):2433-2440. doi:10.1001/jama.2015.6409 
  1. Rozner MA, Schulman PM. Creating an Anesthesiologist-run Pacemaker and Defibrillator Service: Closing the Perioperative Care Gap for These Patients. Anesthesiology. 2015;123(5):990-992. doi:10.1097/ALN.0000000000000839 
  1. Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter–Defibrillators 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices*. Anesthesiology 2020;132(2):225-252. doi: