Question from anesthesiologist

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caligas

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also posted this on our forum:

80 yo for urgent ex lap. CHF, EF 20%. Has ICD. EKG shows atrial paced rhythm at 60. Surgery will involve a lot of bovie/electrocartery.

Interrogation of ICD done by remote interrogation device in pre-op. Rep (well known, smart and very reliable) reviews from home, says patient is “only paced about 60% of time,” all atrial signals are carrying through to ventricle, almost never paces the ventricle. Says the patient is therefore NOT pacer dependent, no reprogramming needed. Says magnet will prevent shocks but will have NO effect on pacing function, which I knew.

Reasonable conclusion that patient is NOT pacer dependent? (My specific concern is that bovie will inhibit pacing function intra-op).

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I think it’s hard to say, the patient may have sinus node dysfunction. I think figuring out if they had a true pacing indication at time of ICD implantation would be helpful.
 
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You can always program it DOO at whatever rate you want (60 or 70) usually. In this way it would not sense the cautery and at the same time keep on pacing (while still maintaining AV synchrony). Having said that in my experience unless bovie is applied very close to device like in case of valvular surgeries usually it does not inhibit the pacing function. Nonetheless, we always recommend applying a burst of cautery followed by a 10 second pause if you do not change pacing mode. Also if ICD is programmed for DOO you can always turn off tachy therapies as well in stead of putting a magnet. Hope that helps.
 
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Thanks.

Just To clarify, my specific question is whether it is reasonable to call the patient “not pacer dependent” being paced 60-70% of the time.
 
Thanks.

Just To clarify, my specific question is whether it is reasonable to call the patient “not pacer dependent” being paced 60-70% of the time.

Well for 100% we say patient is pacer dependent all the time. No such nomenclature (as far as I know) exist when it is less than 100%. 60-70% is a decent pacing burden. No harm to change pacing mode to DOO (temporarily) and temporary shutting off tachy therapies just to be on safe side. No one likes a patient to be asystolic in OR.
 
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Thanks.

Just To clarify, my specific question is whether it is reasonable to call the patient “not pacer dependent” being paced 60-70% of the time.

Pacemaker dependency is generally defined as an inadequate native rhythm that requires pacing to maintain hemodynamics (the percentage of pacing definition varies and is up for debate). What we dont know here is the patient's intrinsic rhythm when not paced, considering his base rate is set at 60 bpm. Is his underlying rhythm sinus brady in 50s, or is there actual evidence of sinus node dysfunction? Keep in mind that he has a CMY and likely is on high dose of beta blockade to reach GDMT (having an ICD allows for cranking up BB dose), which would account for intrinsic sinus brady. As far as the case itself, you could do DOO if you want to be really conservative, but patient should be fine and intact AV nodal conduction is reassuring. As already mentioned, you could look at prior interrogation notes/ICD implant note to get a better sense, as well as just dropping base rate yourself and seeing whats underneath.
 
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