You are contacted about a 61-year-old female patient who is starting a course of electroconvulsive therapy (ECT) for depression the following day. She has been a nursing home resident for the prior 2 years, has not seen a cardiologist in that time, and is a poor historian. Her comorbidities include hypertension and coronary artery disease treated with angioplasty and stents 5 years ago. A chest X-ray was done 2 days prior to rule out pneumonia and is shown below. No other information is available and there is no family.
What does the X-ray demonstrate?
What needs to be done next?
What is the information that needs to be communicated with the CIED team?
What information does the CIED team communicate with the anesthesiologist?
Name some sources of electromagnetic interference (EMI).
What are the adverse effects of EMI on CIED?
Is it necessary to interrogate this device? If so, why?
What is the effect of ECT on CIED?
How is anesthesia managed?
The chest X-ray shows what appears to be a pacemaker device over the right chest with a single lead in the right atrium. Pacemakers have one or two thin leads, and the tip of the lead can be in the atrium, right ventricle, and/or left ventricle as opposed to an ICD which will have two radiodense shock coils with one in the SVC area and the second in the right ventricle.
Apart from the routine pre-anesthesia assessment, the CIED needs to be addressed. ECT is an elective procedure and is a source of electromagnetic interference (EMI). As per the guidelines, before an elective procedure, the patient’s cardiologist, if known, is contacted for recommendations. If not known, then the CIED team (cardiologist, cardiac electrophysiologist, device clinic nurses and staff) from the same or a neighboring hospital is involved.
Information that need to be communicated with the CIED team [1, 4]:
Intended surgical procedure and its anatomic location
Location of the pulse generator
Patient position during the procedure
Type of electrocautery to be used whether monopolar or bipolar
Presence of other sources of EMI
Cardioversion or defibrillation during the procedure
Venue for the procedure
Postoperative plan: Day case/inpatient with telemetry bed
Surgical procedure that can cause mechanical damage the leads to CIED
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Information that the CIED team communicates with the Anesthesiologist [1, 4]:
Details of the settings in the CIED and their functioning status.
Date of last device interrogation (should be 6 months for AICD and 1 year for pacemaker).
Device type, manufacturer, and model
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