Cardiac electrophysiology perioperative implications pacemakers aicd
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Cardiac Electrophysiology, Perioperative Implications, Pacemakers/AICD. Todd Akins, MD April 28 th , 2009. Intraoperative ECG. No Contraindications

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Cardiac Electrophysiology, Perioperative Implications, Pacemakers/AICD

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Cardiac electrophysiology perioperative implications pacemakers aicd

Cardiac Electrophysiology, Perioperative Implications, Pacemakers/AICD

Todd Akins, MD

April 28th, 2009

Intraoperative ecg

Intraoperative ECG

  • No Contraindications

  • ASA Standards “Every patient receiving anesthesia shall have the electrocardiogram continuously displayed from the beginning of anesthesia until preparing to leave the anesthetizing location.”



  • Dysrhythmias, myocardial ischemia, conduction abnormalities, pacemaker malfunction, and electrolyte disturbances

3 lead vs 5 lead

3-Lead vs 5-Lead

  • 3-Lead: lead II axis parallels atria thus greatest p-wave voltage (rate determination)

  • Provides enhanced diagnosis of arrhythmias and inferior wall ischemia

3 lead vs 5 lead1

3-Lead vs 5-Lead

  • 5-Lead: only way to get a “true” V5

  • Lead V5 placed at 5th ICS, anterior axillary line

  • Detects anterior and lateral wall ischemia

  • “Modified V5” with a 3-Lead by placing LA at the V5 position (5th ICS, AAL) and selecting lead I for display



  • Lead II and Lead V5 monitored simultaneously with a 5-Lead

  • Use a 5-Lead in obese patients

  • If monitoring only a single lead, then choose lead to monitor based on patient’s history of prior ischemia or infarct (i.e. II if inferior MI, V5 if anterior or lateral)



  • Caused by patient or lead wire movement, electrocautery, 60 cycle interference, faulty electrodes

  • Monitoring filters help but can distort ST segments

  • Monitor confuses large t-waves or artifact as QRS complexes

  • Better conductance by cleaning skin with alcohol or degreaser, or exfoliating area

Intraoperative mi

Intraoperative MI

  • Commonly accepted criteria:

  • 1. flat or down sloping ST > 2mV, particularly with t-wave inversion

  • 2. ST segment elevation and peaked t-waves

  • *** Make sure volume is loud enough to hear while attention is elsewhere***



  • Classification:

  • 5-letter code (usually omit last 2 letters)

  • Chamber Paced ( O, A, V, D)

  • Chamber Sensed (O, A, V, D) senses p or r

  • Response to Sensing (O, T, I, D)

  • Programmability (O, P, M, C, R)

  • Antitachyarrhythmia Function (O, P, S, D)

  • Most common: VVI, DDD, or on tests DVI



  • If intrinsic HR < program (typically 72) then see spike then QRS and palpable pulse (100% capture)

  • If intrinsic HR > program, NO spike

  • When low battery, sensing lost before pacing output

  • Magnet defaults to VOO mode



  • Electrocautery Interferes

  • Interpreted as intrinsic function and can suppress pacemaker

  • Solution is to place grounding pad as far from pacemaker as possible

  • ***mandatory continuous monitoring of arterial pulse during cautery by palpation or pulse oximetry



  • ***accentuated myospasticity from succinylcholine induced fasciculation or post-operative shivering can also suppress pacemaker

Operative implications

Operative Implications

  • NO MRI------EVER

  • ECT is fine, but have magnet available

  • ESWL:

  • 1. risk of developing arrhythmias

  • 2. shock waves can damage components

  • Contact manufacturer for best method of managing device, i.e. Reprogram vs. magnet

  • Time ESWL shock wave to 20msec after r-wave to decrease incidence of arrhythmias

Cardiac electrophysiology perioperative implications pacemakers


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  • 1. Morgan GE, Mikhail MS, Murray MJ, Clinical Anesthesiology, 3rd ed., New York, McGraw-Hill, 2002, pp. 97-100, 124-125, 431-432

  • 2. Chu, LF, clinical Anesthesiology Board Review, A Test Simulation and Self-Assessment Tool, McGraw-Hill, 2005, pp. 231-232

Test questions

Test Questions???

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