The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA)

In this summary document, we have provided recommendations that are based upon the available literature and input from experts in the field: both health care providers and engineer representatives from the companies that manufacture these devices. The limitations to our recommendations are the nature of the literature available, which are chiefly case reports or small patient series, and the changing technology. Without robust scientific data collected prospectively, the approach to these patients will continue to be based largely upon personal experience. We refer health care providers to the main Consensus Document for a more detailed discussion of the perioperative management of the patient with a CIED. We cannot overemphasize that the best care provided to such patients will be achieved through a careful preoperative assessment of the patient. This assessment relies upon shared communication between the pivotal physicians involved in the patient's procedure. It is not acceptable for a patient to arrive in a pre-operative holding area and a "discovery" be made of a pacemaker or ICD. This scenario generally prompts an anxious call to a cardiology team member, who likely is not familiar with the patient but nevertheless must assure the patient's safety - while a surgical team is waiting to begin the procedure. A complete and thoughtful preoperative evaluation by the surgical and CIED team alike will minimize the risk for the CIED patient. It is our sincere hope that the recommendations we have set forth will result in physicians initiating protocols for their own hospitals and databases to track performance outcomes. We recognize the need for better scientific evaluation of patients with CIEDs who are exposed to EMI. The particular risk of therapeutic radiation is a growing concern. There is a critical need for long-term data collection on radiation-exposed devices, with the outcome data coupled to radiation modeling. Future CIEDs are likely to provide better protection from EMI; however, unless other forms of electrosurgery are developed that have a lower risk of EMI inference with CIEDs, it is unlikely that concern for interactive risks will lessen. We would envision that this will take rigorous bench evaluations as well as large clinical evaluations, likely in the form of a prospective registry, to evaluate the effects of EMI. Tables 7, 10, and Appendix 3A.