Pacemaker misinformation in the perioperative period: programming around the problem.

I n this issue of Anesthesia & Analgesia, Sun et al. (1) describe the correct process for noncardiac radiofrequency ablation in a patient with an implanted cardiac pacemaker. As the authors note, such patients should undergo a comprehensive evaluation of their pacemaker before the procedure. Consideration should be given to appropriate reprogramming of the pacemaker (when indicated). Finally, the pacemaker should be reevaluated after the procedure to ensure that no new issues have arisen either because of electromagnetic interference (EMI) during the procedure or because of changes in the patient’s physiology resulting from the procedure. Such preand postoperative pacemaker evaluations are in keeping with perioperative recommendations from the American College of Cardiologists (ACC) (2) and the Heart Rhythm Society (formerly called the North American Society of Pacing and Electrophysiology) (3). This article is significant—and disturbing—for another reason. For radiofrequency ablation, pacemaker reprogramming to asynchronous mode is often recommended to prevent pacemaker oversensing and inhibition due to EMI. In this case, however, no reprogramming took place because the consulting cardiologist erroneously reported that asynchronous mode was not available in this particular pacemaker. Although this pacemaker was uncommon and the manufacturer (Intermedics, formerly of Angleton, TX) was subsequently purchased by Guidant Corporation (St. Paul, MN), information about the device was readily available. Obtaining a physician’s manual required only a call to Guidant technical support, and a review of this document shows that this pacemaker does, in fact, include asynchronous pacing in single-chamber mode. So why were our colleagues misinformed? Cardiac pacemaking is complicated. Approximately 26 companies have produced nearly 2000 models of pacemaker generators. Many of these manufacturers no longer exist—assets have been sold or traded—but patients still rely on generators from these companies (as in this case). Furthermore, the likelihood of receiving incorrect information about implanted devices will increase as more complicated devices are developed, as indications for pacemaker (and defibrillator) implantation expand, and as more patients undergo device implantation. Granting of pacemaker privileges by a hospital relies, in general, only on the number of devices implanted; rarely does a hospital require documentation of training for follow-up care of pacemakers or implanted cardioverter-defibrillators. Guidelines from the ACC for training in clinical cardiology specify that only 2 months of curriculum (during the 3-yr fellowship) be devoted to “arrhythmia management, permanent pacemaker management, and electrophysiology” (4). Even the policy statement regarding training issues related to “cardiac implantable electronic devices” published by the North American Society of Pacing and Electrophysiology (the Heart Rhythm Society) does not mention the need for knowledge of the large variety of pacing devices from the various manufacturers (5). Interestingly, in their report on medical errors, the Institute of Medicine did not appear to address the possibility of factual errors in consultant recommendations (6). Adding to the complicated nature of this subject, much of the literature regarding perioperative care of patients with implanted cardiac devices is based on old, outdated, and sometimes misinterpreted case reports. For example, a discussion published in 1978 about monopolar electrocautery (7), with possibly incorrect conclusions and recommendations, continues to be cited (8) despite a more recent publication (9) that challenges these old findings and is readily found Accepted for publication July 6, 2004. Address correspondence and reprint requests to Marc Rozner, PhD, MD, Division of Anesthesiology and Critical Care, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Mail Code 42, Houston, TX 77030. Address e-mail to mrozner@mdanderson.org.