Quality improvements anticipated by guideline adherence to peri-operative ICD deactivation
Authors: Finnerty D , O'connell H , O'grady R , Collins L , Sheahan R 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Recent guidelines have been published by the British Heart Rhythm Society (BHRS) regarding the perioperative management of patients with CIED’s (cardiac implantable electronic devices).
The presence of these devices may present a problem when patients undergo operations in which they are exposed to EMI (electromagnetic interference) from surgical diathermy.
The current guidelines recommend not deactivating ICD’s when the site of the operation is below the diaphragm. Rather surgery should proceed ahead with a clinical magnet available should it be required.

Purpose
This goal of the study was to assess compliance with this guideline recommendation in patients who present for surgery in our hospital. Our focus was the response to patients in whom the planned operating site was below the diaphragm. Our hypothesis was that many of these patients had ICDs deactivated prior to surgery regardless of the site of surgery.

Methods
A logbook of device reprogramming requests for surgical patients was examined from October 2020 to October 2022. The patients name and date of scheduled operation was cross referenced with a data base to determine the site of the surgical operation. The changes made to the device (therapies off, magnet used or no change) were noted.

Results
Between the 1st December 2020 and 30th October 2022, 29 documented requests were made requesting CIED reprogramming prior to surgery. 22 had surgery below the diaphragm and 7 above. In all surgeries below the diaphragm, therapies function of the device was deactivated.

Conclusions
Our study demonstrates that a large number of ICD’s are unnecessarily deactivated prior to surgery. In fact, all 29 patients in this audit had their device deactivated regardless of the site of surgery. This is contrary to current guidelines. When the surgical operation is below the diaphragm, the risk of EMI is extremely low. The current evidence recommends close monitoring with immediate availability of a clinical magnet rather than deactivation of therapies.
Requests for CIED reprogramming are often made at short notice due to the unscheduled nature of many operations. This places an additional strain on the workload of our department. From a quality improvement perspective, this can lead to delays in surgical start times due to the patient awaiting re programming of their device. In many cases surgery could have proceeded without reprogramming of the device. The repercussions are reduced operating theatre efficiency and increased bed occupancy.
The deactivation of an ICD prior to surgery is both labour and time intensive. In some circumstances it is justified, however our data shows there are many instances where it is performed unnecessarily with no clinical benefit to the patient.
Compliance with these guidelines will have an immediate positive impact on patient flow and significantly reduce the number of requests for CIED reprogramming to our Cardiology department.