AICD / Pacemaker Placement
Patient phenotype
AICD: ICM/NICM with EF < 35%, sustained VT/VF, primary or secondary prevention. PPM: heart block, sick sinus, AF with bradycardia. Often elderly + multi-comorbid.
Procedure
Subclavian/cephalic vein access, lead placement under fluoroscopy (RV apex for single chamber, RA + RV for dual; LV via coronary sinus for biventricular/CRT). Generator pocket created subcutaneously. Defibrillation threshold (DFT) testing for AICD. ~60-90 min.
Anesthetic plan
MAC + local infiltration is standard (low-stim procedure except for DFT testing). GA for AICD with DFT testing OR if patient cannot tolerate MAC. External defib pads always.
Setup
- ·Standard ASA + 5-lead ECG
- ·PIV
- ·External defibrillator pads on chest (anterior-posterior)
- ·Light sedation: midaz + fentanyl + low-dose propofol infusion
- ·Crash cart + emergency drugs
- ·MAGNET available (in case device behaves unexpectedly)
Biggest concerns by phase
Existing device interrogation + anesthesia plan
If patient has existing PPM/AICD: interrogation by cardiology pre-op. Document: rate dependency, mode, threshold, battery. AICD generally suspended (magnet or programming) intraop to avoid inappropriate shocks from electrocautery; backup pads in place.
MAC sedation + LA infiltration
Low-stimulus procedure mostly. Midaz 1-2 mg + fentanyl 50-100 mcg + propofol 25-50 mcg/kg/min infusion. Surgeon infiltrates pocket with lidocaine + epi. Avoid oversedation in EF < 30%.
Defibrillation threshold testing — induced VF
AICD: VF induced by short-coupled stimulus, AICD detects + shocks. Brief deep sedation (propofol 1 mg/kg push) for the induction-shock-recovery cycle. External pads ready as backup. Document successful detection + termination.
Pneumothorax + lead perforation
Subclavian access risk: pneumothorax (1-2%, sometimes delayed). Lead perforation: pericardial effusion, tamponade. Watch for sudden hypotension or hypoxia mid-case.
Quick recovery + device interrogation
Awake within minutes of stopping sedation. Cardiology re-interrogates AICD post-op (suspension off, parameters confirmed). PACU short stay.
Watch for delayed pneumothorax + lead dislodgment
CXR routinely post-op. Patient instructed to limit ipsilateral arm elevation × 6 weeks (lead dislodgment risk). Watch for worsening dyspnea (delayed pneumo).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
AICD placement under MAC in an EF 20% patient. Surgeon is about to do DFT testing. Patient is on dex 0.5 mcg/kg/hr + minimal midaz. What's your plan for the test?
What an examiner probes for
- ▹Brief deep sedation: propofol 1 mg/kg + 50 mcg fentanyl
- ▹External pads connected to defibrillator + ready as backup
- ▹Anticipate brief hypotension during VF + post-shock
- ▹Recovery: ventilate via mask if needed, restart spontaneous quickly
Sources
- HRS device guidelines
- Miller's Ch 75 (non-OR)
- ASA Practice Advisory: CIED
Anatomy reference
Sourced reference images. 4 matches for "heart cardiac chambers ventricle conduction".
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