• Testing for PD is performed by the cardiology/pacemaker team during each regular device follow up. Various testing protocols exist that establish the presence of an inadequate or absent intrinsic rhythm at a low pacing rate. Testing is done by temporarily programming a low ventricular base rate (30–40 bpm) and assessing for the presence or absence of an underlying rhythm and/or the onset of associated symptoms.
• According to the Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Consensus statement (10), CIED clinic records should be obtained for every patient prior to any elective case to reduce or eliminate confusion regarding CIED function, and the patient's CIED physician should be contacted. In the absence of records, the HRS/ASA statement suggests a preoperative interrogation to ensure appropriate device function and programming with respect to the upcoming procedure. Some parameters (such as a reduced pacing rate for nighttime or a long AV delay) might need to be changed for an operative procedure, especially if large blood loss or fluid shifts are expected. In general, patient reports should not be trusted; many report a pacemaker check after only a simple 12 lead electrocardiographic evaluation and patients rarely understand or are informed about CIED or lead alerts.

Temporary pacing modalities in the perioperative period may be used to stabilize a patient with urgent or emergent pacing indications: transesophageal, transcutaneous, and transvenous pacing. Esophageal pacing (EP) utilizes a specially constructed esophageal stethoscope with two stainless steel rings, designed to stimulate the left atrium. EP requires intact atrial and AV nodal function; thus it is absolutely contraindicated in the presence of AF or flutter, as well as significant AV nodal disease. Transcutaneous pacing utilizes 2 cutaneous pads with pacing achieved via an external defibrillator. Transvenous pacing is achieved by placing a temporary pacing wire through a central vein so that its tip lies in the right ventricle. It is more reliable and can therefore be used for a longer duration than EP or transcutaneous pacing.

• PPM patients should have a comprehensive device interrogation at least annually. ICD patients should undergo a comprehensive device interrogation every 3–6 months, and CRT patients should be checked every 3 months. for some low risk, non PD patients with the latest generators, telephone interrogations can replace office visits.
• Postoperatively, care must be taken to ensure that a CIED continues to function appropriately. CIEDs exposed to EMI, especially if pacing inhibition was observed or blood transfused, should be checked. The HRS/ASA states that for any high-risk patient, or where preoperative or intraoperative programming was performed, or where a question arose about pacing or ICD function, that a postoperative check should be performed prior to discharge from a monitored environment. for a low-risk patient, a CIED could be checked in an ambulatory clinic after patient discharge from the PACU. The site of the postoperative check should be established during the preoperative process, since the patient's CIED physician should be involved in the perioperative planning.

1. Korantzopoulos P , Letsas P , Grekas G , et al. Pacemaker dependency after implantation of electrophysiological devices. Europace. 2009;11:1151–1155.
2. Bardy GH , Lee KL , Mark DB , et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352:225–237.
3. Uslan DZ , Tleyjeh IM , Baddour LM , et al. Temporal trends in permanent pacemaker implantation: A population-based study. Am Heart J. 2008;155: 896–903.
4. Nagatomo T , Abe H , Kikuchi K , et al. New onset of pacemaker dependency after permanent pacemaker implantation. Pacing Clin Electrophysiol. 2004;27:475–479.
5. Lelakowski J , Majewski J , Bednarek J , et al. Pacemaker dependency after pacemaker implantation. Cardiol J. 2007;14:83–86.
6. American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: Pacemakers and implantable cardioverter-defibrillators: An updated report by the American society of anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology. 2011;114:247–261.
7. Tang AS , Roberts RS , Kerr C , et al. Relationship between pacemaker dependency and the effect of pacing mode on cardiovascular outcomes. Circulation. 2001;103:3081–3085.
8. Bernstein AD , Daubert JC , Fletcher RD , et al. The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. Pacing Clin Electrophysiol. 2002;25:260–264.
9. Lau W , Corcoran SJ , Mond HG. Pacemaker tachycardia in a minute ventilation rate-adaptive pacemaker induced by electrocardiographic monitoring. Pacing Clin Electrophysiol. 2006;29:438–440.
10. Crossley GH , Poole JE , Rozner MA , et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers and Arrhythmia Monitors: Facilities and Patient Management This document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm. 2011;8:1114–1154.
11. Maisel WH , Moynahan M , Zuckerman BD , et al. Pacemaker and ICD generator malfunctions: analysis of Food and Drug Administration annual reports. JAMA. 2006;295:1901–1906.
12. Maisel WH , Hauser RG , Hammill SC , et al. Recommendations from the Heart Rhythm Society Task force on Lead Performance Policies and Guidelines Developed in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Heart Rhythm. 2009;6:869–885.

• Moses HW , Mullin JC. A Practical Guide To Cardiac Pacing. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

• PD patients are at high risk for serious injury or death in the event of pacing system malfunction.
• Perioperative pacing system malfunction from EMI and other factors is difficult to predict and occurs commonly.
• A key preoperative consideration is establishing the presence or absence of PD in PPM patients if EMI is likely to be present. When EMI is likely (such as intraoperative monopolar electrosurgery), PD patients might require reprogramming to an asynchronous pacing mode or application of temporary pacing modalities.