Episode 311: Perioperative Management of AICDs and Pacemakers with Mark Nelson
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Hello and welcome back to ACRAC. I'm Jed Wolpaw and I am really excited. We have a great show for you today. If you know me, you know that I love...

cognitive aids. I love things that help us do our job better and make sure we don't forget things. And we're going to talk about someone who has come up with one of these today or been a big part of creating one, one that I think is going to be super helpful for folks. If you don't already know about it, I have with me Dr. Mark Nelson. He's the chair of the ad hoc subcommittee on cardiac implantable electronic devices at

of the ASA Cardiovascular and Thoracic Committee. He's the Director of Cardiac Anesthesiology. He's an Associate Professor of Anesthesiology at the Virginia Commonwealth University Department of Anesthesiology. Fabulous guy who's done some great work, and we're going to talk about his work on this ad hoc subcommittee and the both app and

and cognitive aid that they developed to help people think about how to manage these devices perioperatively. And if you've ever done it, and I'm sure many of you have, you know this can be confusing. There's a million different types and variations and manufacturers and what does a magnet do and all this stuff. And so he has come up with a way to really help us think through this, and we're going to learn a lot today. So, Mark, thank you so much for coming on the show.

Great to be here, and I appreciate you having me. It's really an honor to be here. I've listened to this podcast many times, and I've always enjoyed the diverse folks you have on it and the very back and forth and the openness of it. It's just been incredible. It itself has been an incredible learning for me and many. In fact, you really can't find many people in the anesthesia community that don't know about this podcast. I was amazed.

When Dr. Navarrete introduced us or suggested doing this, I was really amazed how universally listened to this podcast is and how different in the modern era. I'm sort of from a somewhat of a past era, but in the modern era, how medical information is disseminated and some of the new tools we have to talk about it. Well, fabulous. I'm so glad to hear that. Let's talk about what your motivation was for trying to come up with this management aid. Did you do a needs assessment? What led you to get involved in this?

Yeah, we sure did do a needs assessment. I had sort of been doing my own needs assessment for quite some time. And in the beginning, I really sort of even wondered and doubted if there were these real gaps of knowledge when you talk about needs assessments. Really, I just sort of thought maybe it was just me. Maybe I just can't seem to remember the nuances of one device to another. Maybe it just seemed like we were just going over this again and again and again. Every time someone showed up with a pacemaker or an ICD,

It just seemed like we reinvented the wheel every time. And for the longest time, I just thought it was probably just me and I'm just not that familiar with them. I need to update my education. So I attended many seminars and ASA talks and all that sort of thing. They're all very helpful, but there was no retention. I couldn't retain enough of it to get through five manufacturers and the nuance of the device. I'd forget it every single time.

And so I started thinking maybe others were sort of as sort of, you know, there was a gap of knowledge in others as well. So we actually did a very informal sort of a needs assessment. We sent a little survey around among people, just asked them about 10 basic questions about

that you would need if you were going to manage an ICD or a pacemaker intraoperatively sort of in real time. And amazingly, most people really shared the same gaps of knowledge I had. It was sort of reassuring. I was glad to know that I wasn't the only one. But it also really got me thinking, how could we address this? Is there some way that we could sort of get us through this thing in real time, not in

where you have to stop the forward progress of the patient having surgery and call the device company or call the EP doctor. They're in the middle of a procedure doing a procedure, and the device reps were almost invariably in the procedures with them. And

as much as they desire to be helpful, they certainly had, they were busy doing other things. And so it really seemed that there was a huge need and a gap. And so that's what really motivated sort of us to try to put something together that could be used in real time. And real time is the key to this. It's not meant to be historically large. As you can see from the document, it's very short. We intentionally kept it short with just a very distillate of things that

that you could use. And in fact, we wrestled with that. The bigger it got, the less usable it became. And so one of the hardest things we felt and dealt with was parsing and culling material that was somewhat germane but probably, in the end of the day, took away from the user's ability to use it. And when we looked at the existing literature, it was amazingly complete.

But it was just almost incomprehensible because it was so complete. It was marvelously written, but you couldn't comprehend it in usable time. So that was sort of the story that kind of...

kind of got us on this adventure. And that's such a great point because we talk about this when we think about checklists, right? Is that if you try to make your checklist all-encompassing, it's going to be so long that no one's ever going to use it. And the art of a really useful management aid of any kind is exactly what you just described, is making sure it's useful, it has enough that it can help most people in most situations, but not so much that it's overwhelming and people don't want to use it or can't make their way through it because it's too convoluted.

So I'm glad to see that. And when I looked through the document, I absolutely felt that. I thought, look, this is really nice. It seems like the important stuff, but it's not 75 pages that you have to slog through. So I think you guys really hit that well. Yeah, that was certainly the main objective. And to maintain the material that if it wasn't in there, that something bad could happen. So that was really sort of the final stop was we had to have it complete to where nothing bad could happen.

Fabulous. Well, let's probably back up a second, talk about what is a management aid? You know, I mentioned checklist. It's a little different than a checklist. And obviously, ASA comes out with guidelines and consensus statements a lot. It's not that either. So what exactly is a management aid?

It is. It's we actually is the first time we sort of kind of came with the title. The committee came up with that title and absolutely it doesn't rise. It didn't meet the the it doesn't meet the criteria of a guideline or a or a statement, a consensus statement.

It didn't go through the ASA delegates approval process. It is a product of the ASA Cardiovascular and Thoracic Committee. It is a committee product of

And like any other committee product, it's on the ASA website. If you look under resources on the ASA website on the front page, there are four phasing websites to the general public. And go under resources and go down. You'll see many. You'll certainly see guidelines and consensus statements. You'll also see ASA committee products. And this is an ASA committee product. In fact, we sort of wrestle with, you know, but how does that fit into the –

Sort of we're used to things we've always heard about, guidelines and other things like that. But this is a product of the committee. And the committee was a diverse group of people. It was a subcommittee of the ASA Cardiovascular and Thoracic Committee, at that point chaired by Linda Shore-Lesserson. And it was a committee. The subcommittee was really made up of many folks from the actual cardiovascular and thoracic committee itself, along with Ken Ellenbogen, the current chair of the – current president of the HRS committee.

Fred Casamodo, past chair of the Heart Rhythm Society. Greg Janil and Scott Steckenbach, who just were indispensable. And so we all and every device manufacturer. Every device manufacturer has a medical representative who looked at the material, helped us with it, and made certain that the device companies were absolutely comfortable with it.

And so those were sort of the people that came together, and it was titled A Practice Aid. And that's really sort of the – it is a strange thing. Like we don't usually have practice aids. What is a practice aid? And we wanted a document –

That had the right – that has the ASA name on it, our wonderful society that does so much for us. It needed to have some credentials. It needed to have some – so that the user could know that it just didn't – it wasn't probably very valid and good thinking of many intelligent people. But at least it's backed up.

um, by, by committees, uh, such as the ASA and endorsed, fully endorsed by the heart rhythm society. So, you know, it's fully endorsed a product that was written by the ASA cardiovascular thoracic committee, uh, endorsed by HRS and, um, and, um, vetted to, um, to their, um, um, society as well. Yeah, that's fabulous. So we talked about the fact that, you know, you had to kind of pick and choose a little bit. So is it complete? Are there other specific devices that weren't included? How did you come down there?

Well, luckily enough, we have great device reps where I work at Virginia Commonwealth University. And so every single device that's currently out on the market is included in that. There simply are no devices that fall in the category of an ICD or a pacemaker that are not included with the exception of the Medtronic EVICD. And we want to continue to update and upgrade this product annually.

And that's the only device that's not included in that. But otherwise, every device by Biotronic, Boston Scientific, Medtronic, Abbott, and Microport are included in it. And why is that?

Why did that one not make it in? Oh, it just didn't make the deadline. We were already so far down having written it, and this document bounced around for what seemed an eternity, among other things you can imagine. And everybody adding, subtracting, the verbiage had to be just –

You know, spot on that nobody could miss until, like, what was very clear to one person was ambiguous to another. And, again, we wanted to make it small, concise, usable, but complete enough where it didn't lose its precision by being too small. And so we actually were beyond before Medtronic. Just only recently, I think within the last six months or so, the Medtronic EVICD was released.

It just wasn't on the document. We didn't want to go back. We were just thinking that we'd worked so hard to get where we were. We probably just put that in the next version. Absolutely. 100%. So let's talk about the kind of reasons why this stuff can be important to know. And we really are talking about electromagnetic interference or EMI. So what is that and why do we worry about that with patients who have pacemakers or AICDs?

For sure. You know, the very basic concept of electrosurgery is that there's a ground pad, you know, an anode, and I think the cathode is the bovie, what's typically called the bovie. And the current flows between those two things, and the current can be heard by the device. And the device is, of course, sitting in the chest. And if the device hears that, it can interpret that a couple of different ways. And if it's a pacemaker...

and a patient is being paced regularly or if the patient's intrinsic heart rate is so low that the patient would become unstable if they lost pacing regularly,

If that device misinterpreted the signal from the electrocautery as intrinsic activity of the heart, it would stop pacing. It would do what it's supposed to do when it's in synchronous mode. And all devices are, well, any device that is in a patient, a pacemaker in a patient who has their own intrinsic heart conduction of some sort, if they have any intrinsic activity

Conduction, it's going to be set in a synchronous mode. Synchronous means it will not pace if the heart is pacing itself. And those are the patients that if for some reason they are in a synchronous mode and they lose conduction because the device no longer fires,

Because of the interference from the device, they can become bradycardic in the operating room. The other group, people, the ICD patients, and those patients, more straightforward, the electrical interference can be misinterpreted as VT or VF, and then the device delivers therapy. So those are the two things. It's hearing the electrocardiogram. Beyond the electrocardiogram, there's really nothing to be concerned about. Great.

Great. So it can either be seen as beats that are not there, which would mean that a pacer that needs to be firing would stop firing and that a patient would be asystolic or extremely bradycardic. Or it could see them as an arrhythmia like V-fib and then shock, if it's an AICD, shock the patient. And that would be a shock on a perfectly well-functioning beating heart, which could then send the patient into V-fib.

Jed, you distilled down what it took me 20 minutes to say in about one minute. No, not at all. I'm glad I got it. Very well said, yes. I'm glad I got it. So great. So those are the concerns. That's why we worry about EMI.

Now, do we think about, you know, you hear a lot, it depends on where the EMI is going to be, right? So in other words, if we hear a lot below the umbilicus as a cutoff, and is that accurate that if the EMI, if it's an operation on the hip or the knee, that we don't have to worry about this, but if it's on the chest or the neck, then we do?

For sure. It's 15 centimeters. There's been lots of research that's shown that procedures lower than the umbilicus, provided the ground pad is placed on the thigh or the buttock or somewhere below the umbilicus as well, that those patients are not at risk for inappropriate shocks or inhibition of pacing.

Some of the devices can hear some of those sounds, but at this point, at that distance, they rarely misinterpret those or simply essentially never misinterpret those. So it's considered perfectly fine if the surgery is below the umbilicus and the ground pad, again, is below the umbilicus to go ahead with the procedure. You don't have to take precautions about the pacemaker over-sensing or the ICD over-sensing.

One other caveat, though, is there are these underbody grounding pads that are sometimes used in orthopedics where the patient is laying on a pad that is essentially a ground pad. Those cannot be used because the current path will be above the umbilicus regardless of the surgery. So if you have a device, a patient with a device, if you are going to use that ground pad, the device would have to be

either formally reprogrammed if they're pacemaker-dependent or a magnet used otherwise. Great. Now, can you actually harm a device with EMI? Could the EMI actually disable or damage one of these devices such that then it wouldn't work correctly post-operatively?

Now, not in the modern era. I suppose it's possible if you bovee just exactly on top of the device, but normal surgical electromagnetic interference has no – it cannot damage the device in any way.

Right.

which are inefficient and it will cause the battery life of the device to be short. But in terms of the electrocautery interference disabling the device permanently, that just doesn't happen in the modern era. There was, you know, historically there was – well, actually, it just doesn't happen in the modern era. Great. So let's talk about magnets. People ask about these a lot. They're in the ORs in many places. Does putting a magnet on a device always do the same thing or not? Yeah.

Funny you mentioned that. And that was really one of the major driving forces of the management aid. Practice aid was exactly that, that there are small nuances that one – it's very difficult to remember. So you're kind of going from one device to the other. Is this the one that has to be taken off if it's over eight hours? Or is this the one that – this or that or the other? So that's really what we really wanted to do. We sort of assumed that the user –

you know, would have basic understanding of how the device works and maybe why they would want the patient to continue pacing or the ICD be disabled. But which devices are disabled and how they're disabled is exactly what we want to talk about. So in terms of ICDs, the good thing about ICDs

is in the modern era, you can just assume all ICDs are disabled with magnet placement provided, of course, the one caveat, the most important caveat and the caveat that cannot be forgotten is the magnet has to stay on the device.

So I'll just segue for a second about that. If the magnet is off of the device, if the patient is positioned in a way that a magnet falls off or if it was just never placed over the device, the device will not be inhibited and it will function as it normally does.

So and if you're dealing with a patient that you think that the magnet will not be, you don't feel comfortable that you can maintain the magnet's position, you'll have to have that device reprogrammed off.

And now when you reprogram it off, you have to remember you have to reprogram it on when you're done with the procedure or it has to be turned back on. You know, you have to – before you take away – take off the external defibrillator pads, you have to turn it back on. So all ICDs go off with magnets.

um since we're on a talk show i don't get time with this there are there are there are some um people say well but but say a boston scientific or a uh abbott um icd has a um has a programmable magnet function you can program the magnet function to you can program the device to ignore the magnet you can turn the magnet function off in a in a boston scientific or an abbott device um

For example, but nobody has ever done that, nor would they do that. It's just never heard of. It's...

It's one of the things in medicine that you just, that we just don't do. I mean, I suppose, you know, you could put, it would be on the order of, we assume that it's, it's succinylcholine that we're actually taking out the syringe because somebody has sabotaged that they could have, but we, we basically just assume that didn't happen. And this with ICDs is, is, is you can assume this, there's no case reports of a,

of ICDs being discovered with a magnet response turned off. When patients go to MRI, the magnet responses are – the device is reprogrammed. When they come out of MRI, they have to be reprogrammed back on. But barring that, nobody is turning the magnet devices off.

Pacemakers, now there are some caveats with pacemakers. The biggest one would be the Biotronic, which is an uncommon device used in this country. It's probably only 6% of the market. But they strangely come out of the box in the auto mode. And typically when they're implanted, they are reprogrammed back into the asynchronous magnet response.

The auto mode, if you put a magnet on it in the auto mode, it will pace 10 beats asynchronously. And then it goes back to synchronous pacing. If you didn't know that was the case, you'd think the device was, in fact, asynchronous with the magnet placement. So that device, you have to put the magnet on it and watch it for a period of time greater than 10 beats to make sure it maintains itself in the asynchronous mode. Okay.

Two other caveats about pacemakers pacing asynchronously. Again, the Boston Scientific and the Abbott devices, they do have a programmable magnet response as well, which, again, where you can program the magnet response off, where it will not signal to the device to pace asynchronously.

That, again, is a nearly unheard of programming. But we always say when you put a magnet on a pacemaker, look at the – you're going to want to do it anyway. Look at the ECG and make certain that the device is, in fact, pacing. So there are some caveats. And that was, again – those things are all absolutely included in the management aid.

Yeah, super important. What about if you put a magnet on, whether it's an AICD where you're disabling the anti-tachytherapy function or whether it's a pacemaker where you're putting it into asynchronous mode, when you take the magnet off, does it go back to what it was before or does that magnet potentially reprogram the device? 100% of the time it goes back to how it was before. There was a Boston Scientific device called

Back in the era when Boston Scientific was guidance and it had a mechanical read switch in it that was known to get stuck. And that sort of put everybody in a – we sort of got alarmed by that, that some of the devices, if you put a magnet on them, were actually disabled when you – remained disabled when you took the magnet off. That device hasn't been on the market for 20 years. So all devices go back to the way they were –

before you put the magnet out to go back to that mode when you take the magnet off. And so therefore, unless you want to change the programming for another reason, there's no reason to have the device evaluated postoperatively in that instance or do anything with it. Just take the magnet off. Great. What about store EMG programming? What is that? Well,

Well, I'm glad you brought that up. Boston Scientific, again, and Abbott have this function. And what it was used for is if a patient was experiencing syncope or dizziness when they had this device, they could put a magnet over the device themselves, and it would store an EMG. A certain period of time, it would store a loop.

an EMG loop and it would provide information for the electrophysiologist or cardiologist to see if, in fact, there was some rhythm that was occurring that was creating the dizziness in their patient or was there another source of dizziness.

That function is so rarely used. We did mention it. It's in the algorithm. But it is so rarely used. I've never seen it used. I think of only one person I know that has ever heard of a device being programmed like that. That sort of

Patients that have these very uncommon episodes of dizziness who have devices not uncommonly have loop recorders now. And you get an implanted loop recorder and you can wear that for a long time. And it's sort of that's how those are managed nowadays. Those very infrequent things that might be arrhythmias are managed with a loop recorder, not with a patient with a magnet. It was never a very functional practice anyway. It was never functional. But in the algorithm –

And in the app, it does allude to that, that in the case of Abbott, if for some reason that device is in store EMG mode and you put a magnet on it, it will store an EMG. And as soon as it stores that EMG, it will go right back to asynchronous pacing. The Boston Scientific device, however, you have to take the magnet off for three seconds and put it back on.

And, of course, this is such a rare programming that it's just rarely ever used. But, again, this material is in the practice aid. And these were the little things we thought, boy, we just need to put that in there to make sure that people are aware of it. But we didn't want to make people think, oh, this is such a common thing and that we need to be concerned about this all the time and to not have a very simple way to deal with it.

And it's a pacemaker, and it looked like he put a magnet on it. It didn't pace. Take it off, put it back on, and it will start pacing if it were in Storium G mode. But again, it's a very, very rare programming. But I'm glad we're mentioning it on the show because these things do exist. Storium G is a possibility in certain devices. Yeah, well, that's great for people to know about for sure. Stay with us. We'll be right back.

Thank you.

Thank you.

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Let's talk about pacemaker dependence. We say this a lot, right? That it's important to know if the patient is pacemaker dependent. And yet that term is not in the algorithm on the patient management algorithm. So tell me about that. Why isn't it? Or how do we need to think about that? Yeah, for sure. That was something that the committee wrestled with as well. The term pacemaker dependence is a very loosely defined term. In fact, only yesterday I was speaking with one of the EP fellows at our hospital and

And they were saying, yeah, it continues to be a loosely defined term. Pacemaker dependence, I guess in its most fundamental form, would mean that if the pacemaker weren't functioning, the patient would experience adverse events related to their heart rate. And, of course, pacemaker dependence has to do with pacemakers, not ICDs. And the reason we didn't put that in there is many times devices are interrogated and

And the reports by the device companies and reps don't include that term. It's difficult to find that term.

It's confusing reading, but we sort of wanted this management aid to make it where you didn't have to start reading the reports from the device interrogation. They have a lot of information in them that's very difficult to parse through, particularly for a provider who is an ordinary provider. So he's seeing maybe one or two pacemakers a month. To parse through that thing is painful.

So we skipped that term because it really wasn't relative. What we said instead – and pacemaker dependence, again, is a very relative term. Is an 80-year-old pacemaker dependent if she has an underlying rate of 48?

Yeah, I'd say so. If she stood up with a rate of 48 without her pacemaker, she would have syncope or near syncope. And at that age, your autonomic system is not – she's not going to compensate real quickly. So yeah, that patient would be – but if that patient were laying on their back in the operating room having a hip done and the bovie were used for a short period of time, five seconds or in five-second little spurts and there was – there were brief periods of time like that where –

where the heart rate, say her underlying heart rate was, well, say it was 30. So that's a beat every two seconds. And so normally you'd want 70, which is about a beat every second. If you just drop down to a beat of 30 for a couple seconds, you wouldn't know the difference. And so would you want to, you know, start delving into this patient's pacemaker-dependent, we need to have this pacemaker ICD, we need to have this reprogrammed?

Or would you be comfortable, in the case of a pacemaker, just put the magnet on it if you don't like the rate you're getting? When the surgeons are done boveeing, they may say, we're sort of done with that. Well, I'm happy with the rate I've got, so I don't need to do anything. Or they might bovee for a real long time where you really are sort of concerned with a rate of 30. They might have bovee for a couple seconds with a rate of 30. It would mean nothing.

And the other thing, pacemaker dependence can change. Certain patients have complete heart block and they recover from heart block. And when that device is interrogated, what's going on at that time is what's written in the report. And so you really banking on that terminology, we thought was a very soft end. And so what we said is,

If you go to the OR and they begin the surgery, and you always have access to the device. The device, you can either touch it, put your hands on it yourself, put a magnet on it yourself,

or you have a sterile magnet in the room and you can have them put it on it. If you don't like what you're getting, you're as an anesthesiologist, if you don't like the, you know, if you think this is too much bradycardia for this patient, put a magnet on it. If it's a, if it's a, if it's somebody with a congenital heart block and they're 32 years old and it's, and it just drops a couple of bees for a minute and they're sort of done with that. And the surgeon puts the bovie in the, puts it away and starts doing a micro dissection, you know, with bipolar, bipolar,

Then you'd be happy. So you can see it's a much better – we believe it's a much better way to manage these devices instead of trying to find that word pacemaker-dependent and calling reps and having them reprogram on pacemakers and stuff. Just if you don't like what you get, it puts us in the driver's seat. Treat what you've got. You have the ability to do that. The device will respond to you, and we want you to be in charge in the operating room. It just took a lot of the sort of –

You know, and of course, the device reps would sometimes come and say, well, she's not she's pacemaker dependent. Certainly her heart rate underneath is 50 and she's 80 years old to them. That's very pacemaker dependent to us. It's completely not pace. If you wanted to use that in an operating room, I mean, a heart rate of 50 in an eight year old is crazy.

Probably a good thing. I mean, almost an operator. So that's sort of the back story. Yeah, I mean, that makes total sense. And it's much more of a spectrum than it is all or nothing. Right. And that that makes a lot of sense. Well said. So tell me, is it true that with remote monitoring, we don't really need as much of the post-op AICD or PACER interrogation? And tell me what that means and what is remote monitoring?

For sure. In 2015, remote monitoring became the standard of care, and patients increasingly had remote monitoring. What remote monitoring is, is a remote device, either your cell phone or an actual device that the patient is given, that they take with them. Either it's an app that's added to their phone or a physical device they're given at the time of pacemaker implantation.

If you're there when people are putting in pacemakers, you'll notice the device rep is in the room. They're telling them about the device, and they're also telling them about remote monitoring. So either your cell phone app or that device goes with the patient, and once a day that device is interrogated by the remote monitoring, and it looks at the impedances, the thresholds.

the battery life of the device, and also looks for malignant arrhythmias that could have occurred. So these patients are essentially interrogated every single day if they have remote monitoring. In fact, in every quarter, the cardiologist gets a report. The cardiologist doesn't have to go to the patient to get the report. The report is automatically sent. So these patients nowadays, their devices are monitored quite closely online.

Nowadays, when the patient goes to the electrophysiologist or the cardiologist for their yearly visit, it's more to address is the programming appropriate for the patient, not is the device working. They already know the device is working on a day-to-day basis. But does this patient – is this device programming appropriate for this patient? Is this patient being shocked inappropriately or are they being paced more than they need to be paced and they're at risk for pacemaker-induced cardiomyopathy? So –

But there are patients who don't have remote monitoring for a couple reasons. The most common reason is for some reason insurance companies, you know, strangely can imagine, you know, we've never heard insurance companies being problematic, but some don't apparently reimburse for this. And in those instances, somewhere around 5% of patients don't, in fact, have remote monitoring. And those patients consistent with the 2011 ASA HRS guideline are

have to be seen within 30 days. The device, again, looking for the power-on reset, the very uncommon power-on reset. So if you have a patient and they've been operated on and they've been exposed to the electrosurgery, if they're remote monitoring, you can send them home. You can send them to an unmonitored environment very freely, ICD or pacemaker. If they don't have that but they will see their cardiologist in 30 days, they can go home as well.

The patients that you cannot send out of a monitoring environment are people who have either had radiofrequency ablation procedures, have had therapeutic radiation, or any reason to think the leads have been mechanically disrupted.

chest compressions, thoracic surgery, trauma, any reason you think that those leads were no longer working, those patients need to be interrogated before they leave a monitor environment. But otherwise, with remote monitoring, you know, most everybody goes home. Right. And so what you said is, you know, the interrogation, if they need one because they don't have remote monitoring, looking for that power on device reset, which is that rare occurrence where it may have kind of reverted to some inefficient settings. Right.

That would be it. And that's all they're looking for in that. Now, the ones, if somebody is experiencing a therapeutic ionizing radiation or mechanical disruption, that would be different. That's why those people have to be interrogated before leaving the monitored environment. How do you choose to do that if you have your, if your facility has its own interrogators or if you call the device rep or the EP nurse or the EP physicians?

Great. Let's look at how the app might help us with some scenarios. So let's say we have a patient with a pacemaker who's having a cholecystectomy. How would we use the app or the aid to help us think through that? Got it. Well, you know, since I have the app in front of me, and so just a little bit to add to, you know, the app is it's called the ASA Pacemaker app. Again, it is the product. The app, I'll just sort of clarify how the app relates to the document. It's a

The app is the, the, is an app iteration of the document. There's nothing in the app. That's not in the document. It's it's it's, this is all material. It was that was approved and written by the ASA cardiovascular and thoracic committee, all material that was endorsed by the HRS. So the app is, is an iteration of the device management aid. And in fact, I have it in my hand. Now the full management aid is on the front page of the app. And,

And so what the app allows you to do is sort of it does the same thing as the management aid would be. So if it was a gallbladder, you would sort of look and say, okay, it's a pacemaker. And the first thing it would ask you is, you know, who's the manufacturer of the pacemaker? And just so you put, you know, you look on the pacemaker algorithm. The next question it will ask you is the patient undergoing emergency surgery. And you're saying it's elective surgery. So I would say no, I go down that arm.

of the pathway. Has the device been interrogated within a year or does the device have remote monitoring? Well, let's say that this patient does have remote monitoring. Then it takes you to the device manufacturer. So say it was a Medtronic device and it would say proceed to surgery, place the magnet,

on the device in cases of periods of unacceptable bradycardia. And if it was a St. Jude device, it would say the same thing, or Abbott, currently Abbott. If it was a Biotronic, then it would ask you about that rhythm. So it would say, okay, does the patient have a paced rhythm on telemetry? So now you look up on the telemetry. So say they're being paced, and you're thinking, okay, I've got a Biotronic device, and they are being paced. This could be one of those instances where it's in the auto mode. So say they are paced. I would say yes.

plays a magnet with the device, and does it pace uninterrupted at 90 beats per minute? And say it does and continues to do so, then that tells you that the device is in fact responsive to the magnet, and you can go on. If it does not do that, then it would tell you to interrogate the device. So the device aid is meant to be that simple. It's meant there's a lot of work, and what I'm concerned is that users might think, this is too simple. This can't be accurate.

It is absolutely – the amount of thought and nuance that's behind these very simple pages is meant to be very, very complete. We thought of every possible remotely realistic thing that could happen and put it into these and then distilled it down to –

And that's what's so great is that a good cognitive aid is exactly that, right? It's that it makes it seem simple. It makes something complicated seem simple and makes it simple to manage. And I think that's what you've done with this, which is great. And then it gives you all right. You could take that same patient and if they...

have an XCD or if they have a sub-Q ICD, right? You can go down that algorithm and it's going to tell you how to handle that. And these are all slightly different. A sub-Q ICD is different than a regular ICD, right? Oh, for sure. Absolutely. Not only its location, but the nice thing about a sub-Q is currently Boston Scientific is the device that's on the market. And the sub-Q ICD is

is inhibited, TAGI therapies are inhibited 100% of the time with a magnet placement. But those are the things that you're getting sort of the nuance of the whole management aid, the practice aid, is that if you think, God, I can't remember, was this the one that was inhibited? Let's see, the Abbott Aviar is a pacemaker, and that one has a programmable magnet response, whereas the Micra doesn't have any programmable magnet response. All these sort of nuances are

are built into this. So you don't have to try and remember this stuff because truthfully, even having, you know, authored so much of this document, I can't remember this before we do this, this, this podcast, I kind of wrote some of these things now because I can't, I simply can't remember which device is it that has the,

One of them, you have to take the magnet off. If it's an ICD and it's been on for eight hours, which one was that? Was that the Boston? No, the Boston is the one that if it's in Storm G Road, you've got to take the magnet off for three seconds and put it back on. So really all it's done is taken all that material.

And put it in a simplified form into one document. Yep, that's fabulous. All right. So if you had to say, what would you identify as strengths, weaknesses, limitations of this aid that you've come up with? Oh, that's a great question. I think the strengths are going to be simplicity of use and updatability, that we're going to keep it updated and it's simple to use.

The limitations, boy, that's a – we work on it so hard to think of anything we thought that could –

that could happen that would be unforeseen. I think the limitations are it does assume a certain level of competence in the provider, meaning that when you put a magnet on a device, as I said earlier, certainly every single pacemaker is going to pace asynchronously except for the Biotronic can be problematic if it's programmed or for some reason one of these other devices in a store in GMO, it's a Boston Scientific device.

But we want people, people have to be able to know a paced rhythm when they see it.

There's a certain baseline amount of knowledge that's necessary to use this. And, you know, you sort of have to know if it's an ICD or a pacemaker. We're not going to – you know, we didn't parse out these very basic things. You have to keep – if you're going to put the magnet on it, you have to put it on it. Some ICDs make a tone with the magnet placement. Others don't. And it's about 50-50. It's across the board. It would be near impossible to memorize. An example is –

I think Abbott up until 2019, they either did or did not make a tone. But for some reason in 2019, they switched to the other. And I would have to look at the algorithm to tell me that. But I think if there's a limitation, it would be that it assumes that you would recognize a pace rhythm if you saw one, that you would recognize asystole if you experienced it.

that you would recognize certain things like rate responsiveness, that if the patient became tachycardic with – you're doing surgery and the patient's –

has a device that has a rate responsiveness programmed into it, and they became tachycardic, and they were paced at a rate of 120 that you would know to put the magnet on it, and that's going to put it back to the device's magnet rate, the device manufacturer's magnet rate. So there's some assumptions that are in there. The written device aid, which is on the app, reads,

really kind of take even takes into account all that stuff. If you read those two pages, it really, everything I've said is in that, that there is this thing called rate responsiveness and here's what it does. And here's how to defeat it.

A competing rhythm, what would a competing rhythm look like? How would you deal with that if you put the magnet on it and then say the patient were stimulated and their heart rate picked up and now you have this sort of jumbled up competing rhythm? You know, you have, we would assume the provider could recognize certain things and know to take the magnet off. So there's a certain level of competence that, so it's really, you know, it's aimed at people who are providing anesthesia, anesthesiologists that would recognize those things.

Having said that, you know, competing rhythms aren't the end of the world. You know, everybody says, well, what if they get an RNT phenomenon, meaning the device paces on a T wave and creates VF? That is possible. Those are extremely unlikely events, but it is possible. So we sort of discourage people putting magnets on devices when there's a competing rhythm. If there's competing, just take it off. There's something there.

So that would be the limitation is you and I are kind of going back with back and forth. And this just seems very intuitive to folks that live in this world, but it assumes a certain level of competence that if we had written all that stuff into it, it would become unusable, but we did write it much into it. It's in the written document, the practice, the management itself. A lot of that is not in the app that, you know, the pathways are in the app, but full management is fully available as well. So you could go back and read about some of these things. If you,

You know, we're curious about that sort of thing. Fabulous. So do you think this reduces the need to contact EP or the device nurse or device representatives? Absolutely. You know, the device companies were so much involved with this, and it really does. Example, you know, so many of these post-op interrogations that we've historically done just aren't necessary anymore.

You know, the 2011 ACA HRS guideline, you know, really said it within 30 days unless you suspect a mechanical disruption or ionizing radiation event.

But it really is useful in that sense that you can take care of these things yourself. If the patient has not had those sorts of things during surgery and you placed a magnet on the device and you want to send them home, you can just send them home. There's very few times that you really need to call a rep. The one time that...

that you would potentially – that you need somebody to come and see you is if you have an ICD pacemaker or an ICD with pacing. Of course, we always sort of think of ICDs and pacemakers as different, right?

But all ICDs are pacemakers, so everybody knows there's no such thing as an ICD that is not a full pacemaker. So it's really – I wish the word were ICD pacemaker instead of ICD. I wish we would just say ICD pacemaker. He has an ICD pacemaker or he has a pacemaker. Right. An ICD is added to a pacemaker. It's added on top of the device. And so we have – in the management, there was a limb called ICD with pacing, with active pacing. They're all pacemakers. If you're actively pacing with an ICD –

The magnet, and you place a magnet, that will suspend tachytherapies, but it will not convert the pacemaker to asynchronous pacing. So that's the one person that you could sort of get in trouble with if you didn't recognize that patient had very little underlying rhythm. I don't even want to use the word pacemaker dependence because, again, it's the wrong word. But if they had a lot of bradycardia, profound bradycardia, and the surgeon was going to be doing a lot of electrocautery,

That would be the patient that you'd have to call the device rep to have a backup rate put in that. And so, you know, we just, we put in the practice aid that if they're paced and if you look at them, they're actively paced with an ICD pacemaker that you can assume there's

Probably some degree of dependence, if you will, or bradycardia underneath that and just have the reps come and interrogate and reprogram that device. Even though some of the people are going to be by the ICDs and they really aren't intact AV conduction, they probably don't need that. But we're just better off in that instance, again, back and forth in the committee, having a rep come in and reprogram the device unless the rep can tell you that I can tell you what's under this. It's absolutely, this is a straight program.

by the ICD tracking the atrium pacing the ventricle with a shortened PR interval to pace the ventricle.

So that's the one time that you would need somebody. Otherwise, you can manage everything yourself. Yeah, that's fabulous and super useful. Well, this has been great, Mark. I think we covered a lot of great stuff, both for good learning and to help direct people to this app and this document, which will be even better for them to play around with and learn even more and explore and help them manage their patients when they have them. So thank you. Let's turn to the part of our show where we make random recommendations. Do you have anything you'd recommend the audience check out for fun?

Absolutely. A good friend of mine, Gotham Calhasty, I don't want to drop his name, but he is an electrophysiologist at Virginia Commonwealth University, is an audiophile, and he had gotten me encouraged in being an audiophile. And if you are an audiophile and you've not listened to electrostats, I highly suggest that you listen to Martin Logan's electrostats. They're fantastic. I have the 15As, and they sound wonderful. That's fantastic.

So if you're a, a looking for speakers, you've not considered electrostats. I would certainly, I would, didn't think I'd be an electrostat fan, but go with them really encouraged. You say, Oh, you got to hear these things. The vocals are incredible on these things. Nice. Fabulous. Um, well, I will recommend a show that, um, folks may have seen the squid game, the show, uh, when it originally came out season one, I just finished season two with my wife and, uh, it's a lot of fun. It's, you know, very kind of, um,

Certainly very gory, a lot of violence, but it is really kind of interesting. Although I will say season two seems to be kind of a half season. And then I think their plan is to finish it in June. So there's seven episodes and it doesn't really come to a conclusion. So be ready for that. We didn't know that. And then you pick it up in June. I think they're going to have the last episodes to finish out the season, but it's definitely an interesting show. And if you like season one, you'll probably like season two as well.

All right, Mark. Thanks so much for coming on the show. I appreciate your time. That was fantastic. It's an honor to be on the show. All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, akrak.com, where you can leave a comment. Others can learn from what you have to say.

If you are a fan of the show, you can follow us. We're on Twitter, we are on Facebook, we are on Reddit, and we are on Instagram. I'm at jwolpa on Twitter, and we're at Akrak Podcast, and you can find us on all those other platforms as well. If you are a fan of the show, please consider going to Apple Podcasts or wherever you get your podcasts and leaving a comment and a rating. It really helps others find the show.

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All right. That is it for today for the ACRAC podcast. I'm Jed Wolpaw. Thanks for listening. Remember, what you're doing out there every day is really important and valued.

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