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Structural disorder of heart — Clinical Guidelines

Overview

Cardiac implantable electronic devices (CIEDs) include pacemakers, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices, which are essential for managing arrhythmias and heart failure but pose unique challenges in monitoring, extraction, and perioperative management due to their complexity and potential complications such as infections and lead dysfunction 1 2 4 7 10 12 14 19.

Diagnosis

Clinical Presentation: Symptoms may include palpitations, syncope, or signs of infection (fever, local tenderness) 4.

Diagnostic Tests: Electrocardiogram (ECG), device interrogation, blood cultures in suspected infections 4.

Imaging: Echocardiography and fluoroscopy for anatomical assessment and procedural guidance 17.

Infection Screening: Blood cultures, imaging, and device analysis for suspected CIED infections 4.

Management

Lead Extraction: Transvenous lead extraction (TLE) performed by experienced teams using advanced techniques like laser dissection when necessary 2 5 15 16.

Anesthesia Approaches: Deep sedation (DS) shown to be feasible and safe for TLE, though general anesthesia remains common 5 16.

Infection Management: Antibiotic therapy tailored to culture results, surgical debridement if indicated 4.

Remote Monitoring: Utilization of home monitoring systems to improve patient care and reduce in-clinic visits 23 24.

Cybersecurity Awareness: Regular assessment and patient education on device security vulnerabilities 18.

Special Populations

Pediatrics: Specific indications and management guidelines developed by expert consensus for patients ≤21 years old 8.

Elderly: Increased risk of complications; multidisciplinary care essential 19.

Comorbidities: Tailored perioperative management strategies, especially in patients requiring radiotherapy or undergoing surgery 11 15 25.

Key Recommendations

Multidisciplinary Approach for TLE: Perform transvenous lead extraction with a collaborative team including electrophysiologists, cardiac surgeons, and anesthesiologists to minimize complications 15 (Evidence: Strong).

Use of Deep Sedation for TLE: Consider deep sedation as a safe and feasible alternative to general anesthesia for transvenous lead extraction procedures 5 16 (Evidence: Moderate).

Implement Remote Monitoring Systems: Adopt remote monitoring technologies to enhance patient care and reduce the burden on healthcare personnel 23 24 (Evidence: Moderate).

Enhanced Infection Control Protocols: Implement rigorous infection prevention strategies, including preoperative screening and postoperative monitoring for CIED infections 4 (Evidence: Strong).

Specialized Training for Perioperative Management: Ensure anesthesiology teams are trained in CIED interrogation and management to improve perioperative safety 22 (Evidence: Expert opinion).

References

1 Dilaveris P, Antoniou CK, Xydonas S, Chrysohoou C, Apostolopoulos T, Stafylas P et al.. A scientific document for the remote monitoring of cardiac implantable electronic devices in Greece. Hellenic journal of cardiology : HJC = Hellenike kardiologike epitheorese 2025. link 2 Schaller RD, Zeitler EP, Kroman A. Lead Extraction History, Training, Volume, and Location. Cardiology clinics 2025. link 3 Zaky A, Waheed A, Hatter B, Malempati S, Maremalla SH, Hasan R et al.. Cardiac Implantable Electronic Device Educational Application for Cardiac Anesthesiology Trainees: Tutorial on App Development. JMIR medical education 2025. link 4 Traykov V, Dzhinsov K, Matusik PT. Infections of cardiac implantable electronic devices: Epidemiology, mechanisms, and preventive measures. Kardiologia polska 2023. link 5 Schiedat F, Fischer J, Aweimer A, Schöne D, El-Battrawy I, Hanefeld C et al.. Success and safety of deep sedation as a primary anaesthetic approach for transvenous lead extraction: a retrospective analysis. Scientific reports 2023. link 6 Volk L, Verghis N, Ikegami H, Takebe M, Russo MJ, Lee LY et al.. Is cardiopulmonary bypass standby still required for laser lead extractions?. Journal of cardiothoracic surgery 2022. link 7 Bonenberger M, Rice AN, Thompson A, Thompson J, Simmons VC. Standardized Perioperative Note to Improve Perioperative Management of Patients With Cardiac Implantable Electronic Devices. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses 2022. link 8 Shah MJ, Silka MJ, Silva JNA, Balaji S, Beach CM, Benjamin MN et al.. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Developed in collaboration with and endorsed by the Heart Rhythm Society (HRS), the American College of Cardiology (ACC), the American Heart Association (AHA), and the Association for European Paediatric and Congenital Cardiology (AEPC) Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). JACC. Clinical electrophysiology 2021. link 9 Yee R, Karim SS, Bashir J, Bennett MT, Exner DV, Guerra PG et al.. Canadian Heart Rhythm Society Task Force Report on Physician Training and Maintenance of Competency for Cardiovascular Implantable Electronic Device Therapies: Executive Summary. The Canadian journal of cardiology 2021. link 10 Dacher JN, Gandjbakhch E, Taieb J, Chauvin M, Anselme F, Bartoli A et al.. Joint Position Paper of the Working Group of Pacing and Electrophysiology of the French Society of Cardiology (SFC) and the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle (SFICV) on magnetic resonance imaging in patients with cardiac electronic implantable devices. Diagnostic and interventional imaging 2020. link 11 Sharifzadehgan A, Laurans M, Thuillot M, Huertas A, Baudinaud P, Narayanan K et al.. Radiotherapy in Patients With a Cardiac Implantable Electronic Device. The American journal of cardiology 2020. link 12 Bhuva AN, Moralee R, Moon JC, Manisty CH. Making MRI available for patients with cardiac implantable electronic devices: growing need and barriers to change. European radiology 2020. link 13 Fraser AG, Byrne RA, Kautzner J, Butchart EG, Szymański P, Leggeri I et al.. Implementing the new European Regulations on medical devices-clinical responsibilities for evidence-based practice: a report from the Regulatory Affairs Committee of the European Society of Cardiology. European heart journal 2020. link 14 Feldman JB, Stone ME. Anesthesia teams managing pacemakers and ICDs for the perioperative period: enhanced patient safety and improved workflows. Current opinion in anaesthesiology 2020. link 15 Roberto M, Sicuso R, Manganiello S, Catto V, Salvi L, Nafi M et al.. Cardiac surgeon and electrophysiologist shoulder-to-shoulder approach: Hybrid room, a kingdom for two. A zero mortality transvenous lead extraction single center experience. International journal of cardiology 2019. link 16 Bode K, Whittaker P, Lucas J, Müssigbrodt A, Hindricks G, Richter S et al.. Deep sedation for transvenous lead extraction: a large single-centre experience. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2019. link 17 Strachinaru M, Kievit CM, Yap SC, Hirsch A, Geleijnse ML, Szili-Torok T. Multiplane/3D transesophageal echocardiography monitoring to improve the safety and outcome of complex transvenous lead extractions. Echocardiography (Mount Kisco, N.Y.) 2019. link 18 Ransford B, Kramer DB, Foo Kune D, Auto de Medeiros J, Yan C, Xu W et al.. Cybersecurity and medical devices: A practical guide for cardiac electrophysiologists. Pacing and clinical electrophysiology : PACE 2017. link 19 Tan EM, Nagpal A, DeSimone DC, Anderson B, Linderbaum J, De Ziel T et al.. Impacts of a care process model and inpatient electrophysiology service on cardiovascular implantable electronic device infections: a preliminary evaluation. Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing 2017. link 20 Chia PL, Foo D. A practical approach to perioperative management of cardiac implantable electronic devices. Singapore medical journal 2015. link 21 Zhang R, Lin W. A Software Development Platform for Wearable Medical Applications. Journal of medical systems 2015. link 22 Rooke GA, Lombaard SA, Van Norman GA, Dziersk J, Natrajan KM, Larson LW et al.. Initial Experience of an Anesthesiology-based Service for Perioperative Management of Pacemakers and Implantable Cardioverter Defibrillators. Anesthesiology 2015. link 23 Vogtmann T, Stiller S, Marek A, Kespohl S, Gomer M, Kühlkamp V et al.. Workload and usefulness of daily, centralized home monitoring for patients treated with CIEDs: results of the MoniC (Model Project Monitor Centre) prospective multicentre study. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2013. link 24 Yee R, Verma A, Beardsall M, Fraser J, Philippon F, Exner DV. Canadian Cardiovascular Society/Canadian Heart Rhythm Society joint position statement on the use of remote monitoring for cardiovascular implantable electronic device follow-up. The Canadian journal of cardiology 2013. link 25 Hurkmans CW, Knegjens JL, Oei BS, Maas AJ, Uiterwaal GJ, van der Borden AJ et al.. Management of radiation oncology patients with a pacemaker or ICD: a new comprehensive practical guideline in The Netherlands. Dutch Society of Radiotherapy and Oncology (NVRO). Radiation oncology (London, England) 2012. link 26 Boriani G, Auricchio A, Klersy C, Kirchhof P, Brugada J, Morgan J et al.. Healthcare personnel resource burden related to in-clinic follow-up of cardiovascular implantable electronic devices: a European Heart Rhythm Association and Eucomed joint survey. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2011. link 27 Stone ME, Salter B, Fischer A. Perioperative management of patients with cardiac implantable electronic devices. British journal of anaesthesia 2011. link 28 Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB et al.. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010. link 29 Holmes DR, Kent KM. The device with a name on it. The American journal of cardiology 1997. link00872-7)

Structural disorder of heart