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ICD Management Perioperatively — FRCA Final MCQ

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HardAnaesthetic Equipment & SafetyICD Management PerioperativelyFRCA Final

A 55-year-old woman with dilated cardiomyopathy is undergoing right mastectomy and axillary clearance. She has a normally functioning left pectoral transvenous implantable cardioverter-defibrillator (ICD), is not pacing-dependent, and monopolar diathermy is anticipated. The device-specific response to magnet application has not been established. What is the most appropriate planned intervention for the ICD?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Suspend tachyarrhythmia therapy by preoperative device reprogramming

The correct answer is E. Monopolar diathermy during breast and axillary surgery creates clinically relevant electromagnetic interference that may be misinterpreted by an ICD as ventricular tachyarrhythmia, causing inappropriate antitachycardia pacing or shock delivery. Tachyarrhythmia detection and therapy should therefore be suspended. Because the magnet response has not been confirmed, formal preoperative reprogramming is the reliable method. Bradycardia pacing need not be changed because she is not pacing-dependent. A magnet can be appropriate when its response is known and secure positioning is assured, but neither condition is met. Bipolar diathermy reduces interference but does not address the anticipated monopolar use. A left-thigh return electrode may direct current towards the left pectoral generator. Complete avoidance of electrosurgery is unnecessary. External defibrillation capability and continuous rhythm and pulse monitoring are required while ICD therapies are disabled.

Reference: Thomas H, Plummer C, Wright IJ, Foley P, Turley AJ. Guidelines for the peri-operative management of people with cardiac implantable electronic devices: Guidelines from the British Heart Rhythm Society. Anaesthesia. 2022;77:808–817. https://pubmed.ncbi.nlm.nih.gov/35429334/