Anesthetic Concerns: Patient with Pacemaker / ICD (CIED)

PREOPERATIVE

• Type (pacemaker vs. ICD vs. CRT-D), manufacturer, model number, age, current settings
• Date of last interrogation (most devices should be checked within 6-12 months)
• Patient usually carries a manufacturer ID card - use it
• Call the manufacturer if needed for programming/magnet response details

• CIEDs are implanted for HF, IHD, valvular disease, or life-threatening arrhythmias - all carry independent perioperative risk
• Evaluate and optimize these comorbidities before elective surgery

• YES → Program to asynchronous mode (DOO/VOO/AOO) to prevent EMI-induced inhibition
• NO → Careful monitoring and magnet availability may suffice

• Antitachycardia function should be deactivated before surgery (especially if cautery will be used)
• Options: reprogram OFF or apply magnet (magnet suspends anti-tachycardia but does NOT convert to asynchronous pacing in most ICDs)
• Consult electrophysiologist / cardiologist

• Rate-responsive sensors (motion, minute ventilation) may trigger inappropriate pacing rate increases intraoperatively

INTRAOPERATIVE

• Use bipolar cautery whenever possible
• Place dispersive (grounding) pad far from device
• Use short, intermittent cautery bursts (< 1 second)
• Avoid cautery in proximity to the device or leads

1. Cautery artifact interpreted as VF → inappropriate defibrillation shock (patient movement risk)
2. EMI inhibits pacemaker output → bradycardia / asystole
3. Activation of rate-responsive sensor → inappropriate tachycardia
4. Temporary or permanent reset to backup/factory mode

• Continuous pulse oximetry or arterial line (to detect perfusion loss during ECG artifact from cautery)
• ECG monitoring throughout
• External defibrillation pads applied and connected to a defibrillator before incision

POSTOPERATIVE

• Interrogate the device immediately after surgery to confirm all functions restored
• Continuously monitor patient until antitachycardia functions are confirmed active
• Document any intraoperative device-related events
• Cardiology follow-up if any device anomaly was noted

• Miller's Anesthesia, 10e - Chapter 28 (Cardiovascular Implantable Electronic Devices, p. 3934-3935)
• Morgan & Mikhail's Clinical Anesthesiology, 7e - p. 749-751

Management of an 18-Year-Old with a 4 cm Endometrioma

STEP 1: Initial Assessment

• Dysmenorrhea, dyspareunia, chronic pelvic pain, dyschezia, dysuria
• Family history of endometriosis
• Menstrual pattern, sexual/reproductive history

• Pelvic exam: uterosacral nodularity, adnexal tenderness/mass
• Abdominal examination

• Transvaginal/transabdominal ultrasound (confirm 4 cm endometrioma - ground-glass echogenicity, homogeneous low-level internal echoes)
• AMH (baseline ovarian reserve) - essential before any intervention in a young patient
• CA-125 (elevated in endometriosis, also excludes malignancy)
• CBC, inflammatory markers

STEP 2: Surgical vs Medical Decision

Indications for Surgery (at 4 cm)

• Cyst ≥3-4 cm with surgical threshold met
• Symptoms refractory to medical therapy
• Suspicion of malignancy (warrant histology)
• Desire for fertility evaluation

Medical Management (First-Line in Adolescent - Even with 4 cm Cyst)

ASRM: GnRH agonist is not recommended as first-line because it is more expensive and associated with more side effects and bone density concerns than OCPs. - Berek & Novak's Gynecology (p. 664)

STEP 3: If Surgery is Needed

Approach: Laparoscopic Cystectomy (Excision of Cyst Wall)

"According to a systematic review, there is good evidence that excisional surgery for endometriomas with a diameter of 3 cm provides a more favorable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile."

• Berek & Novak's Gynecology, p. 656

• Aspirate cyst → incise wall → strip cyst wall from ovarian cortex
• Maximize preservation of normal ovarian tissue - critical in an 18-year-old
• For hemostasis: prefer suturing over bipolar coagulation - bipolar coagulation causes more thermal damage to primordial follicles
• Send specimen for histopathology

CRITICAL CONCERN: Ovarian Reserve

"Cystectomy and ablation of an endometrioma carry potential risks for the ovarian reserve, either by removal of normal ovarian tissue during excision or by thermal damage to the ovarian cortex during ablation. Although as little as one-tenth of an ovary may be enough to preserve function and fertility, there is concern that ovarian cystectomy with concomitant removal or destruction of normal ovarian tissue may reduce ovarian follicle reserve."

• Berek & Novak's Gynecology, p. 680

• AMH drops from ~3.9 to 2.9 ng/mL at 6 months post-cystectomy (vs. minimal drop with three-stage procedure)
• Counsel patient and guardian pre-operatively about fertility risk
• Consider oocyte/embryo cryopreservation before surgery if the patient requests it
• Recent meta-analyses (PMID: 36334993, 38509401) confirm cystectomy reduces AMH more than ablation in the short term, but provides better long-term outcomes

STEP 4: Post-Operative Management

"The ESHRE guideline recommends the use of postoperative hormonal therapy... after cystectomy for an endometrioma in women not immediately seeking conception... for at least 18 to 24 months, for secondary prevention."

• Berek & Novak's Gynecology, p. 663

• Combined OCP - preferred in adolescents (bone density safe, contraceptive benefit)
• Dienogest 2 mg/day as alternative
• Duration: minimum 18-24 months

• Repeat ultrasound at 3-6 months
• AMH reassessment at 6 months post-op
• Annual review of symptoms and recurrence

Special Adolescent Considerations

"Women aged 30 years or younger at the time of hysterectomy for endometriosis-associated pain are more likely than older women to have residual symptoms, to report a sense of loss... bilateral salpingo-oophorectomy in young women should be considered in only the most severe or recurrent cases."

• Berek & Novak's Gynecology, p. 663

References

1. Berek & Novak's Gynecology (16th ed.) - Ovarian Endometriosis, pp. 656-681
2. ASRM Practice Committee - Endometriosis and Infertility: A Committee Opinion (2012) - Surgery for Endometriomas; Postoperative Hormonal Suppression
3. Zhang Y et al. (2022) - Impact of cystectomy versus ablation for endometrioma on ovarian reserve: a systematic review and meta-analysis. Fertil Steril. [PMID: 36334993]
4. Paik H, Jee BC (2024) - Impact of Ablation Versus Cystectomy for Endometrioma on Ovarian Reserve, Recurrence, and Pregnancy: An Updated Meta-Analysis. Reprod Sci. [PMID: 38509401]
5. Moreno-Sepulveda J et al. (2022) - Effect of Laparoscopic Endometrioma Surgery on AMH: Meta-Analysis. JBRA Assist Reprod. [PMID: 34755503]