Resident Readiness General Surgery 1st Ed.

A 65-year-old Man With a Pacemaker Who Needs Surgery

Alden H. Harken, MD

and Brian C. George, MD

A 65-year-old man arrives, again with a diverticular perforation, but this patient has an old median sternotomy incision and a lump just below his left clavicle. This patient’s BP is 130/90 with a heart rate of 100. By ECG, it looks like the ventricle is being paced, but the atrium is not.

You tell the operating room circulating nurse that you would like to use the electrocautery during surgery. She suggests putting a magnet over the pacemaker.

1. What triggers a ventricular demand pacemaker to fire?

2. What does the magnet do?

3. Is it safe to use electrocautery?

PACEMAKERS AND ELECTROCAUTERY

Answers

1. The early pacemakers were all “fixed rate” and were programmed to emit one pulse/second, for a ventricular rate of 60. However, occasionally, even patients with complete 3° heart block will exhibit a spontaneous ventricular beat. When the repolarization of this spontaneous QRS (upstroke of the T wave) coincides with a fixed-rate pacer stimulus, ventricular fibrillation may result.

So, the “demand” pacemaker was developed. This type of pacemaker is smart about how it fires. This can more easily be seen with an example. To make the math easier, we will pretend we have a demand pacer with a rate set at 60 beats/min. Every time this “demand” pacemaker senses a QRS complex it turns off and waits for one second. If, at the end of one second, it doesn’t sense another QRS, it fires. So, the patient’s ventricular rate can spontaneously rise above 60, but never below. The trick here is that the pacer can sense many electrical stimuli (like an electrocautery) as a QRS and will stop pacing, but only for as long as you use the cautery. So don’t blast away for long periods.

The ventricular demand pacer prevents the patient from dying; however, it does not increase its rate when the patient runs up stairs. Thus, an atrioventricular pacer coordinates electrodes in both the atrium and the ventricle. When this device “senses” an atrial P wave, it waits a short preset interval (say, 0.18 second), and if it senses a QRS, it turns off; if it doesn’t detect a QRS, it paces one. This device can therefore track faster atrial rates and create atrioventricular synchrony (adds atrial “kick”). But if the sensed atrial rate ever drops below 60, the A-V pacer paces both the atrium and the ventricle.

2. Pacemakers are switched into a “fixed-rate” mode whenever a magnet is placed over it. Typically, the fixed ventricular rate is set to 60. If you place a magnet over this man’s pacemaker to convert the pacer into its “fixed-rate” mode, his ventricular rate will actually slow down (from 100 to 60). This would probably be bad for his cardiac output.

3. Yes, but intelligently. The patient’s demand pacemaker will sense the electrocautery as the patient’s heartbeat and transiently turn itself off. If you use it for too long, that means you’ve stopped the patient’s heart. Therefore, you can use the electrocautery for very short bursts so that the patient will miss only one or two heartbeats during each cauterization. Of course, if you need to use electro-cautery for longer bursts, you can apply a magnet to induce a fixed rate.

TIPS TO REMEMBER

Image Atrioventricular demand pacing preserves atrioventricular synchrony (ie, the “atrial kick”) as well as tracks faster native atrial rates.

Image A magnet converts a demand pacemaker to a fixed-rate pacemaker.

Image Electrocautery effectively suppresses a demand pacemaker’s firing—use it for only as long as the patient can tolerate asystole (typically one or two beats).

COMPREHENSION QUESTIONS

1. What does the magnet do to a pacemaker?

A. Changes the mode

B. Turns it off

C. Makes it safe to use electrocautery

D. All of the above

2. What type of pacemaker is most “physiologic?”

A. Fixed ventricular

B. Fixed atrioventricular pacing

C. Demand ventricular

D. Demand atrioventricular pacing

Answers

1. A. A magnet changes the pacemaker from a “demand pacing” mode to “fixed pacing” mode. While a magnet does prevent electrocautery from suppressing the pacemaker firing, it is not safer if the fixed rate is too slow to maintain cardiac output.

2. D. Look closely at the names of each type of pacing. The “atrio” part of “atrioventricular” means that the pacemaker coordinates ventricular pacing with the atrial beat (via the P wave). That coordination means the ventricular is paced just after the “atrial kick,” which improves cardiac output. It also means that it paces the ventricle faster if the native atrial pacemaker is firing more rapidly. The “demand” part means that the pacemaker kicks in only if the heart doesn’t produce its own beat—again, preserving normal physiologic function whenever possible.