Implanted Cardiac Pacemaker and Defibrillator Management Algorithm

Implanted Cardiac Pacemaker and Defibrillator Management Page 1 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women.

INITIAL EVALUATION ● Therapy OFF Yes ● Asynchronous Implantable ICD pacing mode ● Post-operative check cardioverter pacing prior to leaving a defibrillator dependent? monitored area5 4 Surgery or (ICD) No Therapy OFF ● Turn therapy ON endoscopy with ● Check pacing mode electrosurgery Asynchronous above the waist3 Yes pacing mode4 Pacemaker Pacemaker All patients need to dependent? follow-up with their No Consider post-op check4,5 physician All patients with an implantable cardiac ICD pacing device and scheduled for Place magnet6 for ICD dependent or procedure or therapeutic Surgery or temporary Therapy OFF non-dependent Postoperative check can radiation are to be seen at procedure with occur up to 30 days the Cardiopulmonary electrosurgery 6 after surgery Center1,2 below the waist3,5 Pacemaker Consider magnet for Pacemaker dependent or temporary asynchronous non-dependent pacing mode Central line placement See Page 2

Therapeutic radiation See Page 3

MRI See Page 4

Patients with Do Not Resuscitate (DNR) status See Page 5 1 Device check not needed if completed within the last 3 months and with documented NORMAL battery, impedances, and pacing safety 3 Abdominal implants: If surgery between thorax and pelvis, refer to above the waist; if outside margins. Device to be rechecked when transitioning from one treatment to another (i.e., radiation, surgery). After 4:30 PM, weekends, and thorax and pelvis, refer to below the waist holidays, cardiology service on-call can be contacted for emergency device checks. 4 Follow Cardiac Device (Pacemaker/ICD) clinic recommendations note 2 Recommend all surgical procedures to be scheduled early in the morning 5 Refer to Appendix A for Conditions Under Which Postoperative Interrogation is Not Necessary 6  Pacing dependent or surgery above the waist: Recommend scheduling surgery in main operating room Refer to Appendix B for Magnet Application  Pacing non-dependent and surgery below the waist: Recommend scheduling surgery in either main or ACB operating room Department of Clinical Effectiveness V5 rev Approved by the Executive Committee of the Medical Staff on 06/25/2019 Implanted Cardiac Pacemaker and Defibrillator Management Page 2 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women.

CENTRAL LINE/PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) PLACEMENT

PICC Proceed with procedure as clinically indicated1

Patient presents for CVC/PICC placement or exchange1 Note: Avoid placement of CVC/PICC Arrangements33 must be completed by direct communication between on the same side of cardiac device ICD Infusion Therapy Team and Cardiac Device (Pacemaker/ICD) clinic for intra-procedure monitoring

CVC

Yes

Pacemaker Pacemaker dependent?

No Proceed with procedure as clinically indicated

CVC = central venous catheter PICC = peripherally inserted central catheter

1 Special circumstance: If ICD or pacemaker was implanted less than 3 months prior, procedure should be performed under fluoroscopy or in the Cardiac Catheterization Lab

Department of Clinical Effectiveness V5 rev Approved by the Executive Committee of the Medical Staff on 06/25/2019 Implanted Cardiac Pacemaker and Defibrillator Management Page 3 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women.

THERAPEUTIC RADIATION

PRIOR TO START OF RADIATION THERAPY

Multidisciplinary conference: clinician to clinician communication) to discuss Refer to Cardiac At completion of Cardiac Yes treatment plans along with Device Management radiation treatment, Patient to be Device High risk other options plan in electronic Pacemaker Start radiation schedule patient scheduled for (Pacemaker/ device health record (EHR) or ICD treatment2 with Cardiology for radiation treatment ICD) clinic exposure? and schedule follow- final pacemaker/ consult1 Treatment plan per Radiation up as clinically No ICD assessment Oncology Team (morning indicated radiation treatment appointment recommended)

1 Radiation dose specification documented in clinic note is recommended prior to Cardiac Device (Pacemaker/ICD) clinic consult 2 Start radiation treatment in accordance with Division of Radiation Oncology Electronic Medical Device Policy

Department of Clinical Effectiveness V5 rev Approved by the Executive Committee of the Medical Staff on 06/25/2019 Implanted Cardiac Pacemaker and Defibrillator Management Page 4 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women.

MRI PRIOR TO DURING MRI1 POST MRI1 SCHEDULING MRI Follow-up less ● Monitors applied: ● MRI protocoled than or equal to ○ Cardiac monitoring ● CIED checked for implanted 3 months or as devices by DI ○ Pulse oximetry ● Reprogram device Cardiology to Yes noted in the 2 ○ Blood pressure back to original collaborate with ● Consent patient , Cardiac Device MRI ● Program device as settings MRI-conditional Diagnostic Imaging if not previously Management approved and obtained indicated device (DI) faculty scheduled? note in the EHR regarding clinical Consult to indication of MRI No Cardiac Device (Pacemaker/

ICD) clinic noting patient Pacing non-dependent to be scheduled Yes for MRI and ● Electrophysiologist has a CIED to notify primary MRI-non- Electrophysiologist team and DI that Pacing to discuss risks and MRI patient cannot conditional No device dependent benefits of study approved? proceed with MRI 3 with patient ● DI to recommend alternative imaging study

● Cardiac Device clinic to notify primary team, DI and ● Abandoned lead electrophysiologist that patient cannot proceed with MRI ● Epicardial lead ● DI to recommend alternative imaging study CIED = cardiovascular implantable electronic device 1 There will be an appropriate, qualified and credentialed clinician to monitor patient during procedure 2 Patient needs two consents: one for MRI study and one for MRI with CIED 3 Ensure appointment is scheduled for discussion Department of Clinical Effectiveness V5 rev Approved by the Executive Committee of the Medical Staff on 06/25/2019 Implanted Cardiac Pacemaker and Defibrillator Management Page 5 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women.

PATIENTS WITH DO NOT RESUSCITATE (DNR) STATUS

● It is recommended to turn OFF shock therapy ● An order must be placed by the physician to turn OFF the shock therapy ICD ○ Contact Cardiac Device (Pacemaker/ICD) clinic during business hours ○ Notify manufacturer representative after 5 PM and weekends2 Advanced care planning1 has been established. Patient is DNR status Continue advanced care plan with an implanted cardiac device.

Pacemaker No need for any intervention

1 The advanced care planning discussion with the patient/family member should clearly include and document whether or not shock therapy will be turned OFF. 2 Manufacturer’s information may be obtained in the following manner: ● Cardiac Device (Pacemaker/ICD) clinic progress note ● Patient/Family member has manufacturer’s card

Department of Clinical Effectiveness V5 rev Approved by the Executive Committee of the Medical Staff on 06/25/2019 Implanted Cardiac Pacemaker and Defibrillator Management Page 6 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women.

APPENDIX A: Conditions Under Which Postoperative Interrogation is Not Necessary

1. Device is checked preoperatively and found to be working correctly, and 2. No programming of device took place perioperatively, and 3. No monopolar electrosurgery used (bipolar is acceptable), and 4. No blood transfused, and 5. No hemodynamic issues noted, and 6. Procedures not involving electrosurgery (e.g., endoscopic ultrasonography)

APPENDIX B: Magnet Applications Pacemaker Magnet Application Defibrillator Magnet Application

Most Common Magnet Effect Pacemaker Most Common Magnet Effect Programmable Programmable (For ranges listed below, the lower rate Defibrillator Manufacturer (NO defibrillator has asynchronous Magnet Confirmation Manufacturer (On-Off) (On-Off) indicates a shorter remaining battery life) pacing with magnet) Biotronik No sustained asynchronous pacing Yes Biotronik Disables tachy therapy None No Boston Scientific/ Defibrillator will beep with Asynchronous pacing at 100 or 90 bpm Yes Boston Scientific/Guidant CPI Disables tachy therapy Yes Guidant CPI each R wave or 1/second Intermedics No sustained asynchronous pacing No Medtronic Disables tachy therapy None No Medtronic Asynchronous pacing at 85 bpm No Sorin Disables tachy therapy Change pacing rate to 90 bpm No Sorin Asynchronous pacing at 85 - 96 bpm No St. Jude Medical/Pacesetter Disables tachy therapy None Yes St. Jude Medical/ Asynchronous pacing at 86 - 100 bpm Yes Pacesetter

Department of Clinical Effectiveness V5 rev Approved by the Executive Committee of the Medical Staff on 06/25/2019 Implanted Cardiac Pacemaker and Defibrillator Management Page 7 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women.