Outpatient Centers Cautiously Open Doors to Surgery for People With Cardiac Devices

NEW ORLEANS -- As more medically complex patients are caught in the migration of surgeries to ambulatory surgery centers (ASCs), these freestanding facilities face rising pressure to take people with cardiac implantable electronic devices (CIEDs). It remains controversial the question of whether more ASCs should adapt to accommodate this feared patient group.

Skeptics cite safety concerns of outpatient surgery -- even relatively simple hip, gastrointestinal procedures -- for CIED patients. With the elevated risk of major adverse cardiovascular events and challenging perioperative care for these patients at risk of sudden cardiac death, it may be too challenging a scenario for an ASC with limited resources.

In contemporary practice, however, these fears are unfounded, according to ambulatory anesthesia specialist Girish Joshi, MD, of UT Southwestern Medical Center and Parkland Health and Hospital Systems in Dallas.

He said it's no longer acceptable for ASCs to flat-out reject all patients with pacemakers and other CIEDs. "Obviously there has to be a common sense approach," he said during a debate at the American Society of Anesthesiologists (ASA) annual meeting.

Joshi's debate opponent at ASA, Victor Davila, MD, an anesthesia and critical care physician at Ohio State University in Columbus, said he agreed there should be no blanket rule that a CIED patient can or cannot undergo an operation at an ASC.

Nevertheless, Davila emphasized that ASCs considering taking these patients should not fall into the trap of thinking it's always safe.

Joshi said that ASCs can be safe for people with CIEDs with the right patient selection by gate-keeping anesthesiologists. He stressed consideration of the indication for the CIED, which may include sinus node dysfunction, atrioventricular block after an acute myocardial infarction, and advanced heart failure.

Those decidedly not suitable for surgery at the ASC include people with recent CIED implantation and heart failure patients with left ventricular ejection fractions 35% or under on cardiac resynchronization therapy, Joshi acknowledged.

For CIED patients who may be suitable, he reassured that intraoperative complications won't occur with the right preparation: the ASC anesthesiologist should get details about the patient, procedure, and device prior to the day of the surgery, and take steps to reduce electromagnetic interference during the procedure.

Even if it is determined that ICD reprogramming is required beforehand, this can be done remotely for some newer devices by an expert outside the ASC, he said.

It still doesn't beat the ease of reprogramming in the hospital, Davila argued. "If you're inpatient, the cardiologists are there, the device guys are walking around. But if you're an ASC, there's no interest in anybody keeping you happy," he complained. "Right now I call the cardiologist, he says 'Don't worry about it.' I call the device guy, he says 'Don't worry about it, just go.'"

For those at ASCs, if "cardiologists are washing their hands of you" because newer, better-designed CIEDs are making it safer for patients to undergo surgery, one way to interpret this is that you are on your own if you take these patients, Davila said.

That means anesthesiologists will have to get familiar with the particulars of each device, learning, for instance, how each behaves with magnets. Facilities should have temporary pacing and defibrillation equipment on hand and regularly checked; and staff should be trained in emergency use of this equipment.

"It is reasonable and possible to care for CIED patients in a freestanding ASC," Davila said."Caring for these patients safely likely requires a significant infrastructure, a large amount of collaboration with the surgeon, or both, and these collaborations are not typically available," he warned.

"While this infrastructure may make sense in some contexts, many ASCs will likely find it is more trouble than it is worth," he said. "Not all freestanding ASCs are equal. Not everybody has the same resources available to them. Many are already on budget constraints."

ASA session moderator Niraja Rajan, MD, medical director of Hershey Outpatient Surgery Center in Pennsylvania, commented that she is seeing a lot of patients with low ejection fraction and implantable cardioverter-defibrillators for ambulatory surgery at her center. A lot of these surgeries are urology procedures, she noted, and some cannot be done at the main hospital. There have been "no problems" so far, she said.

Ultimately, Davila said that people with CIEDs should not be excluded from the benefits of ambulatory surgery, which include greater patient satisfaction and better value compared with hospitals. By avoiding the hospital environment, patients may experience less infection, fasting, sleep disturbance, and other problems associated with being inpatient.

Therefore, ready or not, outpatient centers can expect more medically complex patients to be knocking on their doors.

"In the next 5 to 10 years, I would expect [CIED patients] to be coming very regularly to your ASC," Davila said.