Marc A. Rozner

Practice guidelines for perioperative transesophageal echocardiography

P RACTICE Guidelines are systematically developed recommendations that assist the practitioner and the patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. This update includes data published since the Practice Guidelines for Perioperative Transesophageal Echocardiography were adopted by the ASA and the Society of Cardiovascular Anesthesiologists in 1995 and published in 1996. Methodology

Practice advisory for the perioperative management of patients with cardiac rhythm management devices: Pacemakers and implantable cardioverter- defibrillators - A report by the American Society of Anesthesiologists Task Force on perioperative management of patients with cardiac rhythm management devices

PRACTICE advisories are systematically developed reports that are intended to assist decision making in areas of patient care. Advisories provide a synthesis and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Advisories are not intended as standards, guidelines, or absolute requirements. They may be adopted, modified, or rejected according to clinical needs and constraints. The use of practice advisories cannot guarantee any specific outcome. Practice advisories summarize the state of the literature and report opinions derived from a synthesis of task force members, expert consultants, open forums, and public commentary. Practice advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. Methodology

Percutaneous radiofrequency ablation of renal tumors: technique, complications, and outcomes.

PURPOSE To report the safety, technical success, and effectiveness of percutaneous radiofrequency (RF) ablation for renal tumors. MATERIALS AND METHODS The authors retrospectively reviewed the medical records and imaging studies of 29 consecutive patients (18 men, 11 women; mean age, 65 ± 2.62 years) with 30 renal tumors (mean diameter, 3.5 ± 0.24 cm) who underwent percutaneous RF ablation at their institution from September 2001 to March 2004. All procedures were performed with computed tomography guidance with general anesthesia, and all patients were admitted to the hospital for overnight observation. Technical success, complications, and their management were recorded. Technique effectiveness was assessed by imaging and clinical follow up. RESULTS Overall, 88 overlapping ablations were performed (mean, 2.6 ± 0.16 ablations per tumor per session) in 34 sessions. There were four major complications (12%). Three patients had gross hematuria and urinary obstruction, all were successfully treated. One patient had persistent anterior abdominal wall weakness. There were also two minor complications (6%) without significant clinical sequelae. One patient had gross hematuria which resolved spontaneously, another patient had transient paresthesia of the anterior abdominal wall. There were no significant changes in renal function after RF ablation. The intent of RF ablation was eradication of the primary tumor in 27 patients and treatment of gross hematuria in the other two. Technical success was achieved in all cases. Follow-up images were available for 26 patients. The primary tumor was completely ablated in 23 of 24 patients (96%) in whom eradication of the primary tumor was attempted (follow up period: mean, 10 months, median 7 months). The two patients treated for hematuria remained asymptomatic for 6 and 27 months each. CONCLUSION Percutaneous RF ablation for renal tumors is safe and well tolerated. High technical success rates are expected. Early reports of the techniques effectiveness are promising.

Transport properties of pancreatic cancer describe gemcitabine delivery and response

BACKGROUND The therapeutic resistance of pancreatic ductal adenocarcinoma (PDAC) is partly ascribed to ineffective delivery of chemotherapy to cancer cells. We hypothesized that physical properties at vascular, extracellular, and cellular scales influence delivery of and response to gemcitabine-based therapy. METHODS We developed a method to measure mass transport properties during routine contrast-enhanced CT scans of individual human PDAC tumors. Additionally, we evaluated gemcitabine infusion during PDAC resection in 12 patients, measuring gemcitabine incorporation into tumor DNA and correlating its uptake with human equilibrative nucleoside transporter (hENT1) levels, stromal reaction, and CT-derived mass transport properties. We also studied associations between CT-derived transport properties and clinical outcomes in patients who received preoperative gemcitabine-based chemoradiotherapy for resectable PDAC. RESULTS Transport modeling of 176 CT scans illustrated striking differences in transport properties between normal pancreas and tumor, with a wide array of enhancement profiles. Reflecting the interpatient differences in contrast enhancement, resected tumors exhibited dramatic differences in gemcitabine DNA incorporation, despite similar intravascular pharmacokinetics. Gemcitabine incorporation into tumor DNA was inversely related to CT-derived transport parameters and PDAC stromal score, after accounting for hENT1 levels. Moreover, stromal score directly correlated with CT-derived parameters. Among 110 patients who received preoperative gemcitabine-based chemoradiotherapy, CT-derived parameters correlated with pathological response and survival. CONCLUSION Gemcitabine incorporation into tumor DNA is highly variable and correlates with multiscale transport properties that can be derived from routine CT scans. Furthermore, pretherapy CT-derived properties correlate with clinically relevant endpoints. TRIAL REGISTRATION Clinicaltrials.gov NCT01276613. FUNDING Lustgarten Foundation (989161), Department of Defense (W81XWH-09-1-0212), NIH (U54CA151668, KCA088084).

2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction

Fred M. Kusumoto, MD, FHRS, FACC, Chair, Mark H. Schoenfeld, MD, FHRS, FACC, FAHA, CCDS, Vice-Chair, Bruce L. Wilkoff, MD, FHRS, CCDS, Vice-Chair, Charles I. Berul, MD, FHRS, Ulrika M. Birgersdotter-Green, MD, FHRS, Roger Carrillo, MD, MBA, FHRS, Yong-Mei Cha, MD, Jude Clancy, MD, Jean-Claude Deharo, MD, FESC, Kenneth A. Ellenbogen, MD, FHRS, Derek Exner, MD, MPH, FHRS, Ayman A. Hussein, MD, FACC, Charles Kennergren, MD, PhD, FETCS, FHRS, Andrew Krahn, MD, FRCPC, FHRS, Richard Lee, MD, MBA, Charles J. Love, MD, CCDS, FHRS, FACC, FAHA, Ruth A. Madden, MPH, RN, Hector Alfredo Mazzetti, MD, JoEllyn Carol Moore, MD, FACC, Jeffrey Parsonnet, MD, Kristen K. Patton, MD, Marc A. Rozner, PhD, MD, CCDS, Kimberly A. Selzman, MD, MPH, FHRS, FACC, Morio Shoda, MD, PhD, Komandoor Srivathsan, MD, Neil F. Strathmore, MBBS, FHRS, Charles D. Swerdlow, MD, FHRS, Christine Tompkins, MD, Oussama Wazni, MD, MBA

2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices

Julia H. Indik, MD, PhD, FHRS, FACC, FAHA (Chair), J. Rod Gimbel, MD (Vice-Chair), Haruhiko Abe, MD,* Ricardo Alkmim-Teixeira, MD, PhD, Ulrika Birgersdotter-Green, MD, FHRS, Geoffrey D. Clarke, PhD, FACR, FAAPM,6,x Timm-Michael L. Dickfeld, MD, PhD, Jerry W. Froelich, MD, FACR,8,{ Jonathan Grant, MD, David L. Hayes, MD, FHRS, Hein Heidbuchel, MD, PhD, FESC,** Salim F. Idriss, MD, PhD, FHRS, FACC, Emanuel Kanal, MD, FACR, FISMRM, MRMD, Rachel Lampert, MD, FHRS, Christian E. Machado, MD, FHRS, CCDS, John M. Mandrola, MD, Saman Nazarian, MD, PhD, FHRS, Kristen K. Patton, MD, Marc A. Rozner, PhD, MD, CCDS, Robert J. Russo, MD, PhD, FACC, Win-Kuang Shen, MD, FHRS,21,xx Jerold S. Shinbane, MD, FHRS, Wee Siong Teo, MBBS (NUS), FRCP (Edin), FHRS,23,{{ William Uribe, MD, FHRS, Atul Verma, MD, FRCPC, FHRS, Bruce L. Wilkoff, MD, FHRS, CCDS, Pamela K. Woodard, MD, FACR, FAHA***

Patients with Pacemaker or Implantable Cardioverter- Defibrillator

The preparation of patients with a cardiac implantable electronic device (CIED) for the perioperative period necessitates familiarity with recommendations from the American Society of Anesthesiologists and Heart Rhythm Society. Even clinicians who are not CIED experts should understand the indications for implantation, as well as the basic functions, operations, and limitations of these devices. Before any scheduled procedure, proper CIED function should be verified and a specific CIED prescription obtained. Acquiring the requisite knowledge base and developing the systems to competently manage the CIED patient ensures safe and efficient perioperative care.

Radiotherapy-Induced Malfunction in Contemporary Cardiovascular Implantable Electronic Devices: Clinical Incidence and Predictors.

IMPORTANCE Risk stratification and management paradigms for patients with cardiovascular implantable electronic devices (CIEDs) requiring radiotherapy (RT) vary widely and are based on limited clinical data. OBJECTIVE To identify the incidence and predictors of CIED malfunction and describe associated clinical consequences in a large cohort of patients treated with photon- and electron-based RT. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of all patients with a functioning CIED who underwent RT between August 2005 and January 2014 with CIED interrogation data following RT at an academic cancer center. We identified 249 courses of photon- and electron-based RT in 215 patients (123 pacemakers [57%]; 92 implantable cardioverter-defibrillators [43%]). Substantial neutron production was generated in 71 courses (29%). EXPOSURE Implantation of CIED with subsequent therapeutic radiation treatment (neutron producing with 15- or 18-MV photons and non-neutron producing with electrons, GammaKnife, or 6-MV photons). MAIN OUTCOMES AND MEASURES Malfunction of CIED, characterized as single-event upset (data loss, parameter resets, unrecoverable resets), and delayed effects including signal interference, pacing threshold changes, and premature battery depletion. RESULTS Malfunction of CIED attributable to RT occurred during 18 courses (7%), with 15 CIEDs experiencing single-event upsets, and 3, transient signal interference. All single-event upsets occurred during neutron-producing RT, at a rate of 21%, 10%, and 34% per neutron-producing course for CIEDs, pacemakers, and implantable cardioverter-defibrillators, respectively. No single-event upsets were found among 178 courses of non-neutron-producing RT. Incident CIED dose did not correlate with device malfunction. Patients treated to the abdomen and pelvis region were more likely to undergo a single-event upset (hazard ratio, 5.2 [95% CI, 1.2-22.6]; P = .03). Six patients with a CIED parameter reset developed clinical symptoms: 3 experienced hypotension and/or bradycardia, 2 experienced abnormal chest ticking consistent with pacemaker syndrome, and 1 developed congestive heart failure. The 3 episodes of signal interference did not result in clinical effects. No delayed malfunctions were directly attributed to RT. CONCLUSIONS AND RELEVANCE In a cohort of contemporary CIEDs, all cases of single-event upset malfunction occurred in the setting of notable neutron production, at a rate of 21% for neutron-producing RT and 0% for non-neutron-producing RT. Where clinically feasible, the use of non-neutron-producing RT is recommended. Given the lack of correlation between CIED malfunction and incident dose observed up to 5.4 Gy, invasive CIED relocation procedures in these settings can be minimized.

Use caution when applying magnets to pacemakers or defibrillators for surgery

The application of a magnet to a pacemaker (intended to cause asynchronous pacing) or implanted cardioverter defibrillator (intended to prevent shocks) during surgery without a clear understanding of actual magnet function(s) or precautions can have unexpected, untoward, or harmful consequences. In this report, we present 3 cases in which inadequate assessment of cardiac implanted electronic device (CIED) function, coupled with magnet application, contributed to or resulted in inappropriate antitachycardia pacing or shocks, CIED damage, or patient injury. Although these cases might be rare, they reinforce the need for a timely, detailed preoperative review of CIED function and programming as recommended by the American Society of Anesthesiologists and the Heart Rhythm Society.

Pacemaker misinformation in the perioperative period: programming around the problem.

I n this issue of Anesthesia & Analgesia, Sun et al. (1) describe the correct process for noncardiac radiofrequency ablation in a patient with an implanted cardiac pacemaker. As the authors note, such patients should undergo a comprehensive evaluation of their pacemaker before the procedure. Consideration should be given to appropriate reprogramming of the pacemaker (when indicated). Finally, the pacemaker should be reevaluated after the procedure to ensure that no new issues have arisen either because of electromagnetic interference (EMI) during the procedure or because of changes in the patient’s physiology resulting from the procedure. Such preand postoperative pacemaker evaluations are in keeping with perioperative recommendations from the American College of Cardiologists (ACC) (2) and the Heart Rhythm Society (formerly called the North American Society of Pacing and Electrophysiology) (3). This article is significant—and disturbing—for another reason. For radiofrequency ablation, pacemaker reprogramming to asynchronous mode is often recommended to prevent pacemaker oversensing and inhibition due to EMI. In this case, however, no reprogramming took place because the consulting cardiologist erroneously reported that asynchronous mode was not available in this particular pacemaker. Although this pacemaker was uncommon and the manufacturer (Intermedics, formerly of Angleton, TX) was subsequently purchased by Guidant Corporation (St. Paul, MN), information about the device was readily available. Obtaining a physician’s manual required only a call to Guidant technical support, and a review of this document shows that this pacemaker does, in fact, include asynchronous pacing in single-chamber mode. So why were our colleagues misinformed? Cardiac pacemaking is complicated. Approximately 26 companies have produced nearly 2000 models of pacemaker generators. Many of these manufacturers no longer exist—assets have been sold or traded—but patients still rely on generators from these companies (as in this case). Furthermore, the likelihood of receiving incorrect information about implanted devices will increase as more complicated devices are developed, as indications for pacemaker (and defibrillator) implantation expand, and as more patients undergo device implantation. Granting of pacemaker privileges by a hospital relies, in general, only on the number of devices implanted; rarely does a hospital require documentation of training for follow-up care of pacemakers or implanted cardioverter-defibrillators. Guidelines from the ACC for training in clinical cardiology specify that only 2 months of curriculum (during the 3-yr fellowship) be devoted to “arrhythmia management, permanent pacemaker management, and electrophysiology” (4). Even the policy statement regarding training issues related to “cardiac implantable electronic devices” published by the North American Society of Pacing and Electrophysiology (the Heart Rhythm Society) does not mention the need for knowledge of the large variety of pacing devices from the various manufacturers (5). Interestingly, in their report on medical errors, the Institute of Medicine did not appear to address the possibility of factual errors in consultant recommendations (6). Adding to the complicated nature of this subject, much of the literature regarding perioperative care of patients with implanted cardiac devices is based on old, outdated, and sometimes misinterpreted case reports. For example, a discussion published in 1978 about monopolar electrocautery (7), with possibly incorrect conclusions and recommendations, continues to be cited (8) despite a more recent publication (9) that challenges these old findings and is readily found Accepted for publication July 6, 2004. Address correspondence and reprint requests to Marc Rozner, PhD, MD, Division of Anesthesiology and Critical Care, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Mail Code 42, Houston, TX 77030. Address e-mail to mrozner@mdanderson.org.