Anesthesia for Insertion of Implantable Cardioverter Defibdilators

Abstract

The use of implantable cardioverter defibrillators (ICDs) for patients at risk for sudden death from ventricular tachycardia or ventricular fibrillation has steadily in creased since the 1980s. ICDs have undergone a signifi cant evolution over the past 2 decades, initially requir ing thoracotomy for placement of epicardial patches to the modern-day devices that involve only transvenously placed leads. Indications for the placement of ICDs are expanding. This article reviews the perioperative anes thetic management of patients undergoing insertion of ICDs. Preoperative assessment of patients for ICD place ment includes careful assessment of underlying medical disease as well as specific determination of the need for continuation or discontinuation of perioperative antiar rhythmic agents. It is important to consider the poten tial effects of anesthetic choice both on hemodynamic stability in patients with limited cardiac reserve and on the ability to intraoperatively induce, and subsequently treat, ventricular dysrhythmias. The relative merits of inhalational and intravenous general anesthesia, as well as those of local anesthesia and intravenous seda tion, should therefore be considered. The present re view also addresses issues of myocardial stunning from repeated defibrillation, cerebral function in the context of repeated circulatory arrest, appropriate intraopera tive monitoring, and postoperative care of patients undergoing ICD placement.