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A Perioperative Management Algorithm for Cardiac Rhythm Management Devices: The PACED-OP Protocol


  • Disclosures: James W. Cox, Jr., M.D.: Atricure; Jeffrey B. Hirsh, M.D.: Medtronic, St. Jude Medical, Boston Scientific, Sanofi-Aventis; Dale C. Wortham, M.D.: Abbott Vascular, Sanofi-Aventis, Medtronic. Other authors: None.

Address for reprints: William Jeremy Mahlow, M.D., Department of Cardiology, University of Tennessee, UT GSM Box U114, 1924 Alcoa Highway, Knoxville, TN 37920. Fax: 865-978-6347; e-mail:



Limited data are available regarding the perioperative management of cardiac rhythm management devices (CRMDs) exposed to intraoperative electromagnetic interference. We postulated that implementation of a simple, standardized approach to CRMD management using our own institution's Pacing And Cardioverting Electronic Devices peri-Operative Protocol (the PACED-OP protocol) would be associated with a reduction in the amount of device reprogramming without an increase in CRMD-related complications.


Records of patients with CRMDs undergoing 497 consecutive surgical procedures were analyzed retrospectively. Roughly half (51%, n = 254) of these procedures occurred before implementation of the PACED-OP protocol, when patients were generally treated according to the American Society of Anesthesiologists' 2005 guidelines. These cases were compared to the remaining surgeries that occurred after implementation of the PACED-OP protocol. Records were screened for evidence of intraoperative CRMD malfunction that was directly associated with the use of electrocautery. Postoperative complications that could be indirectly or possibly linked to electrocautery-mediated CRMD malfunction were also identified.


Implementation of the PACED-OP protocol was associated with a significant reduction in the odds of device reprogramming (adjusted odds ratio [aOR] 0.19, P < 0.001). There was no direct evidence of CRMD malfunction in either cohort. The rate of postoperative complications that could be indirectly or possibly linked with electrocautery-mediated CRMD damage did not differ significantly between cohorts (aOR = 1.37, 95% confidence interval 0.56–3.3, P = 0.49).


The PACED-OP protocol implementation was associated with a significant reduction in the odds of device reprogramming without a significant difference in the odds of CRMD-related complications.