The perioperative management of small animals with previously implanted pacemakers undergoing anaesthesia

  • Alejandra García de Carellán Mateo
    Correspondence: Alejandra García de Carellán Mateo, Teaching Veterinary Hospital, Catholic University of Valencia, Av. Pérez Galdós 51, Valencia 46018, Spain.
    Anaesthesia and Analgesia Service, Teaching Veterinary Hospital, Department of Animal Medicine and Surgery, School of Veterinary Science, Catholic University of Valencia, Valencia, Spain
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  • Domingo Casamián-Sorrosal
    Cardiology and Interventional Cardiology Service, Teaching Veterinary Hospital, Department of Animal Medicine and Surgery, School of Veterinary Science, Catholic University of Valencia, Valencia, Spain
    Search for articles by this author
Published:November 21, 2021DOI:



      There is little information in the veterinary literature about the perioperative management of small animal patients with previously implanted pacemakers undergoing elective or emergency non-cardiac procedures. The purpose of this article is to review the current literature with regard to human patients, with previously implanted pacemakers, undergoing general anaesthesia. Using this and the current information on pacemakers and anaesthesia in dogs and cats, we provide recommendations for small animal patients in this situation.

      Databases used

      Google Scholar, PubMed and CAB Abstracts using and interlinking and narrowing the search terms: “dog”, “cat”, “small animals”, “anaesthesia”, “pacemaker”, “perioperative”, “transvenous pacing”, “temporary pacing”. Scientific reports and human and small animal studies from the reference lists of the retrieved papers were reviewed. In addition, related human and veterinary cardiology and anaesthesia textbooks were also included to create a narrative review of the subject.


      The best perioperative care for these animals comes from a multidisciplinary approach involving the anaesthetist, cardiologist, surgeon and intensive care unit team. When such an approach is not feasible, the anaesthetist should be familiar with pacemaker technology and how to avoid perioperative complications such as electromagnetic interference, lead damage and reprogramming of the device. The preanaesthetic assessment should be thorough. Information regarding the indication for pacemaker placement, complications during the procedure, location, type and programming of the pacemaker should be readily available. The anaesthetic management of these veterinary patients aims to preserve cardiovascular function while avoiding hypotension, and backup pacing should be available during the perioperative period. Further prospective studies are needed to describe the best perioperative care in small animals with a previously implanted pacemaker.


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        • American Society of Anesthesiologists
        Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter–defibrillators 2020: An updated report by the American Society of Anesthesiologists Task Force on perioperative management of patients with cardiac implantable electronic devices.
        Anesthesiology. 2020; 132: 225-252
        • Araos J.
        • Kenny J.E.
        • Rousseau-Blass F.
        • Pang D.S.
        Dynamic prediction of fluid responsiveness during positive pressure ventilation: A review of the physiology underlying heart-lung interactions and a critical interpretation.
        Vet Anaesth Analg. 2020; 47: 3-14
        • Baller M.R.
        • Kirsner K.M.
        Anesthetic implications of implanted pacemakers: A case study.
        J Am Assoc Nurse Anesth. 1995; 63: 209-216
        • Balmer C.
        • Gass M.
        • Dave H.
        • et al.
        Magnetic resonance imaging of patients with epicardial leads: in vitro evaluation of temperature changes at the lead tip.
        Interv Card Electrophysiol. 2019; 56: 321-326
        • Bergström A.
        • Dimopolou M.
        • Eldh M.
        Reduction of surgical complications in dogs and cats by the use of surgical safety checklist.
        Vet Surg. 2016; 45: 571-576
        • Bernstein A.D.
        • Daubert J.C.
        • Fletcher R.D.
        • et al.
        The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group.
        Pacing Clin Electrophysiol. 2002; 25: 260-264
        • Bloria S.D.
        • Soni S.L.
        • Kataria K.
        • Bloria P.
        Anesthetic management of a patient with pacemaker undergoing clipping of intracranial aneurysm.
        J Neuroanaesth Crit Care. 2021; 8: 56-58
        • Bulmer B.J.
        VDD pacing in dogs: When, why and how to perform single-lead atrial synchronous, ventricular inhibited (VDD) pacing.
        J Vet Cardiol. 2006; 8: 25-39
        • Bulmer B.J.
        Cardiac pacemakers and anesthesia.
        in: Tranquilli W.J. Thurmon J.C. Grimm K.A. Lumb and Jones Veterinary Anesthesia and Analgesia. 5th edn. 2015: 490-495 (USA)
        • Bulmer B.J.
        • Sisson D.D.
        • Oyama M.A.
        • et al.
        Physiologic VDD versus nonphysiologic VVI pacing in canine 3rd-degree atrioventricular block.
        J Vet Intern Med. 2006; 20: 257-271
        • Castro-González L.
        • Mejía-Terrazas G.E.
        • Garduño-Juárez M.Á.
        • et al.
        Effect of peripheral nerve stimulation on cardiac pacemaker function.
        Rev Mex Anest. 2018; 41: 268-272
        • Chakravarthy M.
        • Prabhakumar D.
        • George A.
        Anaesthetic consideration in patients with cardiac implantable electronic devices scheduled for surgery.
        Indian J Anaesth. 2017; 61: 736-743
        • Costa A.
        • Richman D.C.
        Implantable devices: Assessment and perioperative management.
        Anesth Clin. 2016; 34: 185-199
        • Côté E.
        • Laste N.J.
        Transvenous cardiac pacing.
        Clin Tech Small Anim Pract. 2000; 15: 165-176
        • Cronin B.
        • Essandoh M.K.
        An update on cardiovascular implantable electronic devices for anesthesiologists.
        J Cardiothorac Vasc Anesth. 2018; 32: 1871-1884
        • DeForge W.F.
        Cardiac pacemakers: a basic review of the history and current technology.
        J Vet Cardiol. 2019; 22: 40-50
        • DeFrancesco T.C.
        • Hansen B.D.
        • Atkins C.E.
        • et al.
        Noninvasive transthoracic temporary cardiac pacing in dogs.
        J Vet Intern Med. 2003; 17: 663-667
        • De Monte V.
        • Staffieri F.
        • Birettoni F.
        • Bufalari A.
        Ketamine as a part of anaesthetic management in a dog with twiddler's syndrome.
        J Small Anim Pract. 2014; 55: 116-120
        • Engelhardt L.
        • Grosse J.
        • Birnbaum J.
        • Volk T.
        Inhibition of a pacemaker during nerve stimulation for regional anaesthesia.
        Anaesthesia. 2007; 62: 1071-1074
        • Erdogan O.
        Electromagnetic interference on pacemakers.
        Indian Pacing Electrophysiol J. 2002; 2: 74-78
        • Estrada A.H.
        • Maisenbacher III, H.W.
        • Jones A.E.
        • et al.
        Transvenous pacing implantation: techniques, tips, and lessons learned along the way.
        J Vet Cardiol. 2019; 22: 51-64
        • Falco M.D.
        • Genovesi D.
        • Caravatta L.
        • et al.
        A randomized in vitro evaluation of transient and permanent cardiac implantable electronic device malfunctions following direct exposure up to 10 Gy.
        Strahlenther Onkol. 2021; 197: 198-208
        • Feldman J.B.
        • Stone M.E.
        Anesthesia teams managing pacemakers and ICDs for the perioperative period: enhanced patient safety and improved workflows.
        Curr Opin Anaesthesiol. 2020; 33: 441-447
        • Genovese D.W.
        • Estrada A.H.
        • Maisenbacher H.W.
        • et al.
        Procedure times, complication rates, and survival times associated with single-chamber versus dual-chamber pacemaker implantation in dogs with clinical signs of bradyarrhythmia: 54 cases (2004–2009).
        J Am Vet Med Assoc. 2013; 242: 230-236
        • Grubb T.
        • Sager J.
        • Gaynor J.S.
        • et al.
        2020 AAHA Anesthesia and monitoring guidelines for dogs and cats.
        J Am Anim Hosp Assoc. 2020; 56: 59-82
        • Hellyer P.W.
        • Mama K.R.
        • Shafford H.L.
        • et al.
        Effects of diazepam and flumazenil on minimum alveolar concentrations for dogs anesthetized with isoflurane or a combination of isoflurane and fentanyl.
        Am J Vet Res. 2001; 62: 555-560
        • Hildebrandt N.
        • Stertmann W.A.
        • Wehner M.
        • et al.
        Dual chamber pacemaker implantation in dogs with atrioventricular block.
        J Vet Intern Med. 2009; 23: 31-38
        • Hofmeister E.H.
        • Quandt J.
        • Braun C.
        • Shepard M.
        Development, implementation and impact of simple patient safety interventions in a university teaching hospital.
        Vet Anaesth Analg. 2014; 41: 243-248
        • Ilkiw J.E.
        • Pascoe P.J.
        • Haskins S.C.
        • et al.
        The cardiovascular sparing effect of fentanyl and atropine, administered to enflurane anesthetized dogs.
        Can J Vet Res. 1994; 58: 248-253
        • Irwin M.G.
        • Chung C.K.
        • Ip K.Y.
        • Wiles M.D.
        Influence of propofol-based total intravenous anaesthesia on peri-operative outcome measures: a narrative review.
        Anaesthesia. 2020; 75: e90-e100
        • Jacob S.
        • Panaich S.S.
        • Maheshwari R.
        • et al.
        Clinical applications of magnets on cardiac rhythm management devices.
        Europace. 2011; 13: 1222-1230
        • Johnson M.S.
        • Martin M.W.
        • Henley W.
        Results of pacemaker implantation in 104 dogs.
        J Small Anim Pract. 2007; 48: 4-11
        • Kay G.N.
        • Shepard R.B.
        Stimulation and Excitation of Cardiac Tissues.
        in: Ellenbogen K.A. Wilkoff B.L. Kay G.N. Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy. 5th edn. Elsevier, Philadelphia2016: 61-113 (USA)
        • Kaya E.
        • Südkamp H.
        • Lortz J.
        • et al.
        Feasibility and safety of using local anaesthesia with conscious sedation during complex cardiac implantable electronic device procedures.
        Sci Rep. 2018; 8: 7103
        • Lennerz C.
        • Pavaci H.
        • Grebmer C.
        • et al.
        Electromagnetic interference in cardiac implantable electronic devices: is the use of smartphones safe?.
        J Am Coll Cardiol. 2017; 69: 108-110
        • Lüker J.
        • Sultan A.
        • Plenge T.
        • et al.
        Effects of propofol sedation on pacing thresholds: Results from an observational cohort study.
        Herzschrittmacherther Elektrophysiol. 2018; 29: 127-132
        • Marchant W.
        Pacemakers and defibrillators: anaesthetic implications.
        Br J Anaesth. 2004; 93: 875
        • Menoud G.
        • Axiak Flammer S.
        • Spadavecchia C.
        • Raillard M.
        Development and implementation of a perianesthetic safety checklist in a veterinary university small animal teaching hospital.
        Front Vet Sci. 2018; 5: 60
        • Moïse N.S.
        • Estrada A.
        Noise reversion in paced dogs.
        J Vet Cardiol. 2002; 4: 13-21
        • Morgaz-Rodríguez J.
        • Muñoz-Rascón P.
        • Navarrete-Calvo R.
        • et al.
        Comparison of the cardiopulmonary parameters after induction of anaesthesia with alphaxalone or etomidate in dogs.
        Vet Anaesth Analg. 2012; 39: 357-365
        • Nadeem F.
        • Nunez Garcia A.
        • Thach Tran C.
        • et al.
        Magnetic interference on cardiac implantable electronic devices from Apple iPhone MagSafe Technology.
        J Am Heart Assoc. 2021; 2e020818
        • Niu Y.
        • Chen Y.
        • Li W.
        • et al.
        Electromagnetic interference effect of dental equipment on cardiac implantable electrical devices: A systematic review.
        Pacing Clin Electrophysiol. 2020; 43: 1588-1598
        • Noomanová N.
        • Perego M.
        • Perini A.
        • Santilli R.A.
        Use of transcutaneous external pacing during transvenous pacemaker implantation in dogs.
        Vet Rec. 2010; 167: 241-244
        • Orton E.C.
        Epicardial pacemaker implantation in small animals.
        J Vet Cardiol. 2019; 22: 65-71
        • Oyama M.A.
        • Sisson D.D.
        • Lehmkuhl L.B.
        Practices and outcome of artificial cardiac pacing in 154 dogs.
        J Vet Intern Med. 2001; 15: 229-239
        • Prutkin J.M.
        • Poole J.E.
        Perioperative and periprocedural management, electromagnetic interference, and cardiac implantable electronic devices.
        in: Ellenbogen K.A. Wilkoff B.L. Kay G.N. Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy. 5th edn. Elsevier, USA2016: 1158-1175
        • Rapsang A.G.
        • Bhattacharyya P.
        Pacemakers and implantable cardioverter defibrillators - general and anesthetic considerations.
        Rev Bras Anestesiol. 2014; 64: 205-214
        • Rastogi S.
        • Goel S.
        • Tempe D.K.
        • Virmani S.
        Anaesthetic management of patients with cardiac pacemakers and defibrillators for non-cardiac surgery.
        Ann Card Anaesth. 2005; 8: 21-32
        • Rooke G.A.
        • Bowdle T.A.
        Perioperative management of pacemakers and implantable cardioverter defibrillators: it’s not just about the magnet.
        Anesth Analg. 2013; 117: 292-294
        • Rooke G.A.
        • Lombaard S.A.
        • Van Norman G.A.
        • et al.
        Initial experience of an anesthesiology-based service for perioperative management of pacemakers and implantable cardioverter defibrillators.
        Anesthesiology. 2015; 123: 1024-1032
        • Salukhe T.V.
        • Dob D.
        • Sutton R.
        Pacemakers and defibrillators: anaesthetic implications.
        Br J Anaesth. 2004; 93: 95-104
        • Samuels J.M.
        • Overbey D.M.
        • Wikiel K.J.
        • et al.
        Electromagnetic interference on cardiac pacemakers and implantable cardioverter defibrillators during endoscopy as reported to the US Federal Drug Administration.
        Surg Endosc. 2021; 35: 3796-3801
        • Sanchis-Mora S.
        • Viscasillas J.
        • Mathis A.
        • et al.
        Anaesthetic management and complications of pacemaker implantation in dogs.
        Vet Rec. 2014; 175: 303
        • Sanders R.A.
        • Green III, H.W.
        • Hogan D.F.
        • et al.
        Efficacy of transesophageal and transgastric cardiac pacing in the dog.
        J Vet Cardiol. 2010; 12: 49-52
        • Sanders R.A.
        • Green III, H.W.
        • Hogan D.F.
        • Sederquist K.
        Use of transesophageal atrial pacing to provide temporary chronotropic support in a dog undergoing permanent pacemaker implantation.
        J Vet Cardiol. 2011; 13: 227-230
        • Santilli R.A.
        • Giacomazzi F.
        • Vázquez D.M.
        • Perego P.
        Indications for permanent pacing in dogs and cats.
        J Vet Cardiol. 2019; 22: 20-39
        • Scansen B.A.
        Interventional cardiology for the criticalist.
        J Vet Emerg Crit Care (San Antonio). 2011; 21: 123-136
        • Schmidt M.
        • Estrada A.
        • Vangilder J.
        • et al.
        Safety and feasibility of transesophageal pacing in a dog.
        J Am Anim Hosp Assoc. 2008; 44: 19-24
        • Shah A.N.
        • Koneru J.
        • Nicoara A.
        • et al.
        Dexmedetomidine related cardiac arrest in a patient with permanent pacemaker; a cautionary tale.
        Pace. 2007; 30: 1158-1160
        • Stone M.E.
        • Salter B.
        • Fischer A.
        Perioperative management of patients with cardiac implantable electronic devices.
        Br J Anaesth. 2011; 107: i16-i26
        • Swerdlow C.D.
        • Brown M.L.
        • Bordachar P.
        Sensing and Detection with Cardiac Implantable Electronic Devices.
        in: Ellenbogen K.A. Wilkoff B.L. Kay G.N. Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy. 5th edn. Elsevier, USA2016: 114-1167
        • Van De Wiele C.M.
        • Hogan D.F.
        • Green III, H.W.
        • Parnell N.K.
        Cranial vena caval syndrome secondary to transvenous pacemaker implantation in two dogs.
        J Vet Cardiol. 2008; 10: 155-161
        • van Kuijk J.P.
        • Valentijn T.M.
        • Flu W.J.
        • Poldermans D.
        Detection of coronary artery disease in patients with a permanent pacemaker.
        Cardiology. 2010; 116: 226-228
        • Visser L.C.
        • Keene B.W.
        • Mathews K.G.
        • et al.
        Outcomes and complications associated with epicardial pacemakers in 28 dogs and 5 cats.
        Vet Surg. 2013; 42: 544-550
        • Ward J.L.
        • DeFrancesco T.C.
        • Tou S.P.
        • et al.
        Complication rates associated with transvenous pacemaker implantation in dogs with high-grade atrioventricular block performed during versus after normal business hours.
        J Vet Intern Med. 2015; 29: 157-163
        • Ward J.
        • McLaughlin A.
        • Burzette R.
        • Keene B.
        The effect of a surgical safety checklist on complication rates associated with permanent transvenous pacemaker implantation in dogs.
        J Vet Cardiol. 2019; 22: 72-83
        • Warne L.N.
        • Bauquier S.H.
        • Pengelly J.
        • et al.
        Standards of care: Anaesthesia guidelines for dogs and cats.
        Aust Vet J. 2018; 96: 413-427
        • Wess G.
        • Thomas W.P.
        • Berger D.M.
        • Kittleson M.D.
        Applications, complications, and outcomes of transvenous pacemaker implantation in 105 dogs (1997-2002).
        J Vet Intern Med. 2006; 20: 877-884
        • Williamson A.J.
        • Soares J.H.
        • Henao-Guerrero N.
        • et al.
        Cardiovascular and respiratory effects of two doses of fentanyl in the presence or absence of bradycardia in isoflurane-anesthetized dogs.
        Vet Anaesth Analg. 2018; 45: 423-431
        • Winter R.L.
        • Congdon J.
        • Boscan P.
        Anesthesia case of the month.
        J Am Vet Med Assoc. 2011; 238: 854-858