Management of patients with cardiac implantable electronic devices in shoulder surgery.

Abstract

Cardiac implantable electronic devices (CIEDs) are becoming increasingly common, and shoulder surgeons encounter patients with these devices with growing frequency. Despite this, practical guidance on managing CIEDs during shoulder surgery remains limited. This narrative review provides a consolidated framework for managing these patients across the perioperative period. We outline essential functions, indications, and structural components of modern devices, including transvenous pacemakers, transvenous implantable cardioverter-defibrillators, subcutaneous implantable cardioverter-defibrillators, and leadless pacemakers. CIED placement techniques and their anatomic relevance to the deltopectoral approach are reviewed. Associated risks, such as lead traction, pocket violation, and electromagnetic interference (EMI), are highlighted. Preoperative management focuses on structured screening: confirming device type and indication, assessing pacing dependency, and coordinating with electrophysiology. Practical guidance clarifies when magnet application is sufficient and when formal reprogramming is required. Intraoperative management centers on maintaining rhythm stability and protecting the device. Continuous electrocardiogram and pulse monitoring are recommended, with external pacing and defibrillation available. EMI risk is reduced by placing the dispersive (grounding) pad on the ipsilateral side, using bipolar cautery when possible, and limiting monopolar cautery to short, low-energy bursts. Mechanical injury is minimized through careful retractor placement. Postoperative care focuses on confirming that the device has returned to baseline function. By integrating device mechanics, anatomic considerations, and perioperative management principles, this review offers a unified, surgery-specific approach to caring for patients with CIEDs undergoing shoulder procedures. The accompanying algorithm provides a stepwise procedure for assessment and decision-making aimed at reducing cardiac risk.