Authors: Tarishi Parmar, Favian Su, Joseph A. Abboud, Robert K. Altman, Eric Black
Categories: Current Concept, Cardiac implantable electronic devices, Shoulder surgery, Perioperative management, Electromagnetic interference, Multidisciplinary care
Source: Clinics in Shoulder and Elbow
Authors: Tarishi Parmar, Favian Su, Joseph A. Abboud, Robert K. Altman, Eric Black
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 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.
More than three million people in the United States have cardiac implantable electronic devices (CIEDs), with approximately 300,000 new devices placed annually [1]. These devices have revolutionized the treatment of arrhythmias, coronary artery disease, and heart failure, improving quality of life and decreasing mortality due to sudden cardiac death. The prevalence of these diseases increases as patients age, and it is not uncommon for orthopedic surgeons treating shoulder problems to see elderly patients with pacemakers or implantable cardioverter defibrillators (ICDs). Although case reports have discussed shoulder procedures in patients with CIEDs, including considerations related to perioperative management, the available literature remains limited and fragmented. To date, there has been no comprehensive review synthesizing practical, shoulder surgery-specific guidance for the management of CIEDs, particularly from the perspective of shoulder surgeons [2,3]. In this review, we highlight the different types of contemporary devices a shoulder surgeon may encounter, focus on the relevant anatomy, and discuss the surgical management of patients with CIEDs to minimize perioperative cardiac risk.
A focused literature review was conducted using PubMed, Cochrane Library, and Google Scholar (pages 1–20) for relevant studies published through December 2025. Searches were performed using Boolean combinations of the following “cardiac implantable electronic device,” “CIED,” “pacemaker,” “implantable cardioverter-defibrillator,” “ICD,” “shoulder surgery,” “total shoulder arthroplasty,” “reverse shoulder arthroplasty,” “electrocautery,” and “electromagnetic interference.”
Major society guidelines and consensus statements from cardiology and anesthesiology organizations were specifically reviewed when applicable. Additional studies were identified through manual review of reference lists from selected articles. Peer-reviewed clinical studies, review articles, consensus statements, and relevant perioperative management guidelines addressing patients with CIEDs undergoing shoulder surgery were included. Editorials without clinical relevance and non-English language publications were excluded.
The two most common categories of CIEDs designed to manage cardiac rhythm disturbances are pacemakers and ICDs [4]. Pacemakers are used to treat bradyarrhythmias such as sinus node dysfunction and atrioventricular (AV) block by sensing intrinsic cardiac activity and delivering pacing stimuli when necessary. Some systems also provide cardiac resynchronization therapy to improve ventricular synchrony in patients with heart failure, most commonly those with reduced left ventricular ejection fraction and electrical conduction delays that produce a widened QRS complex, such as left bundle branch block [5,6]. In contrast, ICDs were introduced in the 1980s to address the growing challenge of sudden cardiac death caused by ventricular arrhythmias [7]. These devices treat life-threatening ventricular tachyarrhythmias with either rapid pacing or a high-energy electrical shock resulting in defibrillation. Many, but not all combine these capabilities with the functions of a pacemaker [8].
While many patients need only intermittent back-up pacing from pacemakers, some are dependent on the device. Dependency refers to the extent to which a patient relies on the implanted device to maintain adequate heart rhythm and cardiac output [9]. Dependency exists on a spectrum; while some patients require continuous pacing due to absent intrinsic cardiac activity, others need pacing only intermittently to prevent bradyarrhythmias or stabilize conduction during transient disturbances [9]. Approximately 16% of patients with CIEDs were found to be pacing-dependent several years after device implantation [10]. Continuous pacing is generally required in patients with absent sinus or AV node function, such as those with chronic atrial arrhythmias or complete AV block, whereas intermittent pacing may suffice in those with intact sinus rhythm or paroxysmal arrhythmias, where pacing supports rate control or prevents pauses [11]. Consequently, understanding an individual’s pacing dependency is critical in perioperative planning to determine if reprogramming will be required preoperatively [12].
Most transvenous pacemakers and ICDs consist of a subcutaneous pulse generator, typically implanted in the upper chest, with leads inserted through the cephalic, axillary, or subclavian vein and advanced into the heart [13]. Left-sided implantation is most common, although right-sided placement also occurs [14].
Devices are commonly implanted using either a horizontal infraclavicular incision or an oblique incision parallel to the deltopectoral groove [11]. The two most common approaches to create the pocket are prepectoral and subpectoral placement, with prepectoral accounting for 60% to 88% of cases (Fig. 1) [15,16]. Cephalic or axillary approaches are generally preferred for lead placement as they provide a more protected lead course and reduce the risk of lead compression between the clavicle and first rib [17].
Subcutaneous ICDs are positioned along the lateral chest wall without transvenous leads, while leadless pacemakers are implanted entirely within the heart and lack a chest wall generator. Importantly, the absence of an anterior chest wall scars does not exclude the presence of a CIED [18,19]. Table 1 summarizes and compares the anatomic approach and function of the CIEDs discussed above.
For shoulder surgeons, this anatomy is highly the cephalic vein runs in the deltopectoral groove, draining into the axillary vein, which then becomes the subclavian vein beneath the clavicle [20]. The pacemaker pocket and venous entry point therefore lie directly within the surgical field of the deltopectoral approach used for shoulder arthroplasty, fracture fixation, or open stabilization procedures (Fig. 2) [21,22]. During dissection or retraction in this region, surgeons risk lead traction, insulation damage, or disruption of the CIED pocket.
The absence of apparent anterior shoulder scars in cases of subcutaneous and leadless placement underscores the importance of preoperative review of chest imaging or cardiology records to identify device type and pocket location before performing shoulder procedures in proximity to a potential pacemaker or ICD site [12]. Both pulse generator sites and lead placement in the shoulder region may be highly variable. While some implants with a medial subcutaneous pocket and axillary venous access may be far from any shoulder surgery field, others such as laterally-placed generators and cephalic vein access may be in the field. Importantly, the risk of mechanical lead disruption is influenced not only by anatomic proximity but also by the timing of device implantation.
Lead dislodgement (LD) is predominantly an early complication following CIED implantation, with risk decreasing substantially over time. Qin et al. [23] found 54% of LD events occurred within the first month, 17% between 1 and 3 months, and nearly all (94.9%) within two years of implantation. Complementing these findings, Ghani et al. [24] reported that the majority of dislodgements occurred before hospital discharge, with fewer events between discharge and two months, and rare cases between two months and one year postimplantation. Together, these data emphasize that lead stability improves markedly after the early postimplantation period. Beyond the first year, the risk of displacement becomes exceedingly low. Passive fixation mechanisms, higher body mass index, and female sex have been identified as independent risk factors for LD, but once fibrotic encapsulation occurs (typically by 90 days), the mechanical integrity of the lead-vein interface stabilizes [23,25]. For shoulder surgeons, this implies that in patients with devices implanted for over a year, the risk of clinically significant LD during peri-shoulder procedures could be significantly reduced. However, significant manipulation of the device pulse generator or leads can still cause dislodgement regardless of timing.
The initial step in perioperative CIED management is a structured preprocedural screening, which, according to the 2024 American Heart Association (AHA) Scientific Statement, “Periprocedural management and multidisciplinary care pathways for patients with cardiac implantable electronic devices,” should begin as soon as surgery is planned to ensure both patient safety and continuity of care [12]. This process involves systematic identification of clinical, procedural, and device-specific factors that could affect intraoperative safety or device function. Close coordination with the cardiology clinic or CIED care center responsible for ongoing device management is essential to guide preop planning and programming [12,26].
The first priority for the surgical team is to determine the presence, type, and anatomic location of the implanted device and the indication for implantation, such as sick sinus syndrome, AV block, or prevention of sudden cardiac death [12]. These details can be obtained from the patient’s device card, prior interrogation report, remote monitoring (RM) data, or chest anteroposterior radiograph, which also helps differentiate between pacemakers and defibrillators by visualizing the presence of high-voltage coils and the presence of a capacitor in addition to the battery within the pulse generator [12,27].
In addition, shoulder surgeons must be aware of other potential sources of electromagnetic interference (EMI) such as nerve stimulators, cochlear implants, ventricular assist devices, and programmable shunts, and should screen for extracardiac comorbidities that may influence procedural safety, including renal, hepatic, pulmonary, or neurologic dysfunction [12]. Cardiology or cardiac electrophysiology consultation is recommended in all patients to review device interrogation parameters, including cardiac rhythm, baseline rate, pacing dependency, lead integrity, battery status, sensing thresholds, and prior arrhythmia episodes prior to surgery [26]. For patients enrolled in RM, preoperative clearance may rely on a recent stable remote transmission, provided the device is part of a continuous or alert-based RM system with daily or near-daily automated transmissions and confirmed patient connectivity. In such cases, documentation of a stable interrogation within the preceding 30 days may suffice at the cardiologist’s discretion [28,29].
Understanding the anticipated surgical site and nature of the procedure is vital for EMI risk stratification. Shoulder procedures performed near the generator or leads may require device reprogramming or magnet application depending on device type and indication [12]. For patients with an implantable defibrillator, arrhythmia detection and therapy should be suspended preoperatively to avoid inappropriate shocks due to EMI. This can be achieved through magnet application (as discussed below) or reprogramming [12,26,29]. Importantly, the response to magnet application should be established preoperatively to ensure predictable behavior, as leadless devices may not respond to magnets or require special testing [12].
Evaluation of pacing dependency is another cornerstone of preoperative assessment. Dependency can sometimes be inferred from interrogation data showing a high burden of ventricular pacing, from electrocardiograms demonstrating pacing spikes before each QRS complex, or from a clinical history of symptomatic bradyarrhythmia or AV nodal ablation [12,27]. However, this is not always reliable as some patients, such as those with resynchronization devices, will pace continuously and may not be dependent. Additionally, dependency may fluctuate under anesthesia, sedation, or pharmacologic influences, and even nondependent patients may exhibit insufficient intrinsic rhythm to maintain adequate perfusion during surgery [12]. In pacemaker-dependent patients, asynchronous pacing (AOO, VOO, or DOO) is recommended, achieved either via magnet application or reprogramming depending on institutional workflow and device type [12,26]. Note, as below, that magnet application will not result in asynchronous pacing in patients with ICDs. We recommend against surgery at an outpatient surgical center for patients who are pacing-dependent, as close perioperative cardiac monitoring is required and even transient device dysfunction can be life threatening.
Prior to surgery, a preprocedural workflow review with the CIED team should confirm that device management recommendations remain current and that a clear plan exists for intraoperative monitoring, including the availability of external defibrillation and transcutaneous pacing if ICD therapies are temporarily disabled [12]. Furthermore, during programming changes or magnet application, the patient must be continuously monitored in a controlled environment by a qualified personnel familiar with CIED behavior [12].
In summary, comprehensive preoperative management of CIEDs involves early multidisciplinary planning, meticulous device identification, assessment of pacing dependency, mitigation of EMI risk, and proactive coordination with cardiology for programming adjustments. Thorough preoperative screening following the AHA CIED management pathway provides the safest foundation for intraoperative care and long-term device integrity (Fig. 3) [12].
A key preoperative consideration in patients with CIEDs is determining whether to employ magnet application or formal device reprogramming to mitigate the risk of EMI. EMI, typically from electrocautery, can lead to pacing inhibition, inappropriate tachyarrhythmia detection, or device reset, especially during procedures of the upper extremity where the current path may intersect the generator or leads [12]. Preoperatively the surgeon’s role is to coordinate with the anesthesia and electrophysiology teams to identify patients in whom pacing dependency, surgical site, and electrosurgical planning necessitate temporary modifications of device behavior [12,29]. While formal electrophysiology consultation may not be necessary for every patient, a risk-stratified approach is recommended.
Magnet application provides a rapid, reversible means of modifying device response without the need for a programmer. In most pacemakers, applying a magnet over the pulse generator induces asynchronous pacing (AOO/VOO/DOO) at a manufacturer-specific fixed rate, which persists only while the magnet remains in place [12,27]. In these modes the device will continuously pace regardless of any sensed electrical activity. Therefore, even if EMI is detected, the patient’s rhythm will be maintained. Removal of the magnet immediately restores baseline programming. This is useful when pacing inhibition from EMI is possible and continuous magnet placement can be maintained throughout procedures. However, asynchronous pacing can be proarrhythmic in patients with an underlying intrinsic rhythm and is therefore reserved for pacing-dependent patients or cases where diathermy is anticipated near the pulse generator [26]. Importantly, leadless pacemakers have variable responses to magnets and magnet placement alone is generally not a reliable practice during surgery. Pacemaker-dependent patients with leadless devices will generally require reprogramming [12]. Such differences should be verified in advance to avoid intraoperative complications.
In ICDs, magnet application suspends tachyarrhythmia detection and therapy delivery but does not affect pacing functions [12,29]. This prevents inappropriate shocks during electrocautery use while maintaining bradycardia support. However, because pacing function in ICDs is not affected by magnet placement, pacemaker-dependent patients with ICDs require reprogramming to allow for asynchronous pacing. Therefore, magnet placement is sufficient, when anatomically feasible, for pacemaker dependent patients with transvenous devices as well as non-pacemaker-dependent patients with ICDs. However, all pacemaker-dependent patients with ICDs will require reprogramming as magnet placement will only disable tachycardia therapy.
Because magnet placement only disables detection while it remains directly over the device, the magnet must be securely fixed with tape to avoid displacement, and its correct function confirmed by audible manufacturer-specific tones where available [27]. The advantage of this approach is its immediacy and reversibility [26]. However, in shoulder surgery, maintaining stable magnet positioning can be challenging, particularly after patient positioning in the beach-chair or lateral decubitus positions and application of sterile draping. Reprogramming, on the other hand, is a definitive electronic adjustment performed preoperatively by an electrophysiologist or technician. It allows precise and sustained control over pacing and defibrillation parameters, independent of magnet positioning. Reprogramming is preferred when magnet placement is impractical (e.g., due to sterile draping or patient positioning), when prolonged diathermy is expected, or when asynchronous pacing is required in a patient with an ICD, since magnet application to an ICD alone does not achieve asynchronous pacing [12,26]. For pacing-dependent ICD patients, the device must be formally reprogrammed to disable tachyarrhythmia detection and enable asynchronous pacing before surgery [12]. Importantly, all patients placed in asynchronous pacing require continuous cardiac monitoring to detect and prevent ventricular arrhythmias (Table 2).
Many patients with CIEDs are prescribed anticoagulant or antiplatelet therapy, most commonly for atrial fibrillation, prior venous thromboembolism, prosthetic heart valves, or coronary artery disease [30]. Perioperative management requires balancing the risk of thromboembolism associated with interruption of therapy against the risk of surgical bleeding if therapy is continued. In general, vitamin K antagonists such as warfarin are discontinued several days prior to surgery, with bridging therapy reserved for select patients at very high thromboembolic risk [31]. Direct oral anticoagulants are typically held for an interval based on renal function and procedural bleeding risk. Antiplatelet therapy management similarly depends on cardiovascular risk and procedural considerations [31]. Notably, there is a paucity of literature specifically addressing anticoagulation management in patients with CIEDs undergoing shoulder surgery. Further research is needed to better define optimal perioperative anticoagulation strategies in this population.
The goal during the intraoperative management of patients with CIEDs is to ensure rhythm stability and protection of the CIED from EMI or mechanical damage. Cardiac monitoring with continuous electrocardiography and manual palpation of peripheral pulses is required as monitoring systems can report errant heart rates secondary to EMI or misinterpretation of pacing signals. Emergency equipment, including transcutaneous pacing and defibrillators, should also be readily available.
According to the 2011 Heart Rhythm Society (HRS) Guidelines, “Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers, and arrhythmia facilities and patient management this document was developed as a joint project with American Society of Anesthesiologists, AHA, and Society of Thoracic Surgeons,” monopolar cautery is the largest source of EMI for CIEDs, whereas bipolar cautery is less prone to interference and adverse events [32]. However, EMI is not predictable and even bipolar cautery may be sensed in close proximity to the device resulting in loss of pacing or shocks. Electrical current generated from monopolar cautery during tissue dissection has been previously reported to cause pacing failure and even life-threatening reprogramming resulting in uncontrolled pacing activity [33]. However, advances made in lead generator design and EMI resistance and the development of newer surgical tools have made these events much less common in modern systems. Today, the most common forms of EMI in shoulder surgery are oversensing, device resetting, and permanent damage to the CIED or its leads [32]. Previous studies have shown that EMI with the CIED is unlikely if the distance between the electrical current path is more than 6 inches away from the device [34]. However, maintaining such a distance is frequently not possible in shoulder surgery, and surgeons should be aware other risk mitigation strategies. Electrosurgical systems that use tightly confined radiofrequency (RF) energy, such as low-thermal-injury RF devices (e.g., the Medtronic PlasmaBlade), generate significantly less stray current and therefore produce markedly reduced EMI compared with conventional monopolar cautery. Due to the lower and more localized energy delivery, these RF systems are also far less likely to cause lead heating or mechanical damage, even when used in close proximity to implanted hardware [35,36]. However, Paniccia et al. [37] reported that PlasmaBlade use still carried substantial EMI risk in patients with implantable defibrillators and advised preferential use of bipolar cautery or electromagnetic shears in this setting. Therefore, although PlasmaBlade offers advantages over monopolar systems in terms of reduced thermal spread and collateral tissue injury, bipolar cautery remains the safest option overall for patients with CIEDs (Table 3) [38].
Oversensing is by far the most frequent form of EMI. It may result in inappropriate inhibition of pacing output or false detection of tachyarrhythmias, leading to inappropriate CIED therapy. The degree to which oversensing occurs is dependent on patient- and device-related factors, such as the duration of exposure to RF current, the path of the current, and the patient’s underlying rhythm. It has been recommended that surgeons utilize short bursts of electrocautery with pauses of 4 to 5 seconds to decrease the risk of oversensing [32]. The risk of oversensing is also greatest when the current path crosses the CIED or its leads. Thus, it is recommended to place the grounding pad on the same side as the operative shoulder preferably on the thigh or abdomen, thereby creating the shortest path for electrical current and directing it away from the generator and leads. This reduces the likelihood of EMI [39]. For a patient with a robust underlying rhythm (pacemaker-independent), EMI resulting in pacing inhibition may be inconsequential. However, for a pacemaker-dependent patient, prolonged pacing inhibition due to continuous EMI may cause patients to experience a hemodynamically unstable rhythm. Furthermore, inappropriate antitachycardia pacing and asynchronous ICD shocks can induce ventricular arrhythmias, though such occurrences are rare [32].
Although CIEDs are rigorously engineered to protect from EMI, electrosurgery in close proximity or directly onto the pulse generator could cause failure or permanent damage of the CIED. Electrical energy can enter the pulse generator through any breach in lead insulation or sealing rings to the lead connectors [32]. Therefore, it is recommended that shoulder procedures utilize bipolar electrocautery or scalpel dissection over monopolar electrosurgery whenever possible. Working at lower energy settings may also reduce exposure of the CIED to the effects of electrosurgery.
Special consideration should be afforded to retractor placement during shoulder surgery as pocket breach or lead dislodgment can occur. The most common location for CIEDs is superficial to the pectoralis major muscle, and sharp retractors such as skin rakes or Gelpis may inadvertently violate the device pocket. This may increase the risk of CIED infection, which carries a high risk of mortality up to 14% [40]. Previous studies have found that reoperations on pacemakers, even minor surgical revisions, increase the risk of infection by three-fold [41,42]. Exposure of the pacemaker pocket during surgery further increases the likelihood of pocket infection, which accounts for nearly two-thirds of all CIED infections. Therefore, avoiding any unnecessary opening or disruption of the pocket is critical [43]. Thus, the use of blunt retractors, such as an Army Navy and Kolbel, to retract the superficial and deep tissues, respectively, is encouraged. In the event of inadvertent CIED pocket violation, the pocket should be thoroughly irrigated with an appropriate antimicrobial solution (e.g., local vancomycin), and the cardiac/electrophysiology team should be consulted for prompt closure and assessment [44].
Another potentially devastating complication is lead dislodgment or fracture. Although the risk of lead dislodgment is low after 3 months when fibrotic encapsulation occurs, aggressive lateral retraction of the cephalic vein should be avoided. We prefer to mobilize the cephalic vein medially when CIEDs are present to minimize traction on the leads. Additionally, lead fractures have been reported to occur between 11 and 31 months after pacemaker implantation, though these are rare in newer designs due to improved manufacturing [45]. Leads can be potentially damaged when retractors are placed medially, such as when exposing the anterior glenoid during arthroplasty. If a lead fracture or dislodgement is suspected intraoperatively, postoperative chest radiographs and formal device interrogation by the cardiac team are recommended to confirm lead integrity and guide further management [46].
Like open procedures, shoulder arthroscopy also carries potential risk of EMI and lead damage. Modern RF ablation devices are typically bipolar and create plasma to cut and coagulate tissue [47]. The plasma created by the probe is localized to the tip of the probe and does not conduct through the patient or irrigation fluid [48]. Moreover, plasma-generating wands operate at lower energy than traditional monopolar or bipolar devices [47]. There have not been adverse cardiac events related to the use of arthroscopic RF probes reported in the literature, although the same strategies for mitigating EMI during open procedures still apply [3]. Another important factor to consider during shoulder arthroscopy is portal placement. The most medial portal commonly used in an elderly patient population is the anterior rotator interval portal, but an anteroinferior portal or a medial coracoid portal theoretically pose a greater risk of lead damage because of closer proximity to the CIED [3]. Grashey radiographs or fluoroscopy can also be helpful to ensure that portals do not interfere with the device during insertion. Lastly, fluid management is also an important intraoperative concern. One case reported that fluid extravasated into the soft tissues during shoulder arthroscopy and caused bradycardia due to excessive tension on the leads [49]. For this reason, we recommend lower pump pressures in patients with CIEDs. Although the specific pump pressure causing intraoperative bradycardia is not mentioned in the literature, we recommend a pump pressure between 30 to 60 mmHg, as this has been demonstrated to allow excellent visual clarity [50].
According to HRS guidelines, patients with CIEDs who undergo surgery in which monopolar electrosurgery was used should have their device evaluated within 1 month of surgery [32]. Since open ipsilateral shoulder surgery carries a higher probability of EMI, we recommend that the device in these patients be interrogated prior to patient discharge. In the immediate postoperative period, the priority is to ensure that the CIED has been safely and fully restored to its baseline configuration, as patient deaths have been reported when ICD therapies were inadvertently left deactivated after elective procedures [12]. When only a magnet was applied intraoperatively, removal of the magnet returns the device to its prior programmed settings, and no additional cardiac monitoring or interrogation is necessary provided there were no intraoperative complications or unexpected events [12,26]. In such cases, patients may proceed through routine postoperative recovery and can generally be discharged according to standard surgical protocols. However, if the device was reprogrammed preoperatively, for example, if tachyarrhythmia detection in an ICD was disabled, it must be actively restored to normal function postoperatively, and continuous cardiac monitoring should be maintained until reactivation is confirmed [12,27]. Documentation of all programming changes and the timing of restoration should be entered into the electronic health record for continuity of care [12].
Patients who experienced major intraoperative or perioperative events, including cardiac arrest, delivery of ICD therapy, external defibrillation, hemodynamic instability requiring temporary pacing, or suspected device reset, should undergo formal postprocedural interrogation by qualified personnel before leaving a cardiac-monitored setting [26,27]. When postoperative interrogation is performed, the aim is to confirm that the device has not entered a backup safety mode and that its pacing, sensing, and therapy functions remain intact [26]. Continuous rhythm monitoring during the recovery phase is advised until reprogramming is verified, with immediate availability of external defibrillation and pacing equipment for any patient whose device function was temporarily altered [27]. In these higher-risk situations, inpatient observation or extended monitored recovery may be warranted prior to discharge.
From a practical standpoint for shoulder surgeons, most elective shoulder procedures that utilize bipolar electrocautery and occur away from the generator site carry minimal postoperative device risk, provided intraoperative EMI exposure is well controlled. If a magnet-only approach is used and no hemodynamic or electrical instability occurs, patients may be safely transferred to routine postoperative care without additional device interrogation. Conversely, if the device is reprogrammed or if EMI exposure is significant, such as during extensive cautery near the pulse generator, then interrogation and monitored recovery are essential to confirm proper reactivation of pacing and defibrillation functions [12,29].
Ultimately, optimal postoperative management hinges on interdisciplinary communication between the surgical team, anesthesiologists, and the CIED management service to ensure timely restoration of device settings and documentation of all perioperative events. For shoulder surgeons, familiarity with this workflow allows confident management of patients with pacemakers or defibrillators, ensuring that postoperative monitoring is applied judiciously only when reprogramming or intraoperative instability warrant it, thus balancing patient safety with efficiency [12].
Patients with CIEDs present a unique set of perioperative considerations for shoulder surgeons. Contemporary CIED systems vary widely in placement, function, and responsiveness to magnets, making thorough preoperative identification of device type, pacing dependency, and anatomic location essential. Careful preoperative planning following AHA guidelines forms the foundation of safe operative management. Intraoperatively, minimizing EMI through bipolar electrocautery use, appropriate grounding, and continuous monitoring is critical to preventing device malfunction. By integrating structured screening, multidisciplinary planning, and EMI-reduction strategies, shoulder surgeons can significantly mitigate perioperative cardiac risk in this growing patient population.