[33], Some CIEDs make use of piezoelectric crystal components in the circuitry or lead connections. Pacing and clinical electrophysiology : PACE. We present a unique case of intermittent failure to capture and describe the Your message has been successfully sent to your colleague. Pacing and clinical electrophysiology : PACE. Yi xue ban = Journal of Peking University. During the device interrogation, there may be an indication of pacing on the near- or far-field electrocardiogram without an appropriate capture of the chamber being paced. WebWhen heart patients with implanted pacemakers undergo electrocardiogram (ECG) testing, a cardiologist must be able to detect the presence and effects of the pacemaker. Failure to capture means that the ventricles fail to response to the pacemaker impulse. WebPacemaker failure to sense ecg strip. Manufacturers also place an identification number in the generator that is sometimes visible on chest x-ray. Unless battery depletion is suspected, magnet application is usually not necessary. The hallmark of the fusion phenomenon is that its morphology lies between a fully paced beat and an intrinsic beat. Pacemaker & CRT: ECG, Function, Troubleshooting and Management, Introduction to Cardiac Pacing and Devices: Pacemaker, ICD, CRT, Components and construction of a pacemaker, Basic cardiac pacing, pacemaker functions and settings, Pacemaker malfunction, troubleshooting and ECG, Other tachyarrhythmias associated with pacemaker, If the ventricular impulse manages to travel in retrograde direction back to the atria, via the. Failure to sense ECG Failure to Capture Failure to Capture Definition Spikes are not closely (Figure.1) Causes of output failure include lead fracture, generator failure, and inhibition of pacing due to over-sensing and crosstalk. Most cases of malfunction are associated with the electronics in the pulse generator or dislodgement or fracture of the leads. Patients who have pacemakers or ICDs who develop hyperkalemia should be managed with reversal of their electrolyte abnormalities immediately, and reprogramming of the cardiac rhythm device may also be needed.10,11 Acidemia and hypoxemia can similarly cause a loss of capture. In rare cases, antiarrhythmic agents can affect the capture threshold significantly and lead to noncapture. Capture and Loss of Capture Intermittent loss of ventricular capture See also: Stroke-Like Symptoms Caused by Pacemaker Malfunction Further Reading Basic Principles of Pacing by Kirk M. ( PDF) Pacemaker Timing Cycles by Hayes and Levine ( PDF) This is an appropriate form of undersensing, and was discussed previously (refer to PVARP). This change can be due to a cardiomyopathy, fibrosis medications, metabolic imbalance, lead fracture, or an exit block. High-impedance readings can frequently be observed in correlation with lead fracture, even though it is not necessarily present in every case or can be intermittent in nature and not observed during the device interrogation period. There is usually no ED intervention for these patients. This wire fracture not only caused the failure to capture, but also failure to sense native ventricular activity as well as some aspect of failure to pace with low amplitude pacer spikes. In Temp Pacing: Make sure generator is on, check heart rate, sensitivity and output settings, make sure all connections from the patient to the generator are secure, change the battery or the generator, limit tension on the wires, if the electrode is damaged, it will need to be replaced. official website and that any information you provide is encrypted Her BP is 72/44. Data is temporarily unavailable. The .gov means its official. 1. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. A: Chest X-ray at implant with atrial and ventricular leads in place. 2005 Jan; [PubMed PMID: 15683511], Sweesy MW,Batey RL,Forney RC, Crosstalk during bipolar pacing. Conventional surface ECG can reveal the following types of pacemaker dysfunction: These failures typically result in missing stimulation artifacts, misplaced stimulation artifacts, irregular pacing, etc. when the heart muscle does not respond to an electrical stimulation, WebAbout; British Mark; Publication; Awards; Nominate; Sponsorship; Contact Actions elicited during scheduled and unscheduled in-hospital follow-up of cardiac devices: results of the ATHENS multicenter registry. Capture failure occurs when the generated pacing stimulus does not initiate myocardial depolarization. A retrograde P wave produced by a premature ventricular complex is sensed by a pacemaker when it falls beyond the PVARP. The ECG may have evidence of fusion or pseudofusion beats if the pacemaker rate and intrinsic heart rate are nearly identical, and the native and paced Pacemakers are implanted in patients with rhythmic cardiac problems. If there is a loss of capture in this context, the output can be increased or the antiarrhythmic regimen can be altered to correct the loss of capture. WebKnowledge of ambulatory electrocardiographic evidence of failure to capture, failure to sense, or failure to pace for cardiac pacemakers and ICDs False-Positive or False-Negative Findings in Detection and Interpretation of Myocardial Ischemia from the Ambulatory Electrocardiogram. Undersensing occurs when a pacemaker fails to sense or detect native cardiac activity. Medical State PacemakerVentricular pacemaker Syndrome with 1:1 ventriculoatrial retrograde (V-A) atria (frecce). Ventricular sense response pacing and ventricular safety pacing. Suppose the advisor relationship set were one-to-one. Failure to capture is defined as the inability of pacing impulse to produce an evoked potential. The most commonly encountered pacer is the DDD pacemaker, where both the atria and the ventricles are sensed and either paced or inhibited depending on the native cardiac activity sensed. WebAn electrocardiogram (ECG or EKG) is a test that measures your hearts electrical activity. WebTo expand on why this IS a failure to sense : The key understanding here is that 'sensing' can have two outcomes - on sensing an impulse (in the atria OR ventricle OR either) the Please try again soon. Additionally, when the T-wave starts to increase in amplitude with hyperkalemia, it can be oversensed as a native QRS, leading to a decrease in the frequency of pacing and, ultimately, to bradycardia. A knowledge of these factors is essential for health care providers, given the morbidity and mortality that can potentially be associated with device-related issues, especially in patients who are dependent on the included pacing function. The effect of hyperkalaemia on cardiac rhythm devices. They have pacemaker activity, although it is inappropriate or without effect. [36], When planning therapeutic radiation for a patient with an implanted pacemaker, the status of the device requires monitoring by a healthcare provider who specializes in monitoring the pacemakers. Therefore, it is important to follow up on the life of the battery and to replace the generator when elective replacement is indicated well before to the end of the devices life. The electrical signatureor artifactsof the pacing signal consists of small, narrow pulses. 8600 Rockville Pike Before American Association of Physicists in Medicine. to maintaining your privacy and will not share your personal information without Acta medica Austriaca. PVARP means that the atrial lead is refractory for a certain time period after each ventricular stimulation. (b) H2O(l)H2O(g)\mathrm{H}_2 \mathrm{O}(l) \longrightarrow \mathrm{H}_2 \mathrm{O}(g)H2O(l)H2O(g) Finally, external electrical stimulus can be another cause of loss of capture. [37], If the malfunction of the device is due to lead dislodgement, the management depends on the timing of the event related to the timing of the implantation of the device, the severity of the dysfunction, the clinical situation of the patient, and the location of the displaced lead (atrial or ventricular). Finally, the sense amplier may detect isoelectric extrasystoles (i.e., in the surface elec-trocardiogram) that properly inhibit stimulus delivery. More than three-fourths of the patients require MRI at some point in time after implanting a pacing device. Received 2019 Jul 30; Accepted 2019 Aug 13. Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing. Oversensing may also occur when the ventricular lead interprets the T-wave as an R-wave. Atrial or dual-chamber pacemaker should have P waves following each atrial ke. Under-sensing is defined by a failure of the pacemaker to see the spontaneous intrinsic activity, which results in asynchronous pacing. [3], The current standard of care for symptomatic bradyarrhythmias due to conduction system diseases is the implantation of a cardiac implantable electronic device. EM Board Bombs with Blake Briggs, MD, and Iltifat Husain, MD, The Physician Grind @ EMN with Zahir Basrai, MD, Current Procalcitonin Utilization and Publications, Procalcitonin: Risk Assessment in COVID-19 Bacterial Co-Infection. Spontaneous atrial or ventricular activity respectively inhibits atrial or ventricular pacing (inhibited functioning). This can occur within hours to days or even weeks after the Increase sensitivity setting. Oversensing may also occur when electrical events in one chamber is sensed by the lead in the other chamber, resulting in inappropriate inhibition of the pacemaker in the latter chamber. A pacemaker spike a mark on the ECG projecting upward or downward from the baseline indicates that the pacemaker has fired. WebAcute ventricular tachyarrhythmias (ventricular tachycardia, ventricular fibrillation) Hypertensive emergency (crisis) - Drugs, doses and administration List of drugs that prolong QT interval and cause torsade de pointes (TdP) Inotropes and Vasopressors: Doses, indications, contraindications and effects (Acad Emerg Med 1998;5:52.). Failure to capture occurs when a pacemaker pulse is given, but the impulse is unable to depolarize non-refractory myocardial tissue. This type of oversensing is referred to as pacemaker crosstalk. [11], Kennedy A,Finlay DD,Guldenring D,Bond R,Moran K,McLaughlin J, The Cardiac Conduction System: Generation and Conduction of the Cardiac Impulse. Please enable scripts and reload this page. Look at the EKG/ECG to see if the rate is regular and how fast the heart is beating; both are important for rhythm interpretation. A stable rhythm often correlates with a stable patient. Figure 3 demonstrates noise on a single-chamber ventricular lead from a pacing-dependent patient who experienced lead fracture. The sensor enabling rate responsiveness may misinterpret signals and assume that the person is physically active, and thus increase the ventricular rate. Electrocardiography for Healthcare Professionals, 5th Edition, Rapid Interpretation of EKG's, Sixth Edition, 12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs, Heart Sounds and Murmurs: A Practical Guide with Audio CD-ROM 3rd Edition, The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds, Murmurs, EKG, Project Semilla, UCLA Emergency Medicine, EKG Training. WebThis mode of pacing, referred to as cardiac resynchronization therapy (CRT), reduces morbidity and mortality in chronic systolic heart failure with a wide QRS complex. At the beginning of the strip, Fracture of pacing wires; Failure to Capture, Ornato JP, Failure to Sense, ECG devices must be able to detect pace pulses and This website provides professional medical education. Fornieles-Perez H, Montoya-Garca M, Levine PA, Sanz O. [9]So, the patients with pacemakers generally face problems related to either sensing or pacing, and these problems can be grouped into the following categories. This process leads to excitation-contraction coupling resulting in the contraction of myocardial tissue.[5]. No atne for ventricular pacer. Pacemaker malfunction can lead to potentially life-threatening situations, including syncope and even cardiac arrest. Fitbits ECG app records those electrical signals and looks for signs of AFib. Extracorporeal shock wave lithotripsy can damage such components due to its effect on those components leading to device malfunction. WebFailure to Sense Definition Spikes are occurring in places where they shouldn't. Are there pacer spikes? Health sciences. Failure to pace (FTP), which means that the pacemaker does not stimulate as expected. Nature reviews. Atrial lead intermittently pacing after undersensing and displaying a loss of capture while the ventricular lead demonstrates appropriate capture upon pacing. The inhibition of pacing is appropriate when there is intrinsic cardiac activity; the presence of spontaneous atrial or ventricular activity should inhibit pacing in the chamber with activity. This is a lack of capture problem. It's used to detect or determine the risk of irregular heartbeats (arrhythmias). [11], Failure to capture is defined as the inability of pacing impulse to produce an evoked potential. Wolters Kluwer Health Another possibility is that the patient is moribund. Continue reading here: Location of MI by ECG Leads. Notably, there are no MRI-safe devices, whichare devices that have no known hazards or risks under all conditions. WebThe issues: In 1994 Resources Unlimited filed for bankruptcy after more than four years of posting what some internal accountants deemed as unrealistic profits. A 76-year-old woman calls 911 because of extreme weakness and near-syncope. (c) point CCC. In TVP, turn the patient on their left side. Modern pacemakers have built-in functions to calibrate the stimulus amplitude and width according to myocardial excitability. Barold SS, Herweg B. Usually demand pacemaker waits for a pause in the basic rhythm before firing as it senses the spontaneous rhythm and works in inhibited mode. This usually occurs in critically ill patients, and addressing their underlying problems will lead to improvements in the capture threshold. 1985 Jun [PubMed PMID: 3998335], Kusumoto FM,Schoenfeld MH,Barrett C,Edgerton JR,Ellenbogen KA,Gold MR,Goldschlager NF,Hamilton RM,Joglar JA,Kim RJ,Lee R,Marine JE,McLeod CJ,Oken KR,Patton KK,Pellegrini CN,Selzman KA,Thompson A,Varosy PD, 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Runaway pacemaker is a potentially life-threatening condition in which the pacemaker fires >200 times per minute, which may degenerate into ventricular fibrillation. [2]This movement of electric potential in an orderly manner controls the rhythmic contraction of the heart's chambers. As more pacemakers and implantable cardioverter-defibrillators (ICDs) are being placed, a basic understanding of some troubleshooting for devices is becoming essential. For medical care contact your doctor. Texas Heart Institute journal. Advances in technology, expanding indications, and the aging population ensure that EPs will encounter more patients with cardiac pacemakers on a regular basis. Permanent pacemaker generator failure in the pediatric patient with an implanted pacemaker. Pacemakers consist of two main components: a pulse generator and the leads. An error has occurred. Cardiology. (Fig. In most cases, the modes of the pacemaker will require changing for undergoing surgical procedures. WebFailure to capture. Appropriate experience with this diagnostic approach is urged prior to its use, however. Ventricular sense response pacing and ventricular safety pacing postoperatively. After the procedure, the patient's symptoms resolved. Anesthesiology. Causes include pacing lead problems, battery or component failure, low pacing voltage or elevated myocardial pacing thresholds, and exit block. Acquired conditions such as myocardial infarction, age-related degeneration, procedural complications, and drug toxicity are the major causes of the native conduction system malfunction. 2018 Nov 6; [PubMed PMID: 30412709], Cingolani E,Goldhaber JI,Marbn E, Next-generation pacemakers: from small devices to biological pacemakers. The typical treatment in this case is repositioning of the lead in the postoperative period. 2019 Jul 1 [PubMed PMID: 30726912], Furman S, Pacemaker sensing. Reopening and reinstating the lead is a good management option in early displacements as the chances of fixation of the lead by the fibrous endocardial reaction are very low. Pacer spikes are seen on an [20]Pacemaker-mediated tachycardia requires the presence of retrograde (ventriculoatrial) conduction and a triggering event like premature ventricular contraction or loss of AV synchrony. 2019 Nov 19 [PubMed PMID: 31738594], Jastrzbski M, Pacemaker-mediated tachycardia: What is the mechanism? 2017 Feb 23; [PubMed PMID: 28225684], Jung W,Zvereva V,Hajredini B,Jckle S, Safe magnetic resonance image scanning of the pacemaker patient: current technologies and future directions. WebFailure to sense and failure to capture requires only the basic evaluation and then pacemaker interrogation by cardiology. Breaking News: A Catastrophic Match: Now What? Oversensing occurs when the pacemaker detects electrical activity that it incorrectly interprets as atrial (P-wave) or ventricular activity (R-wave). Jun 29, 2016. Initial 12-lead ECG. Kiviniemi MS, Pirnes MA, Ernen HJK, Kettunen RVJ, Hartikainen JEK. The 12-lead ECG demonstrates atrial fibrillation with a narrow QRS complex rhythm at a rate of 55 beats/minute with intermittent irregularity. Hayes DL, Vlietstra RE. Over-sensing results in an inappropriate inhibition of the pacing stimulus leading to potentially life-threatening consequences. Placing a magnet on the device during the PMT will change the pacemaker's mode to asynchronous dual-chamber pacing mode (in DOO, intrinsic P waves and R waves are ignored), which results in the termination of tachycardia by suspending the pacemaker's sensing function. Outline different ways in which a pacemaker typically malfunctions. Please try after some time. HRS/EHRA expert consensus on the monitoring of cardiovascular implantable electronic devices (CIEDs): description of techniques, indications, personnel, frequency and ethical considerations. This can be due to a cardiomyopathy, fibrosis, medications, metabolic imbalance, lead fracture, or an exit block.5 Treatment usually involves eliminating or correcting the underlying cause. [30]A research study in patients with non-MRI-conditional devices concluded that there was no failure of the device or lead in these patients when undergoing non-thoracic MRI of approximately 1.5 teslas. Calculate the half-life for this reaction. Understanding the cause of loss of capture in pacemakers and ICDs is crucial for the prevention of morbidity, mortality, and inappropriate treatment. Pacing failure due to flecainide acetate. Therefore, the presence of an implanted pacemaker should not hinder such investigative imaging modality. 2018 Nov [PubMed PMID: 30191581], Alasti M,Machado C,Rangasamy K,Bittinger L,Healy S,Kotschet E,Adam D,Alison J, Pacemaker-mediated arrhythmias. Figure.3: Electrocardiogram of a patient with VVI pacemaker, programmed at a lower rate of 50 beats per minute. Increase current and consider other causes that might alter the threshold such as hypoxia, metabolic and electrolyte derangements. In such cases, introducing the lead in the heart chamber where the displacement has occurred is a good management plan if lead extraction is not possible. In general, the categories can be subdivided by the acuity of the loss of capture, which is usually cardiac in nature. Dr. Harrigan is an associate professor of emergency medicine at Temple University School of Medicine in Philadelphia. (Figure.5), Pseudofusion occurs when the pacemaker spikes coincide with an intrinsic; however, it does not contribute to the actual depolarization. This may be due to lead dislodgement, lead fracture or inadequate myocardial contact. MRI-conditional devices have minimal ferromagnetic material,altered filtering, as well as specially designed lead conductors, which minimize current induction and heating of the tissue. Loss of capture can be an emergent presentation for an unstable patient and can be encountered intermittently in hospitalized patients. Over-sensing can be caused either by a physiologic signal like T waves or by a non-physiologic signal like electromagnetic interference or a lead failure (an insulation break or a lead fracture. This electrical wave causes the muscle to squeeze and pump blood from the heart. However, in case of lack of that information, contacting the manufacturer for that information is the best next step. Fusion and pseudo-fusion beats are considered normal pacemaker behavior. [32], CT scan of the patient does not usually cause problems in the pacemakers. This innate electrical potential moves from the sinoatrial node to the atrioventricular node and finally into the His-Purkinje system. Atrial Failure to Capture On this strip you notice the vertical spike appearing regularly, however, it is not showing an atrial response for each spike. and transmitted securely. 2018 Mar; [PubMed PMID: 29143810], Cantillon DJ,Dukkipati SR,Ip JH,Exner DV,Niazi IK,Banker RS,Rashtian M,Plunkitt K,Tomassoni GF,Nabutovsky Y,Davis KJ,Reddy VY, Comparative study of acute and mid-term complications with leadless and transvenous cardiac pacemakers. A Holter monitor is a small, wearable device that records the heart's rhythm. In comparison, an electrocardiogram can show a change in the morphology of the captured stimulus if the patient is dependent on pacing or, alternatively, there can be pacing spikes with noncapture in the desired chamber (as shown as Figure 1) or capture of a completely different chamber (eg, a dislodged atrial lead can capture ventricular tissue if it has moved past the tricuspid valve). Kang TS, Yoon YW, Park S, et al. Concurrent renal failure was often documented. Sense: Address correspondence to: Saima Karim, DO, Department of Cardiology, Metrohealth Medical Center, 2500 Metrohealth Drive, Cleveland, OH 44109-1998, USA. With failure to capture, there will be visible pacing artifacts in the 12-lead surface electro-cardiogram but no or intermittent atrial or ventricular Some error has occurred while processing your request. [27]Regular follow-up and programming of pacing devices are required for the basic understanding of their function, troubleshooting, and management of pacemaker malfunction. Webproper atrial sensing resulting in an AV delay and ventricular pacing (AS-VP); the ventricular EGMs and the 2 leads show the absence of ventricular capture (no ventricular signal after the stimulus); the spontaneous ventricle following the previous P wave is Position III indicates the pacemaker's response to sensing: triggering (T), inhibition (I), both (D), or none (O). Consideration of the timeline from the implant procedure to the time of the loss of capture is important in determining the cause. Subsequently, the pacemaker gives an inappropriate spike. Since then, indications for pacemakers have grown remarkably and now include atrioventricular (AV) node and sinus node dysfunction, hypersensitive carotid sinus syndrome and neurally-mediated syncope (vasovagal syncope), prevention of tachycardia with long QT syndrome, hypertrophic cardiomyopathy, certain cases of congestive heart failure, and prevention of atrial fibrillation. It is characterized by a morphology similar to an intrinsic beat. The Journal of innovations in cardiac rhythm management. [31], MRI-conditional pacemakers are better able to handle the interference due to magnetic resonance imaging. 2015 Nov [PubMed PMID: 26001958], Hayes DL,Vlietstra RE, Pacemaker malfunction. Here, we can clearly see that the output pulse, which is represented by this pacing spike has triggered a ventricular depolarization and that is what we would usually expect to see. The cause of this patient's pacemaker malfunction and failure to capture were seen on the chest radiograph, which demonstrated a fracture in the pacing wire. How the 12 lead ECG works. Walker PR, Papouchado M, James MA, et al. Pacemaker malfunction includes failure to pace, failure to capture, undersensing, and pacemaker-mediated dysrhythmias. 2002 Dec 25 [PubMed PMID: 12495391], Steinbach K,Laczkovics A,Mohl W, [Sudden cardiac death in patients with pacemakers]. WebCapture is: A. [6]The periodic evaluation of an implanted pacemaker is necessary to optimize programming and to identify correctable problems. In DDD pacing, atrial oversensing leads to rapid ventricular pacing. In DDI pacing, atrial oversensing leads to ventricular underpacing. The most common cause is battery failure or external damage. 2018 Jul [PubMed PMID: 29957188], Nelson GD, A brief history of cardiac pacing. The pacemaker is then set to the minimum energy needed to activate myocardium (a safety margin is often used). In comparison, an increase in the required threshold promoting a loss of capture can happen after months to years of insertion of the pacemaker or ICD. Causes include pacing lead problems, This shock therapy can additionally cause an acute rise in the threshold and lead to a temporary loss of capture as well.17. WebIn most cases, ECG showed the presence of tall T waves; loss of PMK atrial capture was documented in 5 patients. A comparison of the initial chest X-ray and electrocardiogram is usually very helpful. On the electrocardiogram or rhythm strip, a pacing spike can be seen with no P or QRS complex subsequently following the pacing spike.6 An example is shown in Figure 1, where the atrial pacing stimuli do not capture the atrial tissue and, therefore, there is no atrial depolarization with P waves following the pacing stimuli. 2012 May [PubMed PMID: 22237585], Henrikson CA,Leng CT,Yuh DD,Brinker JA, Computed tomography to assess possible cardiac lead perforation. Sketch the direction of the net electric field due to the two charges at Clinical cardiology. On an ECG, the pacemaker does not sense a native beat, and therefore does not inhibit the pacemaker . The pacemaker fires because it fails to detect the heart's intrinsic beats, resulting in abnormal complexes. [21]Pacemaker-mediated tachycardia could therefore be avoided by programming a sufficiently long post ventricular atrial refractory period (PVARP). National Library of Medicine External causes are less common and include electrolyte disorders, metabolic disorders, hypoxemia, antiarrhythmic drugs, or electromagnetic disturbance caused by other machines/devices. There is usually no ED intervention for these patients. It may also be due to the low amplitude (voltage) of the potentials generated by activated myocardium. Arrows indicate output failure of ventricular lead resulting in asystole. Arrow indicates fusion beat. Federal government websites often end in .gov or .mil. sharing sensitive information, make sure youre on a federal The cause may be a dead battery or a disruption in the connecting wires. This activity outlines different ways a pacemaker can malfunction and highlights the role of the interprofessional team in managing the patient with pacemaker malfunction. (a) point AAA, Email: The authors report no conflicts of interest for the published content. The cells present in the sinus node have innate automaticity, which starts the electrical activity in the heart. may email you for journal alerts and information, but is committed Get new journal Tables of Contents sent right to your email inbox, Articles in Google Scholar by Theodore Chan, MD, Other articles in this journal by Theodore Chan, MD. 1978 [PubMed PMID: 685634], Crossley GH,Poole JE,Rozner MA,Asirvatham SJ,Cheng A,Chung MK,Ferguson TB Jr,Gallagher JD,Gold MR,Hoyt RH,Irefin S,Kusumoto FM,Moorman LP,Thompson A, The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). mingo tribe religion, motion challenge test, size of taiwan compared to california,