Perioperative Management of a Spinal Cord Stimulator During Transcatheter Aortic Valve Implantation: A Case Report

Spinal cord stimulation (SCS) is an established treatment for chronic neuropathic pain, and patients with an implanted stimulator are presenting with increasing frequency for transcatheter aortic valve implantation (TAVI). We describe an 88-year-old man with a high-frequency (10 kHz) spinal cord stimulator for chronic back pain who underwent transfemoral TAVI under sedation for severe symptomatic aortic stenosis. After consultation with the implanting pain service, the stimulator was switched off with the patient's own remote control, which was kept in the procedure room; rapid ventricular pacing was delivered through a bipolar right ventricular lead so that the pacing current was confined to the myocardium and remote from the pulse generator; and external defibrillator pads were positioned away from the generator and the course of the leads. The procedure was uneventful. The patient tolerated the interruption of therapy without clinically significant pain; a new left bundle branch block after valve deployment was identified on an artefact-free trace, stimulation was resumed after the procedure with analgesia equivalent to baseline, and subsequent interrogation confirmed normal device function. The case illustrates the application of a precautionary strategy informed by manufacturer labelling and analogous evidence; because the stimulator was off throughout, it does not establish that any individual measure was necessary. We examine how the hazards of the cardiac catheterisation laboratory differ from those of the operating theatre and propose a structured six-step approach to the management of a spinal cord stimulator during TAVI.