Electrosurgery and Implantable Electronic Devices: Review and Implications for Office-Based Procedures

Abstract

The authors have indicated no significant interest with commercial supporters.T he number of patients with implantable electronic devices (IEDs) is growing as indications for a myriad of cardiac and neurological disorders that cannot be managed using medication alone expand. 1 These devices include gastric and cardiac pacemakers, implantable cardioverter defibrillators, cochlear implants, and a range of stimulators of the deep brain, vagal nerve, sacral nerve, phrenic nerve, spinal cord, and bone. Encountering patients with an IED who present for office-based procedures is becoming increasingly common. Electromagnetic interference (EMI) during routine procedures has been reported to be associated with inappropriate functioning of IEDs. 2 Adverse effects of performing electrosurgery on patients with IEDs pose a patient safety risk. Medical and manufacturer reports have primarily focused on larger electrosurgical equipment used in hospitals and their effect on IEDs. Our purpose was to provide a clinical review of commonly encountered IEDs, their clinical indications, potential interference with officebased electrosurgical equipment, and recommendations to prevent complications and injury. IEDs: Clinical Indications Cardiac PacemakersAlthough pacemaker technology has advanced since the first one was implanted in 1958, 3 common indications are still symptomatic bradyarrhythmias, such as sinus node dysfunction and heart block. A pacemaker consists of a battery-powered generator connected to electronic pacing wires inserted intravenously to the right-side chambers of the heart. 4 The earliest devices were asynchronous devices, pacing the heart at a fixed rate regardless of the patient's underlying rhythm and sometimes causing symptomatic hemodynamic consequences. The latest models are demand pacemakers that sense the heart's intrinsic rhythm and inhibit pacing in the same chamber or trigger pacing in another cardiac chamber. 5,6 These devices also have sophisticated timing features to optimize heart rates and even treat some atrial arrhythmias. Implantable Cardioverter DefibrillatorsImplantable cardioverter defibrillators (ICDs) have had a profound effect on patients with ventricular tachyarrhythmias and those at risk for sudden cardiac death. 7 ICDs are programmed to treat lifethreatening ventricular arrhythmias with rapid overdrive pacing or an internal defibrillator shock. These patients most commonly have severe acquired, inherited, or idiopathic forms of cardiomyopathy. Indications continue to expand to include asymptomatic patients with low ejection fractions at risk of sudden death. Similar to pacemakers, these devices

Basal Cell Carcinoma Overlying a Cardiac Pacemaker Successfully Treated Using Mohs Micrographic Surgery

“…This is important because dermatologic surgeons used electrosurgery widely to achieve hemostasis. Electrosurgery, especially with monoterminal devices, has the potential to interfere with pacemaker function by oversensing, altering pacemaker rate, or device reprogramming, but bipolar electrocoagulation is less likely to lead to malfunction, as evidenced by two recent large studies that noted no adverse effects from the use of bipolar electrocoagulation near pacemakers . Specifically, bipolar electrocautery poses less risk to the paced patient because current flows through the tissue only between the tips of the instrument, limiting energy dispersion.…”

“…Although MMS resulted in no adverse effects, our patient was not pacemaker dependent. Approximately 5% to 10% of patients with implanted cardiac pacemakers are dependent on their devices for maintaining adequate heart rhythm . Electromagnetic interference in a pacemaker‐dependent patient is potentially life threatening, whereas in a nondependent patient, it is likely that pacemaker malfunction would result in less‐acute consequences.…”

Investigation of Hyfrecators and Their In Vitro Interference with Implantable Cardiac Devices

“…Advances in CRM devices have decreased the potential for EMI. In approximately 2004, the device input protection capabilities increased because of industry improvements in the technology and miniaturization of certain components (Medtronics personal communication), including improvements in filter feed‐through and signal‐processing algorithms that can squelch signals outside of cardiac depolarization frequencies of 10 to 50 Hz …”

“…In approximately 2004, the device input protection capabilities increased because of industry improvements in the technology and miniaturization of certain components (Medtronics personal communication), including improvements in filter feed-through and signalprocessing algorithms that can squelch signals outside of cardiac depolarization frequencies of 10 to 50 Hz. 1,3 A hyfrecator works by emitting low-power highfrequency alternating current electrical pulses through an electrode mounted on a hand piece. The electrode can be monoterminal, with the current passing to the patient, or biterminal, with the current passing through the patient and returning to a second electrode.…”

“…T here have been previous reports in the dermatologic literature reviewing the electromagnetic interference (EMI) potential of electrosurgical devices in patients with cardiac devices. [1][2][3] They give excellent reviews of the cardiac devices and provided recommended precautionary measures to take when performing surgery on these patients in an office-based setting, but these precautions are not based on safety guidelines specific to hyfrecators. Additionally, our literature search did not reveal any studies specifically addressing the electromagnetic interference of hyfrecators with cardiac devices.…”