See “Endoscopic Electrosurgery in Patients with Cardiac Implantable Electronic Devices”
by Myong Ki Baeg, Sang-Woo Kim, Sun-Hye Ko, et al., on page 176-181.
INTRODUCTION
As the use of cardiac implantable electronic devices (CIEDs) such as pacemakers and
implantable cardioverter-defibrillators is increasing, management of those device-wearing
patients with electrosurgery has attracted growing attention, not only in the area
of gastroenterology, but also in other fields, including dermatology [1] and urology
[2]. For gastroenterologists, there have been concerns about electromagnetic interference
(EMI) occurring in CIED patients during small bowel capsule endoscopy [3] and therapeutic
endoscopy [4].
With the advancement of the field of therapeutic endoscopy, endoscopy using electrosurgical
devices is mounting up, and currently recognized as a safe and essential tool for
modern endoscopy. The rate of electrosurgical procedures in patients with CIEDs is
also increasing. Electromagnetic currents generated during electrosurgery may interfere
with a CIED. However, a reliable protocol that can be followed in such a situation
is not yet established.
In this issue of Clinical Endoscopy, Baeg et al. [5] reported the results of their
retrospective analysis of endoscopic electrosurgery in patients with a CIED. Fifty-nine
procedures including gastric and colonic snare polypectomy (n=45), gastric and colonic
endoscopic submucosal dissection (n=6), and endoscopic retrograde cholangiopancreatography
with endoscopic sphincterotomy (n=8) were reviewed. The authors monitored vital signs
and oxygen saturation, but did not pay schematic attention on special cares such as
real time electrocardiographic (EKG) monitoring in CIED patients before, during, and
after the procedure. Apparently, no patient showed any symptom or adverse event, according
to the medical records. Among 31 pacemaker interrogations with procedure recordings,
two cases of multiple tachycardia events were noted, but the EKG pattern returned
to normal immediately after the procedure was completed. Two possible program changes
were noted later on cardiology outpatient clinic visits among 44 patients with pacemaker,
but the authors were not sure whether these changes were definitely related to electrosurgery.
It is possible that a CIED may sense and incorrectly interpret electrical signals
produced during electrosurgery as intrinsic cardiac activity. Theoretically, inappropriate
reprogramming of the device, inhibition of the pacing system, or inappropriate antitachycardia
pacing or shocks by the CIED may occur during the electrosurgery procedure [6].
There are several published recommendations regarding endoscopic electrosurgery in
patients with a CIED but they are not evidence-based, and adequate study related to
this important issue is still lacking. The guidelines for the perioperative management
of CIED patients undergoing electrosurgery from the American College of Cardiology
Foundation and the American Heart Association (ACCF/AHA) [7] differ from those of
the American Society for Gastrointestinal Endoscopy (ASGE) [8]. The ACCF/AHA recommend
that the pacemaker should be reprogrammed to an asynchronous mode in which regular
uninhibited pacing continues by pacemaker with no sensing capability throughout the
entire procedure. However, according to ASGE, reprogramming is recommended only when
a prolonged electrocautery procedure such as treatment for gastric antral vascular
ectasia or radiation proctitis is anticipated in pacemaker-dependent patients. Pacemaker-dependent
patients are not able to sustain adequate hemodynamic stability or cardiac rhythm
without assistance from the pacemaker. Thus, it is critical to consider pacemaker
dependency, and consultation to a cardiologist is a prerequisite in pacemaker-dependent
patients during preprocedural evaluation.
Experts recommend that the operator should have information on the type and exact
location of the CIED, its programmed settings, the underlying disease process requiring
CIED placement, and whether the patient is device-dependent before the procedure [8].
During the procedure, it is necessary to monitor vital signs and EKG rhythm continuously
in addition to pulse oxymetry. Additional recommendations include intermittent delivery
of the lowest effective amount of electrosurgical current for the shortest possible
duration, ideally no more than 5 seconds at a time. Bipolar or multipolar accessories
are preferred to monopolar devices whenever available. Argon plasma coagulation is
one of the monopolar devices and should be used with minimal feasible power and brief,
intermittent bursts. Grounding pads should be applied as close as possible to the
treatment site trying to make sure that the current does not pass near or through
the CIED. Cardioverter-defibrillation equipment should be readily available.
There are concerns about EMI by electrosurgical currents being used during endoscopy
in CIED patients. Most patients with pacemaker may undergo routine electrosurgical
endoscopic procedures, and serious adverse events related to therapeutic endoscopic
procedures in CIED patients have not been reported [9,10]. However, the endoscopist
must be aware of the risk factors and take precautionary steps to minimize the risks.
Universal guidelines based on objective data rather than on consensus statements are
essential because the chance of encountering CIED patients is increasing for endoscopic
procedures.