PPM/ICD in RFA and SCS

[jwalker12]

Hello,

I can't seem to find a good guidelines(likely cause there is not one out there) on how to handle the following situation as they have come up a few times in my practice and always seem to be confusing so wanted to know what others are doing? Most things say ask the cardiologist but our local cardiologists often just write clear for procedure.

1. Patient with ICD/PPM comes in for a SCS trial.
A. Are you turning the ICD off and placing them into VOO for the whole trial?
B. Are you doing the SCS with a cardiac device rep in the room to monitor and see if the SCS is interfering with it and if not proceed as normal if it is interfering defer to cardiology?
C. Are you just proceeding as normal.

2. Patient with ICD/PPM for cervical RFA (Lumbar is usually far enough away)
Again are you turning of the ICD and placing them into VOO for the procedure or proceeding as normal? Where are you placing the grounding pad?

Thanks again in advance for the help.

---

Members don't see this ad.

 

[Ducttape]

from a clinical perspective:

1. same device company for both ICD and SCS (not necessary for pacer but makes reps happy if you do use same company)

last trial - the cards rep stated no issues at all with their own SCS product. no reason to stop ICD or pacemaker.

2, cervical RFA - rep meets with patient in pre op, turns off device (if appropriate). patient calls rep when they get home to turn device on remotely.

have not had the not appropriate category but if so... well I would probably not RFA regardless if they are that fragile.

for pacemaker, just use magnet.

 

[nvrsumr]

I can’t get ICD reps to come to my office even if same company. Cards usually clears if rep interrogates after case.... I basically don’t do these procedures on ICD patients.

 

[lobelsteve]

Mixed practice patterns. I do scs and rf every week on icd and pm patients. I do not have cardiac reps available. When placing a grounding pad, get it as close to your needle entry site as possible.
Did rf on icd patient in office this AM. Did scs implant on pm patient this afternoon. Cardiology clearance for Eliquis. Neither cared about device interference.

 

[TIVAndy]

ICDs and pacemakers are two different things. also the response to magnet is different depending on programming.
you shouldn't assume magnet will make everything safe. in worst case scenario an ICD will be deactivated and God forbid pt goes into Vt and ICD doesn't activate you will be liable for the magnet deactivation. RF in lumbar should be ok. for cervical it can be concerning. this is assuming pacemaker in upper chest.
management of ICD and pacemakers are complicated and if you don't know how to manage it, then best to have a rep present.

 

[lobelsteve]

ICDs and pacemakers are two different things. also the response to magnet is different depending on programming.
you shouldn't assume magnet will make everything safe. in worst case scenario an ICD will be deactivated and God forbid pt goes into Vt and ICD doesn't activate you will be liable for the magnet deactivation. RF in lumbar should be ok. for cervical it can be concerning. this is assuming pacemaker in upper chest.
management of ICD and pacemakers are complicated and if you don't know how to manage it, then best to have a rep present.

Why do you say concerning for cervical?

no cases of injury or death in spinal rfa with pm patients.

here is the fact finder.

Radiofrequency Neurotomy for Facet Joint Pain in Patients with Permanent Pacemakers and Defibrillators

Myth: Radiofrequency neurotomy (RFN) is an absolute contraindication in patients with a prior permanent pacemaker or implantable cardioverter defibrillator

academic.oup.com

 

[callmeanesthesia]

Why do you say concerning for cervical?

no cases of injury or death in spinal rfa with pm patients.

here is the fact finder.

Radiofrequency Neurotomy for Facet Joint Pain in Patients with Permanent Pacemakers and Defibrillators

Myth: Radiofrequency neurotomy (RFN) is an absolute contraindication in patients with a prior permanent pacemaker or implantable cardioverter defibrillator

academic.oup.com

I’ve done it for cervical but I’ve also seen it affect their paced rate, usually by stopping the pacing, resulting in bradycardia. If they have an ICD I do a bipolar cervical RF to minimize the risk of triggering.

In the new Medicare rules presence of a pacemaker is specifically called out as a possible reason to justify facet injections instead of MBBs.

 

[ateria radicularis magna]

I’ve done it for cervical but I’ve also seen it affect their paced rate, usually by stopping the pacing, resulting in bradycardia. If they have an ICD I do a bipolar cervical RF to minimize the risk of triggering.

In the new Medicare rules presence of a pacemaker is specifically called out as a possible reason to justify facet injections instead of MBBs.

So in the cervical scenario with bradycardia during rf, what is the best preparation in your scenario?
2 options:
1. All out—hospital, pacer pads present, rep present, magnet available, cardiologist signs letter, specific informed consent
2. Minimal—bovie pad close and probably nothing bad will happen.
(If in the minimal camp, do you counsel patient risk of interfering with pacer and harming patient?)

Good conversation—thanks for bringing it up.

 

[callmeanesthesia]

So in the cervical scenario with bradycardia during rf, what is the best preparation in your scenario?
2 options:
1. All out—hospital, pacer pads present, rep present, magnet available, cardiologist signs letter, specific informed consent
2. Minimal—bovie pad close and probably nothing bad will happen.
(If in the minimal camp, do you counsel patient risk of interfering with pacer and harming patient?)

Good conversation—thanks for bringing it up.

Minimal. Still done in office. Counsel patient. Cardiology clearance obtained. No rep. Pulse ox so I can tell if they get bradycardic.

 

[painfree23]

Minimal. Still done in office. Counsel patient. Cardiology clearance obtained. No rep. Pulse ox so I can tell if they get bradycardic.

What’s ur plan if they do get Brady?

 

[callmeanesthesia]

What’s ur plan if they do get Brady?

Stop the ablation. Try moving the grounding pad. Bipolar ablation if time allows.

 

[ateria radicularis magna]

Stop the ablation. Try moving the grounding pad. Bipolar ablation if time allows.

What if the underlying problem is 3rd degree/complete heart block?
I assume you would just stop the rf and/or do the above.
I think part of the confusion around this issue is that it seems unclear whether or not the RF can potentially cause a lasting change in function of the pacemaker, a change that lasts beyond the 90 seconds of the RF.
If it can, then a pacer dependent patient is facing a very serious risk.
If it cannot, the risk seems pretty minor, assuming you monitor the rate.

 

[TIVAndy]

Why do you say concerning for cervical?

no cases of injury or death in spinal rfa with pm patients.

here is the fact finder.

Radiofrequency Neurotomy for Facet Joint Pain in Patients with Permanent Pacemakers and Defibrillators

Myth: Radiofrequency neurotomy (RFN) is an absolute contraindication in patients with a prior permanent pacemaker or implantable cardioverter defibrillator

academic.oup.com

"There are no known reports of RFN procedures for spine or other joint pain causing ICD/PPM dysfunction that led to serious injury or death. However, caution is advised in patients who have cardiac pacemakers and defibrillators. If a decision is made to proceed with RFN in these patients, physicians should consider the following recommendations to maximize safety and minimize complications:"

just because it didn't occur in the past doesn't mean it won't happen. the paper you are quoting still calls for caution and coordination with cardiologist.

in fact, my partner did an RF ablation in cervical spine with ICD. this triggered a defibrillating shock and pt jumped off the table.
i advised him to immediately have ICD interrogated for the pt
i've managed a lot of pacemaker/ICD during my ICU and cardiac anesthesia days and am always extremely cautious about any electrical current that will go through these devices.

 

[lobelsteve]

"There are no known reports of RFN procedures for spine or other joint pain causing ICD/PPM dysfunction that led to serious injury or death. However, caution is advised in patients who have cardiac pacemakers and defibrillators. If a decision is made to proceed with RFN in these patients, physicians should consider the following recommendations to maximize safety and minimize complications:"

just because it didn't occur in the past doesn't mean it won't happen. the paper you are quoting still calls for caution and coordination with cardiologist.

in fact, my partner did an RF ablation in cervical spine with ICD. this triggered a defibrillating shock and pt jumped off the table.
i advised him to immediately have ICD interrogated for the pt
i've managed a lot of pacemaker/ICD during my ICU and cardiac anesthesia days and am always extremely cautious about any electrical current that will go through these devices.

Needs to report and publish. Was it just bad timing? Stressful situation leading to catecholamine release....

 

[SommeRiver]

I do RFA on these pts and never even think about their devices. I have a few pts running around with SCS implants as well. For SCS, one of my MA's contacts the device company and gets an OK - We do this step just for documentation.

I'm not worried about any of this.

 

[jwalker12]

Mixed practice patterns. I do scs and rf every week on icd and pm patients. I do not have cardiac reps available. When placing a grounding pad, get it as close to your needle entry site as possible.
Did rf on icd patient in office this AM. Did scs implant on pm patient this afternoon. Cardiology clearance for Eliquis. Neither cared about device interference.

When you say as close as possible, where are you placing it for a cervical RFA, assuming you do them in the prone position? Between the scapula?

 

[Orin]

I do these in the OR. The AICD gets turned off. Pads go on just in case.

For SCS, the AICD rep is in the room to ensure the device doesn't pick up interference especially in high thoracic or cervical stim cases. Haven't had any issues going up to 1.2 Khz at 2 to 3 times the paresthesia threshold, but haven't tried this with Nevro.

I thought there was an article about this recently from the NANS/INS folks?

 

[lobelsteve]

When you say as close as possible, where are you placing it for a cervical RFA, assuming you do them in the prone position? Between the scapula?

As close to my prepped field as possible. I hold a 4x4 over the pad so the chloroprep does not get under the pad.

 

[kstarm]

I am assuming genicular ablation is far enough away to not be concerning. Would you still recommend cardiology clearance for a person on a ICD if doing genicular?

 

[Ducttape]

I'd send msg to cardiologist and still have rep temporarily turn it off.
Safety first.

 

[callmeanesthesia]

I am assuming genicular ablation is far enough away to not be concerning. Would you still recommend cardiology clearance for a person on a ICD if doing genicular?

Put the grounding pad on the back of the ipsilateral calf. Below the umbilicus is generally safe so genicular I’d have no concern.

 

[Ferrismonk]

For RFA, the closer the pad to your field the better and I usually don't let the electricity path cross an IPG or wires. I also try not to cross any total joints.

If I'm doing RFA close to stim wires or a pacemaker is placed in such a way that the pad is difficult to place appropriately, I'll usually just do bipolar instead in an abundance of caution. Likely doesn't matter.

For stims with ICD/Pacemakers, I think I read somewhere that the amount of electricity and how it's used is so different and far apart that the ICD/pacemaker won't sense the stim and confuse it with an arrhythmia. They did a study in cadavers where they maxed the sensitivity of the ICD/pacemaker and maxed the output on the stim and there was no capture. I don't remember where I saw that though.

 

[callmeanesthesia]

For RFA, the closer the pad to your field the better and I usually don't let the electricity path cross an IPG or wires. I also try not to cross any total joints.

If I'm doing RFA close to stim wires or a pacemaker is placed in such a way that the pad is difficult to place appropriately, I'll usually just do bipolar instead in an abundance of caution. Likely doesn't matter.

For stims with ICD/Pacemakers, I think I read somewhere that the amount of electricity and how it's used is so different and far apart that the ICD/pacemaker won't sense the stim and confuse it with an arrhythmia. They did a study in cadavers where they maxed the sensitivity of the ICD/pacemaker and maxed the output on the stim and there was no capture. I don't remember where I saw that though.

I can tell you first (or second) hand it does. Had a patient who forgot he had an ICD because it had never shocked him. Started up the cervical RF and it immediately discharged. I’ve seen cervical RFs interfere with a pacemaker (inhibited pacing) multiple times as well, despite careful and close pad placement.
Edit: sorry, misread what you wrote. For SCS I’m not typically worried either but I get clearance anyway.

 

[Ducttape]

Local doctor had an ICD fire for low lumbar RFA on the other side of injection and pad.

Some of these devices are extremely sensitive.

With stims and ICD - just use the same company for both. There is a programmed "frequency" and a device companies ICD should never interfere with its SCS product.