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Epicardial pacemaker implantation in an elderly patient with pre-existing bilateral subclavicular deep brain stimulators
European Geriatric Medicine 3 (2012) 386–387
Available online at
www.sciencedirect.com
EGM clinical case
Epicardial pacemaker implantation in an elderly patient with pre-existing bilateral subclavicular deep brain stimulators S. Boule´ a,*, K. Ouchallal b, E. Mutez c, J.-M. El Arid d a
Lille University Hospital, Department of Cardiovascular medicine, Lille, France Douai Regional Hospital, Department of Cardiovascular medicine, Douai, France c Lille University Hospital, Neurology and Movement Disorders Unit, Lille, France d Lille University Hospital, Department of Cardiovascular Surgery, Lille, France b
A R T I C L E I N F O
Article history: Received 30 May 2012 Accepted 1 June 2012 Available online 15 July 2012 Keywords: Cardiac pacemaker Deep brain stimulation Parkinson’s disease
setting of the left DBS was 3.1 V with a pulse width of 90 ms, at a stimulation frequency of 145 Hz. Both ventricular sensing and DBS electrodes were programmed in bipolar configuration. Pacemaker was programmed in VVIR 60 bpm, and the ventricular sensing was programmed to 2.5 mV (bipolar configuration). Despite concerns about potential electromagnetic interferences between the devices, repetitive postoperative testing demonstrated no ventricular oversensing (Fig. 1B). No device-device interaction occurred at any time during follow-up and during devices programming.
2. Discussion
1. Clinical case A 78-year-old woman presented with complete atrioventricular block, with a slow ventricular escape rhythm of 38 bpm. The patient received bilateral subthalamic nucleus deep brain stimulation (DBS) in 1998, because of uncontrolled fluctuations and dyskinesia due to advanced Parkinson’s disease. As both neurostimulators (Soletra neurostimulators, Medtronic Inc.) were implanted in the subclavicular region bilaterally, an epicardial pacemaker (PM) (Evia SR-T, Biotronik Inc.) was implanted (Fig. 1A). DBSs were turned off during pacemaker implantation. As recommended by the manufacturer, the generator was implanted more than 15 cm away from DBSs. It was implanted by minimally invasive subxiphoid approach and placed in an abdominal pocket, below the fascia of the right rectus abdominis muscle. The ventricular electrogram amplitude was 10.4 mV, the pacing threshold was 0.9 V/0.4 ms pulse width, and the lead impedance was 468 Ohms. A second ventricular lead was implanted and left capped, for later use, in case the first lead fails. The output setting of the right DBS was 3.0 V with a pulse width of 90 ms, at a stimulation frequency of 160 Hz. The output
* Corresponding author. Poˆle de Cardiologie, Hoˆpital Cardiologique, CHRU, 50370 Lille, France. Tel.: +33 3 20 44 50 38; fax: +33 3 20 44 68 98. E-mail address: [email protected] (S. Boule´).
DBS of the subthalamic nucleus is being increasingly used for the treatment of tremor in elderly patients. Most patients with DBS are elderly, particularly those with Parkinson’s disease. As cardiac comorbidities are frequent in elderly patients, some of them will also require cardiac pacemaker implantation, thus presenting the possibility of adverse device-device interactions. The issue of simultaneous use of DBS and PM in elderly patients will therefore arise more frequently in the future. There are only few reports [1–4] on the implantation of pre-pectoral pacemakers in patients with DBS, demonstrating that this combination appears safe. Both ventricular sensing and DBS electrodes must be programmed in bipolar configuration, in order to minimize the risk of oversensing the DBS pulse. In our patient, the devices also competed anatomically for optimum implant site: because of both location and size of pre-existing DBSs, the placement of the pulse generator in the subclavicular area was not possible, with the result that an epicardial approach was required. To the best of our knowledge, this epicardial approach in patients with pre-existing DBS has not been previously described. The epicardial location could reduce the risk of interference between the telemetric programmer of the PM and DBS pulse generators. Indeed, placement of the telemetric PM programmer over the DBS pulse generator could deactivate the device, leading to recurrence of tremor [3] associated with an increased risk of pacing inhibition caused by myopotential oversensing. The epicardial approach provides the advantage of increasing the distance between neurostimulators and cardiac pacemaker generator, and then limiting the risk of side effects during device programming or magnet application.
1878-7649/$ – see front matter ß 2012 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. http://dx.doi.org/10.1016/j.eurger.2012.06.001
S. Boule´ et al. / European Geriatric Medicine 3 (2012) 386–387
387
Fig. 1. A. Chest radiograph showing deep brain stimulators (DBSs) in each subclavicular area and the epicardial pacemaker (PM). B. Intracardiac electrograms detected by the pacemaker, demonstrating that there was no interference with deep brain stimulators, even when programming the highest sensitivity: 1: sensitivity 2.5 mV (bipolar sensing); 2: highest sensitivity (0.1 mV) in bipolar configuration; 3: highest sensitivity (0.1 mV) in unipolar configuration.
3. Conclusion This report highlights the fact that the concomitant use of DBS and epicardial cardiac pacemaker in elderly patients may be safe and effective. Optimal pacemaker generator placement (as far as possible from neurostimulators) and device programming (bipolar configuration for both devices) minimizes the risk of interference between the two devices. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Ashino S, Watanabe I, Okumura Y, Kofune M, Ohkubo K, Nakai T, et al. Implantation of a pacemaker in a patient with severe Parkinson’s disease and a preexisting bilateral deep brain stimulator. Europace 2009;11:834–5. [2] Capelle HH, Simpson Jr RK, Kronenbuerger M, Michaelsen J, Tronnier V, Krauss JK. Long-term deep brain stimulation in elderly patients with cardiac pacemakers. J Neurosurg 2005;102:53–9. [3] Obwegeser AA, Uitti RJ, Turk MF, Wszolek UM, Flipse TR, Smallridge RC, et al. Simultaneous thalamic deep brain stimulation and implantable cardioverterdefibrillator. Mayo Clin Proc 2001;76:87–9. [4] Ozben B, Bilge AK, Yilmaz E, Adalet K. Implantation of a permanent pacemaker in a patient with severe Parkinson’s disease and a preexisting bilateral deep brain stimulator. Int Heart J 2006;47:803–10.
Available online at
www.sciencedirect.com
EGM clinical case
Epicardial pacemaker implantation in an elderly patient with pre-existing bilateral subclavicular deep brain stimulators S. Boule´ a,*, K. Ouchallal b, E. Mutez c, J.-M. El Arid d a
Lille University Hospital, Department of Cardiovascular medicine, Lille, France Douai Regional Hospital, Department of Cardiovascular medicine, Douai, France c Lille University Hospital, Neurology and Movement Disorders Unit, Lille, France d Lille University Hospital, Department of Cardiovascular Surgery, Lille, France b
A R T I C L E I N F O
Article history: Received 30 May 2012 Accepted 1 June 2012 Available online 15 July 2012 Keywords: Cardiac pacemaker Deep brain stimulation Parkinson’s disease
setting of the left DBS was 3.1 V with a pulse width of 90 ms, at a stimulation frequency of 145 Hz. Both ventricular sensing and DBS electrodes were programmed in bipolar configuration. Pacemaker was programmed in VVIR 60 bpm, and the ventricular sensing was programmed to 2.5 mV (bipolar configuration). Despite concerns about potential electromagnetic interferences between the devices, repetitive postoperative testing demonstrated no ventricular oversensing (Fig. 1B). No device-device interaction occurred at any time during follow-up and during devices programming.
2. Discussion
1. Clinical case A 78-year-old woman presented with complete atrioventricular block, with a slow ventricular escape rhythm of 38 bpm. The patient received bilateral subthalamic nucleus deep brain stimulation (DBS) in 1998, because of uncontrolled fluctuations and dyskinesia due to advanced Parkinson’s disease. As both neurostimulators (Soletra neurostimulators, Medtronic Inc.) were implanted in the subclavicular region bilaterally, an epicardial pacemaker (PM) (Evia SR-T, Biotronik Inc.) was implanted (Fig. 1A). DBSs were turned off during pacemaker implantation. As recommended by the manufacturer, the generator was implanted more than 15 cm away from DBSs. It was implanted by minimally invasive subxiphoid approach and placed in an abdominal pocket, below the fascia of the right rectus abdominis muscle. The ventricular electrogram amplitude was 10.4 mV, the pacing threshold was 0.9 V/0.4 ms pulse width, and the lead impedance was 468 Ohms. A second ventricular lead was implanted and left capped, for later use, in case the first lead fails. The output setting of the right DBS was 3.0 V with a pulse width of 90 ms, at a stimulation frequency of 160 Hz. The output
* Corresponding author. Poˆle de Cardiologie, Hoˆpital Cardiologique, CHRU, 50370 Lille, France. Tel.: +33 3 20 44 50 38; fax: +33 3 20 44 68 98. E-mail address: [email protected] (S. Boule´).
DBS of the subthalamic nucleus is being increasingly used for the treatment of tremor in elderly patients. Most patients with DBS are elderly, particularly those with Parkinson’s disease. As cardiac comorbidities are frequent in elderly patients, some of them will also require cardiac pacemaker implantation, thus presenting the possibility of adverse device-device interactions. The issue of simultaneous use of DBS and PM in elderly patients will therefore arise more frequently in the future. There are only few reports [1–4] on the implantation of pre-pectoral pacemakers in patients with DBS, demonstrating that this combination appears safe. Both ventricular sensing and DBS electrodes must be programmed in bipolar configuration, in order to minimize the risk of oversensing the DBS pulse. In our patient, the devices also competed anatomically for optimum implant site: because of both location and size of pre-existing DBSs, the placement of the pulse generator in the subclavicular area was not possible, with the result that an epicardial approach was required. To the best of our knowledge, this epicardial approach in patients with pre-existing DBS has not been previously described. The epicardial location could reduce the risk of interference between the telemetric programmer of the PM and DBS pulse generators. Indeed, placement of the telemetric PM programmer over the DBS pulse generator could deactivate the device, leading to recurrence of tremor [3] associated with an increased risk of pacing inhibition caused by myopotential oversensing. The epicardial approach provides the advantage of increasing the distance between neurostimulators and cardiac pacemaker generator, and then limiting the risk of side effects during device programming or magnet application.
1878-7649/$ – see front matter ß 2012 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. http://dx.doi.org/10.1016/j.eurger.2012.06.001
S. Boule´ et al. / European Geriatric Medicine 3 (2012) 386–387
387
Fig. 1. A. Chest radiograph showing deep brain stimulators (DBSs) in each subclavicular area and the epicardial pacemaker (PM). B. Intracardiac electrograms detected by the pacemaker, demonstrating that there was no interference with deep brain stimulators, even when programming the highest sensitivity: 1: sensitivity 2.5 mV (bipolar sensing); 2: highest sensitivity (0.1 mV) in bipolar configuration; 3: highest sensitivity (0.1 mV) in unipolar configuration.
3. Conclusion This report highlights the fact that the concomitant use of DBS and epicardial cardiac pacemaker in elderly patients may be safe and effective. Optimal pacemaker generator placement (as far as possible from neurostimulators) and device programming (bipolar configuration for both devices) minimizes the risk of interference between the two devices. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Ashino S, Watanabe I, Okumura Y, Kofune M, Ohkubo K, Nakai T, et al. Implantation of a pacemaker in a patient with severe Parkinson’s disease and a preexisting bilateral deep brain stimulator. Europace 2009;11:834–5. [2] Capelle HH, Simpson Jr RK, Kronenbuerger M, Michaelsen J, Tronnier V, Krauss JK. Long-term deep brain stimulation in elderly patients with cardiac pacemakers. J Neurosurg 2005;102:53–9. [3] Obwegeser AA, Uitti RJ, Turk MF, Wszolek UM, Flipse TR, Smallridge RC, et al. Simultaneous thalamic deep brain stimulation and implantable cardioverterdefibrillator. Mayo Clin Proc 2001;76:87–9. [4] Ozben B, Bilge AK, Yilmaz E, Adalet K. Implantation of a permanent pacemaker in a patient with severe Parkinson’s disease and a preexisting bilateral deep brain stimulator. Int Heart J 2006;47:803–10.