Single-Center Experience: Electromagnetic Interference During ICD Generator Change With the PEAK PlasmaBlade

Introduction

Use of the PEAK PlasmaBlade^™ (Medtronic, Inc.) for soft tissue dissection has shown reduced thermal injury depth, inflammatory response, and scar width in healing skin compared to traditional electrosurgery.¹ It was also recently introduced into the field of ICD implantation, generator replacement, and lead revision, where use resulted in significantly reduced procedure times and length of hospital stay, as well as cost effectiveness.² However, interference with the function of the ICD when used for cutting or coagulation of tissue at the pocket site is not well understood. We prospectively studied the interaction of the PEAK PlasmaBlade with ICD function when used in cutting (CUT mode) or coagulation (COAG mode) within 6 inches from the location of the ICD generator in the chest in 11 consecutive patients at our center. 

Case Series

We report our experience using the PEAK PlasmaBlade in 11 patients with ICDs. Different ICD brands and types were tested, and tissue cautery and coagulation was done within 6 inches of the location of the generator in the chest. Each application consisted of a 10-second electrogram (EGM) recording performed via the ICD device during PEAK PlasmaBlade delivery. Table 1 summarizes the types of implanted devices and the interactions noticed using different CUT and COAG mode power settings.

Discussion

Different effects have been reported using electrosurgery in patients with implanted cardiac devices when performed within the vicinity of the device, including temporary inhibition of pacing function, temporary loss of capture, induction of arrhythmias, and rarely, permanent damage to the leads. The Heart Rhythm Society/American Society of Anesthesiologists Expert Consensus Statement in 2011 adapted a perioperative approach, including continuous monitoring of rate and rhythm, availability of temporary pacing and defibrillation equipment, using short intermittent bursts with least energy possible, and full system interrogation after the operation.³

We elected to test the electromagnetic
interference using the PEAK PlasmaBlade system during device generator change (within 6 inches of the generator location as worst case scenario). When used in CUT mode, there was no significant interaction in the majority of patients at the three power settings tested (5, 6 and 7), except for occasional oversensing thought to be non-significant (one oversensed beat out of 10 seconds’ application). On the other hand, when used in COAG mode, there was significant oversensing at all of the power settings (6, 7 and 8). It was non-physiological oversensing with cycle lengths as short as less than 100 msec. Only one patient (#8) had occasional undersensing at setting 6 COAG mode. Figure 1 illustrates an example of ventricular oversensing with a cycle length of less than 100 msec. 

Our findings demonstrate safety when using the PEAK PlasmaBlade in CUT mode as shown by lack of persistent oversensing or other significant interactions. However, during COAG mode, ventricular oversensing was noted in almost all patients. None of the patients had permanent damage to the lead, and full interrogation was performed following the procedure.

Conclusion

The PEAK PlasmaBlade is a useful tool for soft tissue dissection in patients with ICDs. It can be safely used in CUT mode with powers of 5 or 6 with no significant interaction. However, when used in COAG mode, regardless of the power setting chosen, we found there is significant interference (usually ventricular oversensing) that requires cautious monitoring. 

Acknowledgement. The authors would like to thank Jessica Wrobel, BSME for her assistance. 

Disclosures: The authors have no conflicts of interest to report regarding the content herein.   

References

1. Ruidiaz ME, Messmer D, Atmodjo DY, et al. Comparative healing of human cutaneous surgical incisions created by the PEAK PlasmaBlade, conventional electrosurgery, and a standard scalpel. Plast Reconstr Surg. 2011;128(1):104-111.
2. Kypta A, et al. An electrical plasma surgery tool for device replacement—retrospective evaluation of complications and economic evaluation of costs and resource use. Pacing Clin Electrophysiol. 2014;38(1):28-34.
3. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management: executive summary this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm. 2011;8(7):e1-18.