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Electromagnetic interference between continuous-flow left ventricular assist device and cardiac resynchronization therapy defibrillator due to an unrecognized mechanism

  • Jun Yokota
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Katsuhito Fujiu
    Correspondence
    Corresponding author at: Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan.
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Precursory Research for Embryonic Science and Technology (PRESTO), Japan Science and Technology Agency (JST), Research Division Gobancho Building, 7, Gobancho, Chiyodaku, Tokyo 102-0076, Japan

    Translational Systems Biology and Medicine Initiative, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Hikaru Tanimito
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Hideyuki Nebiya
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Pain and Palliative Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Koichi Kashiwa
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Osamu Kinoshita
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Cardiovascular Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Translational Systems Biology and Medicine Initiative, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Kan Nawata
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Cardiovascular Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Mitsutoshi Kimura
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Cardiovascular Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Takuma Satsu
    Affiliations
    Department of Cardiovascular Surgery, Kinki University School of Medicine, 377-2 Onohigashi, Osakasayama, Osaka 589-8511, Japan
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  • Kyouhiro Chou
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Medical Engineering, the University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Masahiko Sumitani
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Pain and Palliative Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Minoru Ono
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Cardiovascular Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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  • Issei Komuro
    Affiliations
    University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan

    Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
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Published:November 04, 2014DOI:https://doi.org/10.1016/j.ijcard.2014.11.021
      Overall efficacy and safety of combined continuous-flow LVAD and ICD were recently reported [
      • Pecha S.
      • Wilke I.
      • Bernhardt A.
      • et al.
      Clinical experience of combined HeartWare ventricular assist device and implantable cardioverter defibrillator therapy.
      ]. However, several cases of electromagnetic interference between ICD and LVAD have been reported, such as telemetry instability between ICD and its programmer or inappropriate ICD therapies caused by noise arising from LVAD [
      • Matthews J.C.
      • Betley D.
      • Morady F.
      • et al.
      Adverse interaction between a left ventricular assist device and an implantable cardioverter defibrillator.
      ,
      • Reddy P.
      • Benditt D.G.
      • Adabag S.
      Electromagnetic device-device interaction between a new generation implantable pacemaker and left ventricular assist device: recognition and potential solutions.
      ,
      • Labedi M.R.
      • Alharethi R.
      • Kfoury A.G.
      • et al.
      Electromagnetic interference of automatic implantable cardioverter defibrillator and HeartWare left ventricular assist device.
      ,
      • Netzler P.C.
      • Vasuki N.
      • Peura J.L.
      • et al.
      Interactions between a left ventricular assist device and implantable cardioverter-defibrillator.
      ,
      • Boudghène-Stambouli F.
      • Boulé S.
      • Goéminne C.
      • et al.
      Clinical implications of left ventricular assist device implantation in patients with an implantable cardioverter-defibrillator.
      ]. However, these reports were cases which used HeartMate® II (Thoratec Corporation, Pleasanton, CA, USA) or HeartWare® (HeartWare International, Inc., Framingham, MA, USA) with ICD (St. Jude Medical Corporation, Sunnyvale, CA, USA or Sorin Group, Milan, MI, Italy). Here we report novel electromagnetic interference between CRT-D (COGNIS®, Boston Scientific, St. Paul, MN, USA) and LVAD (DuraHeart®, Terumo Corporation, Shibuya, Tokyo, JAPAN). A 35-year-old man who had been diagnosed in a health examination in 2001 with premature ventricular contraction, was then diagnosed with dilated cardiomyopathy, by endomyocardial biopsy, in 2003. Whereas the best medical treatments for severe heart failure had been done, he was repeatedly hospitalized. Left ventricular ejection fraction was reduced to 20% with wide QRS complex, and non-sustained ventricular tachycardia was also observed. CRT-D: Contak RENEWALl® (Boston Scientific, St. Paul, MN, USA) was implanted in 2003. CRT-D generator was replaced by COGNIS 100-D® (Boston Scientific, St. Paul, MN, USA) due to low battery in 2010. However, the frequency of hospitalization was gradually increased and a LVAD (DuraHeart, Terumo Corporation, Shibuya, Tokyo, Japan) was implanted as a bridge to transplantation (Fig. 1A ). During LVAD implantation surgery, ventricular arrhythmia therapeutic capability was turned off to avoid inappropriate therapy caused by electromagnetic interference of the electrocautery scalpel. Just after the LVAD was inserted and started, the programming head of CRT-D programmer (Boston Scientific, St. Paul, MN, USA) was placed on the skin above the CRT-D generator to communicate with the CRT-D, and incessant intermittent telemetry failure was observed (Fig. 1B). In the perioperative period, power delivery was supplied by hospital console, which is the attached power supply and modulator of rotation setting of the LVAD. During telemetry failure, no information was obtained by the programmer and any manipulation from the CRT-D programmer could not be accepted. Abnormal pacing or sensing manner was not suspected by other biomonitors. Even after moving to the cardiac care unit, incessant intermittent telemetry failures were also observed in the same action. We tried to move the cable of the programming head and programmer itself from VAD insertion site to avoid this telemetry failure. However, no position could resolve this intermittent telemetry failure. We tested shielding of these devices by steel shielding [
      • Biviano A.
      • Mancini D.
      • Naka Y.
      • et al.
      Overcoming electromagnetic interference by LVADs on ICD function by shielding the ICD programmer wand and extension cable.
      ] (Fig. 1C). When we covered the skin above the CRT-D generator and that above the LVAD pump, this telemetry failure disappeared. In addition, when we switched the origin of power supply to battery, this telemetry loss also completely disappeared. After discharge, this patient had no problems with CRT-D and LVAD function including wand-based telemetry, because the patient always used a battery-derived power supply. We confirmed this interference in vitro using the same models of LVAD, CRT-D, and programmer (Fig. 2A ). In this case, distance between the CRT-D generator and the LVAD pump was 13 cm (Fig. 1A). We tested whether the CRT-D generator located at 13 cm away from the LVAD pump was affected (Fig. 2B). As expected, the hospital console-powered LVAD repeatedly interfered with the communication of the CRT-D and its programmer (Fig. 2C). This phenomenon is only observed when the CRT-D generator is located in a horizontal direction to the LVAD, but not in a vertical direction (Fig. 2C). Battery-powered LVAD did not provoke this interference as clinically observed (Fig. 2C). In addition, we measured the power of electromagnetic waves generated from currently used LVASs including DuraHeart using originally-developed equipment. Dominant frequency from DuraHeart was 100 kHz and those of HeartMateII and EvaHeart are 7.2 KHz and 30 Hz as manufacture's report, respectively. Whereas electromagnetic wave from HeartMate II was detected to 24 cm from LVAS pump, those of DuraHeart and EvaHeart were not detected over 8 cm (Fig. 2D). These results suggested that electromagnetic wave from DuraHeart could not reach the location of CRT-D generator.
      Figure thumbnail gr1
      Fig. 1Telemetry failure between cardiac resynchronization therapy defibrillator (CRT-D) and its programmer in patient with continuous-flow left ventricular assist device (LVAD) powered by hospital console and a way of preventing.
      a) Posterior-anterior and right-left chest X-ray images of the respective CRT-D and LVAD. Distance between CRT-D and LVAD pump was 13 cm. b) The loss of telemetry of cardiac resynchronization therapy defibrillator (COGNIS®, Boston Scientific) using wired programmer head (wand) was observed in a patient who had left ventricular assist device (LVAD) (DuraHeart®, Terumo Corporation, Shibuya, Tokyo, JAPAN) when the source of power supply was switched from battery to hospital console. This intermittent telemetry failure was reproducible. Pacing and sensing behavior remained normal as evident in the other ECG recording. To communicate to CRT-D, commercially available 3120 ZOOM programmer and the telemetry wand were normally used. When switched back to battery supply, telemetry failure disappeared.
      Figure thumbnail gr2
      Fig. 2Confirmation of telemetry failure between CRT-D and hospital console-powered LVAD by ex vivo experiments.
      A. Configuration of ex vivo experiments. The same model of LVAD, CRT-D generator and its programmer in this case was placed at the same distance as in vivo. B. Indicated alphabets were CRT-D generator placed-positions for evaluation whether LVAD affects telemetry of CRT-D. C. Summary of emergence of telemetry failure between CRT-D and its programmer. During investigation, whether telemetry failure was provoked or not, LVAD was continuously run, powered by battery-power or hospital console-power. “+” indicates provocation of telemetry failure and “−” indicates no provocation of telemetry failure. D. Relationship between detected power of electromagnetic wave from LVADs (HeartMateII (7.2 kHz), EvaHeart (40 kHz) and DuraHeart (100 kHz) in the hospital console-powered situation) and distance from LVAD to originally-developed electromagnetic wave detector.

      Abbreviations:

      LVAD (Left ventricular assist device), ICD (Implantable cardioverter defibrillators)

      Keywords

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