Implantation of a Permanent Pacemaker in a Patient With Severe Parkinson's Disease and a Preexisting Bilateral Deep Brain Stimulator

Abstract

SUMMARYCardiac pacemakers and implantable defibrillators are commonly used therapeutic modalities in cardiac arrhythmias. Thalamic deep brain stimulation has also become an important modality in the treatment of drug-refractory tremors and other complications in advanced Parkinson's disease. Concerns exist about the potential electrical interaction and interference between these 2 devices in the same patient. There are only a limited number of reports that have investigated this issue. We describe a patient with advanced Parkinson's disease and a previously implanted deep brain stimulator, who subsequently needed a permanent cardiac pacemaker due to severe bradyarrhythmia. Despite the probability of interference between the devices, there were no problems during implantation of the cardiac pacemaker; both the deep brain stimulator and cardiac pacemaker functioned appropriately afterwards. (Int Heart J 2006; 47: 803-810)

Anaesthesia for deep brain stimulation and in patients with implanted neurostimulator devices

“…There have been a few reports on the simultaneous use of cardiac pacemakers and DBS systems. 67 It was found that a bipolar configuration of DBS and pacemaker is less susceptible to interaction, a result consistent with experience with spinal cord stimulators in patients with pacemakers. 73 Patients must be prepared and motivated to tolerate thorough neurological and cardiac testing.…”

“…Anticoagulation has been temporarily administered to patients with DBS for cardiac conditions. 67 There is a report of a patient with DBS who underwent successful aortic valve replacement for tight aortic stenosis. 18 In this case, a biological prosthetic aortic valve was implanted to avoid the need for anticoagulation.…”

Anesthesia considerations for patients with an implanted deep brain stimulator undergoing surgery: a review and update

“…Cardiac pacemakers and ICDs: The insertion of cardiac pacemakers and/or ICDs in patients with neurostimulators, and vice versa, is not contraindicated and has been performed successfully. 31,[36][37][38][39][40] Nevertheless, precautions should be taken because of potential interactions between these devices, including inappropriate sensing and response by the cardiac pacemaker, inappropriate sensing of tachyarrhythmia by the ICD resulting in discharges, and inactivation of or adjustment to the neurostimulator settings. 29,40 A thorough preoperative assessment by a multidisciplinary team (i.e., cardiologist, DBS specialist, and anesthesiologist) is necessary to optimize the patient's clinical status and to adjust settings of the underlying medical devices as required.…”

“…To minimize interactions between the cardiac pacemaker and the DBS device, the cardiac pacemaker should be programmed to bipolar sensing mode to avoid oversensing and inappropriate response. [36][37][38] Similarly, use of bipolar sensing electrodes for the ICD system also reduces oversensing. It is unlikely that inappropriate ICD discharges would occur at DBS outputs of up to 5 V. 31,39,40 In addition, ICD discharges up to 35 J do not seem to affect the functioning of the DBS device, although a case was reported whereby shock delivery converted the generator output to the ''off'' state with an amplitude of 0 V. 40 Therefore, the functioning of the neurostimulator should be checked after the ICD delivers a shock.…”

Practical considerations and nuances in anesthesia for patients undergoing deep brain stimulation implantation surgery

“…In past, deep brain stimulator was contraindicated in patients with cardiac pacemakers because of their possible negative interaction with each other [ 7 ]. Ozben et al [ 53 ] have proven that a bipolar configuration of DBS and cardiac pacemakers are less prone to interaction and can be used together [ 53 54 ]. Pre-operatively, cardiac pacemakers should be interrogated and placed in a bipolar mode for sensing and stimulation to minimize interference [ 55 ].…”