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\begin{document}

\title{Unique Technique to Relieve Left Ventricular Assist Device
Electromagnetic Interference with an Implantable Cardioverter
Defibrillator}



\author[1]{Chengyue Jin}%
\author[2]{Joshua Hsu}%
\author[1]{Daniel Frenkel}%
\author[1]{Jason Jacobson}%
\author[1]{Sei Iwai}%
\author[1]{Aileen M. Ferrick}%
\affil[1]{Westchester Medical Center}%
\affil[2]{New York Medical College}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\selectlanguage{english}
\begin{abstract}
We introduced a simple technique to eliminate electromagnetic
interference between a left ventricular assist device (LVAD) and an
implantable cardioverter-defibrillator (ICD). A 43-year-old male with
heart failure and a reduced ejection fraction (HFrEF) who had an ICD
presented with decompensated heart failure and received an LVAD as a
bridge to transplant. Remote monitoring showed persistent atrial
fibrillation causing an inappropriate ICD shock leading to a decision to
disable shock therapies. However, an in-office interrogation was
unsuccessful due to electromagnetic interference. Patient was instructed
to extend his arm above his head on the ipsilateral side of the ICD,
thus increasing the distance between LVAD and ICD, eliminating the
interaction to allow reprogramming of the device.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Progressive pump failure and malignant ventricular arrhythmias are the
leading causes of death in patients with advanced heart failure with
HFrEF. In patients with refractory HFrEF despite optimal
guideline-directed medical therapy, an LVAD, may be implanted as either
a bridge to heart transplantation or destination therapy for
non-candidates of heart transplant. These patients often meet
recommended indications for an ICD as primary prevention of sudden
cardiac death\textsuperscript{1}. Therefore, many patients with HFrEF
have both devices implanted. Electromagnetic interference (EMI) between
LVAD and ICD may result in an inability to make a telemetric link for
interrogation, or cause an inappropriate shock, or fail to deliver an
appropriate shock. We describe a unique and convenient technique to
increase the distance between LVAD and ICD, eliminating their
interaction to allow successful interrogation of the ICD.

\textbf{Case Report}

The patient is a 43-year-old male with non-ischemic cardiomyopathy, left
ventricular ejection fraction of 15\%, and paroxysmal atrial
fibrillation who had an ICD implanted (Biotronik Intica 7 VRT DX). The
patient presented with decompensated heart failure complicated by
cardiogenic shock approximately 6 weeks post-implant. The patient was
managed with inotropic therapy, an intra-aortic balloon pump, and
evaluated for advanced therapies. A HeartMate III LVAD was placed as a
bridge to transplant. Eleven months later, remote ICD monitoring
reported persistent atrial fibrillation with periods of rapid
ventricular rates resulting in inappropriate anti-tachycardia pacing and
ICD shocks. With shared decision-making, it was decided to deactivate
the tachyarrhythmia therapies. However, in-office interrogation of the
ICD was unsuccessful. A pseudo-Faraday cage created by a cast-iron pan
was placed on top of the ICD and failed. Successful interrogation and
reprogramming were only achieved when the patient was instructed to
extend his arm (on the ipsilateral side of the ICD) above his head, thus
increasing the distance between LVAD and ICD from 4 cm (Fig 1) to over
10 cm, eliminating the interaction.

\textbf{Discussion}

To date, there is a paucity of reported cases of EMI interaction between
ICDs and LVADs, with the first case reported in
2006.\textsuperscript{2}Six cases have reported an interaction between
ICDs and the HeartMate II, resulting in the inability to interrogate and
program the ICD, inappropriate shocks, and pacing inhibition (St. Jude
Medical and Sorin being the most commonly affected
ICDs).\textsuperscript{2-7} Five other case reports show interactions
between HeartWare and ICDs presenting as pacing inhibition or
inappropriate shocks.\textsuperscript{8-12} With HeartMate III, 7 cases
of ICD EMI have been reported, resulting in communication failure in 6
cases and over-sensing LVAD noise signal in one case.
\textsuperscript{13-15}

Several strategies have been proposed to enable successful
communication, interrogation, and reprogramming of an ICD in the setting
of EMI with an LVAD:

\begin{enumerate}
\tightlist
\item
  The HeartMate III user's manual recommends that prior to implanting an
  ICD or pacemaker into a HeartMate III patient, the device to be
  implanted be placed in close proximity to the LVAD pump (approximately
  10 cm) and assure that telemetry communication is established. This
  approach may be the easiest to confirm the safe distance between the
  ICD and the LVAD without requiring special equipment and can be
  performed in office settings. However, this is only a screening
  technique and its effectiveness may be limited after device implant.
  If a patient receives a HeartMate III pump and has a previously
  implanted device that is found to be susceptible to electromagnetic
  interference, the ICD or pacemaker device should be replaced with one
  that is not prone to programming interference.
\item
  A Faraday cage is an enclosure used to block electromagnetic fields
  that can be created temporarily with conductive material such as metal
  sheets, mesh or more conveniently, a cast iron pan/sheet externally
  positioned to isolate the ICD device from the field created by the
  LVAD motor. Creating a Faraday cage has been shown to be useful in
  isolating both devices and thus eliminating potential communication
  interference.\textsuperscript{3}
\item
  Altering the operating frequency of the LVAD or ICD may theoretically
  eliminate EMI between the two devices. The operating frequency of an
  ICD is fixed and only altered by changing to another manufacture's
  pulse generator. This comes with procedural risks, most notably pocket
  infection. LVAD generated EMI, determined by motor speed, can be
  adjusted to below 1300 rpm or above 11,000 rpm to establish ICD
  communication.\textsuperscript{4} However, extreme alterations to the
  LVAD motor may cause hemodynamic compromise and therefore, is not a
  viable option, in general.
\end{enumerate}

Currently, there are no optimal solutions eliminating EMI interactions
between LVADs and ICDs after device implantation. Therefore, selection
of the combination of available LVAD and ICD devices must be carefully
considered before implantation of either device. Further research is
needed to assess, interpret and prevent EMI interaction between ICDs and
third-generation, magnetically driven LVADs.

\textbf{Conclusion}

EMI interaction between LVADs and ICDs can potentially interfere with
ICD interrogation. This case illustrates a simple, yet effective
technique to allow unhindered ICD interrogation and reprogramming as
needed with current technology. Further studies are warranted to assess
and resolve the interactions between ICDs and LVADs.

\textbf{Key Teaching Points}

\begin{itemize}
\tightlist
\item
  Electromagnetic interference between LVAD and ICD may result in an
  inability to make a telemetric link for interrogation, or cause an
  inappropriate shock, or fail to deliver an appropriate shock.
\item
  ICD should be ideally at least 10 cm away from LVAD device to decrease
  the risk of electromagnetic interference.
\item
  Extending patient's arm above the head (on the ipsilateral side of the
  ICD) can increase the distance between LVAD and ICD, which is a
  simple, yet effective technique to allow unhindered ICD interrogation
  and reprogramming.
\end{itemize}

\textbf{References}

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Hohnloser SH, Indik J, Lee R, Mehra MR, Menon V, Page RL, Shen WK,
Slotwiner DJ, Stevenson LW, Varosy PD, Welikovitch L: HRS/ACC/AHA expert
consensus statement on the use of implantable cardioverter-defibrillator
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{[}2{]} Matthews JC, Betley D, Morady F, Pelosi F, Jr.: Adverse
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{[}3{]} Jacob S, Cherian PK, Ghumman WS, Das MK: ''Pseudo'' Faraday
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{[}8{]} Erqou S, Kormos RL, Wang NC, McNamara DM, Bazaz R:
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{[}9{]} Mozes A, DeNofrio D, Pham DT, Homoud MK: Inappropriate
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{[}10{]} Saeed D, Albert A, Westenfeld R, Maxhera B, Gramsch-Zabel H,
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{[}11{]} Ahmed AS, Patel PJ, Bagga S, Gilge JL, Schleeter T, Lakhani BA,
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{[}12{]} Chhabra L, Hiendlmayr B, Kluger J: An Adverse
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{[}13{]} Lopez-Gil M, Fontenla A, Delgado JF, Rodriguez-Munoz D:
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{[}14{]} Schukro C, Schloglhofer T, Khazen C, Rohrich M, Laufer G,
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{[}15{]} Pfeffer TJ, Konig T, Duncker D, Michalski R, Hohmann S, Oswald
H, Schmitto JD, Veltmann C: Subcutaneous Implantable
Cardioverter-Defibrillator Shocks After Left Ventricular Assist Device
Implantation. Circ Arrhythm Electrophysiol 2016; 9.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1. Chest X-Ray showing the distance between Left Ventricular
Assist Device and Implantable Cardioverter Defibrillator before
extending patient's left arm.

\selectlanguage{english}
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