Electromagnetic interference with implantable cardiac pacemakers by video capsule

Imaging-Navigated Surgery

It is vitally important to guide or navigate therapeutic proceedings with a direct and visual approach in order to carefully undertake precision medical manipulations and efficiently evaluate the treatments. Imaging-navigated surgery is one of the common and prevailing technologies to realize this target, and more importantly it merges visualized medicine into next-generation theranostic paradigms in modern medicine. Endoscopes, surgical robots, and nanorobots are three major domains in terms of imaging-navigated surgery. The history of endoscopy has seen upgraded developments since the early 1800s. In contrast, surgical robots have been widely used and investigated in recent years, and they came into clinical uses only in the past decades. Nanorobots which closely depend on innovated and multifunctional biomaterials are still in their infancy. All these imaging-navigated technologies show similar and apparent advantages such as minimal invasiveness, minimized pain, positive prognosis, and relatively expected recovery, which have greatly improved surgery efficiency and patients' life quality. Therefore, the imaging-navigated surgery will be discussed in this chapter, and advanced clinical and preclinical medical applications will also be demonstrated for a diverse readers and comprehensive understanding.

Safety of wireless capsule endoscopy in patients with implantable cardiac devices

Background and Aim

Wireless capsule endoscopy (WCE) has become an increasingly utilized imaging modality for the evaluation of gastrointestinal bleeding. There is a paucity of data evaluating the safety and use of WCE in patients with implantable cardiac devices.

Methods

A retrospective chart review of all patients who had a WCE at Loyola University Medical Center in Maywood, IL, USA completed between January 2007 and December 2016 identified patients with internal cardiac devices and obscure gastrointestinal bleeding. Patient WCE footage was viewed in its entirety before creating a final report to ensure no gaps in footage and video quality.

Results

No patient complaints were documented during the 8‐h procedure duration, and there were no cardiac abnormalities noted on telemetry. There were no device‐related complications documented in the 30‐day postprocedure time period. Postprocedure analysis of the WCE recordings demonstrated no interference in WCE image quality (loss of images or gaps in video) or duration.

Conclusions

There is no significant interference between WCE and implantable cardiac devices, and it appears to be safe to use.

Pooled Analysis of the Efficacy and Safety of Video Capsule Endoscopy in Patients with Implantable Cardiac Devices

BACKGROUND

To date, video capsule endoscopy (VCE) is still contraindicated by the FDA and the main manufacturers of Cardiac Implantable Electronic Devices (CIED) in patients with CIED, given a theoretical electromagnetic interference and possible device malfunction.

OBJECTIVES

The objective of this study was to assess the safety profile and efficacy of VCE in patients with implantable cardiac devices through analyzing the risk of mutual interference.

METHODS

A systematic review of PubMed, Web of Science, and Embase databases was conducted. Peer-reviewed original articles, published in the English language and containing "capsule endoscopy" AND "pacemaker", "defibrillator" OR "left ventricular assist device" as keywords, were selected. Studies performed in vitro, isolated case reports, and abstracts/posters were excluded.

RESULTS

A total of 735 VCE procedures were performed in patients with cardiac devices in various clinical settings. Cardiac events were not seen in any case. Interference on capsule images transmission was noted in 5 cases (left ventricular assist device (LVAD)) where few images were lost when the capsule was closest to the device. Finally, interference between capsule and telemetry leads was noted in 6 cases (4 Permanent Pacemakers (PPM), 2 Implantable Cardioverter-Defibrillator (ICD)) leading to image artifacts.

DISCUSSION

Adverse cardiac events were not seen in any study. Loss of images occurred when the VCE was in proximity to the device (only with LVAD) or after telemetry leads installation without affecting the completion rate and diagnostic yield of VCE.

CONCLUSION

VCE is safe and remains efficient in patients with cardiac devices. If cardiac monitoring is required, wired systems are preferable.

Quality Indicators for Small Bowel Capsule Endoscopy

Capsule endoscopy (CE) enables evaluation of the entire mucosal surface of the small bowel (SB), which is one of the most important steps for evaluating obscure gastrointestinal bleeding. Although the diagnostic yield of SB CE depends on many clinical factors, there are no reports on quality indicators. Thus, the Korean Gut Image Study Group (KGISG) publishes an article titled, “Quality Indicators for Small Bowel Capsule Endoscopy” under approval from the Korean Society of Gastrointestinal Endoscopy (KSGE). Herein, we initially identified process quality indicators, while the structural and outcome indicators are reserved until sufficient clinical data are accumulated. We believe that outcomes of SB CE can be improved by trying to meet our proposed quality indicators.

Endoscopic techniques to detect small-bowel neuroendocrine tumors: A literature review

BACKGROUND

The diagnosis of small-bowel neuroendocrine tumors (SbNETs) has improved with the advent of video capsule endoscopy (CE) and double-balloon enteroscopy (DBE). The data describing the efficacy of CE/DBE in the detection of SbNETs are scanty.

AIM

The aim of this article is to review the current evidence on the role of DBE and CE in the diagnosis of SbNETs.

MATERIAL AND METHODS

A bibliographical search was performed in PubMed using the following keywords: "neuroendocrine tumors and enteroscopy/and capsule endoscopy" and "small bowel neuroendocrine tumors."

RESULTS

CE and DBE can be complementary and show a similar diagnostic yield. The number of false-negative results has not been established yet because of the "work-up bias" observed in the majority of the studies.

CONCLUSIONS

DBE and CE appear to be both safe and effective procedures useful in the diagnosis of SbNETs. Further studies are required to clarify their potential complications and relationship with other techniques, particularly nuclear imaging.

Video capsule endoscopy is successful and effective in outpatients with implantable cardiac devices

BACKGROUND AND AIM

Implantable cardiac devices are a relative contraindication to video capsule endoscopy (VCE) because of concerns regarding interference. As a result of a lack of alternatives, some centers have adopted protocols to allow for VCE in these patients. There are minimal published descriptions of the gastrointestinal outcomes of these procedures. We investigated the completion rate and diagnostic yield of VCE carried out in outpatients with implantable cardiac devices.

METHODS

We carried out a retrospective review of all VCE from April 2010 through March 2013 at our center. Patients that underwent VCE through a specialized protocol for outpatients with implantable cardiac devices were identified. The protocol used telemetry for cardiac monitoring during battery lifespan of the VCE. Demographic data, procedure indications, results and any procedural events were collected.

RESULTS

Twenty-one patients met the study criteria, with 16 (76%) pacemakers, four (19%) implantable cardioverter defibrilla tors and one (5%) implantable hemodynamic monitor. Two (10%) devices were adjusted prior to VCE. Twenty (95%) were completed to the colon, with a median gastric transit time of 18 min and a small bowel transit time of 216 min. The procedure was diagnostic in 13 (62%) patients. One (5%) capsule retention event occurred. No cardiac events or video capture disturbances occurred.

CONCLUSIONS

Video capsule endoscopy done on outpatients with implantable cardiac devices through a cardiac monitoring protocol resulted in a satisfactory completion rate and high diagnostic yield with no adverse cardiac events. A large prospective trial is needed to confirm these novel results.

Effects of external electrical and magnetic fields on pacemakers and defibrillators: from engineering principles to clinical practice

The overall risk of clinically significant adverse events related to EMI in recipients of CIEDs is very low. Therefore, no special precautions are needed when household appliances are used. Environmental and industrial sources of EMI are relatively safe when the exposure time is limited and distance from the CIEDs is maximized. The risk of EMI-induced events is highest within the hospital environment. Physician awareness of the possible interactions and methods to minimize them is warranted.

Wireless capsule endoscopy

Over the last decade, WCE has established itself as a valuable test for imaging the small intestine. It is a safe and relatively easy procedure to perform that can provide valuable information in the diagnosis of small-bowel conditions. Its applications still remain limited within the esophagus and colon. Future developments may include improving visualization within the esophagus and developing technologies that may allow manipulation of the capsule within the GI tract and biopsy capabilities.

Safety of capsule endoscopy using human body communication in patients with cardiac devices

BACKGROUND

The MiroCam (IntroMedic, Ltd., Seoul, Korea) is a small-bowel capsule endoscope that uses human body communication to transmit data. The potential interactions between cardiac devices and the capsule endoscope are causes for concern, but no data are available for this matter.

AIM

This clinical study was designed to evaluate the potential influence of the MiroCam capsules on cardiac devices.

METHODS

Patients with cardiac pacemakers or implantable cardiac defibrillators referred for evaluation of small bowel disease were prospectively enrolled in this study. Before capsule endoscopy, a cardiologist checked baseline electrocardiograms and functions of the cardiac devices. Cardiac rhythms were continuously monitored by 24-h telemetry during capsule endoscopy in the hospital. After completion of procedures, functions of the cardiac devices were checked again for interference. Images from the capsule endoscopy were reviewed and analyzed for technical problems.

RESULTS

Six patients, three with pacemakers and three with implantable cardiac defibrillators, were included in the study. We identified no disturbances in the cardiac devices and no arrhythmias detected on telemetry monitoring during capsule endoscopy. No significant changes in the programmed parameters of the cardiac devices were noted after capsule endoscopy. There were no imaging disturbances from the cardiac devices on capsule endoscopy.

CONCLUSIONS

Capsule endoscopy using human body communication to transmit data was safely performed in patients with cardiac pacemakers or implantable cardiac defibrillators. Images from the capsule endoscopy were not affected by cardiac devices. A further large-scale study is required to confirm the safety of capsule endoscopy with various types of cardiac devices.

Endoscopy and implantable electronic devices

The increasing use of implantable electronic devices such as cardiac pacemakers and neurostimulators means that they are being increasingly encountered in endoscopy departments. The electromagnetic fields generated during electrosurgery and with magnetic imaging systems have the potential to interfere with such devices. The authors present a case that highlights some of the steps necessary for minimising risk, review the evidence and summarise the currently available guidance.

Small bowel capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter defibrillators: Outcome analysis using telemetry review

AIM: To determine if there were any interactions between cardiac devices and small bowel capsules secondary to electromagnetic interference (EMI) in patients who have undergone small bowel capsule endoscopy (SBCE).

METHODS: Authors conducted a chart review of 20 patients with a cardiac pacemaker (CP) or implantable cardioverter defibrillator (ICD) who underwent continuous electrocardiographic monitoring during their SBCE from 2003-2008. authors searched for unexplained electrocardiogram (ECG) findings, changes in CP and ICD set parameters, any abnormality in transmitted capsule data, and adverse clinical events.

RESULTS: There were no adverse events or hemodynamically significant arrhythmias reported. CP and ICD set parameters were preserved. The majority of ECG abnormalities were also found in pre- or post- SBCE ECG tracings and the CP behavior during arrhythmias appeared appropriate. Two patients seemed to have episodes of undersensing by the CP. However, similar findings were documented in ECGs taken outside the time frame of the SBCE. One patient was observed to have a low signal encountered from the capsule resulting in lack of localization, but no images were lost.

CONCLUSION: Capsule-induced EMI remains a possibility but is unlikely to be clinically important. CP-induced interference of SBCE is also possible, but is infrequent and does not result in loss of images transmitted by the capsule.

Capsule Endoscopy in Patients with Cardiac Pacemakers and Implantable Cardioverter Defibrillators: (Re)evaluation of the Current State in Germany, Austria, and Switzerland 2010

Background and Aims. The study was a repeated evaluation of the experience of capsule endoscopy (CE) in patients with cardiac pacemaker or implantable cardioverter defibrillator (ICD). Patients and Methods. A standardized questionnaire was sent by the manufactors Given Imaging and Olympus to all centers in Germany, Austria, and Switzerland providing capsule endoscopy service. The questionnaire covers the number of examined patients, monitoring during CE, check of the electric implants before and after CE, occurrence of arrhythmia, quality of CE video, complications, indication of CE, and type of institution. Results. Overall 580 questionnaires were sent to the users. 26/5% (Germany/Austria + Switzerland) of the questionnaires were sent back anonymously to the authors. 114 centers (82 hospitals, 11 surgeries, 21 without specification) replied. In 58 centers (51%), patients with cardiac pacemaker (n = 300) and ICDs (n = 80) underwent uneventful capsule endoscopy. The predominant indication (patients with CP 97%, patients with ICD 100%) was mid gastrointestinal bleeding. Conclusion. The results of our inquiry show that in spite of formal contraindication CE is increasingly applied in bleeding patients with cardiac pacemakers/ICDs and seems to be safe even in a large cohort.

Capsule endoscopy in patients with cardiac pacemakers, implantable cardioverter defibrillators, and left heart devices: a review of the current literature

Background and Study Aims. Capsule endoscopy is an established tool for investigation of the small intestine. Because of limited clinical experience in patients with cardiac devices, the Food and Drug Administration and the manufacturer recommended not to use capsule endoscopy in these patients. The vast majority of investigations did not reveal any interference between capsule endoscopy and cardiac devices. Methods. Studies investigating interference between CE and cardiac devices were analysed. For the review we considered studies published in English or German and indexed in Medline, as well as highly relevant abstracts. Results. In vitro and in vivo studies mainly revealed no interference between capsule endoscopy and cardiac devices. Technical data of capsule endoscopy (Given Imaging) reveal that interference with cardiac pacemakers and implantable cardioverter defibrillator is impossible. Telemetry can interfere with CE video. Conclusion. The clinical use of capsule endoscopy (Given Imaging) is unproblematic in patients with cardiac pacemakers.

Effects of electromagnetic interference on implanted cardiac devices and their management

Potential interference between implanted cardiac devices such as pacemakers and implantable cardioverter-defibrillators and electromagnetic fields is an important concern for physicians taking care of patients with pacemakers and implantable cardioverter-defibrillators. There are many sources of electromagnetic interference (EMI); however, only a small number of these cause significant problems that need attention. Regardless of its source, EMI is of greater concern for a patient who is dependent on paced rhythm because inhibition of the pacemaker by EMI may produce ventricular standstill. It is important that cardiologists, internists, emergency medicine, critical care physicians, and anesthesiologists be aware of how EMI can affect the function of implanted cardiac devices so that appropriate treatment can be rendered and preventive measures instituted.

Electromagnetic interference from wireless video-capsule endoscopy on implantable cardioverter-defibrillators

OBJECTIVES

The purpose of this study was to evaluate potential interference between the Pill-cam video-capsule and implanted cardio-defibrillators (ICD) in both in vitro and in vivo test environments.

METHODS

Phase I consisted of in vitro testing utilized 6 ICD models. Each was placed in a saline gel bath in conjunction with a tool designed to emit the same wave length as the Pill-Cam (the Test Cap). Tests were performed at both the manufacturer's nominal and most sensitive settings with the test probe placed at 1, 5, 10, and 15 cm from three different points. There were emissions of 10-, 30-, and 60- second duration at each location. Phase II was the in vivo study utilizing patients with implanted ICDs for standard clinical reasons who were undergoing evaluation with the Test Cap.

RESULTS

In Phase I, 864 tests were performed involving the 6 ICDs. There was totally normal behavior in 5 of the devices. The Biotronik Belos (Berlin, Germany) demonstrated oversensing and delivery of inappropriate therapy. In phase II, 6 patients underwent a total number of 288 tests (48 in each patient). There were 4 men and 2 women, mean age 61 (33-77) and none demonstrated any adverse interactions.

CONCLUSIONS

In patients with devices identical to those evaluated that showed no interference, the use of the Pill-Cam is safe. However, in patients with a Biotronik Belos ICD (or any other nontested ICD) the use of the Pill-Cam should be done only in-hospital, after suspended ICD therapy and in conjunction with close monitoring.

Contraindications to capsule endoscopy: do any still exist?

In patients requiring WCE most contraindications are relative and the procedure can be performed safely in almost all clinical settings. The only true remaining contraindications to capsule endoscopy are obstruction/pseudo-obstruction and pregnancy. Informed consent of the risks and benefits, including NNE, should be discussed with all patients undergoing WCE examination.