Ann Thorac Surg 1998;65:1802-1804
© 1998 The Society of Thoracic Surgeons
How to Do It
Use of an Ultrasonic Scalpel as an Alternative to Electrocautery in Patients With Pacemakers
Michael R. Epstein, MDa,
John E. Mayer, Jr, MDb,
Brian W. Duncan, MDb
a Department of Cardiology, Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
b Department of Cardiac Surgery, Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
Accepted for publication December 15, 1997.
Address reprint requests to Dr Epstein, Department of Cardiology, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115-5737
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Abstract
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We report the safe and effective use of an ultrasonically activated scalpel as an alternative to unipolar electrocautery during surgical procedures in 4 patients with pacemakers. This scalpel provided adequate hemostasis without the adverse consequences of electromagnetic interference. As the scalpel was able to easily cut through the silicone connector sleeve of one generator, it is not recommended for routine generator replacement because it may damage existing pacing leads. However, its use during nonpacemaker operations in patients with pacemakers should be considered.
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Introduction
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The use of unipolar electrocautery during surgical procedures in patients with permanent pacemakers can result in pacemaker malfunction with potentially grave consequences [1–8]. Electromagnetic interference caused by electrocautery may inhibit pacemaker firing resulting in asystole; cause the pacemaker to revert either to a default program with a pacing rate that is inadequate to support cardiac output or to an asynchronous mode, which can induce lethal tachyarrhythmias; increase pacing thresholds secondary to electromagnetic coupling with resultant endocardial thermal burns at the lead tip; or cause sudden, irreversible loss of battery output. Published precautionary guidelines [9–11] include limiting electrocautery use to short bursts, restricting electrocautery to greater than 15 cm from the pulse generator, placing the grounding pad as far from the pacemaker as possible and in a position where the flow of diathermy current is not parallel to the pacing leads, and reprogramming the pacemaker to an asynchronous or magnet mode before electrocautery use. However, these measures do not guarantee patient safety, and the use of bipolar electrocautery as an alternative may lead to inadequate hemostasis. This report details our experience with an ultrasonically activated scalpel, which provides hemostasis without electromechanical interference, in patients with permanent pacemakers.
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Technique
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The ultrasonically activated scalpel (Harmonic Scalpel; Ultracision, Inc, Smithfield, RI) (Fig 1) has been used safely and effectively in laparoscopic as well as open abdominal and pelvic operations [12–14]. Operating at a mechanical frequency of 55.5 kHz over a distance of 85 µm, the scalpel thermally transfers heat to the tissue without electrical current passing through the patient. After confirmation that the use of an ultrasonically active scalpel in non–pacemaker-dependent patients with pacemakers was safe, we used the scalpel effectively to assist in the exploration and debridement of an infected former pacemaker site in a pacemaker-dependent patient with complex congenital heart disease, and to implant a new epicardial ventricular pacemaker system in an anticoagulated patient with complete heart block and an intermittently malfunctioning transvenous pacing system.
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Fig 1. The ultrasonically activated scalpel (A) hand piece with hook spatula blade and (B) generator console.
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Results
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Patients 1 and 2
The ultrasonic scalpel was used to assist with generator explantation in 2 non–pacemaker-dependent patients with symptomatic sinus node dysfunction (1 with a CPI [Cardiac Pacemakers, Inc, St. Paul, MN] model 635 Ultra I pulse generator, the other with a CPI model 445 Vista T pulse generator). In both cases, no electromagnetic artifact was seen on the surface electrocardiogram during scalpel operation, and there was no inappropriate pacemaker inhibition, even with the ultrasonic scalpel in direct contact with the generator’s shell. Interrogation of the pacemakers after explantation showed no change in permanent programming or battery voltage. Evaluation of the explanted generators by CPI engineers showed both devices to be functioning within specifications. The case of patient 2 was notable in that the scalpel, which was intentionally brought into contact with the generator’s header after pacemaker removal, easily cut through the header’s silicone connector sleeve.
Patient 3
A 39-year-old man with {S,L,L} corrected transposition, a single left ventricle, and spontaneous atrioventricular block underwent a Fontan operation and simultaneous implantation of an epicardial dual-chamber pacemaker system in 1994. Subsequently, an infection developed in the pacemaker pocket necessitating pacemaker removal and pocket debridement. All pacemaker hardware could not be removed, and several lead fragments were left attached to the heart. After several weeks of systemic antibiotics, during which the patient’s cardiac output was supported with temporary epicardial ventricular pacing, a new epicardial dual-chamber pacing system was implanted at an alternate site. In March 1997, the patient presented with a chronically draining sinus in his epigastrium related to his previously retained infected pacemaker lead fragments. Wound debridement and lead fragment removal was successfully performed with the assistance of the ultrasonic scalpel without adverse effects to the pacemaker system (Medtronic [Medtronic, Inc, Minneapolis, MN] model 7952 Thera DR connected to a bipolar atrial lead [CPI model 4269] and two unipolar ventricular leads [CPI model 4316] with the assistance of a Y adapter [CPI model 6021]) in this pacemaker-dependent patient (escape rate <45 beats/min). Interrogation of the pacemaker after the procedure demonstrated no change in the pacemaker’s permanent programming or battery voltage. Pacemaker evaluation after the operation showed stable pacing and sensing thresholds for both lead systems.
Patient 4
A 42-year-old woman who underwent aortic valve replacement (no. 9 Starr-Edwards valve) in 1965 for severe aortic regurgitation secondary to subacute bacterial endocarditis with resultant complete heart block presented with intermittent failure to capture of her transvenous ventricular pacemaker system (Medtronic model 8416 Legend connected to a bipolar transvenous lead [Medtronic model 6962] with the assistance of an adapter [CPI model 6021]). With the assistance of bipolar electrocautery, a new transvenous dual-chamber pacemaker system was implanted with the old system left in situ. The procedure was complicated by the development of a pacemaker pocket hematoma and eventual pocket infection with associated bacteremia (Staphylococcus aureus). The new pacemaker system was explanted and the infection was treated. An epicardial ventricular pacemaker system was subsequently implanted via a subxiphoid approach with the assistance of the ultrasonic scalpel without existing pacemaker inhibition. Evaluation of the patient’s old pacemaker system after the procedure demonstrated no change in the pacemaker’s permanent programming, battery voltage, or pacing and sensing thresholds. Intraoperative hemostasis was deemed adequate. Risk of repeat pacemaker pocket hematoma was minimized with careful management of anticoagulation perioperatively and with the temporary insertion of a Jackson-Pratt drain.
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Comment
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The dangers of using unipolar electrocautery in patients with pacemakers have been well described [1–8]. Even if current precautionary guidelines [9–11] are followed, catastrophic pacemaker failure can still occur [1, 5]. It has long been our practice to use bipolar electrocautery to explant a patient’s pulse generator with subsequent pacing via the patient’s permanent leads with an external pacing device before the use of unipolar electrocautery. Unfortunately, bipolar electrocautery may not be as effective as unipolar electrocautery in establishing hemostasis, which can lead to wound hematoma and the potential for wound infection.
An ultrasonically activated scalpel was successfully used to explant two generators without causing electromagnetic interference on the surface electrocardiogram, pacemaker inhibition, or pacemaker reprogramming. Analysis by the explanted pacemakers’ manufacturer demonstrated no adverse electrical effects. In addition, as demonstrated in patients 3 and 4, pacing and sensing characteristics were unaffected by scalpel use. Despite this, we do not recommend the use of this device for routine pacemaker explantation because the heat of its blade can cut through silicone, as demonstrated in patient 2, endangering the patient’s existing pacemaker leads. However, as demonstrated in patients 3 and 4, an ultrasonically activated scalpel can be safely and effectively used in patients with preexisting pacemakers without the need for prior pacemaker explantation. Explantation of the pacemaker in patient 3 before exploration and debridement of his infected former pacemaker site with unipolar electrocautery would have substantially increased the risk of infecting his existing pacemaker hardware. In patient 4, a second surgical wound in an anticoagulated patient was avoided by leaving the patient’s transvenous pacemaker in situ while implanting a second pacemaker system via an epicardial approach.
Although not recommended for routine pacemaker explantation because of possible damage to existing pacemaker leads, an ultrasonically activated scalpel can be safely and effectively used in pacemaker-dependent patients without adverse temporary or permanent effects to the patient’s pacemaker system. Use of this device as an alternative to electrocautery in nonpacemaker operations in patients with pacemakers should be considered.
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References
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- Kellow N.H. Pacemaker failure during transurethral resection of the prostate. Anaesthesia 1993;48:136-138.[Medline]
- Moran M.D., Kirchhoffer J.B., Cassavar D.K., Green H.L. Electromagnetic interference caused by electrocautery during surgical procedures [Letter]. PACE 1996;19:1009.
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- Levine P.A., Balady G.J., Lazar H.L., Belott P.H., Roberts A.J. Electrocautery and pacemakers: management of the paced patient subject to electrocautery. Ann Thorac Surg 1986;41:313-317.[Abstract]
- Simon A.B. Perioperative management of the pacemaker patient. Anesthesiology 1977;46:127-131.[Medline]
- Erdman S., Levinsky L., Servadio C., Stoupel E., Levy M.J. Safety precautions in the management of patients with pacemakers when electrocautery operations are performed. Surg Gynecol Obstet 1988;167:311-314.[Medline]
- Amaral J.F. Ultrasonic dissection. Endosc Surg 1994;2:181-185.
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- Amaral J.F. Laparoscopic cholecystectomy in 200 consecutive patients using an ultrasonically activated scalpel. Surg Laparosc Endosc 1995;5:255-262.[Medline]
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Abstract
Introduction
