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Europace 2005 7(2):193-196; doi:10.1016/j.eupc.2004.09.010
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© 2005 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.

CASE REPORT

Inappropriate implantable cardioverter–defibrillator shock due to external alternating current leak: Report of two cases

Ngai Yin Chan* and Lillian Wai-Ling Ho

Princess Margaret Hospital, Department of Medicine and Geriatrics 2-10 Princess Margaret Hospital Road, Lai Chi Kok Kowloon, Hong Kong

Manuscript submitted 27 August 2003. Accepted after revision 29 September 2004.

*Corresponding author. Tel.: +852 29903322; fax: +852 29903329. E-mail address: nywlchan{at}yahoo.com (N.Y. Chan).


   Abstract
Top
 Abstract
Introduction
 Case 1
 Case 2
 Discussion
 References
 
Two cases are reported of inappropriate implantable cardioverter–defibrillator shocks due to external alternating current leak. Electromagnetic interference (EMI) can mimic cardiac signals and cause inappropriate implantable cardioverter–defibrillator (ICD) shocks. EMI can arise from the normal functioning of electrical appliances or from alternating current leak. The two cases had inappropriate ICD shocks due to alternating current leak from a power drill in one and a washing machine in the other. The need for detailed advice on handling electrical equipment is emphasized.

Key Words: implantable cardioverter–defibrillator, electromagnetic interference, alternating current


   Introduction
Top
 Abstract
 Introduction
Case 1
 Case 2
 Discussion
 References
 
There are many reports of EMI mimicking cardiac signals and causing inappropriate ICD shocks. EMI can arise from normally functioning appliances such as electronic article surveillance systems, slot machines, electric razors, hand held radiofrequency remote controls or abdominal muscle stimulator units [1–Go5]Go. It can also arise from alternating current leak from, for example, a washing machine, swimming pool or fish pond cleaning equipment [6–Go8]Go. Two cases of EMI caused by alternating current leak are presented to add to the existing literature in this important area. The need for detailed advice to ICD recipients concerning the handling of electrical appliances is emphasized.


   Case 1
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 Abstract
 Introduction
 Case 1
Case 2
 Discussion
 References
 
A 53-year-old man with a diagnosis of arrhythmogenic right ventricular dysplasia and a history of cardiac arrest due to ventricular fibrillation had a single chamber ICD implantation in June 1996. His ICD was a Jewel Plus model 7220 (Medtronic Inc., Minneapolis, MN, USA) and the ICD lead was a Transvene RV model 6936 (Medtronic Inc., Minneapolis, MN, USA) with dedicated bipolar sensing. There had been no recurrence of ventricular arrhythmia since implantation. He experienced an ICD shock in December 2002. Device interrogation revealed high frequency artifacts on the ventricular channel, interpreted as ventricular fibrillation by the ICD (Fig. 1). A 34-J shock was delivered. Sensitivity was programmed to 0.3 mV. Pacing lead impedance was 672 Ohm and shocking lead impedance was 40 Ohm. There was no evidence of ICD system malfunction. The patient is a construction site worker. He was operating a power drill outdoors when he had the inappropriate ICD shock. It was raining and he wore a pair of wet industrial cotton gloves. He felt a sensation of numbness over both hands just before the shock. He immediately dropped the power drill and was then asymptomatic. The power drill was not available for electrical inspection. The patient was advised to wear electrically insulated gloves to operate electrical machinery and he was advised against operating electrical machinery outdoors in the rain.



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  		Figure 1 ICD tracing from Medtronic Jewel Plus 7220. High frequency artifacts are noted together with the physiological ventricular electrograms.

 

   Case 2
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 Introduction
 Case 1
 Case 2
Discussion
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A 40-year-old man with a history of dilated cardiomyopathy, chronic renal impairment, previous cerebrovascular accident and ankylosing spondylitis presented with recurrent palpitations in November 1999. Electrocardiography documented monomorphic ventricular tachycardia (VT) and cardiac electrophysiological study revealed inducible sustained monomorphic VT. A dual chamber ICD, Gem DR model 7271 (Medtronic Inc., Minneapolis, MN, USA), was implanted. The ICD lead was a Sprint RV/SVC model 6942 (Medtronic Inc., Minneapolis, MN, USA) with integrated bipolar sensing. He had 29 episodes of VT terminated by antitachycardia pacing or low energy cardioversion in December 1999. He has had no further recurrence of ventricular arrhythmias. He experienced an ICD shock in April 2003. Device interrogation revealed typical EMI consistent with 50-Hz alternating current on the ventricular channel (Fig. 2A and Fig. 2B). A 15-J shock was delivered. Sensitivity was programmed to 0.3 mV. Pacing lead impedance was 521 Ohm and shocking lead impedance was 55 Ohm. There was no evidence of ICD system malfunction. He was preparing lunch in the kitchen and touched an old washing machine, which was switched on, with his wet left hand shortly before the inappropriate shock. He moved away from the washing machine after the shock and then remained asymptomatic. The washing machine was inspected by a licensed electrician and a small amount of current leak was detected. The washing machine was removed from the house and the patient was advised not to touch any electrical appliances with wet hands.



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  		Figure 2 (A) ICD tracing from Medtronic Gem DR 7271. EMI consistent with 50-Hz alternating current is noted together with the physiological ventricular electrograms at the onset of the event. (B) ICD tracing from Medtronic Gem DR 7271 before and after ICD discharge.

 

   Discussion
Top
 Abstract
 Introduction
 Case 1
 Case 2
 Discussion
References
 
Two cases of inappropriate ICD shock related to the handling of electrical equipment are reported. In case 1, the patient was operating a power drill outdoors in the rain. High frequency artifacts detected by the ICD can either be EMI due to 50-Hz alternating current leak or vibration arising from the power drill itself. The fact that the patient has been operating power drills as a construction site worker for years without similar episodes, the circumstantial evidence of operating the electrical equipment outdoors in the rain and the numbness sensation experienced just before the shock favour inappropriate shock prompted by EMI due to alternating current leak. Furthermore, there have been no further episodes with the patient operating power drills using correct safety precautions. In case 2, the patient touched a faulty washing machine, which was switched on, with a wet hand. The ICD recorded typical EMI arising from regular 50-Hz alternating current leak. This kind of behaviour, especially in ICD recipients, should be avoided. Detailed advice on handling electrical appliances by ICD recipients is of utmost importance.


   References
Top
 Abstract
 Introduction
 Case 1
 Case 2
 Discussion
 References
 
[1] Mathew P, Lewis C, Neglia J, et al. Interaction between electronic article surveillance systems and implantable defibrillators: insights from a fourth generation ICD. Pacing Clin Electrophysiol 1997; 20: 2857–2859.[Medline]

[2] Madrid A, Sanchez A, Bosch E, et al. Dysfunction of implantable defibrillators caused by slot machines. Pacing Clin Electrophysiol 1997; 20: 212–214.[CrossRef][Medline]

[3] Seifert T, Block M, Borggrefe M, et al. Erroneous discharge of an implantable cardioverter defibrillator caused by an electric razor. Pacing Clin Electrophysiol 1995; 18: 1592–1594.[CrossRef][Medline]

[4] Man KC, Davidson T, Langberg JJ, et al. Interference from a hand held radiofrequency remote control causing discharge of an implantable defibrillator. Pacing Clin Electrophysiol 1993; 16: 1756–1758.[CrossRef][Medline]

[5] Wayar L, Mont L, Silva RMFL, et al. Electrical interference from an abdominal muscle stimulator unit on an implantable cardioverter defibrillator: report of two consecutive cases. Pacing Clin Electrophysiol 2003; 26: 1292–1293.[Medline]

[6] Sabate X, Moure C, Nicolas J, et al. Washing machine associated 50 Hz detected as ventricular fibrillation by an implanted cardioverter defibrillator. Pacing Clin Electrophysiol 2001; 24: 1281–1283.[Medline]

[7] Lee SW, Moak JP, Lewis B. Inadvertent detection of 60-Hz alternating current by an implantable cardioverter defibrillator. Pacing Clin Electrophysiol 2002; 25: 518–519.[Medline]

[8] Vlay SC. Fish pond electromagnetic interference resulting in an inappropriate implantable cardioverter defibrillator shock. Pacing Clin Electrophysiol 2002; 25: 1532.[Medline]


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