th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. https://www.uptodate.com/contents/cardiac-implantable-electronic-devices-long-term-complications/print 11/22 7/6/23, 10:48 AM Cardiac implantable electronic devices: Long-term complications - UpToDate Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topics (see "Patient education: Sudden cardiac arrest (The Basics)") Beyond the Basics topics (see "Patient education: Implantable cardioverter-defibrillators (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Lead-related problems include infection, lead failure (resulting in failure to pace, failure to shock, or inappropriate shocks), tricuspid valve damage, venous thrombosis, and increased defibrillation thresholds. Infection of the generator pocket or leads can occur at the time of CIED implantation or at any subsequent time. Because infection of a CIED can be a life-threatening problem, complete removal of the CIED pulse generator and all leads, along with antibiotic therapy, are strongly recommended for nearly all patients. (See 'Infection' above and "Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis" and "Cardiac implantable electronic device lead removal".) Lead failure, which has had a highly variable frequency from lead to lead, has traditionally most commonly been diagnosed when a patient presents with symptoms related to the failed lead (eg, inappropriate implantable cardioverter-defibrillator [ICD] shocks, dizziness or syncope due to failure to pace, etc) and the device parameters are interrogated. When mechanical lead failure has been identified, lead replacement is indicated. (See 'Lead failure' above.) Severe tricuspid regurgitation (TR) can result from the placement of CIED leads causing damage to the tricuspid valve or impeding the appropriate closure of the valve during systole. (See 'Tricuspid regurgitation' above.) The safety threshold values for pacing and defibrillation may change over time. Causes of both increased pacing and defibrillation threshold include lead dislodgement/micro- dislodgement, inflammation around the tip, exit block, lead failure, progression of left ventricular dysfunction and dilatation, and the effects of certain drugs. (See 'Increased defibrillation threshold' above.) https://www.uptodate.com/contents/cardiac-implantable-electronic-devices-long-term-complications/print 12/22 7/6/23, 10:48 AM Cardiac implantable electronic devices: Long-term complications - UpToDate Long-term complications related to the CIED pulse generator are relatively uncommon, occurring in less than 2 percent of patients, and include skin erosion/infection, device and/or lead migration, tissue necrosis (due to the size and weight of the generator) and electromechanical interference/damage. (See 'Pulse generator complications' above and "Cardiac implantable electronic device interactions with electromagnetic fields in the nonhospital environment", section on 'Equipment with high-strength magnets'.) A variety of arrhythmia-related problems can occur in patients with an ICD. Arrhythmic complications include both inappropriate shocks, usually due to the treatment of supraventricular tachycardias, as well as appropriate shocks and "phantom" shocks. Inappropriate shocks (ie, shocks delivered by an ICD for any rather other than ventricular tachyarrhythmia) occur in up to 40 percent of patients with an ICD. The frequency of inappropriate shocks not related to lead malfunction (ie, those related to supraventricular tachycardia [SVT]) can usually be reduced with modern ICD programming strategies. (See 'Inappropriate shocks' above.) Appropriately-delivered ICD shocks for ventricular tachyarrhythmias are not technically a complication but rather the intended response of the device. While potentially life- saving, appropriate shocks can also have an adverse effect on quality of life, including emotional problems and driving restriction. (See 'Appropriate shocks' above.) The perception of having received an ICD shock when no shock was delivered is called a "phantom shock." The optimal strategy to manage phantom shocks depends on the patient, but typically involves close follow-up and reassurance. (See 'Phantom shocks' above.) ACKNOWLEDGMENT The UpToDate editorial staff acknowledges Leonard Ganz, MD, FHRS, FACC, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Pfeiffer D, Jung W, Fehske W, et al. Complications of pacemaker-defibrillator devices: diagnosis and management. 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Topic 989 Version 53.0 https://www.uptodate.com/contents/cardiac-implantable-electronic-devices-long-term-complications/print 19/22 7/6/23, 10:48 AM Cardiac implantable electronic devices: Long-term complications - UpToDate GRAPHICS Documented sources of electromagnetic interference (EMI) in patients with implanted cardiac devices Source Examples Electromagnetic fields Daily life* Faulty home appliances Metal detectors Anti-theft equipment Slot machines Cellular phones and accessories with strong magnets (eg, wireless charging, magnetic fasteners) [1] Work and industrial environment High voltage power lines Welding equipment Electronic motors while "on" Induction furnaces Degaussing coils Medical/hospital environment Magnetic resonance imaging Defibrillation or cardioversion Device-device interaction (eg, pacemaker and neural stimulator) Radiofrequency ablation Electrocautery Transcutaneous nerve stimulation Therapeutic diathermy Lithotripsy Radiation therapy There are many potential sources of single-beat inhibition. However, single-beat inhibition is not clinically significant and does not merit specific mention. If working at or near the level of the power line. There is no convincing evidence that being under the power lines at ground level will cause interference. Although all welding equipment is capable of causing interference, it most commonly occurs with equipment that operates at 150 amps. https://www.uptodate.com/contents/cardiac-implantable-electronic-devices-long-term-complications/print 20/22 7/6/23, 10:48 AM Cardiac implantable electronic devices: Long-term complications - UpToDate Radiation therapy may cause electromagnetic interference but may also result in direct damage to the pulse generator resulting in sudden no output or "runaway." Reference: 1. Greenberg JC, Altawail MR, Singh G. Life saving therapy inhibition by phones containing magnets. Heart Rhythm; 2021. Reproduced with permission from: Pinski SL, Trohman RG. Interference in implanted cardiac devices, Part I. Pacing Clin Electrophysiol 2002; 25:1367. Copyright 2002 Blackwell Publishing. Graphic 51277 Version 8.0 https://www.uptodate.com/contents/cardiac-implantable-electronic-devices-long-term-complications/print 21/22 7/6/23, 10:48 AM Cardiac implantable electronic devices: Long-term complications - UpToDate Contributor Disclosures Jonathan Piccini, MD, MHS, FACC, FAHA, FHRS Grant/Research/Clinical Trial Support: Abbott [Atrial fibrillation, catheter ablation]; AHA [Atrial fibrillation, cardiovascular disease]; Bayer [Atrial fibrillation]; Boston Scientific [Cardiac mapping, pacemaker/ICD, atrial fibrillation care]; iRhythm [Atrial fibrillation]; NIA [Atrial fibrillation]; Philips [Lead management]. Consultant/Advisory Boards: Abbott [Atrial fibrillation, catheter ablation]; Abbvie [Atrial fibrillation]; Bayer [Atrial fibrillation]; Boston Scientific [Cardiac mapping, atrial fibrillation, pacemaker/ICD]; ElectroPhysiology Frontiers [Atrial fibrillation, catheter ablation]; Element Science [DSMB]; Medtronic [Atrial fibrillation, pacemaker/ICDs]; Milestone [Supraventricular tachycardia]; Pacira [Atrial fibrillation]; Philips [Lead extraction]; ReCor [Cardiac arrhythmias]; Sanofi [Atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. N A Mark Estes, III, MD Consultant/Advisory Boards: Boston Scientific [Arrhythmias]; Medtronic [Arrhythmias]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/cardiac-implantable-electronic-devices-long-term-complications/print 22/22