Table 2.

Sources of EMI and their potential effects

Type of field	Environment	Source	Potential effects												Warranted Precautions
			Damage to CIEDs Circuitry	Pacemaker inhibition	Noise Tracking	Asynchronous pacing	Noise reversion	Communication failure	Current induction	Arrhythmia Detection/ICD shocks	Inhibition of Tachyarrhythmia Detection	Sensing and Pacing Threshold Changes	Power-on-reset	Rate Adaptive Sensor Activation
Electromagnetic	Daily life	Digital music players9,10						⊺							Avoid close proximity (<30 cm) with generator.
		Stereo Speaker and headphones11 (magnetic field strength ≥10 gauss)				⊺	⊺				⊺				Avoid close proximity with generator.
		Neodymium-iron-boron magnets incorporated into toys, jewelry, and clothes12,13				⊺									Avoid close proximity with generator.
		Metal detectors14, 15				⊺				⊺					Alert security personnel regarding the implanted device.
		Electronic Article Surveillance Devices16–19		⊺	⊺	⊺			⊺	⊺					Patients should not linger near surveillance devices to minimize the duration of EMI that might be detected by the CIEDs.
		Cellular Phones20–26		⊺	⊺	⊺			⊺						Avoid close proximity with generator.
		Hand held home phones27		⊺		⊺									Avoid close proximity with generator.
		Tasers28–30		⊺			⊺		⊺	⊺
		Household leakage current from improper grounding31–34		⊺						⊺					Avoid contact with improperly grounded equipment.
		Automotive engine11		⊺			⊺			⊺					Avoid close proximity of ignition system, engine, and alternator with generator.
	Work and industry	Arc welding equipment, electric motors, and degaussing coils35		⊺	⊺		⊺			⊺					Advise employer regarding implanted medical device and consider environmental testing by a trained EMI consultant (list of consultants can be provided by the CIEDs manufacturer). Maintain a minimal distance of 2 ft (61 cm) from the welding arc and cables or large motors. Do not exceed tested currents with the welding equipment, wear insulated gloves while operating electrical equipment, and verify that electrical equipment is properly grounded.
		Aircraft cockpits36		⊺	⊺		⊺			⊺
		RF ID equipment37	⊺	⊺			⊺			⊺
		High voltage power coils38,39		⊺		⊺									Assessment of the threshold safe distance for EMI and follow up device interrogations should be arranged.
	Medical	MRI40	⊺	⊺	⊺	⊺			⊺	⊺					MRI should be performed at experienced centers utilizing a strict protocol for patient monitoring and CIEDs programming (refer to Table 3).
		Electrosurgery41, 42	⊺	⊺		⊺				⊺					No intervention or magnet application is needed for sub-umbilical procedures. For procedures above the umbilicus, programming or magnet application should be performed to activate asynchronous pacing for pacemaker dependent patients as well as deactivation of tachyarrhythmia therapies for ICD recipients. The ground electrode to direct the current path away from the CIEDs.
		LVAD43–45						⊺	⊺
		Cardioversion46–48	⊺									⊺			CIEDs should be programed to a bipolar sensing configuration and should be excluded from the current path by use of an antero-posterior patches/paddles position, placed >6 inches away from the generator.48 Immediate access to a CIEDs programmer is recommended.
		Dental equipment49–51		⊺
		Radiofrequency catheter ablation52–55	⊺	⊺	⊺	⊺	⊺	⊺							Deactivate tachyarrhythmia therapies and activate asynchronous pacing for pacemaker dependent patients.
		Spinal cord56, 57 and deep brain stimulators58, 59		⊺											Program bipolar sensing configuration. Test for interactions intraoperatively and when modifying programming.
		Gastroscopy, endoscopy, and colonoscopy60													No anticipated effects in the absence of electrosurgery.
		Capsule endoscopy61–64				⊺	⊺			⊺					Tachyarrhythmia therapies should be turned off prior to procedure
		Transcutaneous electrical nerve stimulation:65–67		⊺		⊺	⊺			⊺					Magnet application or programming to an asynchronous mode (VOO/DOO) is recommended in pacemaker dependent patients. ICD therapies should be disabled during the treatment.
		Telemetry monitors68			⊺									⊺	Consider deactivation of minute ventilation sensors.
		Electroconvulsive therapy69, 70		⊺											Availability of a magnet or CIEDs programming equipment is advised.
Ionizing Radiation		Radiotherapy71–75	⊺	⊺	⊺		⊺			⊺					CIEDs should be interrogated within 24 hours of each treatment when using a direct beam to the chest or high-energy photon radiation for pacemaker dependent patients.43 Programming the CIEDs to a higher pacing rate than baseline allows rapid recognition of power-on-reset or device malfunction when onsite interrogation is unavailable.
Acoustic Radiation		Lithotripsy76–79		⊺	⊺		⊺			⊺					Patients should be continuously monitored. Also, synchronization of the hydraulic shocks to the R wave should be performed. Dual chamber pacemakers should be reprogrammed to VVI mode. ICD tachyarrhythmia therapies should be deactivated during treatment. CIEDs should be interrogated post procedure.