Safety of Repetitive Transcranial Magnetic Stimulation in Patients with Cardiac Pacemakers: A Case Report

SOURCE: Journal of ECT. 39(3):e15-e16, 2023 09 01.

AUTHORS: Jammigumpula A; Joseph JT; Manibettu V; Purohith AN; Shenoy S; Udupa S; Praharaj SK

BACKGROUND: Early reports suggested caution when using TMS with pacemakers, VNS, and spinal cord stimulators. Expert safety guidelines per Rossi et al. 2021 indicated TMS is safe if the coil is not activated within 10 cm of these devices. This report demonstrates the safe delivery of TMS treatment in patients with cardiac pacemakers using two different coil devices.

METHODS: Two patients with treatment-resistant depression and cardiac pacemakers were treated in two independent clinics. The first patient was a 55-year-old male with chronic atrial fibrillation requiring a cardiac pacemaker and an implantable defibrillator. He was treated with an H-1 coil to the left DLPFC at 18Hz and 120% of MT for 28 sessions. The second patient was a 68-year-old female with a history of complete heart block who was 98% pacemaker-dependent. She was treated with a figure-8 coil stimulating the left DLPFC at 10Hz and 120% of MT for 36 sessions. Observation by oximetry with alarms outside of 50-100 bpm was also used.

During TMS a donut magnet was taped to the patient’s chest. When placed over the pacemaker, the magnet converts the pacemaker into an asynchronized mode, meaning the pacemaker no longer senses the intrinsic heart rhythm. The pacemaker will then discharge at a fixed rate. When the donut magnet is removed, the pacemaker reverts to its original pacing programming.

RESULTS: Both patients safely completed TMS without deleterious effect on their pacemakers or cardiac status.

CONCLUSIONS: TMS use with pacemakers appeared safe in both the H1 and Figure-8 coils.