CASE SERIES

Deep Brain Stimulation in Patients With

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Concomitant Cardiac Pacemakers: A Case Series
Tomas Heard, MBBS∗
Terry Coyne, MBBS∗
Peter Silburn, MBBS, PhD‡
∗
Brizbrain and Spine, Brisbane, Australia;
‡
Asia-Pacific Centre for Neuromodulation,
Queensland Brain Institute, University of
Queensland, Brisbane, Australia
Previously presented in abbreviated form
as a poster at the 73rd Annual Scientific
Meeting of the Neurosurgical Society of
Australasia, September 1, 2017, Adelaide,
South Australia.
Correspondence:
Tomas Heard, MBBS,
Brizbrain and Spine,
Evan Thomson Building,
Suite 20, Level 10, Chasely Street,
Auchenflower 4066,
Queensland, Australia.
E-mail: tomas.heard@gmail.com
Received, June 5, 2018.
Accepted, February 3, 2019.
BACKGROUND: Deep brain stimulation (DBS) is a treatment modality increasingly utilized
in the management of neurological and psychiatric conditions. Neurosurgical technical
considerations and contraindications have yet to be thoroughly characterized in the liter-
ature. The patient population for DBS includes many elderly patients with multiple comor-
bidities who require treatments and investigations that expose them to electromagnetic
fields of varying strengths and durations, including other implanted electromodulatory
devices.
OBJECTIVE: To determine if clinically significant interference arises between DBS and
cardiac pacemaker systems.
METHODS: Here we audited 8 patients, mean age 72, with cardiac pacemakers and DBS
implanted from 2007 to 2015. We investigated details of their neurological and electrocar-
diological treatment and progress and sought evidence for interference between the two
systems.
RESULTS: We found no evidence of DBS dysfunction, and only one case of abnormal
pacemaker interrogation 2 yr post-DBS implantation was found, which was thought to be
secondary to a medication issue rather than neuromodulation interference.
CONCLUSION: Our research reassures the clinician that pacemakers and DBS systems do
not appear to affect one another and provides guidance on minimizing possibility of this.
KEY WORDS: Deep brain stimulation, Cardiac pacemakers, Surgical implantation, Surgical safety, Electronic
interference
Operative Neurosurgery 0:1–5, 2019 DOI: 10.1093/ons/opz018

Copyright 
C 2019 by the

Congress of Neurological Surgeons

D
eep brain stimulation (DBS) is a rapidly
expanding field in the treatment of an
increasingly broad range of conditions,
though the mainstay of clinical applications
remains in the treatment of movement disorders,
especially Parkinson disease (PD). DBS involves
stereotactic guidance of stimulation leads in one
of a number of targets in the basal ganglia,
thalamus, or brainstem, but the most common
target for the treatment of PD is the subthalamic
nucleus. The technique requires constant high-
frequency electrical pulsation delivered through
the stimulation leads for the long term, and,
thus, a power supply must be implanted in the
body. This device is known as an implantable
ABBREVIATIONS: CT, computed tomography; DBS,
deep brain stimulation; ECG, electrocardiogram;
IPG, implantable pulse generator; MRI, magnetic
resonance imaging; PD, Parkinson disease; PPM,
permanent pacemakers
pulse generator (IPG). It is usually implanted
subcutaneously in the chest, superficial to the
pectoralis major, in the same subclavicular area as
commonly used for the implantation of artificial
cardiac pacemakers, also known as permanent
pacemakers (PPM). This brings us to the crux of
the technical issue prompting this report: what
is a surgeon to do when implanting DBS into
a patient with a previously implanted PPM?
What, if any, precautions should they take, what
testing should they perform, and what alterations
should they make to their method? With the
growing use of DBS and expanding range of
indications, many applicable to elderly patients
more likely to have cardiac comorbidities neces-
sitating PPM placement, this scenario will be
increasingly encountered. With both devices
producing electric currents and thus, magnetic
fields, and both containing sensitive circuitry,
the discerning clinician will wonder at the possi-
bility for interference between the two, possible
consequences, and strategies to mitigate the risks.

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HEARD ET AL
METHODS
Subsequent to the approval of the Human Research Ethics Committee
for our hospital system, the archives of our high-volume neurosurgery
clinic were searched for patients whose medical records included a
reference to “pacemaker,” “PPM,” “defibrillator,” or “ICD” throughout
the duration of records from 2007 to 2017. These records were perused
for concordance with broad inclusion criteria, namely, presence of an
active cardiac pacemaker or implanted cardioverter-defibrillator at the
time of implantation of DBS system or a later battery change or stimu-
lation check. Patients found were contacted, and consent obtained
for inclusion in a retrospective case series. Clinical procedures imple-
mented at the time included pacemaker checks preoperatively, intra-
operatively, and postoperatively. Our protocol for intraoperative testing
of pacemaker function was adapted from the Medtronic (Dublin,
Ireland) memorandum on spinal cord stimulators with concomitant
pacemakers/defibrillators, which sets cardiac sensing leads to maximum
sensitivity and stimulator output parameters to maximum, monitoring
for the marker strip detection of stimulator pulses, as well as testing
for interference from battery recharge coils.1 In the event of inter-
ference, consideration must be given to repositioning of devices,
careful monitoring of function of both, and tuning of stimulation
and reception parameters. Our protocol for interoperative testing of
DBS function includes impedance testing, microelectrode and local
field potential recording, and awake clinical testing of microstimulation
efficacy.
RESULTS
Participants
Eight patients were identified undergoing DBS specialist care
with a pacemaker in situ. All 8 agreed to participate and complied
with follow-up by neurosurgical, neurological, and cardiological
teams. A total of 2 patients were in the seventh decade of
life and 6 in the eighth. Table summarizes their demographics,
details of DBS and pacemaker therapies, and electronic and
clinical checks to ensure the functioning of both. All patients
had bilateral subthalamic nuclei DBS for PD, except 1 who had
the same stimulation as required for Meige’s dystonia, a rare
combination of oromandibular dystonia and blepharospasm. All
deep brain stimulators were quadripolar Medtronic models with
a maximum output amplitude of 10.5 V, usually set to output 1
to 5 mA at a high frequency of 130 Hz. All but one pacemaker
was made by Medtronic, with the remainder by St Jude (Saint
Paul, Minnesota). Six were dual-chamber pacemakers, signifying
pacing of right the atrium and ventricle, one biventricular, and
one right univentricular. All pacemakers were functioning on
bipolar settings. All but 2 DBS IPGs were implanted in the right
flank, on the opposite side and opposite extremes of the torso to
the left chest PPM IPGs. Plain radiographs of 2 demonstrative
cases are shown in Figures 1 and 2.
Outcomes and Follow-up
No patients had abnormalities or indications of inter-
ference on DBS impedance measures or functional assess-
ments, or abnormalities on pacemaker interrogation or concerns
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about function, except 1, whose pacemaker abruptly changed
ventricular threshold 2 yr post-DBS implantation. The initial
post-DBS assessment was unremarkable and unconcerning with
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no signs of interference, and no changes to DBS stimulation
parameters were made prior to ventricular threshold change. The
threshold change was, however, coincident with a change in
levodopa dose, which was thought to be the major culprit deter-
mined via a change in cardiac catecholaminergic dose.
DISCUSSION
Key Results
This case series found no evidence of interference between DBS
and PPM systems.
Relevant Literature
Previous evidence from case studies and smaller case series has
largely failed to identify evidence of significant functional inter-
ference,2-8 though an early study did document an ICD resetting
a DBS system on discharge,2 and, worryingly, evidence of thala-
motomy in another ICD/DBS case.9
DBS systems, as passive stimulation devices, currently do not
rely on sensing equipment to titrate or modulate stimulation
parameters in real time. As such, electronic or magnetic fields
would have to directly interfere with output circuitry to affect
function. However, to avoid redundancy, the IPG devices used by
our group are fitted with protective feedthrough filters to shield
internal electronics and dissipate electricity into the external
titanium case. Furthermore, they are conditionally rated for 1.5-
T magnetic resonance imaging (MRI) scanning, during which
they withstand electrical and magnetic field strengths orders of
magnitude above that plausibly generated by a pacemaker.
Theoretical concerns regarding interference from DBS to
pacemaker are more justified in the literature. Like sensitive
receptive and transmissive devices, small perturbations in the
electrical field could theoretically affect pacing parameters and,
ultimately, function. One 2004 study showed significant electro-
cardiogram (ECG) artifacts during monopolar DBS stimu-
lation.10 As such, manufacturer guidelines recommend bipolar
configuration of DBS. However, ECG artifacts have also been
noted in cases of bipolar DBS.11,12
Clinical Implications
While the results of this study are clinically reassuring,
manufacturer advice and our experiences include several points of
consideration to minimize risks. Firstly, the surgeon should place
the DBS IPG at a different site from the pacemaker, either on the
opposite subclavicular pocket or in an abdominal site. Secondly,
to minimize the chance of the PPM detecting the stimulation
field, clinicians should consider setting DBS parameters to bipolar
stimulation, which contains the field to the immediate region of
the surgical target in the basal ganglia, rather than dissipating
toward the precordium as theoretically possible with monopolar
www.operativeneurosurgery-online.com
 DEEP BRAIN STIMULATION WITH CARDIAC PACEMAKERS

TABLE. Demographics, device details, and follow-up summary of all study participants

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Age and sex on DBS
implantation DBS system
73F Bilateral STN DBS
implanted 2012 for PD
71M Bilateral STN DBS
implanted 2012 for PD
65F Bilateral STN DBS
including bilateral IPGs
implanted 2012 for PD
71F Bilateral STN DBS
implanted 2011 for
Meige’s dystonia. IPG
replaced 2013
61F Bilateral STN DBS
implanted 2012 for PD
77M Bilateral STN DBS
implanted 2014 for PD
77M Bilateral STN DBS
implanted 2007 for PD.
IPG replaced 2011
77M Bilateral STN DBS
implanted 2015 for PD
Pacemaker system
Medtronic dual-chamber
pacemaker implanted
2010 for bradycardia and
syncope secondary to
sick sinus syndrome
Medtronic biventricular
pacemaker implanted
2006 post cardiac arrest
for intermittent heart
block
Medtronic dual chamber
pacemaker implanted
2014 for sick sinus
syndrome
Medtronic univentricular
pacemaker implanted
2010 for AV block
Medtronic dual-chamber
pacemaker implanted
2014 for third-degree
complete heart block
Medtronic dual-chamber
pacemaker implanted
2013 for LBBB
Medtronic dual-chamber
pacemaker implanted
2001
St Jude left-sided
dual-chamber
pacemaker implanted
2014 for paroxysmal AF
and recurrent flutter
IPG locations Result of follow-ups
DBS right flank PPM left No concerns with pacemaker
chest Approximately interrogation or DBS impedance or
30 cm apart function up to 2015
DBS right flank PPM left No concerns with pacemaker
chest approximately interrogation or DBS impedance or
30 cm apart function up to 2015
DBS bilateral chest PPM No concerns with pacemaker
left chest Approximately interrogation or DBS impedance or
15 cm and 5 cm apart function up to 2016
DBS right flank PPM left No concerns with pacemaker
chest approximately interrogation or DBS impedance or
30 cm apart function up to 2011
DBS right chest PPM left No concerns with pacemaker
chest approximately interrogation or DBS impedance or
15 cm apart function up to 2015
DBS right flank PPM left No concerns with pacemaker
chest approximately interrogation or DBS impedance or
30 cm apart function up to 2015, but mild
concerns with breathlessness
DBS right flank PPM left No concerns raised regarding
chest Approximately interrogations or symptoms in 2007
30 cm apart after DBS, but in 2009 an abrupt
change in ventricular threshold was
attributed to a change in
antiparkinsonian medications
DBS right flank PPM left No concerns with pacemaker
chest approximately interrogation or DBS impedance or
30 cm apart function up to 2016

DBS, Deep brain stimulation; PD, Parkinson disease; PPM, permanent pacemakers; STN, subthalamic nucleus.

stimulation. Furthermore, a short pulsewidth and limited voltage
of stimulation minimize the magnitude of any ECG artifacts, and
a frequency above heart rate reduces the chance of appearing at
the same point of the cardiac cycle and the PPM interpreting
this as arrhythmia. Thirdly, formal electrocardiography should
be performed pre-, post-, and intraoperatively to confirm pacing
integrity, and formal pacemaker interrogation and cardiologist
review should be performed within weeks of stimulator implan-
tation. If the clinician desires further reassurance, intraoperative
testing can involve testing various stimulator positions against
ECG, and even testing the recharge coil. Any stimulator to
electrocardiogram interference can be minimized by adjustment
of low- and high-pass signal filtration or negated by temporary
inactivation of DBS.
With respect to MRI, an essential step in the stereotactic
implantation of DBS systems is the performance of MRI of
the head within the week prior to surgery, for later fusion
with an immediate preoperative CT. The presence of a cardiac
pacemaker can thus provide another obstacle to DBS therapy—
the contraindication of exposing some pacemakers to magnetic
fields, sometimes excluding all scanning, and sometimes limiting
the magnetic field strength to 1.5 or 3 T depending on the
model. Therefore, alternative targeting methods are sometimes
required. In the case that an MRI of sufficient quality cannot be
obtained, the clinician must perform target-based fusion of early
CT and preoperative CT with the stereotactic frame, navigating
therein relying on judgment and atlas-based systems relative
to cranial and ventricular landmarks as opposed to soft tissue

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HEARD ET AL
FIGURE 1. Plain radiograph of thorax, abdomen, and pelvis, showing DBS
IPG placed in the subcutaneous tissue of the right abdomen, superficial to the
abdominal muscles and their aponeuroses. Cardiac pacemaker IPG implanted
into the left subclavian region.
structures. In this case, it is particularly important to confirm
correct placement with intraoperative impedance sensing,
electrode recording, and testing of clinical symptoms on the
awake patient.
Strengths and Limitations
While this series does not constitute high-level evidence
absolutely confirming the safety of combined DBS and PPM
therapy, and lacks prospective observation, it is the largest in the
literature thus far and reassuring for clinicians while accumu-
lating minable data on the growing populations of PPM and DBS
patients and their overlap.
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FIGURE 2. Plain radiograph of thorax showing DBS IPG implanted in the
left subclavian region. Subsequently a cardiac pacemaker implanted in the left
subclavian region to minimize the possibility of interference.
CONCLUSION
Our study sought to confirm the safety of concomitant DBS
and cardiac pacemaking and found no significant signs of inter-
ference in the largest series yet published. Further research should
involve prospective study designs, perhaps as a component of a
DBS safety and efficacy consortium.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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