INTRODUCTION

Although electrical interference between implanted defibrillators and electro-acupuncture has been reported,1 no information is available regarding electro-acupuncture therapy in patients with a total artificial heart (TAH) (Syncardia Inc, Tucson, Arizona, USA). We describe a case where adjunct electro-acupuncture was successfully used to treat local inflammatory arthritis in a patient with a TAH without any adverse outcomes to the patient or to the device.

CASE REPORT

A 44-year-old patient underwent implantation of a TAH (figure 1) for refractory heart failure of a previously transplanted heart. Unfortunately, the patient had to stay in hospital until the Food and Drug Administration (FDA) approved the portable freedom driver in the USA.

The patient's medical history included myocardial infarction from coronary embolus at the age of 28, hypertension, hyperlipidaemia, related renal insufficiency and prior orthotopic heart transplantation.

During hospitalisation the patient complained of pain in the right wrist. The pain originated abruptly with a maximum intensity of 8/10. It was exacerbated by movement of the wrist and reduced by rest. There was no radiation of the pain and no other joints were involved. The patient reported no trauma to the affected wrist. A diagnosis of inflammatory arthritis was made after initial laboratory and imaging studies were non-specific. Paracetamol (acetaminophen) was initially prescribed every 8 h for pain control; although there was an initial response, it failed to adequately control the pain. Non-steroidal anti-inflammatory drugs were prohibited due to renal failure and the patient was reluctant to take narcotics. Adjunct acupuncture therapy was therefore recommended.

The patient's medications at the time of treatment included warfarin in a daily dose adjusted to maintain international normalised ratio of 2-3, aspirin 81 mg daily, paracetamol 650 mg daily, amlodipine 10 mg daily, clonidine patch #3 weekly, hydralazine 75 mg three times daily, famotidine 20 mg twice daily and dipyridamole 75 mg twice daily.

The patient received acupuncture therapy in the local area of the right wrist daily for three consecutive days. The acupuncture points for therapy were selected by identifying meridians that traversed the right wrist and identifying tender points (Ah-Shi points) in the area according to acupuncture point selection principles (figure 2). The needle retention time of 15 min was accompanied by electrical stimulation by an electro therapy device (Ito IC 1107+, Tokyo, Japan). The frequency switch was set at 'low' (1-20 Hz), the fine frequency control was set at '2' and the intensity was adjusted to induce a sensation of pulsations at the points stimulated. The patient's pain was completely relieved with adjunct acupuncture therapy.

DISCUSSION

Acupuncture

Interaction between the electrical system of implanted cardiovascular devices and electrical stimulation of acupuncture points (electro-acupuncture) is a significant concern in the medical community. 1 Acupuncture is one of the oldest medical practices that is still practised today. Chinese literature points out that acupuncture originated more than 4000 years ago as part of traditional Chinese medicine. Acupuncture is a substantial part of complementary and alternative medicines (CAM) in the USA and an increasing number of Americans use acupuncture for various conditions.2 The use of acupuncture for chronic arthritis and pain control has been described with regard to the lower back and knee.3 4 The safety of acupuncture needles has been established. The US FDA's revised version (1 April 2010) classifies acupuncture needles as a class II medical device for general hospital and personal use.

Total artificial heart

Advances in therapy for coronary artery disease have resulted in a longer lifespan for patients with heart failure.5 Cardiac assist devices are increasingly being used in patients with end-stage heart failure as a bridge to transplantation, recovery or as destination therapy. The TAH (figure 1) is one of the many devices that are implanted in patients with advanced heart failure as a bridge to heart transplantation. 6 Recently, with advances in technology, the smaller portable freedom driver has enabled patients to be discharged home on the TAH.

The Syncardia TAH system consists of two pulsatile artificial ventricles, one driveline for each ventricle and an external console (figure 1). The artificial pulsatile ventricles are sutured to the native atria replacing both native ventricles and the valves. The ventricles are made of a semi-rigid polyurethane housing with four flexible polyurethane diaphragms separating the blood chamber from the air chamber. The diaphragms allow the artificial ventricles to fill and then eject blood when compressed by air from the external console. The air chamber communicates with the external console via a set of pneumatic drivelines. The blood chambers communicate with their inflow and outflow conduits via the respective connectors. Mechanical valves are mounted in the inflow (27 mm) and outflow (25 mm) ports of each ventricle and direct blood flow out of and into the respective conduits. The external console includes a controller and a monitoring computer. The controller is the major component of the external console and supplies pulses of pneumatic pressure to the air chambers of the right and leftartificial ventricles resulting in ejection of blood. Ventricular filling is accomplished through vacuum created by the deflation of air from the air chamber. Thus, the electrical system used to operate the controller, pneumatic pump and the monitor of the TAH is contained within the console, outside the body. There is no body fluid-electrical interface within the patient. Chronic pain related to the device, as well as pain from other comorbidities, is a major concern in these patients which increases the likelihood of seeking CAM therapies.

Electrical interference

When there is a body fluid-electrical interface in a patient as a result of an implanted device, electrical stimulation of acupuncture needles can pose a high risk of electrical interference between the electrical systems of the device and electro-acupuncture. Electrical interference between implanted cardiovascular devices and electro-acupuncture resulting in adverse events has been reported.1 These adverse events can be life-threatening in some instances when related to implantable defibrillators and pacemakers. Unlike pacemakers or defibrillators, the TAH does not have a body fluid-electrical interface within the patient. Electro-acupuncture can therefore be used safely without electrical interference with the TAH.

Other risks

This case report only focuses on complications related to electrical interference. Other complications such as infection and bleeding should be borne in mind at the time of treatment. The acupuncture point location should be selected carefully so as not to cause an infection or bleeding. Needling closer to the central chest where the TAH or driveline exit site is located should be avoided. No information is available with regard to the risk of bleeding or infection in patients with a TAH who are treated with acupuncture. Available information with regard to the risk of bacterial endocarditis in patients with native and artificial heart valves suggests that there may not be any risk.7 However, strict aseptic technique should be observed as much as possible. Patients with a TAH are also anticoagulated so care should be taken to avoid bleeding. No infection or bleeding complications were observed with acupuncture in this patient.

CONCLUSION

Our case illustrates that electro-acupuncture is a safe procedure and can be used as adjunct therapy to control pain and discomfort. In addition, this case also illustrates that electro-acupuncture can be safely performed even in anticoagulated patients, provided appropriate caution is taken. Electro-acupuncture should be performed by individuals who are well trained in this technique and are aware of the contraindications and complications. With an increasing number of patients resorting to alternative and complementary therapies, they should be advised to consult the implanting programme prior to initiating non-conventional medical therapies.

References:

1. Lau EW, Birnie DH, Lemery R, et al. Acupuncture triggering inappropriate ICD shocks. Europace 2005;7:85-6.

2. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008;10:1-23.

3. Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint arthritis: a systematic review and meta-analysis. Rheumatology (Oxford) 2006;45:1331-7.

4. Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med 2004; 141:901-10.

5. Roger VL, Go AS, Donald M, et al. Heart disease and stroke statistics: 2011 update. Circulation 2011;123:e18-209.

6. Copeland JG, Smith RG, Arabia FA, et al for the Cardiowest Total Artificial Heart Investigators. Cardiac replacement with a total artificial heart as a bridge to transplantation. N Engl J Med 2004;351:859-67.

7. Stellon A. Acupuncture in patients with valvular heart disease and prosthetic valves. Acupunct Med 2003;21:87-91.

Author affiliation:

Radha Gopalan,1 Robert Scott,1 Francisco Arabia,2 Krishnaswamy Chandrasekaran1

Author affiliation:

1Department of Internal Medicine, Division of Cardiology, Mayo Clinic, Arizona, USA

2Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic, Arizona, USA

Correspondence to Radha Gopalan, Heart Failure/ Transplantation, Division of Cardiology, Mayo Clinic, Phoenix Campus, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; gopalan.radha@mayo.edu

Acknowledgements The authors acknowledge the editorial support provided by Ms Nicole Srednicki.

Competing interests None.

Patient consent Obtained.

Ethics approval Obtained from the Mayo Clinic.

Provenance and peer review Not commissioned; internally peer reviewed.

Accepted 21 September 2011

Published Online First 4 November 2011

Acupunct Med 2011;29:302-303. doi:10.1136/acupmed.2011.010051