To the Editor: As family physicians practicing and teaching electrosurgery and electrocautery for decades, we write to clarify appropriate practice in response to the article by Lanney and colleagues on pacemaker therapy.1 Although the authors provide a helpful overview, their broad caution about all electrocautery performed above the waist may be appropriate for high-powered operating room devices but perpetuates unfounded concerns about modern office-based practice and contemporary devices.
In the 2024 American Heart Association scientific statement, the authors cite the 2011 Heart Rhythm Society/American Society of Anesthesiologists expert consensus statement without considering technological advances.2,3 Current evidence shows that electromagnetic interference risk is determined primarily by proximity of the electrosurgical tool to the pulse generator and the type of current.4,5 Modern cardiac implantable electronic devices incorporate filtering components, including feedthrough capacitors and band-pass filters, designed to minimize effects of external electrical fields.5
The literature supports a more nuanced approach. The devices most used in family medicine and dermatology, such as the Conmed Hyfrecator, are low-powered monopolar units that do not cycle current through the body to a grounding pad. In vivo data on monopolar hyfrecation show that procedures on the head, neck, and extremities are safe.6 A retrospective study of 45 patients undergoing Mohs surgery and electrodesiccation found no adverse perioperative effects, device malfunction, inappropriate firing, or loss of capture on interrogation.2 This suggests outpatient procedures can generally be performed without excessive monitoring or specialist referral outside a 3 to 15 cm safety margin.6
A 2012 study used a collagen-based gel model implanted with pacemakers and defibrillators to test for interference and found none until the cautery was within 1 cm of the devices at usual clinical power settings or until within 3 cm at the highest power settings. It conservatively recommended avoiding hyfrecator use within approximately 5 cm of pacemakers or defibrillators, an area rarely involved in skin cancers and procedures typically managed in family medicine.4
The above the umbilicus rule may be useful in the operating room for major surgery, but invoking it indiscriminately perpetuates the myth that office electrocautery cannot be used safely in patients with pacemakers.
Daniel Stulberg, MD, FAAFP
Albuquerque, New Mexico
danstulberg@gmail.com
Ricardo Galicia, MD
Albuquerque, New Mexico
Author Disclosure: No relevant financial relationships.
Editor’s Note: This letter was sent to the authors of “Pacemaker Therapy: Indications and Recommendations,” who declined to reply.
