We appreciate the comments of Embil and Geddes. Return to work after implantable cardioverter-defibrillator implantation is potentially complicated by several issues, including lead stability, driving, operating machinery when syncope might result in serious injury or death, and effects of electromagnetic interference.

Endocardial leads are infrequently dislodged after nonthoracotomy implantation of the defibrillator [1]. Although most dislodgments are detected before hospital discharge, optimal lead fixation requires several weeks. We recommend that patients avoid lifting more than 30 pounds and other vigorous arm movements for 6 weeks after lead placement.

Many physicians permit driving about 6 or 7 months after implantation of the defibrillator [2, 3], a decision influenced by state legislation. The hemodynamic stability of the patient's previous arrhythmic episodes should be considered. However, there is no guarantee that subsequent events will not be associated with loss of consciousness. The rate of motor vehicle accidents associated with discharge of implantable cardiac-defibrillators appears to be low; only 10% of discharges that occur while the patient is driving are associated with accidents. One study suggests that the number of injuries and deaths that occur during driving in patients with implanted defibrillators may be less frequent than that in the general population [3]. Most patients with implanted defibrillators drive, even if advised to avoid it permanently. Restrictions for a limited period may be appropriate, but lifelong driving abstinence seems unnecessary.

Operation of potentially dangerous machinery by patients with implanted cardioverter-defibrillators has not been well studied. Negative bias toward these patients should be avoided, but patients should be counseled about potential risks. An individualized approach is recommended. Job retraining can be considered in younger patients, and early retirement may be an option for older patients.

The potential effects of electromagnetic interference in the workplace should not be minimized [4]. Implantable cardioverter-defibrillators that can be deactivated should not be implanted in patients who are likely to encounter strong electromagnetic fields. Transient inhibition poses no problems unless an arrhythmia occurs at exactly the same time. A greater concern is the potential triggering of defibrillator intervention by an oversensing of electrical artifact. Manufacturers of the devices can provide useful information and safety guidelines on electromagnetic interference with different equipment. In special cases, careful evaluation at the workplace, as described by Embil and associates [5], may be indispensable for assuring appropriate defibrillator function in potentially unsafe environments.