DEGRO/DGK guideline for radiotherapy in patients with cardiac implantable electronic devices

Abstract

An increasing number of patients undergoing radiotherapy (RT) have cardiac implantable electronic devices [CIEDs, cardiac pacemakers (PMs) and implanted cardioverters/defibrillators (ICDs)]. Ionizing radiation can cause latent and permanent damage to CIEDs, which may result in loss of function in patients with asystole or ventricular fibrillation. Reviewing the current literature, the interdisciplinary German guideline (DEGRO/DGK) was developed reflecting patient risk according to type of CIED, cardiac condition, and estimated radiation dose to the CIED. Planning for RT should consider the CIED specifications as well as patient-related characteristics (pacing-dependent, previous ventricular tachycardia/fibrillation). Antitachyarrhythmia therapy should be suspended in patients with ICDs, who should be under electrocardiographic monitoring with an external defibrillator on stand-by. The beam energy should be limited to 6 (to 10) MV CIEDs should never be located in the beam, and the cumulative scatter radiation dose should be limited to 2 Gy. Personnel must be able to respond adequately in the case of a cardiac emergency and initiate basic life support, while an emergency team capable of advanced life support should be available within 5 min. CIEDs need to be interrogated 1, 3, and 6 months after the last RT due to the risk of latent damage.

Safe delivery of lung stereotactic body radiation therapy in a patient with a left ventricular assist device and implantable cardioverter defibrillator

“…Recognizing the increasing number of pacemakerdependent patients diagnosed with cancer, several professional organizations and hospitals have recently published guidelines for radiotherapy in patients with ICDs, making recommendations for radiation dosage and appropriate follow-up. [12][13][14][15] Multiple retrospective case series have also considered the potential effect of radiation on ICDs with reported rates of inappropriate device function ranging between 1.5% and 29%. [14][15][16][17] In particular, it has been shown that neutronproducing radiotherapy, especially >10 MV, is associated with malfunction of contemporary implantable cardiac devices (ICDs and pacemakers).…”

Effect of Therapeutic Ionizing Radiation on Implantable Electronic Devices: Systematic Review and Practical Guidance

“…Moreover, new CIED models are constantly being introduced, with accumulated data on radiation resistance of existing CIEDs becoming outdated, especially in the context of modern irradiation techniques like tomotherapy, respiratory‐gated irradiation, or robotic radiosurgery . Useful guidelines and tips have been recently published by the German Society of Cardiology; however, these guidelines have not been proved in practice or by randomized trials but instead are based on the structure and function of the German health care system and expert consensus. According to those position papers, it is indicated to prepare patients to radiotherapy procedures in 3 steps which are summarized in Table .…”

The effect of stereotactic body radiotherapy (SBRT) using flattening filter‐free beams on cardiac implantable electronic devices (CIEDs) in clinical situations

“…Due to this fact, many studies have focused on the effect of radiotherapy on patients with CIEDs, and many aspects of this field have been investigated in the literature. [8][9][10] However, guidelines 11,12 and reviews 9,13 mainly address the management of patients with CIEDs undergoing conventional radiotherapy. 14,15 The first recommendation from the AAPM on the management of radiotherapy patients with CIEDs dates back to 1994 (TG-34).…”