High incidence of implantable cardioverter defibrillator malfunctions during radiation therapy: neutrons as a probable cause of soft errors

Abstract

Despite the fact that all recommended precautions were taken to minimize the damage to the ICDs during radiotherapy and the calculated dose to the ICDs was <1 Gy, in 29% of the treatments a malfunction occurred. We observed a possible correlation between the beam energy and the malfunctions. This correlation may be due to an interaction between neutrons produced in the head of the linear accelerator at beam energies ≥10 MeV, and boron-10 which is present in the integrated circuit.

Malfunctions of Implantable Cardiac Devices in Patients Receiving Proton Beam Therapy: Incidence and Predictors

“…Several reports have been published on the effects of photon-based radiation therapy on implantable CIEDs 1,2,5 , but until now little clinical information has been available as to the specific consequences of PBT. Notably, the risk associated with treating patients with thoracic tumors and implanted CIEDs differs substantially for protons vs. photons because of the production of neutrons from protons; photons of lower energies (e.g., 6 MV) do not produce neutrons.…”

“…Notably, the risk associated with treating patients with thoracic tumors and implanted CIEDs differs substantially for protons vs. photons because of the production of neutrons from protons; photons of lower energies (e.g., 6 MV) do not produce neutrons. Indeed, prior CIED studies have suggested that neutron therapy can cause CIED errors 1 , and therefore it is reasonable to conclude that recommendations for radiation therapy for patients with implanted cardiac CIEDs should be individualized according to treatment modality.…”

“…Thus some percentage of patients who require radiation therapy for such malignancies will have CIEDs in place, which further complicates management of already-complex clinical situations. Photon radiation has been amply demonstrated to induce device resets, with higher-energy photons showing higher risks of device malfunctions 1–5 . However, data regarding the incidence of CIED resets in patients receiving proton beam therapy (PBT), which poses a greater risk of neutron scatter than high-energy photons, are sparse 6 .…”

CIED malfunction in patients receiving radiation is a rare event that could be detected by remote monitoring

“…Currently, recommendations by the Heart Rhythm Society and American Society of Anesthesiologists are to interrogate the devices within 24 hours of each treatment when a direct beam to the chest or high-energy photon radiation is used for pacemaker-dependent patients. 5 Additionally, case reports seem to suggest that proton beam therapy produces more neutron scatter than photon therapy, which should lead to more device malfunctions. 3 Each device manufacturer has its own set of recommendations that are based on expert opinion rather than clinical trials.…”

Revisiting the impact of radiation therapy on cardiac implantable electronic device (CIED) function

“…3,5,12 Destruction of CIEDs' electrical components is most often due to direct effects of ionizing radiation and increases with higher energies of RT. 3,5,14,15 The main mechanism considered to underlie the harmful effects of direct ionizing radiation on modern CIED relates to the creation of electron-hole pairs in the silicon dioxide insulator. 5,6,12,13 Damage to random access memory is suggested to result from scatter radiation, originating from the interaction of the photon beam with the patient tissues.…”