Management of radiation oncology patients with a pacemaker or ICD: A new comprehensive practical guideline in The Netherlands

Abstract

Current clinical guidelines for the management of radiotherapy patients having either a pacemaker or implantable cardioverter defibrillator (both CIEDs: Cardiac Implantable Electronic Devices) do not cover modern radiotherapy techniques and do not take the patient’s perspective into account. Available data on the frequency and cause of CIED failure during radiation therapy are limited and do not converge. The Dutch Society of Radiotherapy and Oncology (NVRO) initiated a multidisciplinary task group consisting of clinical physicists, cardiologists, radiation oncologists, pacemaker and ICD technologists to develop evidence based consensus guidelines for the management of CIED patients. CIED patients receiving radiotherapy should be categorised based on the chance of device failure and the clinical consequences in case of failure. Although there is no clear cut-off point nor a clear linear relationship, in general, chances of device failure increase with increasing doses. Clinical consequences of device failures like loss of pacing, carry the most risks in pacing dependent patients. Cumulative dose and pacing dependency have been combined to categorise patients into low, medium and high risk groups. Patients receiving a dose of less than 2 Gy to their CIED are categorised as low risk, unless pacing dependent since then they are medium risk. Between 2 and 10 Gy, all patients are categorised as medium risk, while above 10 Gy every patient is categorised as high risk. Measures to secure patient safety are described for each category. This guideline for the management of CIED patients receiving radiotherapy takes into account modern radiotherapy techniques, CIED technology, the patients’ perspective and the practical aspects necessary for the safe management of these patients. The guideline is implemented in The Netherlands in 2012 and is expected to find clinical acceptance outside The Netherlands as well.

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

“…Rather, we recommend that each institution generate a specific algorithm to allow careful selection of patients based on radiation dose, tumor and cardiac-device location, and dependence on pacing and other cardiac-device functions, and implement a vigilant monitoring plan such as that described here. The management algorithm for PBT used at our institution is similar to one presented by investigators at the University of Michigan 4 , and a robust and broad approach of risk classification of CIEDs, with a combined set of management procedures, has also been published by the American Association of Physicists in Medicine 14 and by investigators in the Netherlands 15 . Such guidelines are crucial in the multidisciplinary coordination of care for these complex cases.…”

A National Audit of Current Cardiac Device Policies from Radiotherapy Centres across the UK

“…Over the past three decades, the design and technology of CIEDs has evolved and the use of complementary metal oxide semiconductor circuits has expanded [8]. These are more sensitive to ionising radiation than bipolar semiconductor devices used previously, possibly resulting in increased damage and catastrophic failure of the cardiac conduction system in the device [9,10].…”

Radiation Damage Effects on Detectors and Electronic Devices in Harsh Radiation Environment

“…3. Ionizing dose foreseen for CIEDs, when the patient is treated with radiotherapy in dierent areas of the body [10].…”

“…After radiotherapy treatments these devices have reported to fail in dierent ways, for example ICDs experienced from simple malfunctioning, like changes in intervention thresholds, up to complete failure [10]. During radiotherapy treatments such devices have a probability to receive a certain dose depending on the location of the device into the patient body (see Fig.…”

“…3). Three risk groups have been identied by the Dutch Society of Radiotherapy and Oncology for pacemakers and ICDs [10]: a device exposed up to 2 Gy should only be checked for functionality after the treatment, exposure between 2 and 10 Gy needs the presence of a cardiologist and a crash cart during treatment, while over 10 Gy it should be discussed whether the radiotherapy or the cardiac disease are the main concern for the patient, and eventually relocate the device.…”