Management of patients with implantable cardioverter-defibrillators and pacemakers who require radiation therapy
Introduction
Use of cardiac implantable electronic devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs), along with radiation therapy (RT) has increased significantly over the past 2 decades.1, 2 As each of these therapies is increasingly indicated in older patients, it is not surprising that many patients who require RT have some type of CIED. Although it has been demonstrated that RT can cause both transient malfunction of PMs and ICDs as well as permanent damage to device circuitry,3, 4, 5, 6 precise estimates of this risk are not known. As a result, there are no widely accepted guidelines on how to best manage these patients, although individual institutions have developed local guidelines.7, 8, 9, 10
Modern CIEDS incorporate circuitry composed of complementary metal oxide semiconductor (CMOS) transistors, which allows devices to be smaller, reliable, and energy efficient but makes them susceptible to the effects of ionizing radiation.11, 12, 13 This effect may range from mild corruption of their programming to power-on-reset or complete failure of the device. The likelihood of damage increases with cumulative radiation exposure to the device.11, 12, 13, 14, 15 RT may also acutely affect the function of CIEDs through the generation of electromagnetic noise or other phenomena.8, 16
This single-center study sought to determine the prevalence of CIEDs among patients receiving RT, systematically report the common CIED-related problems in this population, and evaluate a management care path, which was modeled on guidelines for perioperative management of PMs and ICDs17 and refined using the published literature of the effects of RT on CIEDs.11, 12, 13, 14, 15, 16
Section snippets
Methods
At a single tertiary-care center between February 2008 and December 2012, we prospectively screened consecutive patients scheduled to undergo RT and identified those patients with an ICD or PM. Patients treated with only orthovoltage therapy were excluded. Clinical and RT treatment plan information as well as CIED-related data, including device location and PM dependency (defined as no intrinsic rhythm >40 bpm), were collected.
Before RT initiation, cumulative radiation exposure to the device,
Results
Of the 34,706 patients receiving RT between February 2008 and December 2012, 261 (0.8%) had a CIED: 207 (79.3%) PMs and 54 (20.7%) ICDs (Table 2). Of these patients, 67 (25.7%) were PM dependent. Clinical characteristics and RT treatment features of the study population are summarized in Table 2. Treatment regions included head and neck (27.4%), chest ipsilateral to device (9.3%), chest contralateral to device (15.2%), bilateral chest (5.6%), abdomen (3.3%), pelvis (29.3%), and limb (4.4%).
Discussion
This large cohort of patients undergoing RT demonstrates that CIEDs are common in this population, present in nearly 1% of individuals. The enrollment of consecutive patients and systematic monitoring for complications also allow precise estimation of the rate of RT-induced CIED complications in this population. Our results suggest that CIED malfunctions are rare in centers that follow a systematic policy of risk assessment in conjunction with an algorithm for device management. Only 1.5% of
Conclusion
Health care professionals will have to care for a growing population of patients with CIEDs who require RT. Although the potential for RT to cause transient and permanent malfunction in cardiac devices is well established, formal guidelines on how to best manage these patients are lacking. However, RT therapy among patients with CIEDs is safe when a systematic policy of risk assessment and patient management is implemented.
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In-vitro investigation of cardiac implantable electronic device malfunction during and after direct photon exposure: A three-centres experience
2022, Physica MedicaCitation Excerpt :The strategies to manage transient and/or permanent issues depend on the eventually expected malfunctions. In order to prevent inappropriate shock delivery in ICDs or pacing inhibition in PM-dependent patients, a magnet over the ICD site can be placed, as also reported by some authors[24–31]. This disables inappropriate VT/VF detection in ICD patients and inappropriate pacing inhibition resulting in ventricular asystole in PM-dependent patients.
Dr. Connolly has received consulting fees, lecture fees, and grant support from Boehringer Ingelheim. Dr. Healey has received consulting fees, lecture fees and grant support from Boehringer-Ingelheim, Astra-Zeneca, Bayer, St. Jude Medical, and Boston Scientific; and has a personnel award from the Heart and Stroke Foundation, Ontario Provincial office (MC7450). Dr. Capucci receives consulting fees from Merck, Sanofi-Aventis, and Meda Pharmaceuticals; lecture fees from Merck and Sanofi-Aventis; and reimbursement for meeting expenses from Sorin, Boston Scientific, Merck, and Sanofi-Aventis. Dr. Morillo receives consulting fees from St. Jude Medical, Biotronik, Medtronic, Boston Scientific, Sanofi-Aventis, and Boehringer Ingelheim; grant support from St. Jude Medical, Medtronic, and Boston Scientific; and lecture fees from Boston Scientific, St. Jude Medical, Medtronic, Boehringer Ingelheim, Sanofi-Aventis, and Biotronik.