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Öztürk HF, Arslan SA, Gani Z, Aras D, Tezcan Y. From organ at risk to target organ: Dosimetric comparison of myocardial stereotactic ablative body radiotherapy between helical tomotherapy and volumetric arc therapy for refractory ventricular tachycardia. Med Dosim 2023; 48:293-298. [PMID: 37673728 DOI: 10.1016/j.meddos.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/19/2023] [Accepted: 08/03/2023] [Indexed: 09/08/2023]
Abstract
Ventricular tachycardia (VT) is an important type of arrhythmia with a risk of sudden death. Although implanted cardiac defibrillation and radiofrequency ablation are used together with medical treatments for VT, the treatment options are limited in cases that do not respond to them. Stereotactic ablative body radiotherapy (SABR) applied to VT substrates in resistant cases is an emerging treatment with positive results. Such clinical results have increased the interest in this subject. However, the ideal treatment device and method have not yet been described for this therapy, which is generally applied at a single fraction using various devices and methods. Herein, treatment planning was conducted for a total of 8 patients (11 VT substrates) using the Varian TrueBeam EDGE and TomoTherapy Radixact devices at a single center, and the results were compared dosimetrically. The Wilcoxon-signed rank test was used for the statistical analysis, and mean values were expressed as medians and interquartile ranges (IQRs). In the volumetric modulated arc therapy (VMAT) and helical tomotherapy (HT) plans, the plan coverages and conformity indexes were similar; meanwhile, the homogeneity indexes were 0.10 (IQR = 0.05) and 0.07 (IQR = 0.05), respectively, and were significantly better in the HT plan (p = 0.02). The gradient indexes were 3.18 (IQR = 0.8) and 5.33 (IQR = 3.68) in the VMAT and HT plans, respectively, and were significantly better in the VMAT plan. For the organs at risk, similar doses were observed. The maximum doses for the stomach and esophagus and the mean doses for the left lung and both lungs were significantly lower in the VMAT plan. Similarly, the maximum and mean doses for the cardiac substructures and great vessels were significantly lower in the VMAT plan. More homogeneous plans were obtained in HT, while a faster dose reduction and lower critical organ dose were observed in VMAT. Reasonable myocardial SABR plans could be obtained with both techniques. The effects of the dosimetric differences on the clinical outcomes should be evaluated in prospective clinical studies.
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Affiliation(s)
- Hüseyin Furkan Öztürk
- Department of Radiation Oncology, Yıldırım Beyazıt University, Ankara 06800, Turkey.
| | - Suheyla Aytaç Arslan
- Department of Radiation Oncology, Yıldırım Beyazıt University, Ankara 06800, Turkey
| | - Zerrin Gani
- Department of Radiation Oncology, Ankara Bilkent City Hospital, Ankara 06800, Turkey
| | - Dursun Aras
- Department of Cardiology, İstanbul Medipol University Bahçelievler Hospital, Istanbul 34196, Turkey
| | - Yılmaz Tezcan
- Department of Radiation Oncology, Yıldırım Beyazıt University, Ankara 06800, Turkey
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Safavi AH, Louie AV, Elzibak AH, Warner A, Donovan EK, Detsky JS. Management of Patients with Cardiovascular Implantable Electronic Devices Undergoing Radiation Therapy: A National Survey of Canadian Multidisciplinary Radiation Oncology Professionals. Adv Radiat Oncol 2023; 8:101184. [PMID: 36874173 PMCID: PMC9975614 DOI: 10.1016/j.adro.2023.101184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/11/2023] [Indexed: 01/26/2023] Open
Abstract
Purpose This study aimed to characterize contemporary management of Canadian patients with cardiovascular implantable electronic devices (CIEDs) undergoing radiation therapy (RT) in light of updated American Association of Physicists in Medicine guidelines. Methods and Materials A 22-question web-based survey was distributed to members of the Canadian Association of Radiation Oncology, Canadian Organization of Medical Physicists, and Canadian Association of Medical Radiation Technologists from January to February 2020. Respondent demographics, knowledge, and management practices were elicited. Statistical comparisons by respondent demographics were performed using χ2 and Fisher exact tests. Results In total, 155 surveys were completed by 54 radiation oncologists, 26 medical physicists, and 75 radiation therapists in academic (51%) and community (49%) practices across all provinces. The majority of respondents (77%) had managed >10 patients with CIEDs in their career. Most respondents (70%) reported using risk-stratified institutional management protocols. Respondents used manufacturer recommendations, rather than American Association of Physicists in Medicine or institutionally recommended dose limits, when the manufacturer limit was 0 Gy (44%), 0 to 2 Gy (45%), or >2 Gy (34%). The majority of respondents (86%) reported institutional policies to refer to a cardiologist for CIED evaluation both before and after completion of RT. Cumulative dose to CIED, pacing dependence, and neutron production were considered during risk stratification by 86%, 74%, and 50% of participants, respectively. Dose and energy thresholds for high-risk management were not known by 45% and 52% of respondents, with radiation oncologists and radiation therapists significantly less likely to report thresholds than medical physicists (P < .001). Although 59% of respondents felt comfortable managing patients with CIEDs, community respondents were less likely to feel comfortable than academic respondents (P = .037). Conclusions The management of Canadian patients with CIEDs undergoing RT is characterized by variability and uncertainty. National consensus guidelines may have a role in improving provider knowledge and confidence in caring for this growing population.
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Affiliation(s)
- Amir H. Safavi
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Alexander V. Louie
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alyaa H. Elzibak
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Elysia K. Donovan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jay S. Detsky
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Corresponding author: Jay S. Detsky, MD, PhD
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3
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Hughey S, Field R, Campbell D, Cole J, Booth G, Stringer M, Stedjelarsen E. Military concerns for chronic pain stimulator devices. BMJ Mil Health 2023:e002366. [PMID: 37336581 DOI: 10.1136/military-2023-002366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/14/2023] [Indexed: 06/21/2023]
Abstract
Spinal cord stimulators (SCS) and peripheral nerve stimulators (PNS) are increasingly used in the treatment of chronic pain, allowing more patients to resume working and return to activities. Military service members face environmental and occupational hazards that expose them to mechanical and electromagnetic forces, both clinical and industrial, that could potentially alter their function. While there are reports of individual hazards, the risk appears to be nominal based on the large number of devices in use and the limited reported complications with these devices. Since a variety of hazards encountered by military patients have the potential to alter SCS and PNS devices, a brief discussion of each patient's specific exposures and related hazards should occur prior to placement. Overall, these devices have demonstrated safety in hazardous areas and few military patients have contraindications for placement based on these factors alone.
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Affiliation(s)
- Scott Hughey
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Anesthesiology and Pain Medicine, Naval Hospital Okinawa, Okinawa, Japan
| | - R Field
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - D Campbell
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - J Cole
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - G Booth
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - M Stringer
- NASA Langley Research Center, Hampton, Virginia, USA
| | - E Stedjelarsen
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
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4
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Azraai M, Miura D, Lin YH, Rodrigues TS, Nadurata V. Incidence and Predictors of Cardiac Implantable Electronic Devices Malfunction with Radiotherapy Treatment. J Clin Med 2022; 11:jcm11216329. [PMID: 36362559 PMCID: PMC9654752 DOI: 10.3390/jcm11216329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 12/01/2022] Open
Abstract
Aims: To investigate the incidence of cardiac implantable electronic devices (CIED) malfunction with radiotherapy (RT) treatment and assess predictors of CIED malfunction. Methods: A 6-year retrospective analysis of patients who underwent RT with CIED identified through the radiation oncology electronic database. Clinical, RT (cumulative dose, dose per fraction, beam energy, beam energy dose, and anatomical area of RT) and CIED details (type, manufacturer, and device malfunction) were collected from electronic medical records. Results: We identified 441 patients with CIED who underwent RT. CIED encountered a permanent pacemaker (PPM) (78%), cardiac resynchronization therapy—pacing (CRT-P) (2%), an implantable cardioverter defibrillator (ICD) (10%), and a CRT-defibrillator (CRT-D) (10%). The mean cumulative dose of RT was 36 gray (Gy) (IQR 1.8–80 Gy) and the most common beam energy used was photon ≥10 megavolt (MV) with a median dose of 7 MV (IQR 5–18 MV). We further identified 17 patients who had CIED malfunction with RT. This group had a higher cumulative RT dose of 42.5 Gy (20–77 Gy) and a photon dose of 14 MV (12–18 MV). None of the malfunctions resulted in clinical symptoms. Using logistic regression, the predictors of CIED malfunction were photon beam energy use ≥10 MV (OR 5.73; 95% CI, 1.58–10.76), anatomical location of RT above the diaphragm (OR 5.2, 95% CI, 1.82–15.2), and having a CIED from the ICD group (OR 4.6, 95% CI, 0.75–10.2). Conclusion: Clinicians should be aware of predictors of CIED malfunction with RT to ensure the safety of patients.
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Affiliation(s)
- Meor Azraai
- Department of Cardiology, Bendigo Health, Bendigo, VIC 3550, Australia
- Faculty of Medicine, Nursing and Health Sciences, School of Rural Health, Monash University, Melbourne, VIC 3550, Australia
- Correspondence: or ; Tel.: +613-5454-6000
| | - Daisuke Miura
- Department of Cardiology, Bendigo Health, Bendigo, VIC 3550, Australia
| | - Yuan-Hong Lin
- Department of Radiation Oncology, Peter McCallum, Bendigo Health, Bendigo, VIC 3550, Australia
| | - Thalys Sampaio Rodrigues
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Voltaire Nadurata
- Department of Cardiology, Bendigo Health, Bendigo, VIC 3550, Australia
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Frey P, Irles D, Dompnier A, Akret C, Hosu IC, Narayanan K, Mazoyer F, Yayehd K, Guillon B, Marijon E. Cardiac Implantable Electronic Device Dysfunctions in Patients Undergoing Radiotherapy A Prospective Cohort Study. J Cardiovasc Electrophysiol 2022; 33:1013-1023. [PMID: 35299286 DOI: 10.1111/jce.15449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/28/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Increasing numbers of patients with cardiac implantable electronic devices (CIEDs) are undergoing radiotherapy for cancer. The aim of the study was to prospectively evaluate the incidence, characteristics, and associated factors of CIED dysfunctions related to radiotherapy. METHODS Between April 2013 and March 2020, all patients with a CIED who underwent ≥1 radiotherapy session were enrolled. Patients were monitored according to a systematic protocol, including device interrogation before the 1st and after each radiotherapy session. The primary endpoint was CIED dysfunction, defined as oversensing, total or partial deprogramming, and/or unrecoverable reset. RESULTS We included a total of 92 CIED radiotherapy courses: 77 (83.7%) in patients with a pacemaker and 15 (16.3%) in those with an implantable cardioverter defibrillator. Overall, 13 dysfunctions (14.1%) were observed during 92 courses (1509 sessions), giving an incidence of 0.9 per 100 sessions. These included nine deprogramming (three total resets to back-up pacing mode and six partial deprogramming that were all successfully reprogrammed), three transient oversensing, and one unrecoverable oversensing requiring CIED and leads replacement. There were no adverse clinical events related to device dysfunction. In multivariable analysis, neutron-producing irradiation (odds ratio [OR], 5.59; 95% confidence interval [CI], 1.09-28.65; P=0.039) and cumulative tumor dose (OR, 1.05; 95% CI, 1.01-1.10; P=0.007) remained significantly associated with CIED dysfunction. CONCLUSIONS In this prospective study, transient or permanent subclinical CIED dysfunction occurred in 14.1% of radiotherapy courses. Our findings emphasize the importance of high-energy beams and neutron-producing irradiation in risk assessment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Pierre Frey
- Department of cardiology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370, Metz-Tessy, France
| | - Didier Irles
- Department of cardiology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370, Metz-Tessy, France
| | - Antoine Dompnier
- Department of cardiology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370, Metz-Tessy, France
| | - Chrystelle Akret
- Department of cardiology, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370, Metz-Tessy, France
| | - Iolanda C Hosu
- Department of radiotherapy, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370, Metz-Tessy, France
| | - Kumar Narayanan
- University of Paris, Paris-Cardiovascular Research Center, INSERM, F-75015, Paris, France.,Medicover Hospitals, Hyderabad, India
| | - Fréderic Mazoyer
- Department of radiotherapy, Centre Hospitalier Annecy Genevois, 1 Avenue de l'Hôpital, 74370, Metz-Tessy, France
| | - Komlavi Yayehd
- Department of cardiology, CHU Campus Lomé, 03 BP, 30284, Lomé, Togo
| | - Benoît Guillon
- Department of cardiology, University Hospital Besancon, 25000, Besancon, France.,EA3920, University of Burgundy-Franche-Comté, Besancon, France
| | - Eloi Marijon
- University of Paris, Paris-Cardiovascular Research Center, INSERM, F-75015, Paris, France.,Cardiology department, European Georges Pompidou Hospital, 75908, Paris, Cedex, 15, France
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Gauter-Fleckenstein B, Tülümen E, Rudic B, Borggrefe M, Polednik M, Fleckenstein J. Local dose rate effects in implantable cardioverter-defibrillators with flattening filter free and flattened photon radiation. Strahlenther Onkol 2022; 198:566-572. [PMID: 35267050 PMCID: PMC9165256 DOI: 10.1007/s00066-022-01911-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/08/2022] [Indexed: 11/28/2022]
Abstract
Purpose In the beam penumbra of stereotactic body radiotherapy volumes, dose rate effects in implantable cardioverter–defibrillators (ICDs) may be the predominant cause for failures in the absence of neutron-generating photon energies. We investigate such dose rate effects in ICDs and provide evidence for safe use of lung tumor stereotactic radioablation with flattening filter free (FFF) and flattened 6 Megavolt (MV) beams in ICD-bearing patients. Methods Sixty-two ICDs were subjected to scatter radiation in 1.0, 2.5, and 7.0 cm distance to 100 Gy within a 5 × 5 cm2 radiation field. Radiation was applied with 6 MV FFF beams (constant dose rate of 1400 cGy/min) and flattened (FLAT) 6 MV beams (430 cGy/min). Local dose rates (LDR) at the position of all ICDs were measured. All ICDs were monitored continuously. Results With 6 MV FFF beams, ICD errors occurred at distances of 1.0 cm (LDR 46.8 cGy/min; maximum ICD dose 3.4 Gy) and 2.5 cm (LDR 15.6 cGy/min; 1.1 Gy). With 6 MV FLAT beams, ICD errors occurred only at 1 cm distance (LDR 16.8 cGy/min; 3.9 Gy). No errors occurred at an LDR below 7 cGy/min, translating to a safe distance of 2.5 cm (1.5 Gy) in flattened and 7 cm (0.4 Gy) in 6 MV FFF beams. Conclusion A LDR in ICDs larger than 7 cGy/min may cause ICD malfunction. At identical LDR, differences between 6 MV FFF and 6 MV FLAT beams do not yield different rates of malfunction. The dominant reason for ICD failures could be the LDR and not the total dose to the ICD. For most stereotactic treatments, it is recommended to generate a planning risk volume around the ICD in which LDR larger than 7 cGy/min are avoided.
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Affiliation(s)
- Benjamin Gauter-Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Erol Tülümen
- I. Medizinische Klinik, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.,Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research (DZHK), Mannheim, Germany
| | - Boris Rudic
- I. Medizinische Klinik, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.,Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research (DZHK), Mannheim, Germany
| | - Martin Borggrefe
- I. Medizinische Klinik, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.,Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research (DZHK), Mannheim, Germany
| | - Martin Polednik
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Daniela Falco M, Andreoli S, Delana A, Barbareschi A, De Filippo P, Leidi C, Marini M, Appignani M, Genovesi D, Di Girolamo E. In-vitro investigation of cardiac implantable electronic device malfunction during and after direct photon exposure: A three-centres experience. Phys Med 2022; 94:94-101. [PMID: 35007940 DOI: 10.1016/j.ejmp.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/26/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Radiotherapy may cause malfunction of implantable cardioverter-defibrillators (ICDs) and pacemakers (PMs). We carried-out a multicentre randomized in-vitro study on 65 ICDs and 145 PMs to evaluate malfunctions during and after direct irradiation to doses up to 10 Gy. METHODS Three centres equipped with different linear accelerator and treatment-planning systems participated in the study. Computed Tomography (CT) acquisitions were performed to build the treatment plans. All devices were exposed to dose of 2, 5, or 10 Gy (6 MV). All devices underwent a baseline examination and 64 wireless real-time telemetry-transmissions (47 ICDs and 17 PMs) were monitored during photon exposures. All devices were interrogated after exposure and once monthly for six subsequent months. RESULTS Fifty-four of the 64 wireless-enabled CIEDs (84.4%) recorded noise-related interferences during exposure. In detail, 40/47 ICDs (85.1%) reported interference, of which 16 ICDs (34%) reported potentially clinically relevant pacing inhibition and inappropriate detections. Following exposure, a soft reset occurred in 1/145 PM (0.7%) while 7/145 PMs (4.8%) reported battery issues. During the six-month follow-up, 1/145 PM (0.7%) reported a soft reset, while 12/145 more PMs (8.3%) and 1/64 ICD (1.5%) showed abnormal battery depletion. All reported issues occurred independently of exposure dose. Finally, irreversible effects on software and battery life occurred in only non-MRI-compatible devices. CONCLUSION ICDs mostly featured real-time transient sensing issues, while PMs mostly experienced long-term battery or software issues that were observed immediately following radiation exposure and during follow-up. Irreversible effects on battery life and software occurred in only non-MRI-compatible devices.
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Affiliation(s)
- Maria Daniela Falco
- Department of Radiation Oncology, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy.
| | - Stefano Andreoli
- Medical Physics Unit, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Anna Delana
- Medical Physics Unit, "S. Chiara" Hospital, Trento, Italy
| | | | - Paolo De Filippo
- Electrophysiology Unit, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Cristina Leidi
- Electrophysiology Unit, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | | | | | - Domenico Genovesi
- Department of Radiation Oncology, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy
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Okano N, Sakai M, Shibuya K, Tsuda K, Kanzaki T, Sano M, Kaneko Y, Ohno T. Safety verification of carbon-ion radiotherapy for patients with cardiac implantable electronic devices (CIEDs). JOURNAL OF RADIATION RESEARCH 2022; 63:122-127. [PMID: 34747483 PMCID: PMC8776694 DOI: 10.1093/jrr/rrab105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/17/2021] [Indexed: 06/13/2023]
Abstract
According to guidelines, carbon-ion beam therapy is considered to carry a high safety risk for patients with cardiac implantable electronic devices (CIEDs), although the actual impacts remain unclear. In this study, we investigated the safety of carbon-ion beam therapy in patients with CIEDs. Patients with CIEDs who underwent carbon-ion therapy at Gunma University Heavy Ion Medical Center between June 2010 and December 2019 were identified and investigated for abnormalities in the operation of their CIEDs, such as oversensing and resetting during irradiation, and abnormalities in operation after treatment. In addition, the risk of irradiation from carbon-ion beam therapy was evaluated by model simulations. Twenty patients (22 sites) with CIEDs were identified, 19 with pacemakers and one with an implantable cardioverter-defibrillator (ICD). Treatments were completed without any problems, except for one case in which the treatment was discontinued because of worsening of the primary disease. Monte Carlo simulation indicated that the carbon beam irradiation produced neutrons at a constant and high level in the irradiation field. Nevertheless, with the distances between the CIEDs and the irradiation fields in the analyzed cases, the quantity of neutrons at the CIEDs was lower than that within the irradiation. Although carbon-ion beam therapy can be safely administered to patients with CIEDs, it is advisable to perform the therapy with sufficient preparation and backup devices because of the risks involved.
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Affiliation(s)
- Naoko Okano
- Corresponding author. Naoko Okano, Gunma University, Heavy Ion Medical Center, 371-8511, 3-39-22 Showa-machi Maebashi, Gunma, Japan. Tel: (+81) 27-220-8383; Fax: (+81) 27-220-8384;
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9
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Zagzoog A, Wronski M, Birnie DH, Yeung C, Baranchuk A, Healey JS, Golian M, Boles U, Carrizo AG, Turner S, Hassan A, Ali E, Kumar SK, Russell S, Shurrab M, Crystal E. Assessment of Radiation-Induced Malfunction in Cardiac Implantable Electronic Devices. CJC Open 2021; 3:1438-1443. [PMID: 34993455 PMCID: PMC8712607 DOI: 10.1016/j.cjco.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/07/2021] [Indexed: 12/25/2022] Open
Abstract
Background Radiation therapy (RT) is a standard cancer treatment modality, and an increasing number of patients with cardiac implantable electronic devices (CIEDs) are being referred for RT. The goals of this study were as follows: (i) to determine the incidence of CIED malfunction following RT; (ii) to characterize the various types of malfunctions that occur; and (iii) to identify risk factors associated with CIED malfunction following RT. Methods A retrospective study of patients with CIEDs who received RT between 2007 and 2018 at 4 Canadian centres (Sunnybrook Health Sciences Centre, Kingston General Hospital, Hamilton Health Sciences Centre, and University of Ottawa Heart Institute) was conducted. Patients underwent CIED interrogation after completion of RT, to assess for late damage to the CIEDs. Data on demographics, devices, and RT were compared for the primary outcome of device malfunction. Results Of 1041 patients with CIEDs who received RT, 811 patients with complete data were included. Device malfunctions occurred in 32 of 811 patients (4%). The most common device malfunctions were reduced ventricular/atrial sensing (in 13 of 32 [41%]), an increase in lead threshold (in 9 of 32 [22%]), lead noise (in 5 of 32 [16%]), and electrical reset (in 2 of 32 [6%]). Higher beam energy (≥ 10 MV) was associated with malfunction (P < 0.0001). Radiation dose was not significantly different between the malfunction and non-malfunction groups (58.3 cGy vs 65 cGy, respectively, P = 0.71). Conclusions Although RT-induced CIED malfunctions are rare (occurring in 4% of patients with a CIED who undergo RT), collaborative efforts between radiation oncologists and cardiac rhythm device clinics to optimize CIED monitoring are needed, to detect and manage CIED malfunctions. Malfunctions are more common in patients receiving higher–beam energy (≥10MV)RT.
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Affiliation(s)
- Amin Zagzoog
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Matt Wronski
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David H. Birnie
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Cynthia Yeung
- Kingston General Hospital, Queens School of Medicine, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Kingston General Hospital, Queens School of Medicine, Kingston, Ontario, Canada
| | - Jeffrey S. Healey
- Hamilton Health Sciences and Centre, McMaster University, Hamilton, Ontario, Canada
| | - Mehrdad Golian
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Usama Boles
- Kingston General Hospital, Queens School of Medicine, Kingston, Ontario, Canada
| | - Aldo G. Carrizo
- Hamilton Health Sciences and Centre, McMaster University, Hamilton, Ontario, Canada
| | - Suzette Turner
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Hassan
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Elsayed Ali
- The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, Ontario, Canada
| | - Sharath K. Kumar
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Steve Russell
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Shurrab
- Health Sciences North, Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Eugene Crystal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Corresponding author: Dr Eugene Crystal, Division of Cardiology, Department of Medicine, D377, 2075 Bayview Ave, Toronto, Onntario M4N 3M5, Canada. Tel.: +1-416-480-6100.
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Azraai M, D'Souza D, Nadurata V. Current Clinical Practice in Patients With Cardiac Implantable Electronic Devices (CIED) Undergoing Radiotherapy (RT). Heart Lung Circ 2021; 31:327-340. [PMID: 34844904 DOI: 10.1016/j.hlc.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/05/2021] [Accepted: 10/25/2021] [Indexed: 11/26/2022]
Abstract
Patients with cardiac implantable electronic devices (CIED) undergoing radiotherapy (RT) are more common due to ageing of the population. With newer CIEDs implementing the complementary metal-oxide semiconductor (CMOS) technology which allows the miniaturisation of CIED, it is also more susceptible to RT. Effects of RT on CIED ranges from device interference, device operational/memory errors of permanent damage. These malfunctions can cause life threatening clinical effects. Cumulative dose is not the only component of RT that causes CIED malfunction, as neutron use and dose rate effect also affects CIEDs. The management of this patient cohort in clinical practice is inconsistent due to lack of a consistent guideline from manufacturers and physician specialty societies. Our review will focus on the current clinical practice and the recent updated guidelines of managing patients with CIED undergoing RT. We aim to simplify the evidence and provide a simple and easy to use guide based on the recent guidelines.
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Affiliation(s)
- Meor Azraai
- Department of Cardiology, Bendigo Health, Bendigo, Vic, Australia.
| | - Daniel D'Souza
- Department of Cardiology, Bendigo Health, Bendigo, Vic, Australia
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Hashimoto T, Demizu Y, Numajiri H, Isobe T, Fukuda S, Wakatsuki M, Yamashita H, Murayama S, Takamatsu S, Katoh H, Murata K, Kohno R, Arimura T, Matsuura T, Ito YM. Particle therapy using protons or carbon ions for cancer patients with cardiac implantable electronic devices (CIED): a retrospective multi-institutional study. Jpn J Radiol 2021; 40:525-533. [PMID: 34779984 PMCID: PMC9068656 DOI: 10.1007/s11604-021-01218-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/05/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the outcomes of particle therapy in cancer patients with cardiac implantable electronic devices (CIEDs). MATERIALS AND METHODS From April 2001 to March 2013, 19,585 patients were treated with proton beam therapy (PBT) or carbon ion therapy (CIT) at 8 institutions. Of these, 69 patients (0.4%, PBT 46, CIT 22, and PBT + CIT 1) with CIEDs (64 pacemakers, 4 implantable cardioverter defibrillators, and 1 with a cardiac resynchronization therapy defibrillator) were retrospectively reviewed. All the patients with CIEDs in this study were treated with the passive scattering type of particle beam therapy. RESULTS Six (13%) of the 47 PBT patients, and none of the 23 CIT patients experienced CIED malfunctions (p = 0.105). Electrical resets (7) and over-sensing (3) occurred transiently in 6 patients. The distance between the edge of the irradiation field and the CIED was not associated with the incidence of malfunctions in 20 patients with lung cancer. A larger field size had a higher event rate but the test to evaluate trends as not statistically significant (p = 0.196). CONCLUSION Differences in the frequency of occurrence of device malfunctions for patients treated with PBT and patients treated with CIT did not reach statistical significance. The present study can be regarded as a benchmark study about the incidence of malfunctioning of CIED in passive scattering particle beam therapy and can be used as a reference for active scanning particle beam therapy.
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Affiliation(s)
- Takayuki Hashimoto
- Department of Radiation Medical Science and Engineering, Faculty of Medicine, Hokkaido University, North 15 West 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Yusuke Demizu
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, Japan
| | - Haruko Numajiri
- Department of Radiation Oncology, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Tomonori Isobe
- Department of Radiation Oncology, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Shigekazu Fukuda
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
| | - Masaru Wakatsuki
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
| | - Haruo Yamashita
- Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, Japan
| | - Shigeyuki Murayama
- Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, Japan
| | - Shigeyuki Takamatsu
- Department of Radiation Therapy, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Katoh
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, Japan
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, Japan
| | - Kazutoshi Murata
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, Japan
| | - Ryosuke Kohno
- National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, Japan
- Department of Accelerator and Medical Physics, National Institute for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
| | - Takeshi Arimura
- Medipolis Proton Therapy and Research Center, 4423, Higashikata, Ibusuki, Kagoshima, Japan
| | - Taeko Matsuura
- Faculty of Engineering, Hokkaido University, Kita 13, Nishi 8, Kita-ku, Sapporo, Hokkaido, Japan
| | - Yoichi M Ito
- Biostatistics Division, Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, Japan
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Matsubara H, Ezura T, Hashimoto Y, Karasawa K, Nishio T, Tsuneda M. Study of feasible and safe condition for total body irradiation using cardiac implantable electronic devices. JOURNAL OF RADIATION RESEARCH 2021:rrab088. [PMID: 34542633 DOI: 10.1093/jrr/rrab088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/09/2021] [Indexed: 06/13/2023]
Abstract
Cardiac implantable electronic devices (CIEDs) were believed to have a tolerance dose and that direct irradiation has to be avoided. Thus, no clinical guidelines have mentioned the feasibility of total body irradiation (TBI) with a CIED directly. The purpose of this work was to study a feasible and safe condition for TBI using a CIED. Eighteen CIEDs were directly irradiated by a 6-MV X-ray beam, where a non-neutron producible beam was employed for the removal of any neutron contribution to CIED malfunction. Irradiation up to 10 Gy in accumulated dose was conducted with a 100-cGy/min dose rate, followed by up to 20 Gy at 200 cGy/min. An irradiation test of whether inappropriate ventricular shock therapy was triggered or not was also performed by using a 6-MV beam of 5, 10, 20 and 40 cGy/min to two CIEDs. No malfunction was observed during irradiation up to 20 Gy at 100 and 200 cGy/min without activation of shock therapy. These results were compared with typical TBI, suggesting that a CIED in TBI will not encounter malfunction because the prescribed dose and the dose rate required for TBI are much safer than those used in this experiment. Several inappropriate shock therapies were, however, observed even at 10 cGy/min if activated. The present result suggested that TBI was feasible and safe if a non-neutron producible beam was employed at low dose-rate without activation of shock therapy, where it was not inconsistent with clinical and non-clinical data in the literature. The feasibility of TBI while using a CIED was discussed for the first time.
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Affiliation(s)
- Hiroaki Matsubara
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Takatomo Ezura
- Department of Radiology, Tokyo Women's Medical University Hospital, Tokyo 162-8666, Japan
| | - Yaichiro Hashimoto
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Kumiko Karasawa
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Teiji Nishio
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Masato Tsuneda
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
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Azraai M, D'Souza D, Lin YH, Nadurata V. Current clinical practice in patients with cardiac implantable electronic devices undergoing radiotherapy: a literature review. Europace 2021; 24:362-374. [PMID: 34516616 DOI: 10.1093/europace/euab241] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 08/25/2021] [Indexed: 12/25/2022] Open
Abstract
Patients with cardiac implantable electronic devices (CIED) undergoing radiotherapy (RT) are more common due to the ageing of the population. With newer CIEDs' implementing the complementary metal-oxide semiconductor (CMOS) technology which allows the miniaturization of CIED, it is also more susceptible to RT. Effects of RT on CIED ranges from device interference, device operational/memory errors of permanent damage. These malfunctions can cause life-threatening clinical effects. Cumulative dose is not the only component of RT that causes CIED malfunction, as neutron use and dose rate effect also affects CIEDs. The management of this patient cohort in clinical practice is inconsistent due to the lack of a consistent guideline from manufacturers and physician specialty societies. Our review will focus on the current clinical practice and the recently updated guidelines of managing patients with CIED undergoing RT. We aim to simplify the evidence and provide a simple and easy to use guide based on the recent guidelines.
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Affiliation(s)
- Meor Azraai
- Department of Cardiology, Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550, Australia
| | - Daniel D'Souza
- Department of Cardiology, Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550, Australia
| | - Yuan-Hong Lin
- Department of Cardiology, Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550, Australia
| | - Voltaire Nadurata
- Department of Cardiology, Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550, Australia
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Baehr A, Conrads L, Oertel M, Frommeyer G, Scobioala S, Eich HT, Haverkamp U. Impact of different radiation techniques and doses on cardiac implantable electronic devices. Z Med Phys 2021; 31:327-335. [PMID: 33518445 DOI: 10.1016/j.zemedi.2020.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/22/2020] [Accepted: 12/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Purpose of this investigation was to get deeper insight into the impact of different radiation techniques and doses on cardiac implantable electric devices (CIEDs). We aimed to mimic a worst-case scenario with very high doses and external radiation being applied directly on the devices. METHODS Radiation was applied on 21 CIEDs as photon or electron therapy with maximum dose of 150Gy in fractions of 2 -20Gy. CIEDS were put directly into the beam. Brachytherapy was applied with doses of 6Gy to a maximum of 42Gy. Check-ups took place after every fraction and one week after radiation. We calculated the estimated potential risk for the health and survival of patients as well as the risk for CIEDs' loss of function. RESULTS 28 life- or health-threatening errors occurred during photon therapy, 3/7 devices showed complete loss of function. During electron therapy, 31 potentially patient-threatening errors and 2 losses of function were detected. During brachytherapy, none of the devices showed loss of function but 8 patient-threatening errors occurred. Inadequate shock releases were mostly seen after photon and brachytherapy, random noises occurred more often during electron therapy. The earliest potentially serious error occurred during after 2Gy photon radiation and 6Gy brachytherapy. Losses of function occurred earliest at 80Gy. CONCLUSION The results underline the warning for precaution concerning CIED patients derived from recommendations in the literature. Our study offers new information especially about the impact of electron radiation and brachytherapy on CIEDs. Risk for the devices to for loss of telemetry or battery capacity might be negligible with normafractionated therapy.
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Affiliation(s)
- Andrea Baehr
- Universitaetsklinikum Muenster, Department of Radiation Oncology, Albert-Schweitzer Campus 1 A, 48149, Muenster, Germany.
| | - Lino Conrads
- Universitaetsklinikum Muenster, Administration, genetics and radiation protection, Pottkamp 17, 48149. Muenster, Germany
| | - Michael Oertel
- Universitaetsklinikum Muenster, Department of Radiation Oncology, Albert-Schweitzer Campus 1 A, 48149, Muenster, Germany
| | - Gerrit Frommeyer
- Universitaetsklinikum Muenster, Clinic for Cardiology II - Electrophysiology, Albert-Schweitzer Campus 1 A, 48149, Muenster, Germany
| | - Sergiu Scobioala
- Universitaetsklinikum Muenster, Department of Radiation Oncology, Albert-Schweitzer Campus 1 A, 48149, Muenster, Germany
| | - Hans Th Eich
- Universitaetsklinikum Muenster, Department of Radiation Oncology, Albert-Schweitzer Campus 1 A, 48149, Muenster, Germany
| | - Uwe Haverkamp
- Universitaetsklinikum Muenster, Department of Radiation Oncology, Albert-Schweitzer Campus 1 A, 48149, Muenster, Germany
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15
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Levis M, Andreis A, Badellino S, Budano C, Caivano D, Cerrato M, Orlandi E, Bissolino A, Angelico G, Cavallin C, Giglioli FR, De Ferrari GM, Ricardi U. Safety of lung stereotactic ablative radiotherapy for the functioning of cardiac implantable electronic devices. Radiother Oncol 2021; 156:193-198. [PMID: 33387584 DOI: 10.1016/j.radonc.2020.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/21/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE The prevalence of patients with a cardiac implantable device (CIED) developing cancer and requiring a course of radiotherapy (RT) is increasing remarkably. Previously published reports agree that standard and conventionally fractionated RT is usually safe for CIEDs, but no "in-vivo" reports are available on the potential effects of thoracic stereotactic ablative radiotherapy (SABR) regimens to CIEDs functioning. The purpose of our study is therefore to evaluate the effects of SABR on CIEDs (pacemakers [PM] or implantable cardiac defibrillators [ICD]) in a cohort of patients affected by primary or metastatic lung lesions. MATERIALS AND METHODS We retrospectively collected all CIED-bearing patients undergoing SABR between 2007 and 2019 at our Institution. All CIEDs were interrogated before and after the SABR course to check for any malfunction. Prescription dose, beam energy and maximum dose (Dmax) to CIEDs were retrieved for each patient. Electrical records of the CIEDs were reviewed by the medical records. RESULTS Thirty-four consecutive patients (24 with a PM and 10 with an ICD), who underwent 38 separate SABR courses, were included in the study. Eight patients (24%) were PM-dependent. Prescription dose of SABR ranged 26-60 Gy in 1-8 fractions, with a photon energy ranging 6-to-10 MV (76.3% and 23.7%, respectively) and a median Dmax to CIEDs of 0.17 Gy (range 0.04-1.97 Gy). Electrical parameters were stable in post-treatment device programming visits and no transient or persistent alteration of the CIED function was recorded in any patient. No inappropriate interventions were recorded in the 10 ICD-bearing patients during the treatment fractions. CONCLUSIONS Thoracic SABR proved to be safe for CIEDs when the dose is kept <2 Gy and the beam energy is ≤10 MV, irrespective of the pacing-dependency and of the CIED type.
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Affiliation(s)
- Mario Levis
- Department of Oncology, University of Torino, Italy.
| | - Alessandro Andreis
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Torino, Italy
| | | | - Carlo Budano
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Torino, Italy
| | | | | | | | - Arianna Bissolino
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Torino, Italy
| | - Gloria Angelico
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Torino, Italy
| | | | | | - Gaetano M De Ferrari
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" Hospital, University of Torino, Italy
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16
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Gauter-Fleckenstein B, Barthel C, Büttner S, Wenz F, Borggrefe M, Tülümen E. Effectivity and applicability of the German DEGRO/DGK-guideline for radiotherapy in CIED-bearing patients. Radiother Oncol 2020; 152:208-215. [DOI: 10.1016/j.radonc.2020.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 12/07/2019] [Accepted: 01/07/2020] [Indexed: 11/26/2022]
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Falco MD, Genovesi D, Caravatta L, Di Carlo C, Bliakharskaia E, Appignani M, Faustino M, Furia N, Di Girolamo E. A randomized in vitro evaluation of transient and permanent cardiac implantable electronic device malfunctions following direct exposure up to 10 Gy. Strahlenther Onkol 2020; 197:198-208. [PMID: 32561941 DOI: 10.1007/s00066-020-01651-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE High-dose 6‑MV radiotherapy may cause cardiac implantable electronic devices (CIEDs) to malfunction. To assess CIED malfunctions resulting from direct exposure up to 10 Gy, 100 pacemakers (PMs) and 40 implantable cardioverter-defibrillators (ICDs) were evaluated. MATERIALS AND METHODS CIEDs underwent baseline interrogation. In ICDs, antitachycardia therapies were disabled via the programmer while the detection windows were left enabled. A computed tomography (CT) scan was performed to build the corresponding treatment plan. CIEDs were "blinded" and randomized to receive single doses of either 2, 5, or, 10 Gy via a 6-MV linear accelerator (linac) in a water phantom. Twenty-two wireless telemetry-enabled CIEDs underwent a real-time session, and their function was recorded by the video camera in the bunker. The CIEDs were interrogated after exposure and once monthly for 6 months. RESULTS During exposure, regardless of dose, 90.9% of the CIEDs recorded electromagnetic interference, with 6 ICDs (27.3%) reporting pacing inhibition and inappropriate arrhythmia detections. After exposure, a backup reset was observed in 1 PM (0.7% overall, 1% among PMs), while 7 PMs (5% overall, 7% among PMs) reported battery issues (overall immediate malfunction rate was 5.7%). During follow-up, 4 PMs (2.9% overall; 4% among PMs) and 1 ICD (0.7% overall; 2.5% among ICDs) reported abnormal battery depletion, and 1 PM (0.7% overall; 1% among PMs) reported a backup reset (overall late malfunction rate was 4.3%). CONCLUSION Apart from transient electromagnetic interference, last-generation CIEDs withstood direct 6‑MV exposure up to 10 Gy. Permanent battery or software errors occurred immediately or later only in less recent CIEDs.
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Affiliation(s)
- Maria Daniela Falco
- Department of Radiation Oncology, "SS. Annunziata" Hospital, "G. D'Annunzio" University, Via De' Vestini, 66100, Chieti, Italy.
| | - Domenico Genovesi
- Department of Radiation Oncology, "SS. Annunziata" Hospital, "G. D'Annunzio" University, Via De' Vestini, 66100, Chieti, Italy
| | - Luciana Caravatta
- Department of Radiation Oncology, "SS. Annunziata" Hospital, "G. D'Annunzio" University, Via De' Vestini, 66100, Chieti, Italy
| | - Clelia Di Carlo
- Department of Radiation Oncology, "SS. Annunziata" Hospital, "G. D'Annunzio" University, Via De' Vestini, 66100, Chieti, Italy
| | - Ekaterina Bliakharskaia
- Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | | | | | - Nanda Furia
- Arrhythmology Unit, "SS. Annunziata" Hospital, Chieti, Italy
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Nakamura K, Aoyama T, Kaneda N, Otsuji M, Minami Y, Sakuragi A, Nakamura M. Effect of X-ray dose rates higher than 8 Gy/min on the functioning of cardiac implantable electronic devices. JOURNAL OF RADIATION RESEARCH 2020; 61:419-425. [PMID: 32253430 PMCID: PMC7299257 DOI: 10.1093/jrr/rraa016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/12/2019] [Accepted: 03/05/2020] [Indexed: 06/11/2023]
Abstract
Direct irradiation may cause malfunctioning of cardiac implantable electronic devices (CIEDs). Therefore, a treatment plan that does not involve direct irradiation of CIEDs should be formulated. However, CIEDs may be directly exposed to radiation because of the sudden intrafractional movement of the patient. The probability of CIED malfunction reportedly depends on the dose rate; however, reports are only limited to dose rates ≤8 Gy/min. The purpose of this study was to investigate the effect of X-ray dose rates >8 Gy/min on CIED function. Four CIEDs were placed at the center of the radiation field and irradiated using 6 MV X-ray with flattening filter free (6 MV FFF) and 10 MV X-ray with flattening filter free (10 MV FFF). The dose rate was 4-14 Gy/min for the 6 MV FFF and 4-24 Gy/min for 10 MV FFF beams. CIED operation was evaluated with an electrocardiogram during each irradiation. Three CIEDs malfunctioned in the 6 MV FFF condition, and all four CIEDs malfunctioned in the 10 MV FFF condition, when the dose rate was >8 Gy/min. Pacing inhibition was the malfunction observed in all four CIEDs. Malfunction occurred simultaneously along with irradiation and simultaneously returned to normal function on stopping the irradiation. An X-ray dose rate >8 Gy/min caused a temporary malfunction due to interference. Therefore, clinicians should be aware of the risk of malfunction and manage patient movement when an X-ray dose rate >8 Gy/min is used for patients with CIEDs.
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Affiliation(s)
- Kazuhiko Nakamura
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195 Japan
| | - Takahiro Aoyama
- Department of Radiation Oncology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-Ku, Nagoya, Aichi, 464-8681 Japan
| | - Naoki Kaneda
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195 Japan
| | - Masashi Otsuji
- Department of Clinical Engineering, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195 Japan
| | - Yoshitaka Minami
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195 Japan
| | - Ami Sakuragi
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195 Japan
| | - Masaru Nakamura
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195 Japan
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Radiotherapy is safe in patients with implantable cardiac devices. Analysis of a systematic interrogation follow-up. Clin Transl Oncol 2020; 22:2286-2292. [PMID: 32419111 DOI: 10.1007/s12094-020-02374-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The number of patients who have a cardiac implantable electronic device (CIEDs) that undergo a course of radiotherapy is increasing due to the ageing population. The majority of clinical studies only evaluate any CIED malfunction at the end of a course of irradiation or in a case of there being symptoms of possible malfunction. As a result, little data has been collected on CIED status acquired during an active course of irradiation. MATERIAL AND METHODS We aimed to evaluate the correct functioning of a CIED during a course of radiotherapy. So, a retrospective analysis was made of all patients having CIEDS in a single institution during their course of radiotherapy. All CIEDs were systematically checked before and during the course of radiotherapy according to the risk of device failure and patient dependence. RESULTS Data was analysed from 56 patients (43 men, 13 women) with a mean age of 78.2 years, of whom 87.5% of the patients carried a pacemaker (PM), the 39% of the patients were PM dependent, and the remaining patients carried an implantable cardioverter-defibrillator (ICD). An observable dose of irradiation was evident in only 10 cases. 69.1% of the CIEDs were checked daily and the remainder were checked weekly. During the radiotherapy course, 82% of the patients did not complain of any cardiological event. The CIED of five patients experienced an increase in the threshold and, in another case, a sudden reduction in the duration of the battery was reported. Another patient with a CIED experienced a cardiac insufficiency episode triggered by a ventricular tachycardia. CONCLUSION In conclusions, although adverse clinical events from exposure of a CIED to irradiation are rare, they can appear in any group of risk. No dose-dependency was observed on the malfunction of the CIED.
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Method to quickly and accurately calculate absorbed dose from therapeutic and stray photon exposures throughout the entire body in individual patients. Med Phys 2020; 47:2254-2266. [DOI: 10.1002/mp.14018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/11/2019] [Accepted: 12/24/2019] [Indexed: 01/26/2023] Open
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Matsubara H, Ezura T, Hashimoto Y, Karasawa K, Nishio T, Tsuneda M. Prediction of radiation‐induced malfunction for cardiac implantable electronic devices (CIEDs). Med Phys 2020; 47:1489-1498. [DOI: 10.1002/mp.14057] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 01/22/2019] [Accepted: 01/25/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- Hiroaki Matsubara
- Department of Radiation Oncology Tokyo Women’s Medical University Tokyo 162‐8666Japan
| | - Takatomo Ezura
- Department of Radiology Tokyo Women’s Medical University Hospital Tokyo 162‐8666Japan
| | - Yaichiro Hashimoto
- Department of Radiation Oncology Tokyo Women’s Medical University Tokyo 162‐8666Japan
| | - Kumiko Karasawa
- Department of Radiation Oncology Tokyo Women’s Medical University Tokyo 162‐8666Japan
| | - Teiji Nishio
- Department of Radiation Oncology Tokyo Women’s Medical University Tokyo 162‐8666Japan
| | - Masato Tsuneda
- Department of Radiation Oncology Tokyo Women’s Medical University Tokyo 162‐8666Japan
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Gimenez De Lorenzo R, Navarra R, Marinelli D, Adorante N, Giancaterino S, Di Carlo C, Di Biase S, Rosa C, Falco MD. Effects of high-energy photon beam radiation therapy on Jarvik 2000 LVAD: in vitro evaluation. Radiol Med 2020; 125:561-568. [PMID: 32067164 DOI: 10.1007/s11547-020-01154-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/06/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Left ventricular assist device (LVAD) is considered a standard care for patients with advanced heart failure. The aim of this work was to study in vitro the effects of direct exposure of the Jarvik 2000 LVAD to 10-MV photon beams. METHODS Jarvik 2000 pump was immersed in a siliconized box filled with deionized water. A 30 × 30 × 15 cm RW3 slabs were added forth and back to the box. A treatment plan consisting of a single direct 10 × 10 cm2 field size beam was used to deliver 1000 MU at the center of the pump. During irradiation, the external Flow Maker controller and the lithium battery were positioned away from the beam. Pump parameter data (included voltage, current and frequency) were measured, recorded and analyzed for changes in pump function among baseline, pre-irradiation, during irradiation, post-irradiation and after 6 months. The whole session lasted 6 months. The Mann-Whitney U test was used to compare the repeated measurements. X-ray radiation attenuation was also studied. RESULTS The parameters investigated remained stable over the 6 months; that is, no pump stops, alarms, events, operational changes or abnormalities during the discharge rate of the connected power sources, were encountered, confirmed by the Mann-Whitney U test applied to all sessions (p > 0.1). The measured X-ray attenuation differed from the calculated one by TPS by 34%. CONCLUSION The Jarvik 2000 resulted stable under direct X-ray beam of 10-MV energy. Its strong attenuation, however, can affect dose deposition in the pump in TPS, and it must be taken into account.
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Affiliation(s)
- Ramon Gimenez De Lorenzo
- Department of Radiation Oncology, University of Chieti "G. D'Annunzio", SS. Annunziata Hospital, Chieti, Italy
| | - Riccardo Navarra
- Department of Radiation Oncology, University of Chieti "G. D'Annunzio", SS. Annunziata Hospital, Chieti, Italy.,Department of Neuroimaging and Cognitive Science, University of Chieti "G. D'Annunzio", Chieti, Italy
| | - Daniele Marinelli
- Department of Cardiac Surgery, University of Chieti "G. D'Annunzio", Chieti, Italy
| | - Nico Adorante
- Department of Radiation Oncology, University of Chieti "G. D'Annunzio", SS. Annunziata Hospital, Chieti, Italy
| | - Stefano Giancaterino
- Department of Radiation Oncology, University of Chieti "G. D'Annunzio", SS. Annunziata Hospital, Chieti, Italy
| | - Clelia Di Carlo
- Department of Radiation Oncology, University of Chieti "G. D'Annunzio", SS. Annunziata Hospital, Chieti, Italy
| | - Saide Di Biase
- Department of Radiation Oncology, University of Chieti "G. D'Annunzio", SS. Annunziata Hospital, Chieti, Italy
| | - Consuelo Rosa
- Department of Radiation Oncology, University of Chieti "G. D'Annunzio", SS. Annunziata Hospital, Chieti, Italy
| | - Maria Daniela Falco
- Department of Radiation Oncology, University of Chieti "G. D'Annunzio", SS. Annunziata Hospital, Chieti, Italy.
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Gauter-Fleckenstein B, Nguyen J, Jahnke L, Gaiser T, Rudic B, Büttner S, Wenz F, Borggrefe M, Tülümen E. Interaction between CIEDs and modern radiotherapy techniques: Flattening filter free-VMAT, dose-rate effects, scatter radiation, and neutron-generating energies. Radiother Oncol 2020; 152:196-202. [PMID: 31973882 DOI: 10.1016/j.radonc.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 12/07/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Providing evidence for radiotherapy (RT)-induced effects on cardiac implantable electric devices (CIEDs) with focus on flattening filter free-volumetric modulated arc therapy (FFF-VMAT) at 6 and 10 MV as well as 3D-conformal radiotherapy (3D-CRT) at 18 MV. MATERIALS AND METHODS 68 CIEDs (64 implantable cardioverter-defibrillators (ICDs) and 4 cardiac pacemakers (PMs)) were located on the left chest position on a slab phantom and irradiated under telemetrical surveillance either directly, or distant to 3D-CRT or FFF-VMAT, dose-rate 2500 cGy/min, and target dose of 150 Gy. Devices were placed within, close by (2.5 cm and 5 cm), and distant (35 cm) to the radiation field. Scatter radiation (SR) and photon neutrons (PN) were recorded. CIEDs were investigated in following groups: 1a) 18 MV 3D-CRT - 4 ICDs/4 PMs out of radiation field, 1b) 18 MV open field - 4 ICDs/4 PMs within radiation field, 2) 6 MV FFF-VMAT, 15 ICDs in 35 cm distance to VMAT, 3) 10 MV-FFF VMAT, 15 ICDs in 35 cm distance to VMAT, 4) 6 MV FFF-VMAT, 15 ICDs in 2.5 cm distance to VMAT, 5) 10 MV FFF-VMAT, 15 ICDs in 2.5 cm distance to VMAT. RESULTS No incidents occurred at 6 MV FFF. 10 MV FFF-VMAT and 18 MV 3D-CRT resulted in data loss, reset, and erroneous sensing with inhibition of pacing (leading to inadequate defibrillation) in 8/34 ICDs and 2/4 PMs which were not located within radiation. Direct radiation triggered instantaneous defibrillation in 3/4 ICDs. CONCLUSIONS 6 MV FFF-VMAT is safe even at high dose-rates of 2500 cGy/min, regardless whether CIEDs are located close (2.5 cm) or distant (35 cm) to the radiation beam. CIEDs should never be placed within radiation and energy should always be limited to 6 MV. At 6 MV, VMAT at high dose-rates can be used to treat tumors, which are located close to CIEDs.
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Affiliation(s)
- Benjamin Gauter-Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
| | - Julia Nguyen
- Medical Faculty Mannheim, Heidelberg University, Germany
| | - Lennart Jahnke
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Timo Gaiser
- Institute of Pathology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Boris Rudic
- First Department of Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; DZHK (German Centre for Cardiovascular Research) partner site, Mannheim, Germany
| | - Sylvia Büttner
- Department of Biomathematics and Medical Statistics, University Medical Center Mannheim, University of Heidelberg, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; DZHK (German Centre for Cardiovascular Research) partner site, Mannheim, Germany
| | - Erol Tülümen
- First Department of Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; DZHK (German Centre for Cardiovascular Research) partner site, Mannheim, Germany
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24
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The degree of translational and rotational movement of implanted pacemakers and cardioverter-defibrillators on coronal plane images in patients treated with radiotherapy for lung malignancy. Med Dosim 2020; 45:309-316. [DOI: 10.1016/j.meddos.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 02/12/2020] [Accepted: 03/02/2020] [Indexed: 11/20/2022]
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25
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Miften M, Mihailidis D, Kry SF, Reft C, Esquivel C, Farr J, Followill D, Hurkmans C, Liu A, Gayou O, Gossman M, Mahesh M, Popple R, Prisciandaro J, Wilkinson J. Management of radiotherapy patients with implanted cardiac pacemakers and defibrillators: A Report of the AAPM TG-203 †. Med Phys 2019; 46:e757-e788. [PMID: 31571229 DOI: 10.1002/mp.13838] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/16/2019] [Accepted: 08/28/2019] [Indexed: 11/11/2022] Open
Abstract
Managing radiotherapy patients with implanted cardiac devices (implantable cardiac pacemakers and implantable cardioverter-defibrillators) has been a great practical and procedural challenge in radiation oncology practice. Since the publication of the AAPM TG-34 in 1994, large bodies of literature and case reports have been published about different kinds of radiation effects on modern technology implantable cardiac devices and patient management before, during, and after radiotherapy. This task group report provides the framework that analyzes the potential failure modes of these devices and lays out the methodology for patient management in a comprehensive and concise way, in every step of the entire radiotherapy process.
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Affiliation(s)
- Moyed Miften
- Task Group 203, Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Dimitris Mihailidis
- Task Group 203, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, 19104, USA
| | - Stephen F Kry
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Chester Reft
- Department of Radiation Oncology, University of Chicago, Chicago, IL, 60637, USA
| | - Carlos Esquivel
- Department of Radiation Oncology, UT Health Sciences Center, San Antonio, TX, 78229, USA
| | - Jonathan Farr
- Division of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - David Followill
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Coen Hurkmans
- Department of Radiotherapy, Catharina Hospital, Eindhoven, the Netherlands
| | - Arthur Liu
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Olivier Gayou
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburg, PA, 15212, USA
| | - Michael Gossman
- Department of Radiation Oncology, Tri-State Regional Cancer Center, Ashland, KY, 41101, USA
| | - Mahadevappa Mahesh
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Richard Popple
- Department of Radiation Oncology, University of Alabama, Birmingham, AL, 35249, USA
| | - Joann Prisciandaro
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, 48109, USA
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26
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Seidensaal K, Harrabi SB, Scholz E, Ellerbrock M, Haberer T, Weykamp F, Mattke M, Welte SE, Herfarth K, Debus J, Uhl M. Active-Scanned Protons and Carbon Ions in Cancer Treatment of Patients With Cardiac Implantable Electronic Devices: Experience of a Single Institution. Front Oncol 2019; 9:798. [PMID: 31508363 PMCID: PMC6714545 DOI: 10.3389/fonc.2019.00798] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 08/06/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Ionizing radiation was shown to be able to influence the function of cardiac implantable electronic devices (CIED's) leading to malfunctions with potentially severe consequences. Those effects presumably correlate with beam energy and neutron production. Thus, particle facilities are commonly cautious to treat patients with CIED's with particles, but substantial evidence is lacking. Methods and Materials: In total 31 patients were investigated, who have been treated at the Heidelberg Ion-Beam Therapy Center (HIT) from September 2012 to February 2019 with protons and carbon ions in active-scanning technique. All CIED's were checked after every single irradiation by the department of cardiology. The minimum distance between the CIED and the planning target volume (PTV), the 10% isodose and the single beam in Beam's Eye View (BEV) was analyzed for 12 patients. Results: In total, 31 patients received 32 courses of radiotherapy (RT). Twenty-two received treatment with carbon ion beam and ten with proton beam. The cumulative number of fractions was 582, the cumulative number of documented controls after RT was 504 (87%). Three patients had an implantable cardioverter-defibrillator (ICD) and 28 patients had a pacemaker at the time of treatment. Seven patients had a heart rate of ≤30/min. The majority of patients (69%) were treated for tumors of the head and neck. The median minimum distance between CIED and PTV, 10% isodose and the single beam on BEV was 13.4, 11.6, and 8.3 cm, respectively. There were no registered events associated with the treatment in this evaluation. Conclusion: Treatment of CIED-patients with protons and carbon ions applied with active raster scanning technique was safe without any incidents in our single center experience. Monitoring after almost every fraction provided systematic and extensive data. Further investigations are necessary in order to form reliable guidelines, which should consider different modes of beam application, as active scanning supposedly provides a greater level of safety from malfunctions for patients with CIED undergoing particle irradiation.
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Affiliation(s)
- Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Semi Ben Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Eberhard Scholz
- Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg, Germany.,Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Malte Ellerbrock
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Haberer
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Mattke
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan E Welte
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Partner Site Heidelberg, Heidelberg, Germany
| | - Matthias Uhl
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
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27
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Radiotherapy of patients with cardiac implantable electronic devices according to the DEGRO/DGK guideline—is the risk of relevant errors overestimated? Strahlenther Onkol 2019; 195:1086-1093. [DOI: 10.1007/s00066-019-01502-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/19/2019] [Indexed: 01/26/2023]
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28
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Lee JW, Seol KH. Inevitable high-dose irradiation to lead of implantable cardioverter defibrillator in small cell lung cancer: a case report. J Med Case Rep 2019; 13:187. [PMID: 31217026 PMCID: PMC6585016 DOI: 10.1186/s13256-019-2111-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/01/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radiotherapy has been shown to cause malfunction of implantable cardioverter-defibrillators, and there are few studies of implantable cardioverter-defibrillators and radiotherapy. We report an unusual case of small cell lung cancer in a patient with an implantable cardioverter-defibrillator in whom direct irradiation to the electrode and lead could not be avoided. CASE PRESENTATION We report a case of radiotherapy in a 72-year-old Korean man with a limited stage of small cell lung cancer who had undergone insertion of an implantable cardioverter-defibrillator because of ventricular fibrillation. The radiation dose was 60 Gy in 30 fractions to the thorax. The mean dose and maximum dose estimated at the body of the implantable cardioverter-defibrillator were 0.89 Gy and 2.23 Gy, respectively. The mean and maximum doses of the lead and electrode were 17.12 Gy and 55.72 Gy in the lead and 1.81 Gy and 7.10 Gy in the electrode, respectively, because part of the lead and electrode was inevitably in the irradiated fields. The function of the patient's implantable cardioverter-defibrillator was checked daily, and no change in implantable cardioverter-defibrillator function was observed for the duration of radiotherapy. The patient was tolerated the treatment well without severe complications. Computed tomography performed at 4 weeks after radiotherapy showed a good response with regression of the tumor. The patient was alive with complete remission of the tumor and without any implantable cardioverter-defibrillator dysfunction more than 36 months after the end of treatment. CONCLUSIONS This case demonstrates that radiotherapy may be a safe and effective treatment modality through careful monitoring of implantable cardioverter-defibrillators in patients with lung cancer who have implantable cardioverter-defibrillators.
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Affiliation(s)
- Jeong Won Lee
- Department of Radiation Oncology, Catholic University of Daegu School of Medicine, 33, Duryugongwon-ro 17-gil, Nam-gu, Daegu, South Korea
| | - Ki Ho Seol
- Department of Radiation Oncology, Catholic University of Daegu School of Medicine, 33, Duryugongwon-ro 17-gil, Nam-gu, Daegu, South Korea.
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29
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Radiotherapy for patients with cardiovascular implantable electronic devices: an 11-year experience. J Interv Card Electrophysiol 2019; 55:333-341. [PMID: 30603854 DOI: 10.1007/s10840-018-0506-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE As cardiovascular implantable electronic devices (CIEDs) are increasingly indicated in older patients, and the burden of cancer is rising with the aging population, the management of patients with CIEDs who require radiotherapy (RT) is a timely concern. The objective of the study was to evaluate the management of, and malfunctions in, patients with CIEDs undergoing RT. METHODS A retrospective study of patients with CIEDs receiving RT at Kingston Health Sciences Center from March 2007-April 2018 was conducted. Data on demographics, RT, devices, and management were compared for the primary outcome of device malfunction. RESULTS Of the 189 patients with CIEDs receiving a total of 297 courses of RT, 4 patients (2.1%) experienced device malfunctions. Higher beam energy was associated with a malfunction (p < 0.05). Patients with malfunctions received a lower dose of radiation per fraction (267 ± 93 cGy vs. 477 ± 282 cGy; p < 0.05) and were significantly younger (71.4 ± 2.2 years vs. 77.8 ± 9.8 years; p < 0.01) compared to patients without malfunctions. CONCLUSION RT-induced device malfunctions are rare, but given the potential complications, a better understanding of the potential predictors of malfunction and the development of evidence-based guidelines will help optimize patient safety.
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30
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Bitterman DS, Zei PC, Mak RH. Radiation Safety and Cardiovascular Implantable Electronic Devices. Int J Radiat Oncol Biol Phys 2018; 102:243-246. [PMID: 30191855 DOI: 10.1016/j.ijrobp.2018.05.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/30/2018] [Accepted: 05/29/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Danielle S Bitterman
- Harvard Radiation Oncology Program, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul C Zei
- Department of Cardiovascular Medicine, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Raymond H Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts.
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31
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Rav Acha M, Corn BW. Revisiting the impact of radiation therapy on cardiac implantable electronic device (CIED) function. J Cardiovasc Electrophysiol 2018; 29:1276-1279. [DOI: 10.1111/jce.13694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/02/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Moshe Rav Acha
- Cardiology Department, Shaare Tzedek HospitalHebrew University Jerusalem Israel
| | - Ben W. Corn
- Radiation Oncology Department, Shaare Tzedek HospitalTel Aviv University School of Medicine Tel Aviv Israel
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32
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Dobson R, Wright DJ. Management of cardiac implantable devices in patients undergoing radiotherapy. Curr Probl Cancer 2018; 42:443-448. [PMID: 30104031 DOI: 10.1016/j.currproblcancer.2018.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/08/2018] [Accepted: 06/30/2018] [Indexed: 11/16/2022]
Abstract
The delivery of radiotherapy to patients with a cardiac implantable electronic device (CIED) is not an infrequent event. Consideration of the potential issues for patients is an important part of their care. An overview of CIEDs is provided, including the potential problems encountered and the steps that can be taken to mitigate this risk.
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Affiliation(s)
- Rebecca Dobson
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK.
| | - David J Wright
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
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33
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Dosimetric study to assess the feasibility of intraoperative radiotherapy with electrons (ELIOT) as partial breast irradiation for patients with cardiac implantable electronic device (CIED). Breast Cancer Res Treat 2018; 171:693-699. [PMID: 29978418 DOI: 10.1007/s10549-018-4878-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To report in-vivo dosimetry in the infraclavicular region, a potential site of a cardiac implantable electronic device (CIED) and to evaluate the absorbed dose from intraoperative radiotherapy with electrons (ELIOT). METHODS 27 non-cardiopathic breast cancer (BC) patients without CIED received quadrantectomy and ELIOT as partial breast irradiation. Before delivering ELIOT, two catheters, each containing eight thermoluminescent dosimeters (TLDs), were positioned in the infraclavicular region. TLDs internal catheter was located deep in the tumor bed while the external catheter was placed on patient's skin. RESULTS Data were available for 24/27 patients. The absorbed doses were referred to the dose of 21 Gy. Values measured by the external catheter were low, although statistically significant higher doses were found close to the applicator (mean values 0.26-0.49 Gy). External TLD doses in proximity of the applicator were lower than those detected by their internal counterparts. Values measured by the internal catheter TLDs varied according to the distance from the applicator while no correlation with tumor site and beam energy was found. The distance from the applicator to deliver < 2 Gy to a CIED was 2 cm, while from 2.5 cm the dose measured in all the patients became negligible. CONCLUSIONS This dosimetric study provided data to support the clinical use of ELIOT in BC patients having CIEDs as long as the suggested minimum safe distance of 2.5 cm is taken from the RT field in case of ELIOT single dose of 21 Gy, in the energy range of 6-10 MeV.
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34
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Zecchin M, Artico J, Morea G, Severgnini M, Bianco E, De Luca A, Fantasia AZ, Salvatore L, Milan V, Lucarelli M, Dissegna R, Cannatà A, Sinagra G. Radiotherapy and risk of implantable cardioverter-defibrillator malfunctions. J Cardiovasc Med (Hagerstown) 2018; 19:155-160. [DOI: 10.2459/jcm.0000000000000623] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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35
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Ferrara T, Baiotto B, Malinverni G, Caria N, Garibaldi E, Barboni G, Stasi M, Gabriele P. Irradiation of Pacemakers and Cardio-Defibrillators in Patients Submitted to Radiotherapy: A Clinical Experience. TUMORI JOURNAL 2018; 96:76-83. [DOI: 10.1177/030089161009600113] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background A prospective analysis was carried out on a group of irradiated patients with pacemakers or implantable cardioverter-defibrillators to identify any relationship between the various types of devices and physical and dosimetric parameters. Cardiac toxicity of the treatment was also investigated. Methods and study design Forty-five irradiated patients, implanted with pacemakers or implantable cardioverter-defibrillators, were prospectively investigated from 1999 to 2007. An analysis of radiation damage to pacemakers, depending on the geometric and dosimetric characteristics of the radiation beams, was carried out. The electric and magnetic fields of linear accelerators (LINACs) were measured to evaluate any interference. The calculation of dose received by pacemakers was evaluated by dose-volume histograms. Results No dysfunction was observed in any pacemaker, nor were the substitution times negatively affected. We did not find problems with the devices due to the interaction with the electromagnetic fields. Dose-volume histograms calculated for patients treated in regions close to devices (head & neck, thorax) showed an average maximum dose equal to 2.5 Gy for the head & neck area and equal to 1.8 Gy for the thoracic area. Acute (3 cases) and late (2 cases) cardiac events were observed only in 5 patients who underwent chemoradiation treatment, but no dysfunction was observed in any pacemaker. Conclusions Our study confirms the safety of radiotherapy for patients implanted with pacemakers or implantable cardioverter-defibrillators but suggests that chemoradiation represents a probable risk factor for cardiac toxicity. Furthermore, all cardiac events were observed in patients treated in the head and neck or left thoracic areas. A standardized protocol is advisable in order to improve patient control during the radiotherapy treatment. It is mandatory to calculate the dose received at the pacemaker/heart, even in the case of palliative treatment.
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Affiliation(s)
- Teresa Ferrara
- Radio-Oncology Department, A Businco Oncologic Hospital, Cagliari, Italy
| | - Barbara Baiotto
- Medical Physics Department, Institute for Cancer Treatment and Research, Candiolo (Turin) and Mauriziano Umberto I Hospital, Turin, Italy
| | - Giuseppe Malinverni
- Radiotherapy Department, Institute for Cancer Treatment and Research, Candiolo (Turin) and Mauriziano Umberto I Hospital, Turin, Italy
| | - Nicola Caria
- Radio-Oncology Department, A Businco Oncologic Hospital, Cagliari, Italy
| | | | - Gilberto Barboni
- Medical Physics Department, Institute for Cancer Treatment and Research, Candiolo (Turin) and Mauriziano Umberto I Hospital, Turin, Italy
| | - Michele Stasi
- Medical Physics Department, Institute for Cancer Treatment and Research, Candiolo (Turin) and Mauriziano Umberto I Hospital, Turin, Italy
| | - Pietro Gabriele
- Radio-Oncology Department, A Businco Oncologic Hospital, Cagliari, Italy
- Medical Physics Department, Institute for Cancer Treatment and Research, Candiolo (Turin) and Mauriziano Umberto I Hospital, Turin, Italy
- Radiotherapy Department, Institute for Cancer Treatment and Research, Candiolo (Turin) and Mauriziano Umberto I Hospital, Turin, Italy
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Yeung C, Chacko S, Glover B, Campbell D, Crystal E, Ben-Dov N, Baranchuk A. Radiotherapy for Patients with Cardiovascular Implantable Electronic Devices: A Review. Can J Cardiol 2017; 34:244-251. [PMID: 29395701 DOI: 10.1016/j.cjca.2017.11.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/16/2022] Open
Abstract
Because cardiovascular implantable electronic devices are increasingly indicated in older patients, and the burden of cancer is rising with the growth and aging of the world population, the management of patients with cardiac devices who require radiotherapy for cancer treatment is a timely concern. Device malfunctions might occur in as high as 3% of radiotherapy courses, posing a substantial issue in clinical practice. A nonsystematic comprehensive review was undertaken. We searched PubMed and the MEDLINE database for randomized controlled trials, meta-analyses, systematic reviews, observational studies, in vitro/in vivo studies, and case reports. Articles were selected by 2 independent reviewers, and emphasis was given to information of interest to a general medical readership. The pathophysiology and predictors of cardiovascular implantable electronic device malfunction due to radiotherapy are reviewed, recommendations for the management of patients with such devices undergoing radiotherapy are summarized, and the clinical significance and future directions of this field are discussed. Radiotherapy-induced device malfunctions are rare, but because of the potential complications, the development of evidence-based guidelines for the management of patients with cardiovascular implantable electronic devices undergoing radiotherapy is a timely concern.
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Affiliation(s)
- Cynthia Yeung
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Sanoj Chacko
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Benedict Glover
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Debra Campbell
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Eugene Crystal
- Arrhythmia Services, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nissan Ben-Dov
- Arrhythmia Services, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Adrian Baranchuk
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada.
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Indik JH, Gimbel JR, Abe H, Alkmim-Teixeira R, Birgersdotter-Green U, Clarke GD, Dickfeld TML, Froelich JW, Grant J, Hayes DL, Heidbuchel H, Idriss SF, Kanal E, Lampert R, Machado CE, Mandrola JM, Nazarian S, Patton KK, Rozner MA, Russo RJ, Shen WK, Shinbane JS, Teo WS, Uribe W, Verma A, Wilkoff BL, Woodard PK. 2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices. Heart Rhythm 2017; 14:e97-e153. [DOI: 10.1016/j.hrthm.2017.04.025] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 11/16/2022]
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A clinical example of extreme dose exposure for an implanted cardioverter-defibrillator : Beyond the DEGRO guidelines. Strahlenther Onkol 2017; 193:756-760. [PMID: 28567504 DOI: 10.1007/s00066-017-1152-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Considering that the number of malignant diseases in patients over 65 years of age is increasing, it often occurs that patients who carry a cardiac implanted electronic device must undergo radiotherapy. Ionizing radiation can disturb the function of the implantable cardioverter-defibrillator (ICD). As a result of this, an update of the DEGRO/DKG guidelines for radiotherapy of this patient group has been published. METHODS We report the case of a patient with an ICD and T‑lymphoblastic lymphoma with cardiac involvement, who received i.a. a total body irradiation with 8 Gy followed by a consolidating radiotherapy of the pericardium with 14 Gy as well as additional radiotherapy courses after consecutive recurrences. For the purposes of the treatment, the antitachyarrhythmia (ATA) therapy was deactivated and temporarily replaced through a life vest. RESULTS According to the current DEGRO guidelines for irradiation of patients with cardiac implanted electronic devices, a categorization of the patient in the "high-risk" group was made. Furthermore, regular telemetric checks of the ICD device were performed before and after treatment. Despite unavailable declaration of the manufacturer regarding the cumulative tolerable dose and DEGRO recommendation for a cumulative dose <2 Gy, the aftercare was unproblematic and normal values were assessed for all relevant ICD parameters, despite a cumulative dose >10 Gy in the device. CONCLUSION This case shows that if the cardiac implanted electronic devices are not directly irradiated und the energy used is reduced to 6 MV, irradiation-induced damage is less likely and can possibly be prevented.
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Bagur R, Chamula M, Brouillard É, Lavoie C, Nombela-Franco L, Julien AS, Archambault L, Varfalvy N, Gaudreault V, Joncas SX, Israeli Z, Parviz Y, Mamas MA, Lavi S. Radiotherapy-Induced Cardiac Implantable Electronic Device Dysfunction in Patients With Cancer. Am J Cardiol 2017; 119:284-289. [PMID: 27823600 DOI: 10.1016/j.amjcard.2016.09.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/19/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
Abstract
Radiotherapy can affect the electronic components of a cardiac implantable electronic device (CIED) resulting in malfunction and/or damage. We sought to assess the incidence, predictors, and clinical impact of CIED dysfunction (CIED-D) after radiotherapy for cancer treatment. Clinical characteristics, cancer, different types of CIEDs, and radiation dose were evaluated. The investigation identified 230 patients, mean age 78 ± 8 years and 70% were men. A total of 199 patients had pacemakers (59% dual chamber), 21 (9%) cardioverter-defibrillators, and 10 (4%) resynchronizators or defibrillators. The left pectoral (n = 192, 83%) was the most common CIED location. Sixteen patients (7%) experienced 18 events of CIED-D after radiotherapy. Reset to backup pacing mode was the most common encountered dysfunction, and only 1 (6%) patient of those with CIED-D experienced symptoms of atrioventricular dyssynchrony. Those who had CIED-D tended to have a shorter device age at the time of radiotherapy compared to those who did not (2.5 ± 1.5 vs 3.8 ± 3.4 years, p = 0.09). The total dose prescribed to the tumor was significantly greater among those who had CIED-D (66 ± 30 vs 42 ± 23 Gy, p <0.0001). Multivariate logistic regression analysis identified the total dose prescribed to the tumor as the only independent predictor for CIED-D (odds ratio 1.19 for each increase in 5 Gy, 95% confidence interval 1.08 to 1.31, p = 0.0005). In conclusion, in this large population of patients with CIEDs undergoing radiotherapy for cancer treatment, the occurrence of newly diagnosed CIED-D was 7%, and the reset to backup pacing mode was the most common encountered dysfunction. The total dose prescribed to the tumor was a predictor of CIED-D. Importantly, although the unpredictability of CIEDs under radiotherapy is still an issue, none of our patients experienced significant symptoms, life-threatening arrhythmias, or conduction disorders.
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Affiliation(s)
- Rodrigo Bagur
- Cardiology Division, Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.
| | - Mathilde Chamula
- Cardiology Division, Department of Medicine, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada
| | - Émilie Brouillard
- Department of Radio-Oncology, Cancer Research Center, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada
| | - Caroline Lavoie
- Department of Radio-Oncology, Cancer Research Center, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada
| | | | - Anne-Sophie Julien
- Clinical Research Platform, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada
| | - Louis Archambault
- Department of Radio-Oncology, Cancer Research Center, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada; Department of Physics, Engineering and Optics, Cancer Research Center, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada
| | - Nicolas Varfalvy
- Department of Radio-Oncology, Cancer Research Center, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada; Department of Physics, Engineering and Optics, Cancer Research Center, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada
| | - Valérie Gaudreault
- Cardiology Division, Department of Medicine, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada
| | - Sébastien X Joncas
- Cardiology Division, Department of Medicine, Quebec University Hospital Centre, Laval University, Quebec City, Quebec, Canada
| | - Zeev Israeli
- Cardiology Division, Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Yasir Parviz
- Cardiology Division, Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute of Science and Technology in Medicine and Primary Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Shahar Lavi
- Cardiology Division, Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
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Chakravarthy M, Prabhakumar D, George A. Anaesthetic consideration in patients with cardiac implantable electronic devices scheduled for surgery. Indian J Anaesth 2017; 61:736-743. [PMID: 28970632 PMCID: PMC5613599 DOI: 10.4103/ija.ija_346_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
With advances in cardiology and cardiothoracic surgery, several newer implantable cardiac devices have become common in the surgical population. Multichamber pacemakers, implanted cardiac defibrillators and ventricular assist devices are frequent in current day practice. Many of the newer implantable cardiac electronic devices are targeted at managing heart failure. While managing such patients for non-cardiac surgeries, specific issues related to equipment characteristics and troubleshooting should be a priority for the anaesthesiologists. There is a possibility of malfunction of the devices resulting in catastrophic outcomes. Therefore, it is imperative to understand the pathophysiology, device characteristics and troubleshooting before embarking on anaesthetising patients with implantable cardiac electronic devices.
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Affiliation(s)
- Murali Chakravarthy
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Dattatreya Prabhakumar
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Antony George
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
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Tajstra M, Gadula-Gacek E, Buchta P, Blamek S, Gasior M, Kosiuk J. Effect of Therapeutic Ionizing Radiation on Implantable Electronic Devices: Systematic Review and Practical Guidance. J Cardiovasc Electrophysiol 2016; 27:1247-1251. [PMID: 27325433 DOI: 10.1111/jce.13034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 05/30/2016] [Accepted: 06/07/2016] [Indexed: 11/28/2022]
Abstract
Cardiac implantable electronic devices (CIEDs) have been in use for over 50 years and their therapeutic value is undisputable. With the rapidly aging population, it is estimated that the number of CIEDs will grow dramatically over the next 2 decades. Given these predictions, the topic of management of concomitant conditions associated with older age becomes more relevant than ever. In particular, the number of patients with an implanted CIED diagnosed with cancer is expected to rise by about 70%, from 14 million in 2012 to 22 million within the next 2 decades. Treatment of most of these tumors and tumor metastases requires radiation therapy. However, the necessary high doses of radiation can potentially interact with the function, longevity, and integrity of the CIEDs and/or cause harm to the patient. The impact of an absence of clear therapeutic guidelines for oncology patients with CIEDs who should undergo radiation therapy is vast; and due to the fear of possible complications related to device failure, many of these patients may not be treated adequately to their needs, which can strongly affect their prognosis. This article summarizes the available data on the management of patients with CIEDs undergoing radiotherapy. It systematically presents possible causes and consequences of direct and scattered radiation on CIEDs, highlights possible complications that may occur during this kind of treatment, and provides practical guidance for this challenging real life clinical setting.
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Affiliation(s)
- Mateusz Tajstra
- Third Department of Cardiology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Elzbieta Gadula-Gacek
- Third Department of Cardiology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Piotr Buchta
- Third Department of Cardiology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Slawomir Blamek
- Radiotherapy Department, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice Branch, Poland
| | - Mariusz Gasior
- Third Department of Cardiology, SMDZ in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Jedrzej Kosiuk
- Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
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Emerson LY, Deek MP, Almendral J, Jabbour SK. Radiation therapy in patients with left ventricular assist device: A case report and literature review. Pract Radiat Oncol 2016; 6:e145-e147. [PMID: 27017262 DOI: 10.1016/j.prro.2015.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/25/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Liane Y Emerson
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Matthew P Deek
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Jesus Almendral
- Rutgers Robert Wood Johnson Medical School, Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, New Jersey
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey.
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Viganego F, Singh R, Fradley MG. Arrhythmias and Other Electrophysiology Issues in Cancer Patients Receiving Chemotherapy or Radiation. Curr Cardiol Rep 2016; 18:52. [DOI: 10.1007/s11886-016-0730-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Augustynek M, Korpas D, Penhaker M, Cvek J, Binarova A. Monitoring of CRT-D devices during radiation therapy in vitro. Biomed Eng Online 2016; 15:29. [PMID: 26960554 PMCID: PMC4784340 DOI: 10.1186/s12938-016-0144-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 02/22/2016] [Indexed: 11/19/2022] Open
Abstract
Background Using of active cardiac medical devices increases steadily. In Europe, there were 183 implants of ICD and 944 implants of PM, 119 of biventricular ICD and 41 of biventricular PM, all per million inhabitants in 2014. Healthcare environments, including radiotherapy treatment rooms, are considered challenging for these implantable devices. Exposure to radiation may cause the device to experience premature elective replacement indicator, decreased pacing amplitude or pacing inhibition, inappropriate shocks or inhibition of tachyarrhythmia therapy and loss of device function. These impacts may be temporary or permanent. The aim of this study was to evaluate the influence of linear accelerator ionizing radiation dose of 10 Gy on the activity of the biventricular cardioverter-defibrillator in different position in radiation beam. Methods Two identical wireless communication devices with all three leads were used for the measurement. Both systems were soused into solution saline and exposed in different position in the beam of linear accelerator per 10 Gy fractions. In comparison of usually used maximum recommended dose of 2 Gy, the radiation doses used in test were five times higher. Using the simultaneous monitoring wireless communication between device and its programmer allowed watching of the devices activities, noise occurrence or drop of biventricular pacing on the programmer screen, observed by local television loop camera. Results At any device position in radiation beam, there were no influences of the device activity at dose of 10 Gy neither a significant increase of a solution saline temperature in any of the measured positions of CRT-D systems in linear accelerator. Conclusions The results of the study indicated, that the recommendation dose for treating the patients with implantable devices are too conservative and the risk of device failure is not so high. The systems can easily withstand the dose fractions of tens Gy, which would allow current single-dose-procedure treatment in radiation therapy. Even though the process of the random alteration of device memory and electrical components by scatter particles not allowed to specify a safe dose during ionizing radiation, this study showed that the safe limit are above the today used dose fractions.
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Affiliation(s)
- Martin Augustynek
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB - Technical University, Ostrava, Czech Republic.
| | - David Korpas
- Institute of Nursing, Faculty of Public Policies, Silesian University, Opava, Czech Republic.
| | - Marek Penhaker
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB - Technical University, Ostrava, Czech Republic.
| | - Jakub Cvek
- Oncology clinic, University Hospital Ostrava, Ostrava, Czech Republic.
| | - Andrea Binarova
- Oncology clinic, University Hospital Ostrava, Ostrava, Czech Republic.
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Salerno F, Gomellini S, Caruso C, Barbara R, Musio D, Coppi T, Cardinale M, Tombolini V, de Paula U. Management of radiation therapy patients with cardiac defibrillator or pacemaker. Radiol Med 2015; 121:515-20. [DOI: 10.1007/s11547-015-0616-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
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Influence of Ionizing Radiation on Two Generations of Cochlear Implants. BIOMED RESEARCH INTERNATIONAL 2015; 2015:609607. [PMID: 26491679 PMCID: PMC4600872 DOI: 10.1155/2015/609607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/02/2015] [Indexed: 11/18/2022]
Abstract
The purpose of the present study was to test the behavior of two different generations of cochlear implant systems subjected to a clinical radiotherapy scheme and to determine the maximal acceptable cumulative radiation levels at which the devices show out-of-specification behaviors. Using stereotactic irradiation (Cyberknife, 6 MV photon beam), three Digisonic SP and three Neuro devices were submitted to 5 Gy doses that cumulated to 60 Gy (12 sessions) and 80 Gy (16 sessions), respectively. A follow-up series of irradiation was then applied, in which Digisonic SP devices received two additional fractions of 50 Gy each, cumulating to 160 Gy, and Neuro devices three additional fractions of 20, 40, and 150 Gy, cumulating to 290 Gy. Output current values were monitored during the treatment. At clinical doses, with 60 or 80 Gy cumulative radiation exposure, no single measurement showed more than 10% divergence from the reference measure. The cochlear implants tested in this study showed high resistance to clinically relevant cumulative radiation doses and showed no out-of-bounds behavior up to cumulative doses of 140 or 160 Gy. These observations suggest that cochlear implant users can undergo radiotherapy up to cumulative doses well above those currently used in clinical situations without risk of failure.
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47
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Brambatti M, Mathew R, Strang B, Dean J, Goyal A, Hayward JE, Long L, DeMeis P, Smoke M, Connolly SJ, Morillo CA, Amit G, Capucci A, Healey JS. Management of patients with implantable cardioverter-defibrillators and pacemakers who require radiation therapy. Heart Rhythm 2015; 12:2148-54. [DOI: 10.1016/j.hrthm.2015.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Indexed: 10/23/2022]
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Zaremba T, Jakobsen AR, Søgaard M, Thøgersen AM, Riahi S. Radiotherapy in patients with pacemakers and implantable cardioverter defibrillators: a literature review. Europace 2015; 18:479-91. [PMID: 26041870 DOI: 10.1093/europace/euv135] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/16/2015] [Indexed: 11/14/2022] Open
Abstract
An increasing number of patients with implantable cardiac rhythm devices undergo radiotherapy (RT) for cancer and are thereby exposed to the risk of device failure. Current safety recommendations seem to have limitations by not accounting for the risk of pacemakers and implantable cardioverter defibrillators malfunctioning at low radiation doses. Besides scant knowledge about optimal safety measures, only little is known about the exact prevalence of patients with devices undergoing RT. In this review, we provide a short overview of the principles of RT and present the current evidence on the predictors and mechanisms of device malfunctions during RT. We also summarize practical recommendations from recent publications and from the industry. Strongly associated with beam energy of photon RT, device malfunctions occur at ∼3% of RT courses, posing a substantial issue in clinical practice. Malfunctions described in the literature typically consist of transient software disturbances and only seldom manifest as a permanent damage of the device. Through close cooperation between cardiologists and oncologists, a tailored individualized approach might be necessary in this patient group in waiting time for updated international guidelines in the field.
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Affiliation(s)
- Tomas Zaremba
- Department of Cardiology, Center for Cardiovascular Research, Aalborg University Hospital, Hobrovej 18-22, Aalborg 9000, Denmark
| | - Annette Ross Jakobsen
- Department of Medical Physics, Oncology Department, Aalborg University Hospital, Hobrovej 18-22, Aalborg 9000, Denmark
| | - Mette Søgaard
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N 8200, Denmark
| | - Anna Margrethe Thøgersen
- Department of Cardiology, Center for Cardiovascular Research, Aalborg University Hospital, Hobrovej 18-22, Aalborg 9000, Denmark
| | - Sam Riahi
- Department of Cardiology, Center for Cardiovascular Research, Aalborg University Hospital, Hobrovej 18-22, Aalborg 9000, Denmark Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Sdr. Skovvej 15, Aalborg 9000, Denmark
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DEGRO/DGK guideline for radiotherapy in patients with cardiac implantable electronic devices. Strahlenther Onkol 2015; 191:393-404. [PMID: 25739476 DOI: 10.1007/s00066-015-0817-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/22/2015] [Indexed: 01/16/2023]
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.
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Zaremba T, JAKOBSEN ANNETTEROSS, SØGAARD METTE, THØGERSEN ANNAMARGRETHE, JOHANSEN MARTINBERG, MADSEN LAERKEBRUUN, RIAHI SAM. Risk of Device Malfunction in Cancer Patients with Implantable Cardiac Device Undergoing Radiotherapy: A Population-Based Cohort Study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:343-56. [DOI: 10.1111/pace.12572] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 11/30/2014] [Accepted: 12/14/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Tomas Zaremba
- Department of Cardiology, Center for Cardiovascular Research; Aalborg University Hospital; Aalborg Denmark
| | - ANNETTE ROSS JAKOBSEN
- Department of Medical Physics, Oncology Department; Aalborg University Hospital; Aalborg Denmark
| | - METTE SØGAARD
- Department of Clinical Epidemiology, Institute of Clinical Medicine; Aarhus University Hospital; Aarhus Denmark
| | - ANNA MARGRETHE THØGERSEN
- Department of Cardiology, Center for Cardiovascular Research; Aalborg University Hospital; Aalborg Denmark
| | - MARTIN BERG JOHANSEN
- Department of Clinical Medicine; Aalborg University and Aalborg University Hospital; Aalborg Denmark
| | - LAERKE BRUUN MADSEN
- Department of Cardiology, Center for Cardiovascular Research; Aalborg University Hospital; Aalborg Denmark
| | - SAM RIAHI
- Department of Cardiology, Center for Cardiovascular Research; Aalborg University Hospital; Aalborg Denmark
- Department of Clinical Medicine; Aalborg University and Aalborg University Hospital; Aalborg Denmark
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