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

Leitlinie der DEGRO/DGK zur Strahlentherapie bei Patienten mit kardialen implantierten elektronischen Geräten

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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.

Zusammenfassung

Strahlentherapie (RT) ist zunehmend häufig bei Patienten mit kardialen implantierten elektronischen Geräten (CIED; Herzschrittmacher [SM] und Kardioverter-Defibrillatoren [ICD]) indiziert. Durch ionisierende Strahlen können Schäden und Fehlfunktionen des CIED auftreten, die einen permanenten Funktionsverlust beim Gerät und eine Asystolie oder Kammerflimmern beim Patienten auslösen. Deshalb wurde vor dem Hintergrund der bisher verfügbaren Daten eine interdisziplinäre Leitlinie (DEGRO/DGK) erarbeitet, die sich an der zu erwartenden Strahlendosis am CIED sowie dem kardialen Risiko des Patienten orientiert. In die Planung zur Strahlentherapie sollten sowohl CIED-Spezifika als auch Charakteristika der kardialen Erkrankung (SM-Abhängigkeit, stattgehabte ventrikuläre Tachykardie/Kammerflimmern) einfließen. In implantierten ICDs sollte die antitachyarrhythmische Therapie zur RT pausiert werden. Diese Patienten sollten dann zwingend mittels Elektrokradioghramm überwacht werden und ein externer Defibrillator sollte unmittelbar verfügbar sein. Bei allen CIEDs sollte die Strahlenenergie auf 6(− 10) MV limitiert werden. Der CIED sollte niemals im direkten Strahlengang liegen. Eine Gesamtstreustrahlendosis sollte 2 Gy nicht überschreiten. Das Personal sollte in der Lage sein, adäquat auf kardiale Notfälle nach „Basic-life-support“-Kriterien zu reagieren. Ein Reanimationsteam muss innerhalb von 5 min präsent sein. Nach der letzten RT sollten die CIED innerhalb von 1, 3 und 6 Monaten erneut abgefragt werden, da ein Risiko für verspätet auftretende CIED-Schäden besteht.

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Authors and Affiliations

  1. Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Ruprecht-Karls-Universität Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Deutschland

    Benjamin Gauter-Fleckenstein MD, Volker Steil & Frederik Wenz MD

  2. Klinik für Innere Medizin—Kardiologie, Diabetologie und Nephrologie, Ev. Krankenhaus Bielefeld, Bielefeld, Deutschland

    Carsten W. Israel MD

  3. Medizinische Klinik mit Schwerpunkt Kardiologie, Charité—Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland

    Marc Dorenkamp MD

  4. Klinik für Strahlentherapie, Universitätsklinik Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland

    Jürgen Dunst MD

  5. Medizinische Klinik für Kardiologie und Pulmologie, Charité—Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland

    Mattias Roser MD

  6. I. Medizinische Klinik—Kardiologie, Universitätsmedizin Mannheim, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland

    Rainer Schimpf MD

  7. Strahlentherapie Speyer, Paul-Egell-Straße 31, 67346, Speyer, Deutschland

    Jörg Schäfer MD

  8. Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Deutschland

    Ulrike Höller MD

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  1. Benjamin Gauter-Fleckenstein MD
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  2. Carsten W. Israel MD
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  3. Marc Dorenkamp MD
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  4. Jürgen Dunst MD
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  5. Mattias Roser MD
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  6. Rainer Schimpf MD
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  7. Volker Steil
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  8. Jörg Schäfer MD
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  9. Ulrike Höller MD
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  10. Frederik Wenz MD
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Correspondence to Benjamin Gauter-Fleckenstein MD.

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Conflict of interest

M. Roser has received speaker’s fees from the companies Medtronic, Biotronik, and St. Jude Medical. He has also received counseling fees from Biotronik. R. Schimpf has received speaker’s fees from Medtronic and St. Jude Medical. B. Gauter-Fleckenstein, C.W. Israel, M. Dorenkamp, J. Dunst, V. Steil, J. Schäfer, U. Höller, and F. Wenz state that there are no conflicts of interest.

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Carsten W. Israel and Rainer Schimpf, Representatives of the German Society for Cardiology (Deutschen Gesellschaft für Kardiologie; DGK)

Jürgen Dunst and Frederik Wenz, Representatives of the German Society for Radiation Oncology (Deutschen Gesellschaft für Radioonkologie; DEGRO)

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Gauter-Fleckenstein, B., Israel, C., Dorenkamp, M. et al. DEGRO/DGK guideline for radiotherapy in patients with cardiac implantable electronic devices. Strahlenther Onkol 191, 393–404 (2015). https://doi.org/10.1007/s00066-015-0817-3

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