WE-G-218-01: Management of RT Patients with Implanted Cardiac Devices: Updated Recommendations?

It has been long time since AAPM published TG-34 on cardiac pacemakers of older technology, which has been the standard document for clinical use, even today, for pacemakers (ICPs) and for defibrillators (ICDs), alike. Management of RT patients with recent technology cardiac devices has been widely published in literature without the provision of a new comprehensive and concise set of recommendations. The various effects of interaction of non-ionizing and ionizing radiations with those devices are crucial to be studied and accounted for during RT treatment deliveries. Thus, AAPM has formed the new TG-203 to work on this issue and provide recommendations to the clinical user for management of patients with cardiac devices when receiving RT. It has been numerous postings that we see in medical physics list server groups inquiring advices on dealing with these devices during patient imaging and radiation treatments. As treatment delivery technologies (IMRT, SBRT, dose escalations, proton beams, etc) and ICP/ICD technology advance, the need to address the management of patients with such devices receiving radiation treatment becomes increasingly important. ICDs offer the same functionality as ICPs, but they are also able to deliver a high-voltage shock to the heart, if needed. Finally, major discrepancies exist among manufacturer recommendations and wide variations exist among radiation therapy facilities regarding patient management precautions.

1. Provide a review on sources of potential malfunctions of modern ICPs and ICDs, including malfunction mechanisms from high-LET radiations and transient effects attributed to medical imaging procedures for radiotherapy. 2. Provide a review on management of radiotherapy patients with cardiac implanted devices. 3. Utilize recently available data and computation methods of out-of-field/peripheral dose by scattered photons and secondary neutrons in order to assess cumulative doses on the ICPs and ICDs, during current treatment deliveries (IMRT, SBRT, proton beam therapy, etc). Risk of failure associated with these doses will be discussed. 4. Provide recommendations for management of radiotherapy patients with implanted cardiac devices including the initial patient evaluation stage, dosimetric evaluation to the ICP/ICD during treatment simulation, treatment planning and treatment delivery. Recommendations for the final evaluation of the integrity and functionality of the device after treatment completion will be assessed.