Options when AICD constraints can't be met

[Pewl]

Just wondering, how many of you have treated a locally advanced lung patient whose AICD constraints couldn't be met? Most of the manufacturers still quote the 2Gy limit. Have you guys had the cardiologist move the AICD or maybe interrogate it every week?

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[OTN]

I've successfully had several moved. Not always easy for them to do, depending on scar tissue build-up.

 

[RadOncMegatron]

I’ve had several moved. Two things I learned, call the cardiologist and work with them to tell them where to move it or they may put it in a place that is not much better. They also have limitations due to the lead lengths and what not. The cardiologists tell me that moving those ICD are often not trivial. One patient also told me that moving the PM hurt like crazy so certainly not something that is easy on the patient either.

 

[medgator]

Just wondering, how many of you have treated a locally advanced lung patient whose AICD constraints couldn't be met? Most of the manufacturers still quote the 2Gy limit. Have you guys had the cardiologist move the AICD or maybe interrogate it every week?

If it can't be moved could have the device checked/interrogated weekly with the company representative

 

[RickyScott]

I once treated in a very palliative situation through pacemaker 850 x 2. Nothing happened. Risk is really from neutrons btw

 

[elementaryschooleconomics]

I've also had several moved without issue. Agree with @RickyScott, the risk is from neutrons, so you could always considering using 6MV if possible.

 

[Ray D. Ayshun]

I one time SBRT'd the primary and treated the nodes conventionally. It was an anatomic situation that allowed it, but i thought it was pretty cool.

 

[elementaryschooleconomics]

I one time SBRT'd the primary and treated the nodes conventionally. It was an anatomic situation that allowed it, but i thought it was pretty cool.

I've often thought about that. How well did it work out for the patient?

 

[RickyScott]

I've often thought about that. How well did it work out for the patient?

They went to hospice immediately after xrt.

 

[RickyScott]

I've often thought about that. How well did it work out for the patient?

Went to hospice immediately after xrt.

 

[Ray D. Ayshun]

Went to hospice immediately after xrt.

I'm a PP doc now, so yes, I did 5 fx SBRT then 30 fx IMRT, then hospice. If I ever head back to academics I'll write a paper about how I shouldn't have done that. In all seriousness, it worked fine. Was a rare, but fortuitous, situation with a 2-3 cm peripheral primary and mediastinal nodes. If I can sensically connect my primary to the hilum I do, but this was one of those cases where even if I did it all conventionally, I'd have untreated lung between the primary and nodes. In any case, was dumb luck they were separated enough to do this.

 

[RadOncDoc21]

I'm a PP doc now, so yes, I did 5 fx SBRT then 30 fx IMRT, then hospice. If I ever head back to academics I'll write a paper about how I shouldn't have done that. In all seriousness, it worked fine. Was a rare, but fortuitous, situation with a 2-3 cm peripheral primary and mediastinal nodes. If I can sensically connect my primary to the hilum I do, but this was one of those cases where even if I did it all conventionally, I'd have untreated lung between the primary and nodes. In any case, was dumb luck they were separated enough to do this.

That’s innovation!

 

[thecarbonionangle]

I get them moved. I have also had them place a second pacemaker inside the heart in some cases when they don’t want to move it

 

[Palex80]

Generally we try to move those devices away, whenever possible.

We have had a few patients though where removal was not possible (patient decline, patient in need of anticoagulation and intervention problematic).

Our cardiologists lent us a magnet which we placed directly on the AICD when the patient was positioned on the treatment couch for RT. The magnet turns off the AICD (which is important, since a malfunction of the AICD because of RT can theoretically lead to the AICD accidentally defibrillating the patient on the couch!). Once the session is completed, the magnet was removed and the AICD resumed its function

Important points:
1. Regular checks of the AICD are still necessary. Apparently however, "turned-off" AICDs are less prone to malfunction due to RT than those who are running.
2. This workflow is only applicable in patients who have an own, sufficient cardiac rhythm and does bear a risk: you "remove" the AICD for a few minutes during the daily sessions of RT; should the patient have an episode of arrhythmia at precisely that time, you still have a problem. The cardiologist can however estimate the risk by reading the AICD log prior to treatment : if the AICD was only in action once per month for a short period of time, the risk is probably justified.

 

[taserlaser]

My old practice the residents and fellows had to place the magnet and watch the cardiac tracing for dependent patients being treated. Like we know how to read and manage abnormal ecg’s anymore, ha.

As an aside I’ve got a patient with an LVAD right now I’m planning, and the manufacturer didn’t have any limits for dose. But I’m treating the scalp with 6MV-FFF so I’m not anticipating any problems.

 

[scarbrtj]

I one time SBRT'd the primary and treated the nodes conventionally. It was an anatomic situation that allowed it, but i thought it was pretty cool.

And you wouldn't nec HAVE to SBRT that primary. You could've just typed a different fraction number and dose/fx in the TPS once planned. Primaries and nodes don't have to be contoured spatially contiguously (at least they don't have to be in my clinic). But when there's an appreciable spatial discontiguousness and a two isocenter approach can be used (ie "an anatomic situation that allows it"), I about guarantee the two isocenter approach 1) makes sparing AICDs easier and 2) makes V20s better.

 

[Mandelin Rain]

When they can't be moved, I've seen EPs temporarily remove them and have the patient wear a defibrillator vest for the extent of treatment. Obviously, they can't wear the vest during treatment/showering, so there's some risk, and.... patients HATE them. But, it's an option.

 

[w00tz]

My old practice the residents and fellows had to place the magnet and watch the cardiac tracing for dependent patients being treated. Like we know how to read and manage abnormal ecg’s anymore, ha.

In residency, there were some patients that the attendings scutted the residents to monitoring cardiac tracing during treatment. Some were Cyberknife patients, so sometimes 30mins+ per fraction. Sitting there. Watching the tracing. Dying inside, slowly. Some residents outsourced the scut to therapists that had no idea what to look for. Good residency experience. Good medicine. Good times.

 

[scarbrtj]

In residency, there were some patients that the attendings scutted the residents to monitoring cardiac tracing during treatment. Some were Cyberknife patients, so sometimes 30mins+ per fraction. Sitting there. Watching the tracing. Dying inside, slowly. Some residents outsourced the scut to therapists that had no idea what to look for. Good residency experience. Good medicine. Good times.

A rad onc monitoring a cardiac tracing is about as good as Tiger Woods driving a car.

 

[arthurdent]

Generally, if you stay away from neutron producing beams, the risk is exceptionally low:

Radiotherapy-Induced Malfunction in Contemporary Cardiovascular Implantable Electronic Devices: Clinical Incidence and Predictors - PubMed

In a cohort of contemporary CIEDs, all cases of single-event upset malfunction occurred in the setting of notable neutron production, at a rate of 21% for neutron-producing RT and 0% for non-neutron-producing RT. Where clinically feasible, the use of non-neutron-producing RT is recommended...

pubmed.ncbi.nlm.nih.gov

 

[thecarbonionangle]

In residency, there were some patients that the attendings scutted the residents to monitoring cardiac tracing during treatment. Some were Cyberknife patients, so sometimes 30mins+ per fraction. Sitting there. Watching the tracing. Dying inside, slowly. Some residents outsourced the scut to therapists that had no idea what to look for. Good residency experience. Good medicine. Good times.

sounds like classic hellpit place. No attending ownership of anything or responsability. All on residents. Great stuff!!

 

[elementaryschooleconomics]

sounds like classic hellpit place. No attending ownership of anything or responsability. All on residents. Great stuff!!

I take great pride in my pacer interrogation scheduling skills and ability to watch tele monitors from a linac control room.

That's board-testable material, right?

 

[RadOncDoc21]

I take great pride in my pacer interrogation scheduling skills and ability to watch tele monitors from a linac control room.

That's board-testable material, right?

I’ve done worst unimaginable things during my residency.

 

[thecarbonionangle]

I’ve done worst unimaginable things during my residency.

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[evilbooyaa]

In residency, there were some patients that the attendings scutted the residents to monitoring cardiac tracing during treatment. Some were Cyberknife patients, so sometimes 30mins+ per fraction. Sitting there. Watching the tracing. Dying inside, slowly. Some residents outsourced the scut to therapists that had no idea what to look for. Good residency experience. Good medicine. Good times.

I take great pride in my pacer interrogation scheduling skills and ability to watch tele monitors from a linac control room.

That's board-testable material, right?

I am open to anonymous naming and shaming of any program that expects residents to do this!