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particular importance in patients receiving chemotherapy or those who are immunosuppressed. For most patients in whom definitive tumour treatment is planned, the risk/benefit ratio will usually favour device relocation, whereas for patients receiving palliative RT or with significant comorbidities, relocation could be avoided.826 These decisions should be made by a MDT in conjunction with the patient. Device relocation is not recommended for CIEDs receiving a maximum cumulative incident dose of ,5 Gy, where the risk is considered negligible.826,828

There should be continuous visual and voice contact with the patient during each treatment fraction. CIEDs should be periodically checked in patients with ICDs, especially those receiving .10 MV

OR

Consider moving CIED

CIED evaluation:

Leave device in situ

CIED evaluation:

f o f f r e R T

R R b ECG and/or pulse o ximet r y monitoring and external pacing a vailable

a a

during R T sessions

R R W eek W W l y during R T

R R

Reduce radiation ener g

r y to minimize exposu r e to neut r ons

Limit cu m ulati v e dose

Be f o

f f r e R T

R R b (Class I)

Audio-visual monitoring

o w-risk patients High-risk patients

CIED in the R T t

R R r eatment v olume

MDT a Consider R T type and dose

R R (Figu r e 46)

CIED check-up after completing R T

R R

(Class I)

Pacing dependent or f r equent ICD ther a pies

Maxi m um cu m ulati v e incident dose of >5 Gy

(Class I)

N N N

Risk stratification of patients with CIED under g

r oing thoracic R T

R R

Y Y

Y

Figure 45 Management of patients with a cardiac implantable electronic device located in the radiotherapy treatment beam. CIED, cardiac implantable electronic device; ECG, electrocardiogram; Gy, Gray; ICD, implantable cardioverter defibrillator; MDT, multidisciplinary team; N, no; RT, radiotherapy; Y, yes. aMultidisciplinary discussion must consider: (1) whether the CIED is interfering with the RT dose delivered to the tumour; (2) whether the RT is interfering with CIED function (aim to not exceed 2 Gy to permanent pacemaker and 1 Gy to ICD); (3) risks of moving the CIED: infection (especially in immunocompromised patients), procedural complications (e.g. bleeding with thrombocytopaenia); for younger patients with good prognosis, consider long-term effects of losing an access site (lead extraction/RT-induced thrombosis). bIf last CIED check .3 months earlier. Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026