Safe delivery of lung stereotactic body radiation therapy in a patient with a left ventricular assist device and implantable cardioverter defibrillator

Ostertag‐Hill, Claire A.; Mudd, James O.; Werle, Daniel P.; Tieu, Brandon H.; Nabavizadeh, Nima

doi:10.1002/ccr3.1666

Cited by 5 publications

(8 citation statements)

References 20 publications

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“…Previously, LVAD patients requiring radiation treatment for malignancy have received photon radiation, which has been demonstrated to be safe and effective. 2,3 To our knowledge, this is the first report of a patient with a HeartMate II and ICD who was treated with proton beam therapy.…”

Section: Discussionmentioning

confidence: 86%

First Report of Proton Beam Therapy in a Patient With a Left Ventricular Assist Device

et al. 2021

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A 77 year old man previously implanted with a HeartMate II left ventricular assist device (LVAD) as destination therapy and an implantable cardioverter defibrillator presented with a left upper lobe squamous cell lung cancer. Oncology determined that proton beam therapy was indicated for treatment, and a multidisciplinary team of radiation physicists, radiation oncologists, and LVAD providers developed a protocol to proceed safely. He was successfully treated with combined proton beam radiation therapy and reduced dose chemotherapy. This case demonstrates feasibility and considerations of proton beam therapy for malignancy relevant to patients with implantable cardiac devices including LVADs.

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Section: Discussionmentioning

confidence: 86%

First Report of Proton Beam Therapy in a Patient With a Left Ventricular Assist Device

et al. 2021

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“…Multiple case studies have reported on patients with LVADs receiving external beam radiation. [6][7][8][9][10][11][12][13][14][15] All these studies looked at directed radiation, with none involving a patient receiving TBI or LVAD controller dose. Directly comparing techniques and dose estimates is challenging.…”

Section: Discussionmentioning

confidence: 99%

“…While the effect of radiation on other cardiac implantable electrical devices (CIEDs), including pacemakers and defibrillators, has been well studied, there remains limited data on radiation to LVAD 3–7 . Much of the existing radiation data is in the form of in‐vitro studies and case reports 8–15 . None of these studies considered the radiation sensitivity of the LVAD external controller.…”

Section: Introductionmentioning

confidence: 99%

“… 3 , 4 , 5 , 6 , 7 Much of the existing radiation data is in the form of in‐vitro studies and case reports. 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 None of these studies considered the radiation sensitivity of the LVAD external controller. Here, we report the first case of dose delivered to the controller and the first reported case of total body irradiation (TBI) to a patient with an LVAD.…”

Section: Introductionmentioning

confidence: 99%

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Case study with dosimetric analysis: Total body irradiation to a patient with a left ventricular assist device

Webster,

Dona Lemus,

Zheng

et al. 2024

Clinical Case Reports

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Key Clinical MessageA patient presented with cardiogenic shock, requiring the implantation of a left ventricular assist device (LVAD), and acute myeloblastic leukemia. This necessitated total body irradiation (TBI) while balancing dose reduction to the LVAD components to avoid potential radiation damage. Here we outline our treatment approach and dose estimates to the LVAD.AbstractThis case report discusses the delivery of TBI to a patient with an LVAD. This treatment required radiation‐dose determinations and consequential reductions for the heart, LVAD, and an external controller connected to the LVAD. The patient was treated using a traditional 16MV anterior posterior (AP)/posterior anterior (PA) technique at a source‐to‐surface‐distance of 515 cm for 400 cGy in two fractions. A 3 cm thick Cerrobend block was placed on the beam spoiler to reduce dose to the heart and LVAD to 150 cGy. The external controller was placed in a 1 cm thick acrylic box to reduce neutron dose and positioned as far from the treatment fields as achievable. In vivo measurements were made using optically stimulated luminescence dosimeters (OSLDs) placed inside the box at distances of 2 cm, 8.5 cm, and 14 cm from the field edge, and on the patient along the central axis and centered behind the LVAD block. Further ion chamber measurements were made using a solid water phantom to more accurately estimate the dose delivered to the LVAD. Neutron dose measurements were also conducted. The total estimated dose to the controller ranged from 135.3 cGy to 91.5 cGy. The LVAD block reduced the surface dose to the patient to 271.6 cGy (68.1%). The block transmission factors of the 3 cm Cerrobend block measured in the phantom were 45% at 1 cm depth and decreased asymptotically to around 30% at 3 cm depth. Applying these transmission factors to the in vivo measurements yielded a dose of 120 cGy to the implanted device. The neutron dose the LVAD region is estimated around 0.46 cGy. Physical limitations of the controller made it impossible to completely avoid dose. Shielding is recommended. The block had limited dose reduction to the surface, due to secondary particles, but appropriately reduced the dose at 3 cm and beyond. More research on LVADs dose limits would be beneficial.

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“…As mentioned in the reports, when a patient's disease was too advanced for surgery or if the patient presented with metastasis, alternative options such as chemotherapy, radiotherapy or palliative care were chosen (20,21,28). The effects of radiation on CF-LVADs were discussed by Emerson et al and Ostertag et al (29,30) who suggested that the rotor and rotor magnets within the CF-LVAD were of particular concern in patients receiving radiation. Recommendations for CF-LVAD protection during radiotherapy include protecting the CF-LVAD battery source by placing it outside the RT field.…”

Section: Discussionmentioning

confidence: 99%

Development of malignancies and their outcomes in patients supported on continuous-flow left ventricular assist devices—a systematic review

Maynes¹,

Gordon²,

Weber³

et al. 2021

Ann Cardiothorac Surg

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Background: With increased use of continuous-flow left ventricular assist devices (CF-LVAD), development of malignant tumors in this population is not uncommon. We sought to evaluate malignancies in CF-LVAD patients and evaluate the outcomes of treatment strategies.Methods: Overall, 18 articles consisting of 28 patients were identified who developed malignancies after CF-LVAD placement. Patient-level data were extracted for systematic review.Results: Median patient age was 60 years [59-67] and 85.7% (24/28) were male. CF-LVAD was placed as bridge-to-transplant (BTT) in 60.9% (14/23) of patients. The three most common malignancy types were GI in 35.7% (10/28) of patients, lung in 21.4% (6/28) and skin in 10.7% (3/28). Median time from CF-LVAD implant to malignancy diagnosis was 6.9 [2.5-12.8] months. Metastatic disease occurred in 17.9%(5/28) over a median time of 5.0 [1.0-82.0] months from the diagnosis. Surgical resection of the malignancy was performed in 57.1% (16/28) of patients. Our results showed that while there was a significantly higher probability of survival among patients who underwent surgery versus those who did not, when only stage I and II patients were included in the analysis, this difference was no longer statistically significant. Three patients were relisted for heart transplant after surgical treatment, and two received the transplant.Conclusions: Surgical management of malignancies in patients on CF-LVADs may improve survival and transplant eligibility status, therefore, a CF-LVAD should not always preclude surgical treatment.

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Safe delivery of lung stereotactic body radiation therapy in a patient with a left ventricular assist device and implantable cardioverter defibrillator

Abstract: Key Clinical MessageThis is the first case to discuss the safe delivery of stereotactic body radiation therapy to a left lower lobe lung nodule in a patient with a third generation left ventricular assist device (Heartware®) and implantable cardioverter defibrillator.

Cited by 5 publications

References 20 publications

First Report of Proton Beam Therapy in a Patient With a Left Ventricular Assist Device

First Report of Proton Beam Therapy in a Patient With a Left Ventricular Assist Device

Case study with dosimetric analysis: Total body irradiation to a patient with a left ventricular assist device

Development of malignancies and their outcomes in patients supported on continuous-flow left ventricular assist devices—a systematic review

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