Updated Dutch guideline for management of radiation oncology patients with a pacemaker, implantable cardioverter defibrillator or non-cardiac active implant.

Abstract

To revise and expand the 2011 Dutch guideline for radiotherapy in patients with cardiac implantable electronic devices (CIEDs), incorporating MR-linac treatment, proton therapy, and non-cardiac active implants. A literature review was performed using Embase and Ovid/Medline, covering studies from 2008 onwards. In addition, a survey was conducted among all Dutch radiation oncology centres to assess CIED-related incidents and current clinical practices. The updated guideline was developed by a multidisciplinary task group. The literature search identified 374 unique publications which were screened for relevance and analysed. Device malfunctions were found to occur predominantly with neutron-producing beam energies (> 10 MV photons or protons). The survey achieved a 100% response rate and reported only five resets, two cases of reduced battery longevity, and three transient devise malfunctions among 4942 radiotherapy patients with CIEDs treated in the Netherlands between 2011 and 2022. Based on these findings and literature, the updated guideline recommends that tachycardia therapies do not need to be deactivated during radiotherapy and that additional CIED checks are not required when photon energies ≤ 10 MV or electron beams are used and the cumulative CIED dose is < 10 Gy. Furthermore, recommendations for MR-linac treatment and non-cardiac implants are provided. The updated Dutch guideline introduces a risk-stratified approach based on neutron exposure rather than photon/electron dose alone. It simplifies monitoring protocols for nearly all radiotherapy patients treated with photons and electrons and extends guidance to newer treatment modalities and device types, thereby ensuring patient safety while streamlining radiotherapy workflows.