Management of patients with implantable cardioverter defibrillator needing radiation therapy for cancer.

epidural analgesia for emergency Caesarean section: a meta-analysis. Epidural lidocaine– bicarbonate– adrenaline vs levobupivacaine for emergency Cae-sarean section: a randomised controlled trial. Anaesthesia 2008; 63: 243–9 3 Regan KJ, O'Sullivan G. The extension of epidural blockade for emergency Caesarean section: a survey of current UK practice. Editor—Stone and colleagues 1 published an excellent review on 'Perioperative management of patients with cardiac implantable devices' focusing on management during surgery. They also covered electromagnetic interference (EMI) on cardiac implantable electronic devices (CIEDs) in non-surgical settings, such as monitoring of evoked potentials , shivering, magnetic resonance imaging, electroconvul-sive therapy, and radio frequency ablation or lesioning. Unfortunately, the management of patients with CIEDs, particularly implantable cardioverter defibrillators (ICDs), during radiation therapy is not included. ICDs are increasingly used in patients with cardiomyopathy and decreased left ventricular function and these patients may be referred for radiotherapy instead of surgery, if a susceptible malignancy is diagnosed. EMI from radiation therapy and its effects on different pacemakers and ICDs have been investigated both in vitro and in vivo, 2 3 and suggest that irradiation of a pacemaker or ICD may result in potentially lethal problems. Much less experience in managing this risk during radiation therapy than in the surgical context is available and some advice from an experienced group like Stone and coworkers would be helpful. As a Cancer Institute, we had to face the problem and set up the following protocol which we outlined according to decisions and actions proposed: 1 Before radiotherapy in patients with ICDs: – investigate and obtain documentation on the cardiac disease which led to the CIED implant and if the patient is pacemaker-dependent or non-pacemaker-dependent; – contact the producer of the device and ask for information about the 'in vitro' and 'in vivo' data during radiation exposure (i.e. maximum allowed dose to the ICD and possible outcomes due to its irradiation), if available; – during radiotherapy planning, define location and shape of ICD on CT adopted images. Make sure that the device does not receive a direct, unshielded irradiation. If the device is outside the collimated beam, minimize the dose to the ICD as low as reasonably achievable, and anyway respect the prescribed dose limits (if available) to the ICD. Alternatively, have the device either temporarily or permanently moved; – calculate the maximal cumulative dose to the ICD; – alert the cardiologist (patient's cardiologist, the cardi-ologist of the institution, or both) …