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Wei C, Qian PC, Boeck M, Bredfeldt JS, Blankstein R, Tedrow UB, Mak R, Zei PC. Cardiac stereotactic body radiation therapy for ventricular tachycardia: Current experience and technical gaps. J Cardiovasc Electrophysiol 2021; 32:2901-2914. [PMID: 34587335 DOI: 10.1111/jce.15259] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite advances in drug and catheter ablation therapy, long-term recurrence rates for ventricular tachycardia remain suboptimal. Cardiac stereotactic body radiotherapy (SBRT) is a novel treatment that has demonstrated reduction of arrhythmia episodes and favorable short-term safety profile in treatment-refractory patients. Nevertheless, the current clinical experience is early and limited. Recent studies have highlighted variable duration of treatment effect and substantial recurrence rates several months postradiation. Contributing to these differential outcomes are disparate approaches groups have taken in planning and delivering radiation, owing to both technical and knowledge gaps limiting optimization and standardization of cardiac SBRT. METHODS AND FINDINGS In this report, we review the historical basis for cardiac SBRT and existing clinical data. We then elucidate the current technical gaps in cardiac radioablation, incorporating the current clinical experience, and summarize the ongoing and needed efforts to resolve them. CONCLUSION Cardiac SBRT is an emerging therapy that holds promise for the treatment of ventricular tachycardia. Technical gaps remain, to be addressed by ongoing research and growing clincial experience.
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Affiliation(s)
- Chen Wei
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pierre C Qian
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michelle Boeck
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jeremy S Bredfeldt
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Usha B Tedrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raymond Mak
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Paul C Zei
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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2
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Gimelli A, Ernst S, Liga R. Multi-Modality Imaging for the Identification of Arrhythmogenic Substrates Prior to Electrophysiology Studies. Front Cardiovasc Med 2021; 8:640087. [PMID: 33996938 PMCID: PMC8113383 DOI: 10.3389/fcvm.2021.640087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Noninvasive cardiac imaging is crucial for the characterization of patients who are candidates for cardiac ablations, for both procedure planning and long-term management. Multimodality cardiac imaging can provide not only anatomical parameters but even more importantly functional information that may allow a better risk stratification of cardiac patients. Moreover, fusion of anatomical and functional data derived from noninvasive cardiac imaging with the results of endocavitary mapping may possibly allow a better identification of the ablation substrate and also avoid peri-procedural complications. As a result, imaging-guided electrophysiological procedures are associated with an improved outcome than traditional ablation procedures, with a consistently lower recurrence rate.
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Affiliation(s)
| | - Sabine Ernst
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Riccardo Liga
- Cardiothoracic and Vascular Department, Università di Pisa, Pisa, Italy
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3
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Kuo L, Liang JJ, Nazarian S, Marchlinski FE. Multimodality Imaging to Guide Ventricular Tachycardia Ablation in Patients with Non-ischaemic Cardiomyopathy. Arrhythm Electrophysiol Rev 2020; 8:255-264. [PMID: 32685156 PMCID: PMC7358957 DOI: 10.15420/aer.2019.37.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Catheter ablation is an effective treatment option for ventricular tachycardia (VT) in patients with non-ischaemic cardiomyopathy (NICM). The heterogeneous nature of NICM aetiologies and VT substrate in patients with NICM play a role in long-term ablation outcomes in this population. Over the past decades, more precise identification of NICM aetiologies and better characterisation of various substrates have been made. Application of multimodal imaging has greatly contributed to the accurate diagnosis of NICM subtypes and improved VT ablation strategies. This article summarises the current knowledge of multimodal imaging used in the characterisation of non-ischaemic NICM substrates, procedural planning and image integration for the optimisation of VT ablation.
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Affiliation(s)
- Ling Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jackson J Liang
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Saman Nazarian
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
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4
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Mukherjee RK, Whitaker J, Williams SE, Razavi R, O'Neill MD. Magnetic resonance imaging guidance for the optimization of ventricular tachycardia ablation. Europace 2019; 20:1721-1732. [PMID: 29584897 PMCID: PMC6212773 DOI: 10.1093/europace/euy040] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/19/2018] [Indexed: 01/02/2023] Open
Abstract
Catheter ablation has an important role in the management of patients with ventricular tachycardia (VT) but is limited by modest long-term success rates. Magnetic resonance imaging (MRI) can provide valuable anatomic and functional information as well as potentially improve identification of target sites for ablation. A major limitation of current MRI protocols is the spatial resolution required to identify the areas of tissue responsible for VT but recent developments have led to new strategies which may improve substrate assessment. Potential ways in which detailed information gained from MRI may be utilized during electrophysiology procedures include image integration or performing a procedure under real-time MRI guidance. Image integration allows pre-procedural magnetic resonance (MR) images to be registered with electroanatomical maps to help guide VT ablation and has shown promise in preliminary studies. However, multiple errors can arise during this process due to the registration technique used, changes in ventricular geometry between the time of MRI and the ablation procedure, respiratory and cardiac motion. As isthmus sites may only be a few millimetres wide, reducing these errors may be critical to improve outcomes in VT ablation. Real-time MR-guided intervention has emerged as an alternative solution to address the limitations of pre-acquired imaging to guide ablation. There is now a growing body of literature describing the feasibility, techniques, and potential applications of real-time MR-guided electrophysiology. We review whether real-time MR-guided intervention could be applied in the setting of VT ablation and the potential challenges that need to be overcome.
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Affiliation(s)
- Rahul K Mukherjee
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Mark D O'Neill
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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5
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Sramko M, Hoogendoorn JC, Glashan CA, Zeppenfeld K. Advancement in cardiac imaging for treatment of ventricular arrhythmias in structural heart disease. Europace 2018; 21:383-403. [DOI: 10.1093/europace/euy150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/23/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Marek Sramko
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Jarieke C Hoogendoorn
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Claire A Glashan
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
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6
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Imanli H, Ume KL, Jeudy J, Bob-Manuel T, Smith MF, Chen W, Abdulghani M, Ghzally Y, Mahat JB, Itah R, Restrepo A, See VY, Shorofsky S, Dilsizian V, Dickfeld T. Ventricular Tachycardia (VT) Substrate Characteristics: Insights from Multimodality Structural and Functional Imaging of the VT Substrate Using Cardiac MRI Scar, 123I-Metaiodobenzylguanidine SPECT Innervation, and Bipolar Voltage. J Nucl Med 2018; 60:79-85. [PMID: 29959218 DOI: 10.2967/jnumed.118.211698] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/22/2018] [Indexed: 11/16/2022] Open
Abstract
Postischemic adaptation results in characteristic myocardial structural and functional changes in the ventricular tachycardia (VT) substrate. The aim of this study was to compare myocardial structural and functional adaptations (late gadolinium enhancement/abnormal innervation) with detailed VT mapping data to identify regional heterogeneities in postischemic changes. Methods: Fifteen patients with ischemic cardiomyopathy and drug-refractory VT underwent late gadolinium enhancement cardiac MRI (CMR), 123I-metaiodobenzylguanidine SPECT, and high-resolution bipolar voltage mapping to assess fibrosis (>3 SDs), abnormal innervation (<50% tracer uptake), and low-voltage area (<1.5 mV), respectively. Three-dimensional reconstructed CMR/123I-metaiodobenzylguanidine models were coregistered for further comparison. Results: Postischemic structural and functional adaptations in all 3 categories were similar in size (reported as median [quartile 1-quartile 3]: CMR scar, 46.1 cm2 [33.1-86.9 cm2]; abnormal innervation, 47.8 cm2 [40.5-68.1 cm2]; and low-voltage area, 29.5 cm2 [24.5-102.6 cm2]; P > 0.05). However, any single modality underestimated the total VT substrate area defined as abnormal in at least 1 of the 3 modalities (76.0 cm2 [57.9-143.2 cm2]; P < 0.001). Within the total VT substrate area, regions abnormal in all 3 modalities were most common (25.2%). However, significant parts of the VT substrate had undergone heterogeneous adaptation (abnormal in <3 modalities); the most common categories were "abnormal innervation only" (18.2%), "CMR scar plus abnormal innervation only" (14.9%), and "CMR scar only" (14.6%). All 14 VT channel/exit sites (0.88 ± 0.74 mV) were localized to myocardium demonstrating CMR scar and abnormal innervation. This specific tissue category accounted for 68.3% of the CMR scar and 31.2% of the total abnormal postischemic VT substrate area. Conclusion: Structural and functional imaging demonstrated regional heterogeneities in the postischemic VT substrate not appreciated by any single modality alone. The coexistence of abnormal innervation and CMR scar may identify a particularly "proarrhythmic" adaptation and may represent a potential novel target for VT ablation.
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Affiliation(s)
- Hasan Imanli
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kiddy L Ume
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jean Jeudy
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Tamunoinemi Bob-Manuel
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mark F Smith
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Wengen Chen
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohammed Abdulghani
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yousra Ghzally
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.,Assiut University, Arab Republic of Egypt
| | - Jagat Bandhu Mahat
- Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Alejandro Restrepo
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vincent Y See
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephen Shorofsky
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vasken Dilsizian
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Timm Dickfeld
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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7
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Andreu D, Penela D, Acosta J, Fernández-Armenta J, Perea RJ, Soto-Iglesias D, de Caralt TM, Ortiz-Perez JT, Prat-González S, Borràs R, Guasch E, Tolosana JM, Mont L, Berruezo A. Cardiac magnetic resonance-aided scar dechanneling: Influence on acute and long-term outcomes. Heart Rhythm 2018; 14:1121-1128. [PMID: 28760258 DOI: 10.1016/j.hrthm.2017.05.018] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Indexed: 10/19/2022]
Abstract
BACKGROUND Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) provides tissue characterization of ventricular myocardium and scar that can be depicted as pixel signal intensity (PSI) maps. OBJECTIVE To assess the possible benefit of guiding the ventricular tachycardia (VT) substrate mapping by integrating these PSI maps into the navigation system. METHODS In total, 159 consecutive patients (66 ± 11 years old, 151 men [95%]) with scar-related left ventricular (LV) VT were included. VT substrate ablation used the scar dechanneling technique. A CMR-aided ablation using the PSI maps was performed in 54 patients (34%). Procedural data as well as acute and long-term outcomes were compared with those of the remaining 105 patients (66%). RESULTS Mean procedure duration and fluoroscopy time were 229 ± 67 minutes and 20 ± 9 minutes, respectively, without significant differences between groups. Both the number of radiofrequency (RF) applications and RF delivery time were lower in the CMR-aided group (28 ± 18 applications vs 36 ± 18 applications, P = .037, and 19 ± 12 minutes vs 27 ± 16 minutes, P = .009, respectively). After substrate ablation, monomorphic VT inducibility was lower in the CMR-aided than in the control group (17 [32%] vs 53 [51%] patients, P = .022). After a mean follow-up period of 20 ± 19 months, patients from the CMR-aided group had a lower recurrence rate than those in the control group (10 patients [18.5%] vs 46 patients [43.8%], respectively, P = .002; log-rank P = .017). Multivariate analysis found that CMR-aided ablation (hazard ratio, 0.48 [95% Confirdence Interval (CI) 0.24-0.96], P = .037) was an independent predictor of recurrences. CONCLUSION CMR-aided scar dechanneling is associated with a lower need for RF delivery, higher noninducibility rates after substrate ablation, and a higher VT-recurrence-free survival.
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Affiliation(s)
- David Andreu
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Diego Penela
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Juan Acosta
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | | | - Rosario J Perea
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - David Soto-Iglesias
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Teresa M de Caralt
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Jose T Ortiz-Perez
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Susana Prat-González
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Roger Borràs
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Eduard Guasch
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Jose María Tolosana
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Lluis Mont
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Antonio Berruezo
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain.
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Zeppenfeld K, Wijnmaalen AP. Clinical Aspects and Ablation of Ventricular Arrhythmias in Tetralogy of Fallot. Card Electrophysiol Clin 2017; 9:285-294. [PMID: 28457242 DOI: 10.1016/j.ccep.2017.02.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Life expectancy of patients with rToF has considerably improved due to refined surgical interventions. Monomorphic fast VTs are frequently encountered in adult patients with rToF. The dominant substrate of VT is anatomical isthmuses bordered by surgical incisions, patch material and valve annuli. Substrate based ablation strategies aim to transect all slow conducting anatomical isthmuses (SCAI) as identified by electroanatomical mapping. Procedural success is defined as non-inducibility of VT and confirmed conduction block over the SCAI resulting in long-term VT free survival in most patients. The identification of SCAIs in rToF may have important implications for risk stratification and preventive treatment.
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Affiliation(s)
- Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Postal Zone: C-05-P, PO Box 9600, Leiden 2300 RC, The Netherlands.
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Leiden University Medical Center, Postal Zone: C-05-P, PO Box 9600, Leiden 2300 RC, The Netherlands
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9
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Cardiac CT With Delayed Enhancement in the Characterization of Ventricular Tachycardia Structural Substrate. JACC Cardiovasc Imaging 2016; 9:822-832. [DOI: 10.1016/j.jcmg.2015.10.024] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 09/22/2015] [Accepted: 10/21/2015] [Indexed: 11/19/2022]
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10
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Cardiovascular imaging 2015 in the International Journal of Cardiovascular Imaging. Int J Cardiovasc Imaging 2016; 32:697-709. [DOI: 10.1007/s10554-016-0877-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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