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Viani GA, Gouveia AG, Pavoni JF, Louie AV, Detsky J, Spratt DE, Moraes FY. A Meta-analysis of the Efficacy and Safety of Stereotactic Arrhythmia Radioablation (STAR) in Patients with Refractory Ventricular Tachycardia. Clin Oncol (R Coll Radiol) 2023; 35:611-620. [PMID: 37365062 DOI: 10.1016/j.clon.2023.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/24/2023] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
AIMS Reports of stereotactic arrhythmia radioablation (STAR) in patients with refractory ventricular tachycardia after catheter ablation are limited to small series. Here, we carried out a systematic review and meta-analysis of studies to better determine the efficacy and toxicity of STAR for ventricular tachycardia. MATERIALS AND METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines, eligible studies were identified on Medline, Embase, Cochrane Library and the proceedings of annual meetings to 10 February 2023. Efficacy was defined as a ventricular tachycardia burden reduction >70% at 6 months; safety was defined as <10% of any grade ≥3 toxicity. RESULTS Seven observational studies with a total of 61 patients treated were included. At 6 months, the ventricular tachycardia burden reduction was 92% (95% confidence interval 85-100%) and use of fewer than two anti-arrhythmic drugs was seen in 85% (95% confidence interval 50-100). Six months after STAR, an 86% reduction (95% confidence interval 80-93) in the number of implantable cardioverter-defibrillator shocks was observed. The rates for improved, unchanged and decreased cardiac ejection fraction were 10%, 84% and 6%, respectively. Overall survival at 6 and 12 months was 89% (95% confidence interval 81-97) and 82% (95% confidence interval 65-98). The cardiac-specific survival at 6 months was 87%. Late grade 3 toxicity occurred in 2% (95% confidence interval 0-5%) with no grade 4-5 toxicity. CONCLUSION STAR demonstrated both satisfactory efficacy and safety for the management of refractory ventricular tachycardia and was also associated with a significant decline in anti-arrhythmic drugs consumption. These findings support the continued development of STAR as a treatment option.
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Affiliation(s)
- G A Viani
- Ribeirão Preto Medical School, Department of Medical Imaging, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - A G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department - Americas Oncologia, Rio de Janeiro, Brazil
| | - J F Pavoni
- Faculdade de Filosofia, Letras e Ciências Naturais, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - A V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - J Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - D E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - F Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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2
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Narducci ML, Cellini F, Natale A. Editorial: Stereotactic radioablation of cardiac arrhythmias: pros and cons. Front Cardiovasc Med 2023; 10:1208851. [PMID: 37408657 PMCID: PMC10319153 DOI: 10.3389/fcvm.2023.1208851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/25/2023] [Indexed: 07/07/2023] Open
Affiliation(s)
- Maria Lucia Narducci
- Cardiovascular Science Department, Agostino Gemelli University Polyclinic, IRCCS, Rome, Italy
| | - Francesco Cellini
- Dipartimento Universitario Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Center for Atrial Fibrillation, St. David’s Medical Center, Austin, TX, United States
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3
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van der Ree MH, Dieleman EMT, Visser J, Planken RN, Boekholdt SM, de Bruin-Bon RHA, Rasch CRN, Hoeksema WF, de Jong RMAJ, Kemme MJB, Balt JC, Wilde AAM, Balgobind BV, Postema PG. Non-invasive stereotactic arrhythmia radiotherapy for ventricular tachycardia: results of the prospective STARNL-1 trial. Europace 2023; 25:1015-1024. [PMID: 36746553 PMCID: PMC10062344 DOI: 10.1093/europace/euad020] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/09/2023] [Indexed: 02/08/2023] Open
Abstract
AIMS Stereotactic arrhythmia radiotherapy (STAR) is suggested as potentially effective and safe treatment for patients with therapy-refractory ventricular tachycardia (VT). However, the current prospective knowledge base and experience with STAR is limited. In this study we aimed to prospectively evaluate the efficacy and safety of STAR. METHODS AND RESULTS The StereoTactic Arrhythmia Radiotherapy in the Netherlands no.1 was a pre-post intervention study to prospectively evaluate efficacy and safety of STAR. In patients with therapy-refractory VT, the pro-arrhythmic region was treated with a 25 Gy single radiotherapy fraction. The main efficacy measure was a reduction in the number of treated VT-episodes by ≥50%, comparing the 12 months before and after treatment (or end of follow-up, excluding a 6-week blanking period). The study was deemed positive when ≥50% of patients would meet this criterion. Safety evaluation included left ventricular ejection fraction, pulmonary function, and adverse events. Six male patients with an ischaemic cardiomyopathy were enrolled, and median age was 73 years (range 54-83). Median left ventricular ejection fraction was 38% (range 24-52). The median planning target volume was 187 mL (range 93-372). Four (67%) patients completed the 12-month follow-up, and two patients died (not STAR related) during follow-up. The main efficacy measure of ≥50% reduction in treated VT-episodes at the end of follow-up was achieved in four patients (67%). The median number of treated VT-episodes was reduced by 87%. No reduction in left ventricular ejection fraction or pulmonary function was observed. No treatment related serious adverse events occurred. CONCLUSIONS STAR resulted in a ≥ 50% reduction in treated VT-episodes in 4/6 (67%) patients. No reduction in cardiac and pulmonary function nor treatment-related serious adverse events were observed during follow-up. CLINICAL TRIAL REGISTRATION Netherlands Trial Register-NL7510.
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Affiliation(s)
- Martijn H van der Ree
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Edith M T Dieleman
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jorrit Visser
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - R Nils Planken
- Amsterdam UMC location University of Amsterdam, Department of Radiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Rianne H A de Bruin-Bon
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Coen R N Rasch
- Leiden UMC, University of Leiden, Department of Radiation Oncology, Albinusdreef 2, Leiden, The Netherlands
| | - Wiert F Hoeksema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Rianne M A J de Jong
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Michiel J B Kemme
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Clinical and Experimental Cardiology, Boelelaan 1117, Amsterdam, The Netherlands
| | - Jippe C Balt
- St. Antonius Hospital, Department of Cardiology, Koekoekslaan 1, Nieuwegein, The Netherlands
| | - Arthur A M Wilde
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Brian V Balgobind
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Pieter G Postema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
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4
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STereotactic Arrhythmia Radioablation: current status of the art. The old world and the new world connected. JOURNAL OF RADIOTHERAPY IN PRACTICE 2023. [DOI: 10.1017/s1460396922000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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5
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Levis M, Dusi V, Magnano M, Cerrato M, Gallio E, Depaoli A, Ferraris F, De Ferrari GM, Ricardi U, Anselmino M. A case report of long-term successful stereotactic arrhythmia radioablation in a cardiac contractility modulation device carrier with giant left atrium, including a detailed dosimetric analysis. Front Cardiovasc Med 2022; 9:934686. [PMID: 36072883 PMCID: PMC9441661 DOI: 10.3389/fcvm.2022.934686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/25/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Catheter ablation (CA) is the current standard of care for patients suffering drug-refractory monomorphic ventricular tachycardias (MMVTs). Yet, despite significant technological improvements, recurrences remain common, leading to increased morbidity and mortality. Stereotactic arrhythmia radioablation (STAR) is increasingly being adopted to overcome the limitations of conventional CA, but its safety and efficacy are still under evaluation. Case presentation We hereby present the case of a 73-year-old patient implanted with a mitral valve prosthesis, a cardiac resynchronization therapy-defibrillator, and a cardiac contractility modulation device, who was successfully treated with STAR for recurrent drug and CA-resistant MMVT in the setting of advanced heart failure and a giant left atrium. We report a 2-year follow-up and a detailed dosimetric analysis. Conclusion Our case report supports the early as well as the long-term efficacy of 25 Gy single-session STAR. Despite the concomitant severe heart failure, with an overall heart minus planned target volume mean dosage below 5 Gy, no major detrimental cardiac side effects were detected. To the best of our knowledge, our dosimetric analysis is the most accurate reported so far in the setting of STAR, particularly for what concerns cardiac substructures and coronary arteries. A shared dosimetric planning among centers performing STAR will be crucial in the next future to fully disclose its safety profile.
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Affiliation(s)
- Mario Levis
- Department of Oncology, University of Turin, Turin, Italy
| | - Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Massimo Magnano
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Marzia Cerrato
- Department of Oncology, University of Turin, Turin, Italy
| | - Elena Gallio
- Medical Physics Unit, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Alessandro Depaoli
- Department of Radiology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Federico Ferraris
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
- *Correspondence: Gaetano Maria De Ferrari
| | | | - Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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6
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Chalkia M, Kouloulias V, Tousoulis D, Deftereos S, Tsiachris D, Vrachatis D, Platoni K. Stereotactic Arrhythmia Radioablation as a Novel Treatment Approach for Cardiac Arrhythmias: Facts and Limitations. Biomedicines 2021; 9:1461. [PMID: 34680578 PMCID: PMC8533522 DOI: 10.3390/biomedicines9101461] [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: 09/05/2021] [Revised: 09/29/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
Stereotactic ablative radiotherapy (SABR) is highly focused radiation therapy that targets well-demarcated, limited-volume malignant or benign tumors with high accuracy and precision using image guidance. Stereotactic arrhythmia radioablation (STAR) applies SABR to treat cardiac arrhythmias, including ventricular tachycardia (VT) and atrial fibrillation (AF), and has recently been a focus in research. Clinical studies have demonstrated electrophysiologic conduction blockade and histologic fibrosis after STAR, which provides a proof of principle for its potential for treating arrhythmias. This review will present the basic STAR principles, available clinical study outcomes, and how the technique has evolved since the first pre-clinical study. In addition to the clinical workflow, focus will be given on the process for stereotactic radiotherapy Quality Assurance (QA) tests, as well as the need for establishing a standardized QA protocol. Future implications and potential courses of research will also be discussed.
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Affiliation(s)
- Marina Chalkia
- Radiotherapy Unit, Second Department of Radiology, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (V.K.); (K.P.)
| | - Vassilis Kouloulias
- Radiotherapy Unit, Second Department of Radiology, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (V.K.); (K.P.)
| | - Dimitris Tousoulis
- First Department of Cardiology, ‘Hippokration’ General Hospital, Vasilissis Sofias 114, 115 27 Athens, Greece;
| | - Spyridon Deftereos
- Second Department of Cardiology, “Attikon” University Hospital, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (S.D.); (D.V.)
| | | | - Dimitrios Vrachatis
- Second Department of Cardiology, “Attikon” University Hospital, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (S.D.); (D.V.)
| | - Kalliopi Platoni
- Radiotherapy Unit, Second Department of Radiology, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (V.K.); (K.P.)
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7
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Krug D, Blanck O, Andratschke N, Guckenberger M, Jumeau R, Mehrhof F, Boda-Heggemann J, Seidensaal K, Dunst J, Pruvot E, Scholz E, Saguner AM, Rudic B, Boldt LH, Bonnemeier H. Recommendations regarding cardiac stereotactic body radiotherapy for treatment refractory ventricular tachycardia. Heart Rhythm 2021; 18:2137-2145. [PMID: 34380072 DOI: 10.1016/j.hrthm.2021.08.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ventricular tachycardia (VT) is a potentially lethal complication of structural heart disease. Despite optimal management, a subgroup of patients continue to suffer from recurrent VT. Recently, cardiac stereotactic body radiotherapy (CSBRT) has been introduced as a treatment option in patients with VT refractory to antiarrhythmic drugs and catheter ablation. OBJECTIVE The purpose of this study was to establish an expert consensus regarding the conduct and use of CSBRT for refractory VT. METHODS We conducted a modified Delphi process. Thirteen experts from institutions from Germany and Switzerland participated in the modified Delphi process. Statements regarding the following topics were generated: treatment setting, institutional expertise and technical requirements, patient selection, target volume definition, and monitoring during and after CSBRT. Agreement was rated on a 5-point Likert scale. Cutoffs for agreement were defined in analogy to the RAND methodology. RESULTS There was strong agreement regarding the experimental status of the procedure and the preference for treatment in clinical trials. CSBRT should be conducted at specialized centers with a strong expertise in the management of patients with ventricular arrhythmias and in stereotactic body radiotherapy for moving targets. CSBRT should be restricted to patients with refractory VT with optimal antiarrhythmic medication who underwent prior catheter ablation or have contraindications. Target volume delineation for CSBRT is complex. Therefore, interdisciplinary processes that should include cardiology/electrophysiology and radiation oncology as well as medical physics, radiology, and nuclear medicine are needed. Optimal follow-up is required. CONCLUSION Prospective trials and pooled registries are needed to gain further insight into this promising treatment option for patients with refractory VT.
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Affiliation(s)
- David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany.
| | - Oliver Blanck
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | | | - Raphael Jumeau
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Radiation Oncology Institute, Hirslanden Clinique Bois-Cerf, Lausanne, Switzerland
| | - Felix Mehrhof
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Medical Faculty Mannheim, Mannheim, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eberhard Scholz
- Department of Cardiology, Heidelberg Center for Heart Rhythm Disorders (HCR), University of Heidelberg, Heidelberg, Germany
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - Boris Rudic
- Department of Internal Medicine I, Section for Electrophysiology und Rhythmology, University Medical Center Mannheim, University of Heidelberg, Medical Faculty Mannheim, Mannheim, Germany
| | - Leif-Hendrik Boldt
- Department of Internal Medicine and Cardiology, Charité University Medicine Berlin-Campus Virchow Klinikum, Berlin, Germany
| | - Hendrik Bonnemeier
- Department of Internal Medicine III, Section for Electrophysiology und Rhythmology, University Hospital Schleswig-Holstein, Kiel, Germany
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8
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Knybel L, Cvek J, Neuwirth R, Jiravsky O, Hecko J, Penhaker M, Sramko M, Kautzner J. Real-time measurement of ICD lead motion during stereotactic body radiotherapy of ventricular tachycardia. ACTA ACUST UNITED AC 2021; 26:128-137. [PMID: 34046223 DOI: 10.5603/rpor.a2021.0020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
Background Here we aimed to evaluate the respiratory and cardiac-induced motion of a ICD lead used as surrogate in the heart during stereotactic body radiotherapy (SBRT) of ventricular tachycardia (VT). Data provides insight regarding motion and motion variations during treatment. Materials and methods We analyzed the log files of surrogate motion during SBRT of ventricular tachycardia performed in 20 patients. Evaluated parameters included the ICD lead motion amplitudes; intrafraction amplitude variability; correlation error between the ICD lead and external markers; and margin expansion in the superior-inferior (SI), latero-lateral (LL), and anterior-posterior (AP) directions to cover 90% or 95% of all amplitudes. Results In the SI, LL, and AP directions, respectively, the mean motion amplitudes were 5.0 ± 2.6, 3.4. ± 1.9, and 3.1 ± 1.6 mm. The mean intrafraction amplitude variability was 2.6 ± 0.9, 1.9 ± 1.3, and 1.6 ± 0.8 mm in the SI, LL, and AP directions, respectively. The margins required to cover 95% of ICD lead motion amplitudes were 9.5, 6.7, and 5.5 mm in the SI, LL, and AP directions, respectively. The mean correlation error was 2.2 ± 0.9 mm. Conclusions Data from online tracking indicated motion irregularities and correlation errors, necessitating an increased CTV-PTV margin of 3 mm. In 35% of cases, the motion variability exceeded 3 mm in one or more directions. We recommend verifying the correlation between CTV and surrogate individually for every patient, especially for targets with posterobasal localization where we observed the highest difference between the lead and CTV motion.
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Affiliation(s)
- Lukas Knybel
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | | | - Otakar Jiravsky
- Department of Cardiology, Podlesi Hospital, Trinec, Czech Republic
| | - Jan Hecko
- VŠB-Technical University of Ostrava, Ostrava, Czech Republic
| | - Marek Penhaker
- VŠB-Technical University of Ostrava, Ostrava, Czech Republic
| | - Marek Sramko
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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9
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Tschabrunn CM, Pothineni NVK, Sauer WH, Doynow D, Salas J, Liao TW, Santangeli P, Arkles J, Hyman MC, Frankel DS, Supple GE, Garcia FC, Nazarian S, Dixit S, Epstein AE, Schaller RD, Callans DJ, Marchlinski FE. Evaluation of Radiofrequency Ablation Irrigation Type: In Vivo Comparison of Normal Versus Half-Normal Saline Lesion Characteristics. JACC Clin Electrophysiol 2020; 6:684-692. [PMID: 32553219 DOI: 10.1016/j.jacep.2020.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/23/2020] [Accepted: 02/20/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study investigated the impact of the type of catheter irrigant used during delivery of radiofrequency ablation. BACKGROUND The use of half-normal saline (HNS) as an irrigant has been suggested as a method for increasing ablation lesion size but has not been rigorously studied in the beating heart or the use of a low-flow irrigation catheter. METHODS Sixteen swine underwent left ventricular mapping and ablation using either normal saline (NS) (group 1: n = 9) or half-normal saline (HNS) (group 2: n = 7). All lesions were delivered using identical parameters (40 W with 10-second ramp, 30-second duration, 15 ml/min flow, and 8- to14-g target contact force). An occurrence of steam pop, catheter char, or thrombus was assessed using intracardiac echocardiography and catheter inspection following each application. Lesion depth, width, and area were measured using electronic calibers. RESULTS A total of 109 lesions were delivered in group 1 and 77 in group 2. There were significantly more steam pops in group 2 (32 of 77 [42%] vs. 24 of 109 [22%], respectively). The frequencies of catheter tip char were similar (group 1: 9 of 109 [8%] vs. group 2: 10 of 77 [13%]; p = 0.29). Lesion depths, widths, and areas also were similar in both groups. CONCLUSIONS The use of an HNS irrigant using a low-flow open irrigated ablation catheter platform results in more tissue heating due to higher radiofrequency current delivery directed to tissue, but this can lead to higher rate of steam pops. In this in vivo porcine beating-heart model, the use of HNS does not appear to significantly increase lesion size in normal myocardium despite evidence of increased radiofrequency heating.
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Affiliation(s)
- Cory M Tschabrunn
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Naga Venkata K Pothineni
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Doynow
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan Salas
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ting-Wei Liao
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin C Garcia
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Blanck O, Buergy D, Vens M, Eidinger L, Zaman A, Krug D, Rudic B, Boda-Heggemann J, Giordano FA, Boldt LH, Mehrhof F, Budach V, Schweikard A, Olbrich D, König IR, Siebert FA, Vonthein R, Dunst J, Bonnemeier H. Radiosurgery for ventricular tachycardia: preclinical and clinical evidence and study design for a German multi-center multi-platform feasibility trial (RAVENTA). Clin Res Cardiol 2020; 109:1319-1332. [PMID: 32306083 PMCID: PMC7588361 DOI: 10.1007/s00392-020-01650-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/08/2020] [Indexed: 12/25/2022]
Abstract
Background Single-session high-dose stereotactic radiotherapy (radiosurgery) is a new treatment option for otherwise untreatable patients suffering from refractory ventricular tachycardia (VT). In the initial single-center case studies and feasibility trials, cardiac radiosurgery has led to significant reductions of VT burden with limited toxicities. However, the full safety profile remains largely unknown. Methods/design In this multi-center, multi-platform clinical feasibility trial which we plan is to assess the initial safety profile of radiosurgery for ventricular tachycardia (RAVENTA). High-precision image-guided single-session radiosurgery with 25 Gy will be delivered to the VT substrate determined by high-definition endocardial electrophysiological mapping. The primary endpoint is safety in terms of successful dose delivery without severe treatment-related side effects in the first 30 days after radiosurgery. Secondary endpoints are the assessment of VT burden, reduction of implantable cardioverter defibrillator (ICD) interventions [shock, anti-tachycardia pacing (ATP)], mid-term side effects and quality-of-life (QoL) in the first year after radiosurgery. The planned sample size is 20 patients with the goal of demonstrating safety and feasibility of cardiac radiosurgery in ≥ 70% of the patients. Quality assurance is provided by initial contouring and planning benchmark studies, joint multi-center treatment decisions, sequential patient safety evaluations, interim analyses, independent monitoring, and a dedicated data and safety monitoring board. Discussion RAVENTA will be the first study to provide the initial robust multi-center multi-platform prospective data on the therapeutic value of cardiac radiosurgery for ventricular tachycardia. Trial registration number NCT03867747 (clinicaltrials.gov). Registered March 8, 2019. The study was initiated on November 18th, 2019, and is currently recruiting patients. Graphic abstract ![]()
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Affiliation(s)
- Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.
| | - Daniel Buergy
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Maren Vens
- Universität zu Lübeck, Zentrum für Klinische Studien, Lübeck, Germany.,Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Lina Eidinger
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.,Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Adrian Zaman
- Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Boris Rudic
- Medizinische Klinik I, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsmedizin Mannheim, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Judit Boda-Heggemann
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Frank A Giordano
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Germany
| | - Leif-Hendrik Boldt
- Medizinische Klinik mit Schwerpunkt Kardiologie (CVK), Abteilung für Elektrophysiologie und Rhythmologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Mehrhof
- Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Volker Budach
- Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Achim Schweikard
- Institut für Robotik und Kognitive Systeme, Universität zu Lübeck, Lübeck, Germany
| | - Denise Olbrich
- Universität zu Lübeck, Zentrum für Klinische Studien, Lübeck, Germany
| | - Inke R König
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Frank-Andre Siebert
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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11
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Wei C, Qian P, Tedrow U, Mak R, Zei PC. Non-invasive Stereotactic Radioablation: A New Option for the Treatment of Ventricular Arrhythmias. Arrhythm Electrophysiol Rev 2020; 8:285-293. [PMID: 32685159 PMCID: PMC7358955 DOI: 10.15420/aer.2019.04] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Ventricular tachycardia (VT) is associated with significant morbidity and mortality. Radiofrequency catheter ablation can be effective for the treatment of VT but it carries a high rate of recurrence often attributable to insufficient depth of penetration for reaching critical arrhythmogenic substrates. Stereotactic body radioablation (SBRT) is a commonly used technology developed for the non-invasive treatment of solid tumours. Recent evidence suggests that it can also be effective for the treatment of VT. It is a non-invasive procedure and it has the unique advantage of delivering ablative energy to any desired volume within the body to reach sites that are inaccessible with catheter ablation. This article summarises the pre-clinical studies that have formed the evidence base for SBRT in the heart, describes the clinical approaches for SBRT VT ablation and provides perspective on next steps for this new treatment modality.
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Affiliation(s)
- Chen Wei
- Harvard Medical School, Boston, MA, US.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, US
| | - Pierre Qian
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, US
| | - Usha Tedrow
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, US
| | - Raymond Mak
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, US
| | - Paul C Zei
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, US
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12
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Stereotactic body radiotherapy for ventricular tachycardia (cardiac radiosurgery). Strahlenther Onkol 2019; 196:23-30. [DOI: 10.1007/s00066-019-01530-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 10/09/2019] [Indexed: 11/26/2022]
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13
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Electrocardiographic features, mapping and ablation of idiopathic outflow tract ventricular arrhythmias. J Interv Card Electrophysiol 2019; 57:207-218. [PMID: 31650457 DOI: 10.1007/s10840-019-00617-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Idiopathic outflow tract ventricular arrhythmias are ventricular tachycardias or premature ventricular contractions presumably not related to myocardial scar or disorders of ion channels. These arrhythmias have focal origin and display characteristic electrocardiographic features. The purpose of this article is to review the state of the art of diagnosis and treatment of idiopathic outflow tract ventricular arrhythmias. METHODS We systematically reviewed scientific literature about idiopathic outflow tract ventricular arrhythmias selecting the most relevant papers on this topic. RESULTS The right ventricle outflow tract is the most common site of origin for outflow tract ventricular arrhythmias, but also left ventricle outflow tract can harbour these arrhythmias. Outflow tract ventricular arrhythmias are generally benign and may require treatment if they are symptomatic, incessant or give rise to cardiomyopathy. Radiofrequency catheter ablation is an effective and safe therapeutic strategy. A successful procedure requires a thorough preoperative analysis of the 12-lead electrocardiogram of the spontaneous arrhythmia combined with a detailed electroanatomical mapping and intracardiac echocardiography. CONCLUSIONS Idiopathic outflow tract arrhythmias are frequent in daily clinical practice and can be successfully eliminated through discrete radiofrequency catheter ablation with low rates of complications.
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Neuwirth R, Cvek J, Knybel L, Jiravsky O, Molenda L, Kodaj M, Fiala M, Peichl P, Feltl D, Januška J, Hecko J, Kautzner J. Stereotactic radiosurgery for ablation of ventricular tachycardia. Europace 2019; 21:1088-1095. [DOI: 10.1093/europace/euz133] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 04/16/2019] [Indexed: 11/13/2022] Open
Abstract
Aims
Stereotactic body radiotherapy (SBRT) for ventricular tachycardias (VTs) could be an option after failed catheter ablation. In this study, we analysed the long-term efficacy and toxicity of SBRT applied as a bail-out procedure.
Methods and results
Patients with structural heart disease and unsuccessful catheter ablations for VTs underwent SBRT. The planning target volume (PTV) was accurately delineated using exported 3D electroanatomical maps with the delineated critical part of re-entry circuits. This was defined by detailed electroanatomic mapping and by pacing manoeuvres during the procedure. Using the implantable cardioverter-defibrillator lead as a surrogate contrast marker for respiratory movement compensation, 25 Gy was delivered to the PTV using CyberKnife. We evaluated occurrences of sustained VT, electrical storm, antitachycardia pacing, and shock; time to death; and radiation-induced events. From 2014 until March 2017, 10 patients underwent radiosurgical ablation (mean PTV, 22.15 mL; treatment duration, 68 min). After radiosurgery, four patients experienced nausea and one patient presented gradual progression of mitral regurgitation. During the follow-up (median 28 months), VT burden was reduced by 87.5% compared with baseline (P = 0.012) and three patients suffered non-arrhythmic deaths. After the blanking period, VT recurred in eight of 10 patients. The mean time to first antitachycardia pacing and shock were 6.5 and 21 months, respectively.
Conclusion
Stereotactic body radiotherapy appears to show long-term safety and effectiveness for VT ablation in structural heart disease inaccessible to catheter ablation. We report one possible radiation-related toxicity and promising overall survival, warranting evaluation in a prospective multicentre clinical trial.
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Affiliation(s)
- Radek Neuwirth
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, 17. listopadu 1790, Ostrava, Czech Republic
| | - Lukas Knybel
- Department of Oncology, University Hospital Ostrava, 17. listopadu 1790, Ostrava, Czech Republic
| | | | - Lukas Molenda
- Department of Oncology, University Hospital Ostrava, 17. listopadu 1790, Ostrava, Czech Republic
| | - Michal Kodaj
- Cardiology, Podlesi Hospital Trinec, Czech Republic
| | - Martin Fiala
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - David Feltl
- Department of Oncology, General University Hospital, Prague, Czech Republic
| | | | - Jan Hecko
- Cardiology, Podlesi Hospital Trinec, Czech Republic
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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15
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Sharp AJ, Mak R, Zei PC. Noninvasive Cardiac Radioablation for Ventricular Arrhythmias. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0596-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Tung R, Liu Q, Jiang R, Jiang C. Nonionic irrigated radiofrequency ablation of refractory incessant ventricular tachycardia via great cardiac vein. HeartRhythm Case Rep 2018; 4:572-575. [PMID: 30581735 PMCID: PMC6301884 DOI: 10.1016/j.hrcr.2018.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Roderick Tung
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Chicago, Illinois
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Spartalis M, Spartalis E, Tzatzaki E, Tsilimigras DI, Moris D, Kontogiannis C, Livanis E, Iliopoulos DC, Voudris V, Theodorakis GN. Novel approaches for the treatment of ventricular tachycardia. World J Cardiol 2018; 10:52-59. [PMID: 30079151 PMCID: PMC6068734 DOI: 10.4330/wjc.v10.i7.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 03/24/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
Ventricular tachycardia (VT) is a crucial cause of sudden cardiac death (SCD) and a primary cause of mortality and morbidity in patients with structural cardiac disease. VT includes clinical disorders varying from benign to life-threatening. Most life-threatening episodes are correlated with coronary artery disease, but the risk of SCD varies in certain populations, with various underlying heart conditions, specific family history, and genetic variants. The targets of VT management are symptom alleviation, improved quality of life, reduced implantable cardioverter defibrillator shocks, prevention of reduction of left ventricular function, reduced risk of SCD, and improved overall survival. Antiarrhythmic drug therapy and endocardial catheter ablation remains the cornerstone of guideline-endorsed VT treatment strategies in patients with structural cardiac abnormalities. Novel strategies such as epicardial ablation, surgical cryoablation, transcoronary alcohol ablation, pre-procedural imaging, and stereotactic ablative radiotherapy are an appealing area of research. In this review, we gathered all recent advances in innovative therapies as well as experimental evidence focusing on different aspects of VT treatment that could be significant for future favorable clinical applications.
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Affiliation(s)
- Michael Spartalis
- ESC Working Group on Cardiac Cellular Electrophysiology, Sophia Antipolis Cedex 06903, France
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Eleni Tzatzaki
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Diamantis I Tsilimigras
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Demetrios Moris
- Department of Surgery, Duke University, Durham, NC 27710, United States
| | - Christos Kontogiannis
- Department of Clinical Therapeutics, “Alexandra” Hospital, University of Athens, Athens 11528, Greece
| | - Efthimios Livanis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Vassilis Voudris
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
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18
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Pérez JJ, González-Suárez A, d'Avila A, Berjano E. RF-energised intracoronary guidewire to enhance bipolar ablation of the interventricular septum: in-silico feasibility study. Int J Hyperthermia 2018; 34:1202-1212. [PMID: 29392974 DOI: 10.1080/02656736.2018.1425487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Although bipolar radiofrequency (RF) ablation (RFA) is broadly used to eliminate ventricular tachycardias in the interventricular septum wall, it can fail to create transmural lesions in thick ventricular walls. To solve this problem, we explored whether an RF-energised guidewire inserted into the ventricular wall would enhance bipolar RFA in the creation of transmural lesions through the ventricular wall. METHODS We built three-dimensional computational models including two irrigated electrodes placed on opposing sides of the interventricular septum and a metal guidewire inserted into the septum. Computer simulations were conducted to compare the temperature distributions obtained with two ablation modes: bipolar mode (RF power delivered between both irrigated electrode) and time-division multiplexing (TDM) technique, which consists of activating the bipolar mode for 90% of the time and applying RF power between the guidewire and both irrigated electrodes during the remaining time. RESULTS The TDM technique was the most suitable in terms of creating wider lesions through the entire ventricular wall, avoiding the hour-glass shape of thermal lesions associated with the bipolar mode. This was especially apparent in the case of thick walls (15 mm). Furthermore, the TDM technique was able to create transmural lesions even when the guidewire was displaced from the midplane of the wall. CONCLUSIONS An RF-energised guidewire could enhance bipolar RFA by allowing transmural lesions to be made through thick ventricular walls. However, the safety of this new approach must be assessed in future pre-clinical studies, especially in terms of the risk of stenosis and its clinical impact.
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Affiliation(s)
- Juan J Pérez
- a Department of Electronic Engineering, BioMIT , Universitat Politècnica de València , Valencia , Spain
| | - Ana González-Suárez
- b Department of Information and Communication Technologies , Universitat Pompeu Fabra , Barcelona , Spain
| | | | - Enrique Berjano
- a Department of Electronic Engineering, BioMIT , Universitat Politècnica de València , Valencia , Spain
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Abstract
Purpose of Review Stereotactic radioablation is a commonly utilized technology to noninvasively treat solid tumors with precision and efficacy. Using a robotic arm mounted delivery system, multiple low-dose ionizing radiation beams are delivered from multiple angles, concentrating ablative energy at the target tissue. Recently, this technology has been evaluated for treatment of cardiac arrhythmias. This review will present the basic underlying principles, proof-of-principle studies, and clinical experience with stereotactic arrhythmia radioablation. Recent Findings Most recently, stereotactic radioablation has been used to safely and effectively treat a limited number of patients with malignant arrhythmias, including ventricular tachycardia (VT) and atrial fibrillation (AF). Treatment protocols, outcomes, ongoing studies, and future directions will be discussed. Summary Stereotactic radioablation is a well-established technology that has been shown to be a safe and effective therapy for patients with drug-refractory cardiac arrhythmias, including VT and AF. Further clinical evaluation to define safety and efficacy in larger populations of patients is needed.
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Affiliation(s)
- Paul C Zei
- Department of Medicine, Electrophysiology Section, Brigham and Women's Hospital, 70 Francis Street, Shapiro Building - Room 05088, Boston, MA, 02115, USA.
| | - Scott Soltys
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
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Batul SA, Olshansky B, Fisher JD, Gopinathannair R. Recent advances in the management of ventricular tachyarrhythmias. F1000Res 2017; 6:1027. [PMID: 28721212 PMCID: PMC5497814 DOI: 10.12688/f1000research.11202.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2017] [Indexed: 01/14/2023] Open
Abstract
Ventricular arrhythmias are an important cause of cardiovascular morbidity and mortality, particularly in those with structural heart disease, inherited cardiomyopathies, and channelopathies. The goals of ventricular arrhythmia management include symptom relief, improving quality of life, reducing implantable cardioverter defibrillator shocks, preventing deterioration of left ventricular function, reducing risk of arrhythmic death, and potentially improving overall survival. Guideline-directed medical therapy and implantable cardioverter defibrillator implantation remain the mainstay of therapy to prevent sudden cardiac death in patients with ventricular arrhythmias in the setting of structural heart disease. Recent advances in imaging modalities and commercial availability of genetic testing panels have enhanced our mechanistic understanding of the disease processes and, along with significant progress in catheter-based ablative therapies, have enabled a tailored and more effective management of drug-refractory ventricular arrhythmias. Several gaps in our knowledge remain and require further research. In this article, we review the recent advances in the diagnosis and management of ventricular arrhythmias.
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Affiliation(s)
- Syeda Atiqa Batul
- Arrhythmia Division, Montefiore Medical Center, Bronx, New York, USA
| | | | - John D Fisher
- Arrhythmia Division, Montefiore Medical Center, Bronx, New York, USA
| | - Rakesh Gopinathannair
- Division of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, USA
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