1
|
Li G, Wang G, Wei W, Li Z, Xiao Q, He H, Luo D, Chen L, Li J, Zhang X, Song Y, Bai S. Cardiorespiratory motion characteristics and their dosimetric impact on cardiac stereotactic body radiotherapy. Med Phys 2024. [PMID: 38994881 DOI: 10.1002/mp.17284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Cardiac stereotactic body radiotherapy (CSBRT) is an emerging and promising noninvasive technique for treating refractory arrhythmias utilizing highly precise, single or limited-fraction high-dose irradiations. This method promises to revolutionize the treatment of cardiac conditions by delivering targeted therapy with minimal exposure to surrounding healthy tissues. However, the dynamic nature of cardiorespiratory motion poses significant challenges to the precise delivery of dose in CSBRT, introducing potential variabilities that can impact treatment efficacy. The complexities of the influence of cardiorespiratory motion on dose distribution are compounded by interplay and blurring effects, introducing additional layers of dose uncertainty. These effects, critical to the understanding and improvement of the accuracy of CSBRT, remain unexplored, presenting a gap in current clinical literature. PURPOSE To investigate the cardiorespiratory motion characteristics in arrhythmia patients and the dosimetric impact of interplay and blurring effects induced by cardiorespiratory motion on CSBRT plan quality. METHODS The position and volume variations in the substrate target and cardiac substructures were evaluated in 12 arrhythmia patients using displacement maximum (DMX) and volume metrics. Moreover, a four-dimensional (4D) dose reconstruction approach was employed to examine the dose uncertainty of the cardiorespiratory motion. RESULTS Cardiac pulsation induced lower DMX than respiratory motion but increased the coefficient of variation and relative range in cardiac substructure volumes. The mean DMX of the substrate target was 0.52 cm (range: 0.26-0.80 cm) for cardiac pulsation and 0.82 cm (range: 0.32-2.05 cm) for respiratory motion. The mean DMX of the cardiac structure ranged from 0.15 to 1.56 cm during cardiac pulsation and from 0.35 to 1.89 cm during respiratory motion. Cardiac pulsation resulted in an average deviation of -0.73% (range: -4.01%-4.47%) in V25 between the 3D and 4D doses. The mean deviations in the homogeneity index (HI) and gradient index (GI) were 1.70% (range: -3.10%-4.36%) and 0.03 (range: -0.14-0.11), respectively. For cardiac substructures, the deviations in D50 due to cardiac pulsation ranged from -1.88% to 1.44%, whereas the deviations in Dmax ranged from -2.96% to 0.88% of the prescription dose. By contrast, the respiratory motion led to a mean deviation of -1.50% (range: -10.73%-4.23%) in V25. The mean deviations in HI and GI due to respiratory motion were 4.43% (range: -3.89%-13.98%) and 0.18 (range: -0.01-0.47) (p < 0.05), respectively. Furthermore, the deviations in D50 and Dmax in cardiac substructures for the respiratory motion ranged from -0.28% to 4.24% and -4.12% to 1.16%, respectively. CONCLUSIONS Cardiorespiratory motion characteristics vary among patients, with the respiratory motion being more significant. The intricate cardiorespiratory motion characteristics and CSBRT plan complexity can induce substantial dose uncertainty. Therefore, assessing individual motion characteristics and 4D dose reconstruction techniques is critical for implementing CSBRT without compromising efficacy and safety.
Collapse
Affiliation(s)
- Guangjun Li
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guangyu Wang
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Weige Wei
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhibin Li
- Department of Radiotherapy & Oncology, The First Affiliated Hospital of Soochow University, Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China
| | - Qing Xiao
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Haiping He
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dashuang Luo
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Chen
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jing Li
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiangyu Zhang
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ying Song
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sen Bai
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
2
|
Wei W, Li Z, Xiao Q, Wang G, He H, Luo D, Chen L, Li J, Zhang X, Qin T, Song Y, Li G, Bai S. Quantifying dose uncertainties resulting from cardiorespiratory motion in intensity-modulated proton therapy for cardiac stereotactic body radiotherapy. Front Oncol 2024; 14:1399589. [PMID: 39040445 PMCID: PMC11260676 DOI: 10.3389/fonc.2024.1399589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/19/2024] [Indexed: 07/24/2024] Open
Abstract
Background Cardiac stereotactic body radiotherapy (CSBRT) with photons efficaciously and safely treats cardiovascular arrhythmias. Proton therapy, with its unique physical and radiobiological properties, can offer advantages over traditional photon-based therapies in certain clinical scenarios, particularly pediatric tumors and those in anatomically challenging areas. However, dose uncertainties induced by cardiorespiratory motion are unknown. Objective This study investigated the effect of cardiorespiratory motion on intensity-modulated proton therapy (IMPT) and the effectiveness of motion-encompassing methods. Methods We retrospectively included 12 patients with refractory arrhythmia who underwent CSBRT with four-dimensional computed tomography (4DCT) and 4D cardiac CT (4DcCT). Proton plans were simulated using an IBA accelerator based on the 4D average CT. The prescription was 25 Gy in a single fraction, with all plans normalized to ensure that 95% of the target volume received the prescribed dose. 4D dose reconstruction was performed to generate 4D accumulated and dynamic doses. Furthermore, dose uncertainties due to the interplay effect of the substrate target and organs at risk (OARs) were assessed. The differences between internal organs at risk volume (IRV) and OARreal (manually contoured on average CT) were compared. In 4D dynamic dose, meeting prescription requirements entails V25 and D95 reaching 95% and 25 Gy, respectively. Results The 4D dynamic dose significantly differed from the 3D static dose. The mean V25 and D95 were 89.23% and 24.69 Gy, respectively, in 4DCT and 94.35% and 24.99 Gy, respectively, in 4DcCT. Eleven patients in 4DCT and six in 4DcCT failed to meet the prescription requirements. Critical organs showed varying dose increases. All metrics, except for Dmean and D50, significantly changed in 4DCT; in 4DcCT, only D50 remained unchanged with regards to the target dose uncertainties induced by the interplay effect. The interplay effect was only significant for the Dmax values of several OARs. Generally, respiratory motion caused a more pronounced interplay effect than cardiac pulsation. Neither IRV nor OARreal effectively evaluated the dose discrepancies of the OARs. Conclusions Complex cardiorespiratory motion can introduce dose uncertainties during IMPT. Motion-encompassing techniques may mitigate but cannot entirely compensate for the dose discrepancies. Individualized 4D dose assessments are recommended to verify the effectiveness and safety of CSBRT.
Collapse
Affiliation(s)
- Weige Wei
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhibin Li
- Department of Radiotherapy & Oncology, The First Affiliated Hospital of Soochow University, Institute of Radiotherapy & Oncology, Soochow University, Suzhou, China
| | - Qing Xiao
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guangyu Wang
- State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Haiping He
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dashuang Luo
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Chen
- Department of Radiotherapy & Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jing Li
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiangyu Zhang
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Taolin Qin
- Department of Medical Physics, Brown University, Providence, RI, United States
| | - Ying Song
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guangjun Li
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sen Bai
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
3
|
Kovacs B, Lehmann HI, Manninger M, Saguner AM, Futyma P, Duncker D, Chun J. Stereotactic arrhythmia radioablation and its implications for modern cardiac electrophysiology: results of an EHRA survey. Europace 2024; 26:euae110. [PMID: 38666444 PMCID: PMC11086561 DOI: 10.1093/europace/euae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
Stereotactic arrhythmia radioablation (STAR) is a treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in patients with structural heart disease (SHD). The current and future role of STAR as viewed by cardiologists is unknown. The study aimed to assess the current role, barriers to application, and expected future role of STAR. An online survey consisting of 20 questions on baseline demographics, awareness/access, current use, and the future role of STAR was conducted. A total of 129 international participants completed the survey [mean age 43 ± 11 years, 25 (16.4%) female]. Ninety-one (59.9%) participants were electrophysiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR, while 62 (48.1%) had treated/referred a patient for treatment. Common primary indications for STAR were recurrent VT/VF in SHD (45%), recurrent VT/VF without SHD (7.8%), or premature ventricular contraction (3.9%). Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%) and non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%). Most respondents have foreseen a future clinical role of STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively), although only a minority expected a first-line indication for it (7% and 5%, respectively). Stereotactic arrhythmia radioablation as a novel treatment option of recurrent VT appears to gain acceptance within the cardiology community. Further trials are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.
Collapse
Affiliation(s)
- Boldizsar Kovacs
- Department of Cardiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, 48109 MI, USA
- Department of Cardiology, University Heart Center Zurich, Raemistrasse 100, Zurich 8091, Switzerland
| | - Helge Immo Lehmann
- Department of Cardiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, 48109 MI, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, 55 Fruit St, Boston, 02114 MA, USA
| | - Martin Manninger
- Division of Cardiology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Ardan Muammer Saguner
- Department of Cardiology, University Heart Center Zurich, Raemistrasse 100, Zurich 8091, Switzerland
| | - Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph’s Heart Rhythm Center, Rzeszów, Poland
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Julian Chun
- Cardioangiologisches Centrum Bethanien, Agaplesion Bethanien Krankenhaus, Frankfurt, Germany
| |
Collapse
|
4
|
Liulu X, Balaji P, Barber J, De Silva K, Murray T, Hickey A, Campbell T, Harris J, Gee H, Ahern V, Kumar S, Hau E, Qian PC. Radiation therapy for ventricular arrhythmias. J Med Imaging Radiat Oncol 2024. [PMID: 38698577 DOI: 10.1111/1754-9485.13662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
Ventricular arrhythmias (VA) can be life-threatening arrhythmias that result in significant morbidity and mortality. Catheter ablation (CA) is an invasive treatment modality that can be effective in the treatment of VA where medications fail. Recurrence occurs commonly following CA due to an inability to deliver lesions of adequate depth to cauterise the electrical circuits that drive VA or reach areas of scar responsible for VA. Stereotactic body radiotherapy is a non-invasive treatment modality that allows volumetric delivery of energy to treat circuits that cannot be reached by CA. It overcomes the weaknesses of CA and has been successfully utilised in small clinical trials to treat refractory VA. This article summarises the current evidence for this novel treatment modality and the steps that will be required to bring it to the forefront of VA treatment.
Collapse
Affiliation(s)
- Xingzhou Liulu
- Cardiology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Poornima Balaji
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey Barber
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Kasun De Silva
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tiarne Murray
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Andrew Hickey
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Timothy Campbell
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jill Harris
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Harriet Gee
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Verity Ahern
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Hau
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- Blacktown Hematology and Cancer Centre, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Pierre C Qian
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
5
|
Haberl C, Crean AM, Zelt JGE, Redpath CJ, deKemp RA. Role of Nuclear Imaging in Cardiac Stereotactic Body Radiotherapy for Ablation of Ventricular Tachycardia. Semin Nucl Med 2024; 54:427-437. [PMID: 38658301 DOI: 10.1053/j.semnuclmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia common in patients with structural heart disease or nonischemic cardiomyopathy. Many VTs originate from regions of fibrotic scar tissue, where delayed electrical signals exit scar and re-enter viable myocardium. Cardiac stereotactic body radiotherapy (SBRT) has emerged as a completely noninvasive alternative to catheter ablation for the treatment of recurrent or refractory ventricular tachycardia. While there is no common consensus on the ideal imaging workflow, therapy planning for cardiac SBRT often combines information from a plurality of imaging modalities including MRI, CT, electroanatomic mapping and nuclear imaging. MRI and CT provide detailed anatomic information, and late enhancement contrast imaging can indicate regions of fibrosis. Electroanatomic maps indicate regions of heterogenous conduction voltage or early activation which are indicative of arrhythmogenic tissue. Some early clinical adopters performing cardiac SBRT report the use of myocardial perfusion and viability nuclear imaging to identify regions of scar. Nuclear imaging of hibernating myocardium, inflammation and sympathetic innervation have been studied for ventricular arrhythmia prognosis and in research relating to catheter ablation of VT but have yet to be studied in their potential applications for cardiac SBRT. The integration of information from these many imaging modalities to identify a target for ablation can be challenging. Multimodality image registration and dedicated therapy planning tools may enable higher target accuracy, accelerate therapy planning workflows and improve patient outcomes. Understanding the pathophysiology of ventricular arrhythmias, and localizing the arrhythmogenic tissues, is vital for successful ablation with cardiac SBRT. Nuclear imaging provides an arsenal of imaging strategies to identify regional scar, hibernation, inflammation, and sympathetic denervation with some advantages over alternative imaging strategies.
Collapse
Affiliation(s)
- Connor Haberl
- University of Ottawa Heart Institute, Ottawa, ON; Carleton University, Ottawa, ON
| | - Andrew M Crean
- University of Ottawa Heart Institute, Ottawa, ON; North West Heart Center, University of Manchester Foundation NHS Trust, Manchester, UK
| | - Jason G E Zelt
- The Ottawa Hospital, Ottawa, ON; Department of Medicine, University of Ottawa, Ottawa, ON
| | | | | |
Collapse
|
6
|
Botrugno C, Crico C, Iori M, Blanck O, Blamek S, Postema PG, Quesada A, Pruvot E, Verhoeff JJC, De Panfilis L. Patient vulnerability in stereotactic arrhythmia radioablation (STAR): a preliminary ethical appraisal from the STOPSTORM.eu consortium. Strahlenther Onkol 2024:10.1007/s00066-024-02230-w. [PMID: 38652131 DOI: 10.1007/s00066-024-02230-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/17/2024] [Indexed: 04/25/2024]
Abstract
This preliminary ethical appraisal from the STOPSTORM.eu consortium is meant to raise critical points that clinicians administering stereotactic arrhythmia radioablation should consider to meet the highest standards in medical ethics and thus promote quality of life of patients recruited for radiotherapy treatments at a stage in which they experience a significant degree of vulnerability.
Collapse
Affiliation(s)
- Carlo Botrugno
- Research Unit on Everyday Bioethics and Ethics of Science, Department of Legal Sciences, University of Florence, Florence, Italy
- Legal Medicine and Bioethics, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Chiara Crico
- Legal Medicine and Bioethics, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Fondazione IRCCS Istituto Tumori, Milano, Italy
| | - Mauro Iori
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany.
| | - Slawomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Pieter G Postema
- Department of Clinical and Experimental Cardiology, Heart Failure & Arrhythmias, Amsterdam Heart Center and Cardiovascular Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Aurelio Quesada
- Cardiology Department, Arrhythmias Unit, Consorcio Hospital General Universitario de Valencia, Faculty of Medicine, Catholic University of Valencia "San Vicente Martir", Valencia, Spain
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Joost J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Radiotherapy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludovica De Panfilis
- Legal Medicine and Bioethics, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| |
Collapse
|
7
|
Thariat J, Little MP, Zablotska LB, Samson P, O’Banion MK, Leuraud K, Bergom C, Girault G, Azimzadeh O, Bouffler S, Hamada N. Radiotherapy for non-cancer diseases: benefits and long-term risks. Int J Radiat Biol 2024; 100:505-526. [PMID: 38180039 PMCID: PMC11039429 DOI: 10.1080/09553002.2023.2295966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE The discovery of X-rays was followed by a variety of attempts to treat infectious diseases and various other non-cancer diseases with ionizing radiation, in addition to cancer. There has been a recent resurgence of interest in the use of such radiotherapy for non-cancer diseases. Non-cancer diseases for which use of radiotherapy has currently been proposed include refractory ventricular tachycardia, neurodegenerative diseases (e.g. Alzheimer's disease and dementia), and Coronavirus Disease 2019 (COVID-19) pneumonia, all with ongoing clinical studies that deliver radiation doses of 0.5-25 Gy in a single fraction or in multiple daily fractions. In addition to such non-cancer effects, historical indications predominantly used in some countries (e.g. Germany) include osteoarthritis and degenerative diseases of the bones and joints. This narrative review gives an overview of the biological rationale and ongoing preclinical and clinical studies for radiotherapy proposed for various non-cancer diseases, discusses the plausibility of the proposed biological rationale, and considers the long-term radiation risks of cancer and non-cancer diseases. CONCLUSIONS A growing body of evidence has suggested that radiation represents a double-edged sword, not only for cancer, but also for non-cancer diseases. At present, clinical evidence has shown some beneficial effects of radiotherapy for ventricular tachycardia, but there is little or no such evidence of radiotherapy for other newly proposed non-cancer diseases (e.g. Alzheimer's disease, COVID-19 pneumonia). Patients with ventricular tachycardia and COVID-19 pneumonia have thus far been treated with radiotherapy when they are an urgent life threat with no efficient alternative treatment, but some survivors may encounter a paradoxical situation where patients were rescued by radiotherapy but then get harmed by radiotherapy. Further studies are needed to justify the clinical use of radiotherapy for non-cancer diseases, and optimize dose to diseased tissue while minimizing dose to healthy tissue.
Collapse
Affiliation(s)
- Juliette Thariat
- Department of Radiation Oncology, Comprehensive Cancer Centre François Baclesse, Caen, France
- Laboratoire de Physique Corpusculaire IN2P3, ENSICAEN/CNRS UMR 6534, Normandie Université, Caen, France
| | - Mark P. Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, Maryland, USA
| | - Lydia B. Zablotska
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Pamela Samson
- Department of Radiation Oncology, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M. Kerry O’Banion
- Department of Neuroscience, Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Klervi Leuraud
- Research Department on Biological and Health Effects of Ionizing Radiation (SESANE), Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Carmen Bergom
- Department of Radiation Oncology, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri, USA
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri, USA
| | - Gilles Girault
- Comprehensive Cancer Centre François Baclesse, Medical Library, Caen, France
| | - Omid Azimzadeh
- Federal Office for Radiation Protection (BfS), Section Radiation Biology, Neuherberg, Germany
| | - Simon Bouffler
- Radiation Protection Sciences Division, UK Health Security Agency (UKHSA), Chilton, Didcot, UK
| | - Nobuyuki Hamada
- Biology and Environmental Chemistry Division, Sustainable System Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), Abiko, Chiba, Japan
| |
Collapse
|
8
|
Rosu-Bubulac M, Trankle CR, Mankad P, Grizzard JD, Ellenbogen KA, Jordan JH, Weiss E. Institutional experience report on the target contouring workflow in the radiotherapy department for stereotactic arrhythmia radioablation delivered on conventional linear accelerators. Strahlenther Onkol 2024; 200:83-96. [PMID: 37872398 DOI: 10.1007/s00066-023-02159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/17/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE In stereotactic arrhythmia radioablation (STAR), the target is defined using multiple imaging studies and a multidisciplinary team consisting of electrophysiologist, cardiologist, cardiac radiologist, and radiation oncologist collaborate to identify the target and delineate it on the imaging studies of interest. This report describes the workflow employed in our radiotherapy department to transfer the target identified based on electrophysiology and cardiology imaging to the treatment planning image set. METHODS The radiotherapy team was presented with an initial target in cardiac axes orientation, contoured on a wideband late gadolinium-enhanced (WB-LGE) cardiac magnetic resonance (CMR) study, which was subsequently transferred to the computed tomography (CT) scan used for treatment planning-i.e., the average intensity projection (AIP) image set derived from a 4D CT-via an axial CMR image set, using rigid image registration focused on the target area. The cardiac and the respiratory motion of the target were resolved using ciné-CMR and 4D CT imaging studies, respectively. RESULTS The workflow was carried out for 6 patients and resulted in an internal target defined in standard anatomical orientation that encompassed the cardiac and the respiratory motion of the initial target. CONCLUSION An image registration-based workflow was implemented to render the STAR target on the planning image set in a consistent manner, using commercial software traditionally available for radiation therapy.
Collapse
Affiliation(s)
- Mihaela Rosu-Bubulac
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Cory R Trankle
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Pranav Mankad
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - John D Grizzard
- Department of Radiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth A Ellenbogen
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Jennifer H Jordan
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
9
|
van der Ree MH, Hoeksema WF, Luca A, Visser J, Balgobind BV, Zumbrink M, Spier R, Herrera-Siklody C, Lee J, Bates M, Daniel J, Peedell C, Boda-Heggemann J, Rudic B, Merten R, Dieleman EM, Rinaldi CA, Ahmad S, Whitaker J, Bhagirath P, Hatton MQ, Riley S, Grehn M, Schiappacasse L, Blanck O, Hohmann S, Pruvot E, Postema PG. Stereotactic arrhythmia radioablation: A multicenter pre-post intervention safety evaluation of the implantable cardioverter-defibrillator function. Radiother Oncol 2023; 189:109910. [PMID: 37709052 DOI: 10.1016/j.radonc.2023.109910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Stereotactic arrhythmia radioablation (STAR) appears to be beneficial in selected patients with therapy-refractory ventricular tachycardia (VT). However, high-dose radiotherapy used for STAR-treatment may affect functioning of the patients' implantable cardioverter defibrillator (ICD) by direct effects of radiation on ICD components or cardiac tissue. Currently, the effect of STAR on ICD functioning remains unknown. METHODS A retrospective pre-post multicenter study evaluating ICD functioning in the 12-month before and after STAR was performed. Patients with (non)ischemic cardiomyopathies with therapy-refractory VT and ICD who underwent STAR were included and the occurrence of ICD-related adverse events was collected. Evaluated ICD parameters included sensing, capture threshold and impedance. A linear mixed-effects model was used to investigate the association between STAR, radiotherapy dose and changes in lead parameters over time. RESULTS In total, 43 patients (88% male) were included in this study. All patients had an ICD with an additional right atrial lead in 34 (79%) and a ventricular lead in 17 (40%) patients. Median ICD-generator dose was 0.1 Gy and lead tip dose ranged from 0-32 Gy. In one patient (2%), a reset occurred during treatment, but otherwise, STAR and radiotherapy dose were not associated with clinically relevant alterations in ICD leads parameters. CONCLUSIONS STAR treatment did not result in major ICD malfunction. Only one radiotherapy related adverse event occurred during the study follow-up without patient harm. No clinically relevant alterations in ICD functioning were observed after STAR in any of the leads. With the reported doses STAR appears to be safe.
Collapse
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; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Wiert F Hoeksema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Adrian Luca
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Jorrit Visser
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Brian V Balgobind
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Michiel Zumbrink
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Raymond Spier
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - Justin Lee
- Department of Cardiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Matthew Bates
- Department of Cardiology, South Tees Hospitals NHS Foundation Trust, Middleborough, UK
| | - Jim Daniel
- Department of Radiation Oncology, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Clive Peedell
- Department of Radiation Oncology, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Boris Rudic
- Department of Cardiology, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Roland Merten
- Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Edith M Dieleman
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Cristopher A Rinaldi
- Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Shahreen Ahmad
- Department of Radiation Oncology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - John Whitaker
- Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Pranav Bhagirath
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands; Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Matthew Q Hatton
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - Stephen Riley
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Luis Schiappacasse
- Department of Radiation Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Etienne Pruvot
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pieter G Postema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.
| |
Collapse
|
10
|
Kovacs B, Mayinger M, Ehrbar S, Fesslmeier D, Ahmadsei M, Sazgary L, Manka R, Alkadhi H, Ruschitzka F, Duru F, Papachristofilou A, Sticherling C, Blamek S, Gołba KS, Guckenberger M, Saguner AM, Andratschke N. Dose escalation for stereotactic arrhythmia radioablation of recurrent ventricular tachyarrhythmia - a phase II clinical trial. Radiat Oncol 2023; 18:185. [PMID: 37941012 PMCID: PMC10634182 DOI: 10.1186/s13014-023-02361-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/08/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Stereotactic arrhythmia radioablation (STAR) is delivered with a planning target volume (PTV) prescription dose of 25 Gy, mostly to the surrounding 75-85% isodose line. This means that the average and maximum dose received by the target is less than 35 Gy, which is the minimum threshold required to create a homogenous transmural fibrosis. Similar to catheter ablation, the primary objective of STAR should be transmural fibrosis to prevent heterogenous intracardiac conduction velocities and the occurrence of sustained ventricular arrhythmias (sVA) caused by reentry. We hypothesize that the current dose prescription used in STAR is inadequate for the long-term prevention of sVA and that a significant increase in dose is necessary to induce transmural scar formation. OBJECTIVE A single arm, multi-center, phase II, dose escalation prospective clinical trial employing the i3 + 3 design is being conducted to examine the safety of a radiation dose-escalation strategy aimed at inducing transmural scar formation. The ultimate objective of this trial is to decrease the likelihood of sVA recurrence in patients at risk. METHODS Patients with ischemic or non-ischemic cardiomyopathy and recurrent sVA, with an ICD and history of ≥ 1 catheter ablation for sVA will be included. This is a prospective, multicenter, one-arm, dose-escalation trial utilizing the i3 + 3 design, a modified 3 + 3 specifically created to overcome limitations in traditional dose-finding studies. A total of 15 patients will be recruited. The trial aims to escalate the ITV dose from 27.0 Gy to an ITV prescription dose-equivalent level of maximum 35.1 Gy by keeping the PTV prescription dose constant at 25 Gy while increasing the dose to the target (i.e. the VT substrate without PTV margin) by step-wise reduction of the prescribing isodose line (85% down to 65%). The primary outcome of this trial is safety measured by registered radiation associated adverse events (AE) up to 90 days after study intervention including radiation associated serious adverse events graded as at least 4 or 5 according to CTCAE v5, radiation pneumonitis or pericarditis requiring hospitalization and decrease in LVEF ≥ 10% as assessed by echocardiography or cardiac MRI at 90 days after STAR. The sample size was determined assuming an acceptable primary outcome event rate of 20%. Secondary outcomes include sVA burden at 6 months after STAR, time to first sVA recurrence, reduction in appropriate ICD therapies, the need for escalation of antiarrhythmic drugs, non-radiation associated safety and patient reported outcome measures such as SF-36 and EQ5D. DISCUSSION DEFT-STAR is an innovative prospective phase II trial that aims to evaluate the optimal radiation dose for STAR in patients with therapy-refractory sVA. The trial has obtained IRB approval and focuses on determining the safe and effective radiation dose to be employed in the STAR procedure. TRIAL REGISTRATION NCT05594368.
Collapse
Affiliation(s)
- Boldizsar Kovacs
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Stefanie Ehrbar
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Debra Fesslmeier
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Maiwand Ahmadsei
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Lorraine Sazgary
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
| | - Robert Manka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
- Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
- Center for Integrative Human Physiology, University Zurich, Zurich, Switzerland
| | - Firat Duru
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
- Center for Integrative Human Physiology, University Zurich, Zurich, Switzerland
| | | | | | - Slawomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Krzysztof S Gołba
- Department of Electrocardiology, Upper Silesian Heart Center, Medical University of Silesia, Katowice, Poland
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | | | - Ardan M Saguner
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
- Center for Integrative Human Physiology, University Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
11
|
Kaestner L, Boda-Heggemann J, Fanslau H, Xie J, Schweikard A, Giordano FA, Blanck O, Rudic B. Electroanatomical mapping after cardiac radioablation for treatment of incessant electrical storm: a case report from the RAVENTA trial. Strahlenther Onkol 2023; 199:1018-1024. [PMID: 37698592 PMCID: PMC10598131 DOI: 10.1007/s00066-023-02136-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/07/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Electroanatomical mapping (EAM)-guided stereotactic arrhythmia radioablation (STAR) is a novel noninvasive therapy option for patients with monomorphic ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or urgent catheter ablation (CA). Data on success rates in an emergency situation such as electrical storm (ES) are rare. We present a case of a patient with an initially very poor life expectancy after extensive myocardial infarction with therapy-resistant ES, not amendable for further antiarrhythmic drug therapy, implantable cardioverter-defibrillator implantation, or repeated CA who was introduced to the radiation oncology department for emergency STAR as a bail-out therapy. METHODS Target volume definition and transfer from EAM to CT were validated and quality assured with a semi-automatic, dedicated visualization tool (CARDIO-RT). Emergency STAR was performed with 25 Gy in the framework of the RAVENTA study. The VT burden gradually decreased after STAR; however, a second VT morphology occurred, which was successfully treated with EAM-guided CA 12 days after STAR. RESULTS The second EAM-guided CA showed areas of low voltage in the irradiated segments, indicating a precise targeting and early functional response to STAR. The patient remained free of any VT recurrence or any radiation-related toxicities and in good general condition during the recent follow-up of 18 months. CONCLUSION The case highlights the possible approach, caveats, difficulties, and prognosis of a patient severely affected by therapy-resistant VT in whom CA could not lead to VT suppression. Further studies of putative mechanisms of STAR in the acute and chronic phase of this novel therapy are warranted.
Collapse
Affiliation(s)
- Lena Kaestner
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany.
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Judit Boda-Heggemann
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Hannah Fanslau
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jingyang Xie
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Frank A Giordano
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Boris Rudic
- I. Department of Medicine: Cardiology, Angiology, Hemostaseology and Intensive Care, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Mannheim, Mannheim, Germany
| |
Collapse
|
12
|
Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 300] [Impact Index Per Article: 300.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
|
13
|
Marashly Q, Najjar SN, Hahn J, Rector GJ, Khawaja M, Chelu MG. Innovations in ventricular tachycardia ablation. J Interv Card Electrophysiol 2023; 66:1499-1518. [PMID: 35879516 DOI: 10.1007/s10840-022-01311-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
Catheter ablation of ventricular arrhythmias (VAs) has evolved significantly over the past decade and is currently a well-established therapeutic option. Technological advances and improved understanding of VA mechanisms have led to tremendous innovations in VA ablation. The purpose of this review article is to provide an overview of current innovations in VA ablation. Mapping techniques, such as ultra-high density mapping, isochronal late activation mapping, and ripple mapping, have provided improved arrhythmogenic substrate delineation and potential procedural success while limiting duration of ablation procedure and potential hemodynamic compromise. Besides, more advanced mapping and ablation techniques such as epicardial and intramyocardial ablation approaches have allowed operators to more precisely target arrhythmogenic substrate. Moreover, advances in alternate energy sources, such as electroporation, as well as stereotactic radiation therapy have been proposed to be effective and safe. New catheters, such as the lattice and the saline-enhanced radiofrequency catheters, have been designed to provide deeper and more durable tissue ablation lesions compared to conventional catheters. Contact force optimization and baseline impedance modulation are important tools to optimize VT radiofrequency ablation and improve procedural success. Furthermore, advances in cardiac imaging, specifically cardiac MRI, have great potential in identifying arrhythmogenic substrate and evaluating ablation success. Overall, VA ablation has undergone significant advances over the past years. Innovations in VA mapping techniques, alternate energy source, new catheters, and utilization of cardiac imaging have great potential to improve overall procedural safety, hemodynamic stability, and procedural success.
Collapse
Affiliation(s)
- Qussay Marashly
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Salim N Najjar
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Joshua Hahn
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Graham J Rector
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Muzamil Khawaja
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Mihail G Chelu
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA.
- Baylor St. Luke's Medical Center, Houston, USA.
- Texas Heart Institute, Houston, USA.
| |
Collapse
|
14
|
Lin YN, Miguel-Dos-Santos R, Cingolani E. Biological Modification of Arrhythmogenic Substrates by Cell-Free Therapeutics. Heart Lung Circ 2023; 32:844-851. [PMID: 37353457 PMCID: PMC10526725 DOI: 10.1016/j.hlc.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/21/2023] [Accepted: 05/02/2023] [Indexed: 06/25/2023]
Abstract
Ventricular arrhythmias (VAs) represent a major cause of sudden cardiac death and afflict patients with heart failure from both ischaemic and non-ischaemic origins, and inherited cardiomyopathies. Current VA management, including anti-arrhythmic medications, autonomic modulation, implantable cardioverter-defibrillator implantation, and catheter ablation, remains suboptimal. Catheter ablation may even cause significant cardiomyocyte loss. Cell-based therapies and exosome treatment have been proposed as promising strategies to lessen cardiomyocyte death, modulate immune reaction, and reduce myocardial scarring, and, therefore, are potentially beneficial in treating VAs. In this review, we summarise the current cornerstones of VA management. We also discuss recent advances and ongoing evidence regarding cell-based and exosome therapy, with special attention to VA treatment.
Collapse
Affiliation(s)
- Yen-Nien Lin
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Cardiovascular Medicine, Department of Medicine, China Medical University and Hospital, Taipei, Taiwan
| | | | - Eugenio Cingolani
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| |
Collapse
|
15
|
Krug D, Zaman A, Eidinger L, Grehn M, Boda-Heggemann J, Rudic B, Mehrhof F, Boldt LH, Hohmann S, Merten R, Buergy D, Fleckenstein J, Kluge A, Rogge A, Both M, Rades D, Tilz RR, Olbrich D, König IR, Siebert FA, Schweikard A, Vonthein R, Bonnemeier H, Dunst J, Blanck O. Radiosurgery for ventricular tachycardia (RAVENTA): interim analysis of a multicenter multiplatform feasibility trial. Strahlenther Onkol 2023:10.1007/s00066-023-02091-9. [PMID: 37285038 DOI: 10.1007/s00066-023-02091-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/23/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Single-session cardiac stereotactic radiation therapy (SBRT) has demonstrated promising results for patients with refractory ventricular tachycardia (VT). However, the full safety profile of this novel treatment remains unknown and very limited data from prospective clinical multicenter trials are available. METHODS The prospective multicenter multiplatform RAVENTA (radiosurgery for ventricular tachycardia) study assesses high-precision image-guided cardiac SBRT with 25 Gy delivered to the VT substrate determined by high-definition endocardial and/or epicardial electrophysiological mapping in patients with refractory VT ineligible for catheter ablation and an implanted cardioverter defibrillator (ICD). Primary endpoint is the feasibility of full-dose application and procedural safety (defined as an incidence of serious [grade ≥ 3] treatment-related complications ≤ 5% within 30 days after therapy). Secondary endpoints comprise VT burden, ICD interventions, treatment-related toxicity, and quality of life. We present the results of a protocol-defined interim analysis. RESULTS Between 10/2019 and 12/2021, a total of five patients were included at three university medical centers. In all cases, the treatment was carried out without complications. There were no serious potentially treatment-related adverse events and no deterioration of left ventricular ejection fraction upon echocardiography. Three patients had a decrease in VT episodes during follow-up. One patient underwent subsequent catheter ablation for a new VT with different morphology. One patient with local VT recurrence died 6 weeks after treatment in cardiogenic shock. CONCLUSION The interim analysis of the RAVENTA trial demonstrates early initial feasibility of this new treatment without serious complications within 30 days after treatment in five patients. Recruitment will continue as planned and the study has been expanded to further university medical centers. TRIAL REGISTRATION NUMBER NCT03867747 (clinicaltrials.gov). Registered March 8, 2019. Study start: October 1, 2019.
Collapse
Affiliation(s)
- David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany.
| | - Adrian Zaman
- Klinik für Innere Medizin III, Kardiologie, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Lina Eidinger
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
- Klinik für Innere Medizin III, Kardiologie, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Melanie Grehn
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
| | - Judit Boda-Heggemann
- Universitätsmedizin Mannheim, Klinik für Strahlentherapie und Radioonkologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Boris Rudic
- Universitätsmedizin Mannheim, Medizinische Klinik I, Abteilung für Elektrophysiologie und Rhythmologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Felix Mehrhof
- Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Leif-Hendrik Boldt
- Medizinische Klinik mit Schwerpunkt Kardiologie (CVK), Abteilung für Elektrophysiologie und Rhythmologie, Charité Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Stephan Hohmann
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Roland Merten
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Daniel Buergy
- Universitätsmedizin Mannheim, Klinik für Strahlentherapie und Radioonkologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Jens Fleckenstein
- Universitätsmedizin Mannheim, Klinik für Strahlentherapie und Radioonkologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Anne Kluge
- Klinik für Radioonkologie und Strahlentherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Annette Rogge
- Klinisches Ethikkomitee, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Marcus Both
- Klinik für Radiologie und Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Dirk Rades
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Roland Richard Tilz
- Klinik für Rhythmologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Denise Olbrich
- Zentrum für Klinische Studien, Universität zu Lübeck, Lübeck, Germany
| | - Inke R König
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Frank-Andre Siebert
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
| | - Achim Schweikard
- Institut für Robotik und Kognitive Systeme, Universität zu Lübeck, Lübeck, Germany
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Kardiologie, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
- Klinik für Kardiologie, Helios Klinik Cuxhaven, Cuxhaven, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
| | - Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus L, 24105, Kiel, Germany
| |
Collapse
|
16
|
Jentzer JC, Noseworthy PA, Kashou AH, May AM, Chrispin J, Kabra R, Arps K, Blumer V, Tisdale JE, Solomon MA. Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:2189-2206. [PMID: 37257955 PMCID: PMC10683004 DOI: 10.1016/j.jacc.2023.03.424] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/14/2023] [Indexed: 06/02/2023]
Abstract
Electrical storm (ES) reflects life-threatening cardiac electrical instability with 3 or more ventricular arrhythmia episodes within 24 hours. Identification of underlying arrhythmogenic cardiac substrate and reversible triggers is essential, as is interrogation and programming of an implantable cardioverter-defibrillator, if present. Medical management includes antiarrhythmic drugs, beta-adrenergic blockade, sedation, and hemodynamic support. The initial intensity of these interventions should be matched to the severity of ES using a stepped-care algorithm involving escalating treatments for higher-risk presentations or recurrent ventricular arrhythmias. Many patients with ES are considered for catheter ablation, which may require the use of temporary mechanical circulatory support. Outcomes after ES are poor, including frequent ES recurrences and deaths caused by progressive heart failure and other cardiac causes. A multidisciplinary collaborative approach to the management of ES is crucial, and evaluation for heart transplantation or palliative care is often appropriate, even for patients who survive the initial episode.
Collapse
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony H Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam M May
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rajesh Kabra
- Kansas City Heart Rhythm Institute, Overland Park, Kansas, USA
| | - Kelly Arps
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Vanessa Blumer
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - James E Tisdale
- College of Pharmacy, Purdue University, West Lafayette, Indiana, USA; School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, Maryland, USA; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
17
|
Guarracini F, Tritto M, Di Monaco A, Mariani MV, Gasperetti A, Compagnucci P, Muser D, Preda A, Mazzone P, Themistoclakis S, Carbucicchio C. Stereotactic Arrhythmia Radioablation Treatment of Ventricular Tachycardia: Current Technology and Evolving Indications. J Cardiovasc Dev Dis 2023; 10:jcdd10040172. [PMID: 37103051 PMCID: PMC10143260 DOI: 10.3390/jcdd10040172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 04/28/2023] Open
Abstract
Ventricular tachycardia in patients with structural heart disease is a significant cause of morbidity and mortality. According to current guidelines, cardioverter defibrillator implantation, antiarrhythmic drugs, and catheter ablation are established therapies in the management of ventricular arrhythmias but their efficacy is limited in some cases. Sustained ventricular tachycardia can be terminated by cardioverter-defibrillator therapies although shocks in particular have been demonstrated to increase mortality and worsen patients' quality of life. Antiarrhythmic drugs have important side effects and relatively low efficacy, while catheter ablation, even if it is actually an established treatment, is an invasive procedure with intrinsic procedural risks and is frequently affected by patients' hemodynamic instability. Stereotactic arrhythmia radioablation for ventricular arrhythmias was developed as bail-out therapy in patients unresponsive to traditional treatments. Radiotherapy has been mainly applied in the oncological field, but new current perspectives have developed in the field of ventricular arrhythmias. Stereotactic arrhythmia radioablation provides an alternative non-invasive and painless therapeutic strategy for the treatment of previously detected cardiac arrhythmic substrate by three-dimensional intracardiac mapping or different tools. Since preliminary experiences have been reported, several retrospective studies, registries, and case reports have been published in the literature. Although, for now, stereotactic arrhythmia radioablation is considered an alternative palliative treatment for patients with refractory ventricular tachycardia and no other therapeutic options, this research field is currently extremely promising.
Collapse
Affiliation(s)
| | - Massimo Tritto
- Electrophysiology and Cardiac Pacing Unit, Humanitas Mater Domini Hospital, 21053 Castellanza, Italy
| | - Antonio Di Monaco
- Cardiology Department, General Regional Hospital F. Miulli, 70021 Acquaviva delle Fonti, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, 00100 Rome, Italy
| | - Alessio Gasperetti
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti Umberto I-Lancisi-Salesi, 60126 Ancona, Italy
| | - Daniele Muser
- Cardiothoracic Department, University Hospital, 33100 Udine, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Patrizio Mazzone
- Cardiothoracovascular Department, Electrophysiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Sakis Themistoclakis
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell'Angelo Hospital, Mestre, 30174 Venice, Italy
| | - Corrado Carbucicchio
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| |
Collapse
|
18
|
Harms J, Schreibmann E, Mccall NS, Lloyd MS, Higgins KA, Castillo R. Cardiac motion and its dosimetric impact during radioablation for refractory ventricular tachycardia. J Appl Clin Med Phys 2023:e13925. [PMID: 36747376 DOI: 10.1002/acm2.13925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/09/2022] [Accepted: 01/19/2023] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Cardiac radioablation (CR) is a noninvasive treatment option for patients with refractory ventricular tachycardia (VT) during which high doses of radiation, typically 25 Gy, are delivered to myocardial scar. In this study, we investigate motion from cardiac cycle and evaluate the dosimetric impact in a cohort of patients treated with CR. METHODS This retrospective study included eight patients treated at our institution who had respiratory-correlated and ECG-gated 4DCT scans acquired within 2 weeks of CR. Deformable image registration was applied between maximum systole (SYS) and diastole (DIAS) CTs to assess cardiac motion. The average respiratory-correlated CT (AVGresp ) was deformably registered to the average cardiac (AVGcardiac ), SYS, and DIAS CTs, and contours were propagated using the deformation vector fields (DVFs). Finally, the original treatment plan was recalculated on the deformed AVGresp CT for dosimetric assessment. RESULTS Motion magnitudes were measured as the mean (SD) value over the DVFs within each structure. Displacement during the cardiac cycle for all chambers was 1.4 (0.9) mm medially/laterally (ML), 1.6 (1.0) mm anteriorly/posteriorly (AP), and 3.0 (2.8) mm superiorly/inferiorly (SI). Displacement for the 12 distinct clinical target volumes (CTVs) was 1.7 (1.5) mm ML, 2.4 (1.1) mm AP, and 2.1 (1.5) SI. Displacements between the AVGresp and AVGcardiac scans were 4.2 (2.0) mm SI and 5.8 (1.4) mm total. Dose recalculations showed that cardiac motion may impact dosimetry, with dose to 95% of the CTV dropping from 27.0 (1.3) Gy on the AVGresp to 20.5 (7.1) Gy as estimated on the AVGcardiac . CONCLUSIONS Cardiac CTV motion in this patient cohort is on average below 3 mm, location-dependent, and when not accounted for in treatment planning may impact target coverage. Further study is needed to assess the impact of cardiac motion on clinical outcomes.
Collapse
Affiliation(s)
- Joseph Harms
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eduard Schreibmann
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Neal S Mccall
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Michael S Lloyd
- Section of Clinical Cardiac Electrophysiology, Emory University, Atlanta, Georgia, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Richard Castillo
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| |
Collapse
|
19
|
Mayinger M, Boda-Heggemann J, Mehrhof F, Krug D, Hohmann S, Xie J, Ehrbar S, Kovacs B, Merten R, Grehn M, Zaman A, Fleckenstein J, Kaestner L, Buergy D, Rudic B, Kluge A, Boldt LH, Dunst J, Bonnemeier H, Saguner AM, Andratschke N, Blanck O, Schweikard A. Quality assurance process within the RAdiosurgery for VENtricular TAchycardia (RAVENTA) trial for the fusion of electroanatomical mapping and radiotherapy planning imaging data in cardiac radioablation. Phys Imaging Radiat Oncol 2022; 25:100406. [PMID: 36655216 PMCID: PMC9841340 DOI: 10.1016/j.phro.2022.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 12/27/2022] Open
Abstract
A novel quality assurance process for electroanatomical mapping (EAM)-to-radiotherapy planning imaging (RTPI) target transport was assessed within the multi-center multi-platform framework of the RAdiosurgery for VENtricular TAchycardia (RAVENTA) trial. A stand-alone software (CARDIO-RT) was developed to enable platform independent registration of EAM and RTPI of the left ventricle (LV), based on pre-generated radiotherapy contours (RTC). LV-RTC were automatically segmented into the American-Heart-Association 17-segment-model and a manual 3D-3D method based on EAM 3D-geometry data and a semi-automated 2D-3D method based on EAM screenshot projections were developed. The quality of substrate transfer was evaluated in five clinical cases and the structural analyses showed substantial differences between manual target transfer and target transport using CARDIO-RT.
Collapse
Affiliation(s)
- Michael Mayinger
- Department of Radiation Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland,Corresponding author.
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Felix Mehrhof
- Department of Radiation Oncology, Charité University Medicine Berlin, Berlin, Germany
| | - David Krug
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stephan Hohmann
- Department of Cardiology and Angiology, Hannover Heart Rhythm Center, Hannover Medical School, Hannover, Germany
| | - Jingyang Xie
- Institute for Robotics and Cognitive Systems, Univesity of Lübeck, Lübeck, Germany
| | - Stefanie Ehrbar
- Department of Radiation Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Boldizsar Kovacs
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland
| | - Roland Merten
- Department of Radiotherapy, Hannover Medical School, Hannover, Germany
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Adrian Zaman
- Department of Internal Medicine III, Section for Electrophysiology und Rhythmology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Lena Kaestner
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Buergy
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Boris Rudic
- Medizinische Klinik I, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Kluge
- Department of Radiation Oncology, Charité University Medicine Berlin, Berlin, Germany
| | - Leif-Hendrik Boldt
- Department of Cardiology, University Medicine Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Hendrik Bonnemeier
- Department of Internal Medicine III, Section for Electrophysiology und Rhythmology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Ardan M. Saguner
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, Univesity of Lübeck, Lübeck, Germany
| |
Collapse
|
20
|
Ninni S, Gallot-Lavallée T, Klein C, Longère B, Brigadeau F, Potelle C, Crop F, Rault E, Decoene C, Lacornerie T, Lals S, Kouakam C, Pontana F, Lacroix D, Klug D, Mirabel X. Stereotactic Radioablation for Ventricular Tachycardia in the Setting of Electrical Storm. Circ Arrhythm Electrophysiol 2022; 15:e010955. [PMID: 36074658 DOI: 10.1161/circep.122.010955] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy for treating refractory ventricular tachycardia (VT) despite optimal medical treatment and catheter ablation. However, data on the use of SBRT in patients with electrical storm (ES) is lacking. The aim of this study was to assess the clinical outcomes associated with SBRT in the context of ES. METHODS This retrospective study included patients who underwent SBRT in the context of ES from March 2020 to March 2021 in one tertiary center (CHU Lille). The target volume was delineated according to a predefined workflow. The efficacy was assessed with the following end points: sustained VT recurrence, VT reduced with antitachycardia pacing, and implantable cardioverter defibrillator shock. RESULTS Seventeen patients underwent SBRT to treat refractory VT in the context of ES (mean 67±12.8 age, 59% presenting ischemic heart disease, mean left ventricular ejection fraction: 33.7± 9.7%). Five patients presented with ES related to incessant VT. Among these 5 patients, the time to effectiveness ranged from 1 to 7 weeks after SBRT. In the 12 remaining patients, VT recurrences occurred in 7 patients during the first 6 weeks following SBRT. After a median 12.5 (10.5-17.8) months follow-up, a significant reduction of the VT burden was observed beyond 6 weeks (-91% [95% CI, 78-103]), P<0.0001). The incidence of implantable cardioverter defibrillator shock and antitachycardia pacing was 36% at 1 year. CONCLUSIONS SBRT is associated with a significant reduction of the VT burden in the event of an ES; however, prospective randomized control trials are needed. In patients without incessant VT, recurrences are observed in half of patients during the first 6 weeks. VT tolerance and implantable cardioverter defibrillator programming adjustments should be integrated as part of an action plan defined before SBRT for each patient.
Collapse
Affiliation(s)
- Sandro Ninni
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - Thomas Gallot-Lavallée
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - Cédric Klein
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - Benjamin Longère
- CHU Lille, Institut Cœur-Poumon, Service De Radiologie (B.L., F.P.)
| | - François Brigadeau
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | | | - Frederik Crop
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.).,Medical Physics, Centre Oscar Lambret, Lille, France (F.C., E.R., C.D., T.L.)
| | - Erwann Rault
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.).,Medical Physics, Centre Oscar Lambret, Lille, France (F.C., E.R., C.D., T.L.)
| | - Camille Decoene
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.).,Medical Physics, Centre Oscar Lambret, Lille, France (F.C., E.R., C.D., T.L.)
| | - Thomas Lacornerie
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.).,Medical Physics, Centre Oscar Lambret, Lille, France (F.C., E.R., C.D., T.L.)
| | - Séverine Lals
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.)
| | - Claude Kouakam
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - François Pontana
- CHU Lille, Institut Cœur-Poumon, Service De Radiologie (B.L., F.P.)
| | - Dominique Lacroix
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - Didier Klug
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | | |
Collapse
|
21
|
Bernstein HM, Leon W, Daly ME, Park P, Ghasemiesfe A, Beri N, Eng M, Srivatsa UN. Noninvasive Stereotactic Radiation for Refractory Ventricular Tachycardia After Failure of Cardiac Sympathetic Denervation. JACC Case Rep 2022; 4:1189-1194. [PMID: 36213875 PMCID: PMC9537071 DOI: 10.1016/j.jaccas.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/17/2022] [Accepted: 06/23/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Hannah M. Bernstein
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California, USA
- Address for correspondence: Dr Hannah M. Bernstein, University of California Davis Medical Center, 4860 Y Street, Suite 2820, Sacramento, California 95817, USA.
| | - William Leon
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California, USA
| | - Megan E. Daly
- Division of Radiation Oncology, University of California Davis Medical Center, Sacramento, California, USA
| | - Peter Park
- Division of Radiation Oncology, University of California Davis Medical Center, Sacramento, California, USA
| | - Ahmadreza Ghasemiesfe
- Division of Radiology, University of California Davis Medical Center, Sacramento, California, USA
| | - Neil Beri
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California, USA
| | - Maia Eng
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California, USA
| | - Uma N. Srivatsa
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California, USA
| |
Collapse
|
22
|
Volpato G, Compagnucci P, Cipolletta L, Parisi Q, Valeri Y, Carboni L, Giovagnoni A, Dello Russo A, Casella M. Safety and Efficacy of Stereotactic Arrhythmia Radioablation for the Treatment of Ventricular Tachycardia: A Systematic Review. Front Cardiovasc Med 2022; 9:870001. [PMID: 36072869 PMCID: PMC9441659 DOI: 10.3389/fcvm.2022.870001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Catheter ablation (CA) is a fundamental therapeutic option for the treatment of recurrent ventricular arrhythmias. Notwithstanding the tremendous improvements in the available technology and the increasing amount of evidence in support of CA, in some patients the procedure fails, or is absolutely contraindicated due to technical or clinical issues. In these cases, the clinical management of patients is highly challenging, and mainly involves antiarrhythmic drugs escalation. Over the last 5 years, stereotactic arrhythmia radioablation (STAR) has been introduced into clinical practice, with several small studies reporting favorable arrhythmia-free outcomes, without severe side effects at a short to mid-term follow-up. In the present systematic review, we provide an overview of the available studies on stereotactic arrhythmia radioablation, by describing the potential indications and technical aspects of this promising therapy.
Collapse
Affiliation(s)
- Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- *Correspondence: Giovanni Volpato,
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Ancona, Italy
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Ancona, Italy
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Ancona, Italy
| | - Laura Carboni
- Cardiac Surgery Anesthesia and Critical Care Unit, University Hospital “Ospedali Riuniti”, Ancona, Italy
| | - Andrea Giovagnoni
- Department of Radiology, University Hospital “Ospedali Riuniti”, Ancona, Italy
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Ancona, Italy
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Kluge A, Ehrbar S, Grehn M, Fleckenstein J, Baus WW, Siebert FA, Schweikard A, Andratschke N, Mayinger MC, Boda-Heggemann J, Buergy D, Celik E, Krug D, Kovacs B, Saguner AM, Rudic B, Bergengruen P, Boldt LH, Stauber A, Zaman A, Bonnemeier H, Dunst J, Budach V, Blanck O, Mehrhof F. Treatment Planning for Cardiac Radioablation: Multicenter Multiplatform Benchmarking for the XXX Trial. Int J Radiat Oncol Biol Phys 2022; 114:360-372. [PMID: 35716847 DOI: 10.1016/j.ijrobp.2022.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/15/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Cardiac radioablation is a novel treatment option for patients with refractory ventricular tachycardia (VT) unsuitable for catheter ablation. The quality of treatment planning depends on dose specifications, platform capabilities, and experience of the treating staff. To harmonize the treatment planning, benchmarking of this process is necessary for multicenter clinical studies such as the XXX trial. METHODS AND MATERIALS Planning computed tomography data and consensus structures from three patients were sent to five academic centers for independent plan development using a variety of platforms and techniques with the XXX study protocol serving as guideline. Three-dimensional dose distributions and treatment plan details were collected and analyzed. In addition, an objective relative plan quality ranking system for VT treatments was established. RESULTS For each case, three coplanar volumetric modulated arc (VMAT) plans for C-arm linear accelerators (LINAC) and three non-coplanar treatment plans for robotic arm LINAC were generated. All plans were suitable for clinical applications with minor deviations from study guidelines in most centers. Eleven of 18 treatment plans showed maximal one minor deviation each for target and cardiac substructures. However, dose-volume histograms showed substantial differences: in one case, the PTV≥30Gy ranged from 0.0% to 79.9% and the RIVA V14Gy ranged from 4.0% to 45.4%. Overall, the VMAT plans had steeper dose gradients in the high dose region, while the plans for the robotic arm LINAC had smaller low dose regions. Thereby, VMAT plans required only about half as many monitor units, resulting in shorter delivery times, possibly an important factor in treatment outcome. CONCLUSIONS Cardiac radioablation is feasible with robotic arm and C-arm LINAC systems with comparable plan quality. Although cross-center training and best practice guidelines have been provided, further recommendations, especially for cardiac substructures, and ranking of dose guidelines will be helpful to optimize cardiac radioablation outcomes.
Collapse
Affiliation(s)
- Anne Kluge
- Klinik für Radioonkologie und Strahlentherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefanie Ehrbar
- Klinik für Radio-Onkologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Wolfgang W Baus
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Frank-Andre Siebert
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Achim Schweikard
- University of Lübeck, Institute for Robotic and Cognitive Systems, Lübeck, Germany
| | - Nicolaus Andratschke
- Klinik für Radio-Onkologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Michael C Mayinger
- Klinik für Radio-Onkologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Buergy
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Eren Celik
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David Krug
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Boldizsar Kovacs
- Universitäres Herzzentrum, Klinik für Kardiologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Ardan M Saguner
- Universitäres Herzzentrum, Klinik für Kardiologie, UniversitätsSpital Zürich, University of Zurich, Zürich, CH
| | - Boris Rudic
- Medizinische Klinik, Universitätsmedizin Mannheim and German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Paula Bergengruen
- Klinik für Radioonkologie und Strahlentherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Leif-Hendrik Boldt
- Med. Klinik m.S. Kardiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Annina Stauber
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Adrian Zaman
- Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Volker Budach
- Klinik für Radioonkologie und Strahlentherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Felix Mehrhof
- Klinik für Radioonkologie und Strahlentherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| |
Collapse
|
25
|
Casula M, Dusi V, Camps S, Gringet J, Benoit T, Garonna A, Rordorf R. Feasibility of an Automatic Ultrasonographic Image Acquisition System Associated With an Artificial Intelligence Algorithm for Real-Time Monitoring of Cardiac Motion During Cardiac Radio-Ablation. Front Cardiovasc Med 2022; 9:849234. [PMID: 35548427 PMCID: PMC9081646 DOI: 10.3389/fcvm.2022.849234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background The management of the cardio-respiratory motion of the target and the reduction of the uncertainties related to patient's positioning are two of the main challenges that stereotactic arrhythmia radio-ablation (STAR) has to overcome. A prototype of a system was developed that can automatically acquire and interpret echocardiographic images using an artificial intelligence (AI) algorithm to calculate cardiac displacement in real-time. Methods We conducted a single center study enrolling consecutive patients with a history of ventricular arrhythmias (VA) in order to evaluate the feasibility of this automatic acquisition system. Echocardiographic images were automatically acquired from the parasternal and apical views with a dedicated probe. The system was designed to hold the probe fixed to the chest in the supine position during both free-breathing and short expiratory breath-hold sequences, to simulate STAR treatment. The primary endpoint was the percentage of patients reaching a score ≥2 in a multi-parametric assessment evaluating the quality of automatically acquired images. Moreover, we investigated the potential impact of clinical and demographic characteristics on achieving the primary endpoint. Results We enrolled 24 patients (63 ± 14 years, 21% females). All of them had a history of VA and 21 (88%) had an ICD. Eight patients (33%) had coronary artery disease, 12 (50%) had non-ischemic cardiomyopathy, and 3 had idiopathic VA. Parasternal, as well as apical images were obtained from all patients except from one, in whom parasternal view could not be collected due to the patient's inability to maintain the supine position. The primary endpoint was achieved in 23 patients (96%) for the apical view, in 20 patients (87%) for the parasternal view, and in all patients in at least one of the two views. The images' quality was maximal (i.e., score = 4) in at least one of the two windows in 19 patients (79%). Atrial fibrillation arrhythmia was the only clinical characteristics associated with a poor score outcome in both imaging windows (apical p = 0.022, parasternal p = 0.014). Conclusions These results provide the proof-of-concept for the feasibility of an automatic ultrasonographic image acquisition system associated with an AI algorithm for real-time monitoring of cardiac motion in patients with a history of VA.
Collapse
Affiliation(s)
- Matteo Casula
- Arrhythmia and Electrophysiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Section of Cardiology, Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Veronica Dusi
- Arrhythmia and Electrophysiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Unit of Cardiology, AOU Città della Salute e della Scienza, Turin, Italy
| | | | | | | | | | - Roberto Rordorf
- Arrhythmia and Electrophysiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- *Correspondence: Roberto Rordorf
| |
Collapse
|
26
|
Kim JS, Choi SW, Park YG, Kim SJ, Choi CH, Cha MJ, Chang JH. Impact of High-Dose Irradiation on Human iPSC-Derived Cardiomyocytes Using Multi-Electrode Arrays: Implications for the Antiarrhythmic Effects of Cardiac Radioablation. Int J Mol Sci 2021; 23:351. [PMID: 35008778 PMCID: PMC8745341 DOI: 10.3390/ijms23010351] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiac radioablation is emerging as an alternative option for refractory ventricular arrhythmias. However, the immediate acute effect of high-dose irradiation on human cardiomyocytes remains poorly known. We measured the electrical activities of human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) upon irradiation with 0, 20, 25, 30, 40, and 50 Gy using a multi-electrode array, and cardiomyocyte function gene levels were evaluated. iPSC-CMs showed to recover their electrophysiological activities (total active electrode, spike amplitude and slope, and corrected field potential duration) within 3-6 h from the acute effects of high-dose irradiation. The beat rate immediately increased until 3 h after irradiation, but it steadily decreased afterward. Conduction velocity slowed in cells irradiated with ≥25 Gy until 6-12 h and recovered within 24 h; notably, 20 and 25 Gy-treated groups showed subsequent continuous increase. At day 7 post-irradiation, except for cTnT, cardiomyocyte function gene levels increased with increasing irradiation dose, but uniquely peaked at 25-30 Gy. Altogether, high-dose irradiation immediately and reversibly modifies the electrical conduction of cardiomyocytes. Thus, compensatory mechanisms at the cellular level may be activated after the high-dose irradiation acute effects, thereby, contributing to the immediate antiarrhythmic outcome of cardiac radioablation for refractory ventricular arrhythmias.
Collapse
Affiliation(s)
- Jae Sik Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Korea; (J.S.K.); (C.H.C.)
- Department of Radiation Oncology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
| | - Seong Woo Choi
- Department of Physiology, Dongguk University College of Medicine, Gyeongju 38066, Korea;
| | - Yun-Gwi Park
- Stem Cell Research Institute, T&R Biofab Co., Ltd., Siheung 15073, Korea;
| | - Sung Joon Kim
- Department of Physiology & Ischemic/Hypoxic Disease Institute, Seoul National University College of Medicine, Seoul 03080, Korea;
| | - Chang Heon Choi
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Korea; (J.S.K.); (C.H.C.)
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Korea
| | - Myung-Jin Cha
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Korea; (J.S.K.); (C.H.C.)
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Korea
| |
Collapse
|
27
|
[Cardiac stereotactic radiotherapy induces electrical conduction reprogramming]. Strahlenther Onkol 2021; 198:209-211. [PMID: 34928433 PMCID: PMC8789705 DOI: 10.1007/s00066-021-01891-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 12/04/2022]
|
28
|
Stevenson WG, Sapp JL. Newer Methods for VT Ablation and When to Use Them. Can J Cardiol 2021; 38:502-514. [PMID: 34942300 DOI: 10.1016/j.cjca.2021.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/03/2021] [Accepted: 12/11/2021] [Indexed: 02/07/2023] Open
Abstract
Radiofrequency (RF) catheter ablation has long been an important therapy for ventricular tachycardia and frequent symptomatic premature ventricular beats and nonsustained arrhythmias when antiarrhythmic drugs fail to suppress the arrhythmias. It is increasingly used in preference to antiarrhythmic drugs, sparing the patient drug adverse effects. Ablation success varies with the underlying heart disease and type of arrhythmia, being very effective for patients without structural heart disease, less in structural heart disease. Failure occurs when a target for ablation cannot be identified, or ablation lesions fail to reach and abolish the arrhythmia substrate that may be extensive, intramural or subepicardial in location. Approaches to improving ablation lesion creation are modifications to RF ablation and emerging investigational techniques. Easily implemented modifications to RF methods include manipulating the size and location of the cutaneous dispersive electrode, increasing RF delivery duration, and use of lower tonicity catheter irrigation (usually 0.45% saline). When catheters can be placed on either side of culprit substrate RF can be delivered in a bipolar or simultaneous unipolar configuration that can be successful. Catheters with extendable/retractable irrigated needles for RF delivery are under investigation in clinical trials. Cryoablation is potentially useful in specific situations when maintaining contact is difficult. Transvascular ethanol ablation and stereotactic radioablation have both shown promise for arrhythmias that fail other ablation strategies. Although substantial clinical progress has been achieved, further improvement is clearly needed. With ability to increase ablation lesion size, continued careful evaluation of safety, which has been excellent for standard RF ablation, remains important.
Collapse
Affiliation(s)
- William G Stevenson
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; The Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
| | - John L Sapp
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; The Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| |
Collapse
|
29
|
Hohmann S, Hillmann HAK, Müller-Leisse J, Eiringhaus J, Zormpas C, Merten R, Veltmann C, Duncker D. Stereotactic radioablation for ventricular tachycardia. Herzschrittmacherther Elektrophysiol 2021; 33:49-54. [PMID: 34825951 DOI: 10.1007/s00399-021-00830-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
Non-invasive stereotactic radioablation of ventricular tachycardia (VT) substrate has been proposed as a novel treatment modality for patients not eligible for catheter-based ablation or in whom this approach has failed. Initial clinical results are promising with good short-term efficacy in VT suppression and tolerable side effects. This article reviews the current clinical evidence for cardiac radioablation and gives an overview of important preclinical and translational results. Practical guidance is provided, and a cardiac radioablation planning and treatment workflow based on expert consensus and the authors' institutional experience is set out.
Collapse
Affiliation(s)
- Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Henrike A K Hillmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Johanna Müller-Leisse
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jörg Eiringhaus
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christos Zormpas
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Roland Merten
- Department of Radiotherapy, Hannover Medical School, Hannover, Germany
| | - Christian Veltmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| |
Collapse
|
30
|
Zei PC, Sauer WH. Cardiac stereotactic radiation therapy: Charting a course through unchartered waters. Heart Rhythm 2021; 18:2146-2147. [PMID: 34418542 DOI: 10.1016/j.hrthm.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Paul C Zei
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, Massachusetts.
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|