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Zhang S, Hu L, Tang H, Liao L, Li X. Stereotactic arrhythmia radioablation (STAR) opens a new era in the treatment of arrhythmias? Front Cardiovasc Med 2024; 11:1449028. [PMID: 39399514 PMCID: PMC11469775 DOI: 10.3389/fcvm.2024.1449028] [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: 06/14/2024] [Accepted: 09/10/2024] [Indexed: 10/15/2024] Open
Abstract
Tachyarrhythmias are common cardiovascular emergencies encountered in clinical practice. Among these, atrial fibrillation (AF) and ventricular tachycardia (VT) pose significant hazards due to their prevalence and severity. Initially, non-invasive pharmacological antiarrhythmic interventions were the primary treatment modality; however, due to their limited control rates and side effects, invasive therapies have been introduced in recent years. These include catheter ablation, alcohol ablation, cardiac implantable electronic devices, and heart transplantation. Nonetheless, for some patients, invasive treatments do not offer a definitive cure for arrhythmias and carry the risk of recurrence, especially with AF and VT, where the relapse rates are high and the treatment for VT is correlated with the type of tachycardia present. Currently, novel non-invasive treatment methods are emerging, with stereotactic radioablation therapy becoming an effective alternative for the management of refractory tachyarrhythmias. This review provides an overview of the application background of Stereotactic Arrhythmia Radioablation (STAR) therapy and promising results from its use in animal models and clinical applications.
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Affiliation(s)
| | | | | | | | - Xuping Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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2
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Balaji P, Liulu X, Sivakumar S, Chong JJH, Kizana E, Vandenberg JI, Hill AP, Hau E, Qian PC. Mechanistic Insights and Knowledge Gaps in the Effects of Radiation Therapy on Cardiac Arrhythmias. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03316-9. [PMID: 39222823 DOI: 10.1016/j.ijrobp.2024.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 08/05/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
Stereotactic body radiation therapy (SBRT) is an innovative modality for the treatment of refractory ventricular arrhythmias (VAs). Phase 1/2 clinical trials have demonstrated the remarkable efficacy of SBRT at reducing VA burden (by >85%) in patients with good short-term safety. SBRT as an option for VA treatment delivered in an ambulatory nonsedated patient in a single fraction during an outpatient session of 15 to 30 minutes, without added risks of anesthetic or surgery, is clinically relevant. However, the underlying mechanism remains unclear. Currently, the clinical dosing of SBRT has been derived from preclinical studies aimed at inducing transmural fibrosis in the atria. The propitious clinical effects of SBRT appear earlier than the time course for fibrosis. This review addresses the plausible mechanisms by which radiation alters the electrophysiological properties of myocytes and myocardial conduction to impart an antiarrhythmic effect, elucidate clinical observations, and point the direction for further research in this promising area.
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Affiliation(s)
- Poornima Balaji
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia
| | - Xingzhou Liulu
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sonaali Sivakumar
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia
| | - James J H Chong
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Eddy Kizana
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Jamie I Vandenberg
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Adam P Hill
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Eric Hau
- 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, Westmead, New South Wales, Australia; Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, 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, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
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Trojani V, Grehn M, Botti A, Balgobind B, Savini A, Boda-Heggemann J, Miszczyk M, Elicin O, Krug D, Andratschke N, Schmidhalter D, van Elmpt W, Bogowicz M, de Areba Iglesias J, Dolla L, Ehrbar S, Fernandez-Velilla E, Fleckenstein J, Granero D, Henzen D, Hurkmans C, Kluge A, Knybel L, Loopeker S, Mirandola A, Richetto V, Sicignano G, Vallet V, van Asselen B, Worm E, Pruvot E, Verhoeff J, Fast M, Iori M, Blanck O. Refining Treatment Planning in STereotactic Arrhythmia Radioablation: Benchmark Results and Consensus Statement From the STOPSTORM.eu Consortium. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03171-7. [PMID: 39122095 DOI: 10.1016/j.ijrobp.2024.07.2331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 07/09/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE STereotactic Arrhythmia Radioablation (STAR) showed promising results in patients with refractory ventricular tachycardia. However, clinical data are scarce and heterogeneous. The STOPSTORM.eu consortium was established to investigate and harmonize STAR in Europe. The primary goal of this benchmark study was to investigate current treatment planning practice within the STOPSTORM project as a baseline for future harmonization. METHODS AND MATERIALS Planning target volumes (PTVs) overlapping extracardiac organs-at-risk and/or cardiac substructures were generated for 3 STAR cases. Participating centers were asked to create single-fraction treatment plans with 25 Gy dose prescriptions based on in-house clinical practice. All treatment plans were reviewed by an expert panel and quantitative crowd knowledge-based analysis was performed with independent software using descriptive statistics for International Commission on Radiation Units and Measurements report 91 relevant parameters and crowd dose-volume histograms. Thereafter, treatment planning consensus statements were established using a dual-stage voting process. RESULTS Twenty centers submitted 67 treatment plans for this study. In most plans (75%) intensity modulated arc therapy with 6 MV flattening filter free beams was used. Dose prescription was mainly based on PTV D95% (49%) or D96%-100% (19%). Many participants preferred to spare close extracardiac organs-at-risk (75%) and cardiac substructures (50%) by PTV coverage reduction. PTV D0.035cm3 ranged from 25.5 to 34.6 Gy, demonstrating a large variety of dose inhomogeneity. Estimated treatment times without motion compensation or setup ranged from 2 to 80 minutes. For the consensus statements, a strong agreement was reached for beam technique planning, dose calculation, prescription methods, and trade-offs between target and extracardiac critical structures. No agreement was reached on cardiac substructure dose limitations and on desired dose inhomogeneity in the target. CONCLUSIONS This STOPSTORM multicenter treatment planning benchmark study not only showed strong agreement on several aspects of STAR treatment planning, but also revealed disagreement on others. To standardize and harmonize STAR in the future, consensus statements were established; however, clinical data are urgently needed for actionable guidelines for treatment planning.
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Affiliation(s)
- Valeria Trojani
- Department of Medical Physics, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Andrea Botti
- Department of Medical Physics, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Brian Balgobind
- Department of Radiation Oncology, Amsterdam UMC, Radiation Oncology, Amsterdam, The Netherlands
| | | | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marcin Miszczyk
- IIIrd Radiotherapy and Chemotherapy Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland; Collegium Medicum - Faculty of Medicine, WSB University, Dąbrowa Górnicza, Poland
| | - Olgun Elicin
- Department of Radiation Oncology and Division of Medical Radiation Physics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Krug
- Department of Radiation Oncology, University Medical Center of Schleswig-Holstein, Kiel, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
| | - Daniel Schmidhalter
- Department of Radiation Oncology and Division of Medical Radiation Physics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Wouter van Elmpt
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marta Bogowicz
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
| | | | - Lukasz Dolla
- Radiotherapy Planning Department, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Stefanie Ehrbar
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
| | | | - Jens Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Domingo Granero
- Department of Radiation Oncology, Hospital General Valencia, Valencia, Spain
| | - Dominik Henzen
- Department of Radiation Oncology and Division of Medical Radiation Physics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Coen Hurkmans
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands; Department of Electrical Engineering and Department of Applied Physics, Technical University Eindhoven, The Netherlands
| | - Anne Kluge
- Department for Radiation Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lukas Knybel
- Department of Oncology, University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | - Sandy Loopeker
- Department of Radiation Oncology, Amsterdam UMC, Radiation Oncology, Amsterdam, The Netherlands
| | - Alfredo Mirandola
- Radiation Oncology Clinical Department, National Center of Oncological Hadrontherapy (Fondazione CNAO), Pavia, Italy
| | - Veronica Richetto
- Medical Physics Unit, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gianluisa Sicignano
- Department of Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Veronique Vallet
- Department of Radiophysics, Lausanne University Hospital, Lausanne, Switzerland
| | - Bram van Asselen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Esben Worm
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Joost Verhoeff
- Department of Radiation Oncology, Amsterdam UMC, Radiation Oncology, Amsterdam, The Netherlands; Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mauro Iori
- Department of Medical Physics, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center of Schleswig-Holstein, Kiel, Germany.
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Sheikh K, Daniel BL, Roumeliotis M, Lee J, Hrinivich WT, Benkert T, Bhat H, Seethamraju RT, Viswanathan AN, Schmidt EJ. Inversion-recovery ultrashort-echo-time (IR-UTE) MRI-based detection of radiation dose heterogeneity in gynecologic cancer patients treated with HDR brachytherapy. Radiat Oncol 2024; 19:105. [PMID: 39107776 PMCID: PMC11305063 DOI: 10.1186/s13014-024-02499-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024] Open
Abstract
PURPOSE To evaluate the relationship between delivered radiation (RT) and post-RT inversion-recovery ultrashort-echo-time (IR-UTE) MRI signal-intensity (SI) in gynecologic cancer patients treated with high-dose-rate (HDR) brachytherapy (BT). METHODS Seven patients underwent whole-pelvis RT (WPRT) followed by BT to the high-risk clinical target volume (HR-CTV). MR images were acquired at three time-points; pre-RT, post-WPRT/pre-BT, and 3-6 months post-BT. Diffuse-fibrosis (FDiffuse) was imaged with a non-contrast dual-echo IR (inversion time [TI] = 60 ms) UTE research application, with image-subtraction of the later echo, only retaining the ultrashort-echo SI. Dense-fibrosis (FDense) imaging utilized single-echo Late-Gadolinium-Enhanced IR-UTE, acquired ∼ 15 min post-Gadavist injection. Resulting FDiffuse and FDense SI were normalized to the corresponding gluteal-muscle SI. Images were deformably registered between time-points based on normal tissue anatomy. The remnant tumor at both time-points was segmented using multi-parametric MRI. Contours corresponding to the 50%, 100%, 150%, and 200% isodose lines (IDLs) of the prescription BT-dose were created. Mean FDiffuse and FDense SI within (i) each IDL contour and (ii) the remnant tumor were calculated. Post-BT FDiffuse and FDense SI were correlated with prescribed BT-dose. To determine the relationship between BT-dose and IR-UTE SI, the differences in the post-BT FDense across IDLs was determined using paired t-tests with Bonferroni correction. RESULTS FDense was higher in regions of higher dose for 6/7 patients, with mean ± SD values of 357 ± 103% and 331 ± 97% (p = .03) in the 100% and 50% IDL, respectively. FDense was higher in regions of higher dose in the responsive regions with mean ± SD values of 380 ± 122% and 356 ± 135% (p = .03) in the 150% and 50% IDL, respectively. Within the segmented remnant tumor, an increase in prescribed dose correlated with an increase in FDense post-BT (n = 5, r = .89, p = .04). Post-BT FDiffuse inversely correlated (n = 7, r = -.83, p = .02) with prescribed BT-dose within the 100% IDL. CONCLUSIONS Results suggest that FDense SI 3-6 months post-BT is a sensitive measure of tissue response to heterogeneous BT radiation-dose. Future studies will validate whether FDiffuse and FDense are accurate biomarkers of fibrotic radiation response.
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Affiliation(s)
- Khadija Sheikh
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, 5255 Loughboro Road NW, Washington, DC, USA.
| | - Bruce L Daniel
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Michael Roumeliotis
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, 5255 Loughboro Road NW, Washington, DC, USA
| | - Junghoon Lee
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, 5255 Loughboro Road NW, Washington, DC, USA
| | - William T Hrinivich
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, 5255 Loughboro Road NW, Washington, DC, USA
| | - Thomas Benkert
- MR Application Predevelopment, Siemens Healthineers AG, Erlangen, Germany
| | | | | | - Akila N Viswanathan
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, 5255 Loughboro Road NW, Washington, DC, USA
| | - Ehud J Schmidt
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, 5255 Loughboro Road NW, Washington, DC, USA
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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5
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Mages C, Gampp H, Rahm AK, Hackbarth J, Pfeiffer J, Petersenn F, Kramp X, Kermani F, Zhang J, Pijnappels DA, de Vries AAF, Seidensaal K, Rhein B, Debus J, Ullrich ND, Frey N, Thomas D, Lugenbiel P. Cardiac stereotactic body radiotherapy to treat malignant ventricular arrhythmias directly affects the cardiomyocyte electrophysiology. Heart Rhythm 2024:S1547-5271(24)02817-0. [PMID: 38936449 DOI: 10.1016/j.hrthm.2024.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Promising as a treatment option for life-threatening ventricular arrhythmias, cardiac stereotactic body radiotherapy (cSBRT) has demonstrated early antiarrhythmic effects within days of treatment. The mechanisms underlying the immediate and short-term antiarrhythmic effects are poorly understood. OBJECTIVE We hypothesize that cSBRT has a direct antiarrhythmic effect on cellular electrophysiology through reprogramming of ion channel and gap junction protein expression. METHODS After exposure to 20 Gy of x-rays in a single fraction, neonatal rat ventricular cardiomyocytes were analyzed 24 and 96 hours postradiation to determine changes in conduction velocity, beating frequency, calcium transients, and action potential duration in both monolayers and single cells. In addition, the expression of gap junction proteins, ion channels, and calcium handling proteins was evaluated at protein and messenger RNA levels. RESULTS After irradiation with 20 Gy, neonatal rat ventricular cardiomyocytes exhibited increased beat rate and conduction velocity 24 and 96 hours after treatment. Messenger RNA and protein levels of ion channels were altered, with the most significant changes observed at the 96-hour mark. Upregulation of Cacna1c (Cav1.2), Kcnd3 (Kv4.3), Kcnh2 (Kv11.1), Kcnq1 (Kv7.1), Kcnk2 (K2P2.1), Kcnj2 (Kir2.1), and Gja1 (Cx43) was noted, along with improved gap junctional coupling. Calcium handling was affected, with increased Ryr2 ryanodin-rezeptor 2 and Slc8a1 Na+/Ca2+ exchanger expression and altered properties 96 hours posttreatment. Fibroblast and myofibroblast levels remained unchanged. CONCLUSION cSBRT modulates the expression of various ion channels, calcium handling proteins, and gap junction proteins. The described alterations in cellular electrophysiology may be the underlying cause of the immediate antiarrhythmic effects observed after cSBRT.
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Affiliation(s)
- Christine Mages
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany; Informatics4Life Consortium (Institute for Informatics Heidelberg), Heidelberg, Germany
| | - Heike Gampp
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Ann-Kathrin Rahm
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany; Informatics4Life Consortium (Institute for Informatics Heidelberg), Heidelberg, Germany
| | - Juline Hackbarth
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Pfeiffer
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Finn Petersenn
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Xenia Kramp
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Fatemeh Kermani
- Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg, Germany
| | - Juan Zhang
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel A Pijnappels
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Antoine A F de Vries
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Bernhard Rhein
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Nina D Ullrich
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany; Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg, Germany; Department of Physiology, University of Bern, Bern, Switzerland
| | - Norbert Frey
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany; Informatics4Life Consortium (Institute for Informatics Heidelberg), Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Patrick Lugenbiel
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.
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Blanck O, Miszczyk M, Postema PG. Letter on 'linear accelerator-based stereotactic arrhythmia radioablation for paroxysmal atrial fibrillation in elderly: a prospective phase II trial'. Europace 2024; 26:euae138. [PMID: 38818972 PMCID: PMC11164102 DOI: 10.1093/europace/euae138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 06/01/2024] Open
Affiliation(s)
- Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Arnold-Heller-Strasse 3, Kiel 24105, Germany
| | - Marcin Miszczyk
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Spitalgasse 23, Wien 1090, Austria
- Collegium Medicum—Faculty of Medicine, WSB University, Zygmunta Cieplaka 1c, Dąbrowa Górnicza 41-300, Poland
| | - Pieter G Postema
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 15, Amsterdam 1105AZ, The Netherlands
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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.
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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
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8
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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.
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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
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9
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Kawamura M, Shimojo M, Inden Y, Kamomae T, Okudaira K, Komada T, Aoki S, Shindo Y, Yasui R, Yanagi Y, Okumura M, Yamada T, Kozai Y, Oie Y, Kato Y, Ishihara S, Murohara T, Naganawa S. Stereotactic radiotherapy for ventricular tachycardia: A study protocol. F1000Res 2023; 12:798. [PMID: 38204487 PMCID: PMC10776963 DOI: 10.12688/f1000research.138758.2] [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] [Accepted: 12/07/2023] [Indexed: 01/12/2024] Open
Abstract
Background Currently, the standard curative treatment for ventricular tachycardia (VT) and ventricular fibrillation (VF) is radiofrequency catheter ablation. However, when the VT circuit is deep in the myocardium, the catheter may not be delivered, and a new, minimally invasive treatment using different energies is desired. Methods This is a protocol paper for a feasibility study designed to provide stereotactic radiotherapy for refractory VT not cured by catheter ablation after at least one catheter ablation. The primary end point is to evaluate the short-term safety of this treatment and the secondary endpoint is to evaluate its efficacy as assessed by the reduction in VT episode. Cyberknife M6 radiosurgery system will be used for treatment, and the prescribed dose to the target will be 25Gy in one fraction. The study will be conducted on three patients. Conclusion Since catheter ablation is the only treatment option for VT that is covered by insurance in Japan, there is currently no other treatment for VT/VF that cannot be cured by catheter ablation. We hope that this feasibility study will provide hope for patients who are currently under the stress of ICD activation. Trial registration The study has been registered in the Japan Registry of Clinical Trials (jRCTs042230030).
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Affiliation(s)
- Mariko Kawamura
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Masafumi Shimojo
- Cardiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yasuya Inden
- Cardiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Takeshi Kamomae
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Kuniyasu Okudaira
- Radiological Technology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Tomohiro Komada
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Sumire Aoki
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yurika Shindo
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Ryotaro Yasui
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yusuke Yanagi
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Masayuki Okumura
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Takehiro Yamada
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yuka Kozai
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yumi Oie
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Yutaka Kato
- Radiological Technology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Shunichi Ishihara
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Toyoaki Murohara
- Cardiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
| | - Shinji Naganawa
- Radiology, Nagoya University Hospital, Nagoya, Aichi Prefecture, Japan
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10
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Herrera Siklody C, Schiappacasse L, Jumeau R, Reichlin T, Saguner AM, Andratschke N, Elicin O, Schreiner F, Kovacs B, Mayinger M, Huber A, Verhoeff JJC, Pascale P, Solana Muñoz J, Luca A, Domenichini G, Moeckli R, Bourhis J, Ozsahin EM, Pruvot E. Recurrences of ventricular tachycardia after stereotactic arrhythmia radioablation arise outside the treated volume: analysis of the Swiss cohort. Europace 2023; 25:euad268. [PMID: 37695314 PMCID: PMC10551232 DOI: 10.1093/europace/euad268] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/16/2023] [Indexed: 09/12/2023] Open
Abstract
AIMS Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of therapy-refractory ventricular tachycardia (VT). VT recurrences have been reported after STAR but the mechanisms remain largely unknown. We analysed recurrences in our patients after STAR. METHODS AND RESULTS From 09.2017 to 01.2020, 20 patients (68 ± 8 y, LVEF 37 ± 15%) suffering from refractory VT were enrolled, 16/20 with a history of at least one electrical storm. Before STAR, an invasive electroanatomical mapping (Carto3) of the VT substrate was performed. A mean dose of 23 ± 2 Gy was delivered to the planning target volume (PTV). The median ablation volume was 26 mL (range 14-115) and involved the interventricular septum in 75% of patients. During the first 6 months after STAR, VT burden decreased by 92% (median value, from 108 to 10 VT/semester). After a median follow-up of 25 months, 12/20 (60%) developed a recurrence and underwent a redo ablation. VT recurrence was located in the proximity of the treated substrate in nine cases, remote from the PTV in three cases and involved a larger substrate over ≥3 LV segments in two cases. No recurrences occurred inside the PTV. Voltage measurements showed a significant decrease in both bipolar and unipolar signal amplitude after STAR. CONCLUSION STAR is a new tool available for the treatment of VT, allowing for a significant reduction of VT burden. VT recurrences are common during follow-up, but no recurrences were observed inside the PTV. Local efficacy was supported by a significant decrease in both bipolar and unipolar signal amplitude.
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Affiliation(s)
| | - Luis Schiappacasse
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Raphaël Jumeau
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Ardan M Saguner
- Department of Cardiology, Universitätsspital Zürich, University Hospital Zürich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, Universitätsspital Zürich, University Hospital Zürich, Zurich, Switzerland
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Boldizsar Kovacs
- Department of Cardiology, Universitätsspital Zürich, University Hospital Zürich, Zurich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, Universitätsspital Zürich, University Hospital Zürich, Zurich, Switzerland
| | - Adrian Huber
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Joost J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patrizio Pascale
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Jorge Solana Muñoz
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Adrian Luca
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Giulia Domenichini
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Raphael Moeckli
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Esat M Ozsahin
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Etienne Pruvot
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
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11
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Fast MF, Lydiard S, Boda-Heggemann J, Tanadini-Lang S, Muren LP, Clark CH, Blanck O. Precision requirements in stereotactic arrhythmia radioablation for ventricular tachycardia. Phys Imaging Radiat Oncol 2023; 28:100508. [PMID: 38026083 PMCID: PMC10679852 DOI: 10.1016/j.phro.2023.100508] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Affiliation(s)
- Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Germany
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Catharine H Clark
- Radiotherapy Physics, University College London Hospital, 250 Euston Rd, London NW1 2PG, UK
- Department of Medical Physics and Bioengineering, University College London, Malet Place, London WC1E 6BT, UK
- Medical Physics Dept, National Physical Laboratory, Hampton Rd, London TW11 0PX, UK
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Arnold-Heller-Strasse 3, Kiel 24105, Germany
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12
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Wang S, Luo H, Mao T, Xiang C, Hu H, Zhao J, Wang X, Wang J, Liu H, Yu L, Jiang H. Stereotactic arrhythmia radioablation: A novel therapy for cardiac arrhythmia. Heart Rhythm 2023; 20:1327-1336. [PMID: 37150313 DOI: 10.1016/j.hrthm.2023.04.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 05/09/2023]
Abstract
Cardiac arrhythmia is a global health problem, and catheter ablation has been one of its main treatments for decades. However, catheter ablation is an invasive method that cannot reach the deep myocardium, and it carries a considerable risk of side effects and recurrence. Therefore, it is necessary to explore a novel approach. Stereotactic body radiotherapy, which has been widely used in the field of radiation oncology, has recently expanded in the treatment of cardiac arrhythmia; when used in this context, it is known as stereotactic arrhythmia radioablation (STAR). As a noninvasive, effective, and well-tolerated treatment, STAR may be a suitable alternative method for patients with cardiac arrhythmia who are resistant or intolerant to catheter ablation. The main particles used to deliver energy in STAR are photons, protons, and carbon ions. Most studies have shown the short-term effectiveness of STAR, but problems such as a high long-term recurrence rate with a cumulative ventricular tachycardia-free survival rate from the published literature of 38.6% and related complications have also emerged. Therefore, in this article, we review the application of stereotactic body radiotherapy in cardiac arrhythmia, analyze its potential problems, and explore methods for improvement.
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Affiliation(s)
- Songyun Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Hao Luo
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Tianlong Mao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Chunrong Xiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Haoyuan Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Jiahui Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Xinqi Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Jiale Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Huafen Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China.
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13
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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.
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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
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14
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Mehrhof F, Bergengruen P, Gerds-Li JH, Jahn A, Kluge AK, Parwani A, Zips D, Boldt LH, Schönrath F. Cardiac radioablation of incessant ventricular tachycardia in patients with terminal heart failure under permanent left ventricular assist device therapy-description of two cases. Strahlenther Onkol 2023; 199:511-519. [PMID: 36750509 PMCID: PMC10133058 DOI: 10.1007/s00066-023-02045-1] [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: 09/27/2022] [Accepted: 01/08/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE Cardiac radioablation (cRA) using a stereotactic single-session radioablative approach has recently been described as a possible treatment option for patients with otherwise untreatable recurrent ventricular tachycardia (VT). There is very limited experience in cRA for patients undergoing left ventricular assist device (LVAD) therapy. We present clinical experiences of two patients treated with cRA for incessant VT under long-term LVAD therapy. METHODS Two male patients (54 and 61 years old) with terminal heart failure under LVAD therapy (both patients for 8 years) showed incessant VT despite extensive antiarrhythmic drug therapy and repeated catheter ablation. cRA with a single dose of 25 Gy was applied as a last resort strategy under compassionate use in both patients following an electroanatomical mapping procedure. RESULTS Both patients displayed ongoing VT during and after the cRA procedure. Repeated attempts at post-procedural rhythm conversion failed in both patients; however, one patient was hemodynamically stabilized and could be discharged home for several months before falling prey to a fatal bleeding complication. The second patient initially stabilized for a few days following cRA before renewed acceleration of running VT required bilateral ablation of the stellate ganglion; the patient died 50 days later. No immediate side effects of cRA were detected in either patient. CONCLUSION cRA might serve as a last resort strategy for patients with terminal heart failure undergoing LVAD therapy and displaying incessant VT. Intermediate- and long-term outcomes of these seriously ill patients often remain poor; therefore, best supportive care strategies should also be evaluated as long as no clear beneficial effects of cRA procedures can be shown. For patients treated with cRA under running ventricular rhythm abnormality, strategies for post-procedural generation of stabilized rhythm have to be established.
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Affiliation(s)
- Felix Mehrhof
- Department for Radiation Oncology, Charité-University Medicine Berlin, Berlin, Germany.
| | - Paula Bergengruen
- Department for Radiation Oncology, Charité-University Medicine Berlin, Berlin, Germany
| | - Jin-Hong Gerds-Li
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Andrea Jahn
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Anne Kathrin Kluge
- Department for Radiation Oncology, Charité-University Medicine Berlin, Berlin, Germany
| | - Abdul Parwani
- Department for Cardiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Daniel Zips
- Department for Radiation Oncology, Charité-University Medicine Berlin, Berlin, Germany
| | - Leif-Hendrik Boldt
- Department for Cardiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Felix Schönrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
- DZHK (German Center for Cardiovascular Research) Partnersite Berlin, Berlin, Germany
- Charité-University Medicine Berlin, Berlin, Germany
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15
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Li X, Zhu Z, Liu J, Gao Y, Xiao Y, Fang Z, Liu Q, Liu X, Hu C, Ma F, Zeng M, Liu Z, Hu L, Liu N, Xiang F, Hu X, Huang L, Zhou S. Septal radioablation therapy for patients with hypertrophic obstructive cardiomyopathy: first-in-human study. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead052. [PMID: 37503357 PMCID: PMC10371052 DOI: 10.1093/ehjopen/oead052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 07/29/2023]
Abstract
Aims There is still no non-invasive septal reduction therapy for patients with hypertrophic obstructive cardiomyopathy (HOCM). This study aimed to investigate the feasibility, safety, and efficacy of stereotactic body radiotherapy (SBRT) in patients with drug-refractory symptomatic HOCM. Methods and results The radiation target of ventricular septum was determined by multiple anatomical imaging. Stereotactic body radiotherapy was performed with standard techniques. Patients were treated with a single fraction of 25 Gy, followed up at 1, 3, 6, and 12 months by clinical visit. Five patients were enrolled and completed the 12 months follow-up. The mean radioablation time was 21.6 min, and the mean target volume was 10.5 cm3. All five patients survived and showed improvements in symptoms after SBRT. At 12 months post-SBRT, the echocardiography-derived left ventricular outflow tract gradient decreased from 88 mmHg (range, 63-105) to 52 mmHg (range, 36-66) at rest and from 101 mmHg (range, 72-121) to 74 mmHg (range, 65-100) after Valsalva. The end-diastolic thickness of the targeted septum reduced from 23.7 mm (range, 20.3-29) to 22.4 mm (range, 19.7-26.5); 6 min walking distance increased from 190.4 m (range, 50-370) to 412.0 m (range, 320-480). All patients presented with new fibrosis in the irradiated septum area. No radiation-related complications were observed during SBRT and up to 12 months post procedure. Conclusion The current study suggests that SBRT might be a feasible radioablation therapeutic option for patients with drug-refractory symptomatic HOCM. Trial registration ClinicalTrials.gov Identifier: NCT04686487.
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Affiliation(s)
| | | | - Jun Liu
- Radiology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yawen Gao
- Oncology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Zhenfei Fang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Xianling Liu
- Oncology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chunhong Hu
- Oncology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fang Ma
- Oncology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mu Zeng
- Radiology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhi Liu
- Anesthesiology Department, Hunan Provincial People’s Hospital, Changsha, Hunan, China
| | - Lin Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Na Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Fan Xiang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Xinqun Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Lihong Huang
- Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Shenghua Zhou
- Corresponding author. Tel: +86 731 85292012, Fax: +86 731 85292013,
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16
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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.
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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
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17
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Bonaparte I, Gregucci F, Di Monaco A, Troisi F, Surgo A, Ludovico E, Carbonara R, Paulicelli E, Sanfrancesco G, De Pascali C, Vitulano N, Quadrini F, Ciliberti MP, Romanazzi I, Di Guglielmo FC, Cusumano D, Calbi R, Grimaldi M, Fiorentino A. Phase II Trial of LINAC-Based STereotactic Arrhythmia Radioablation (STAR) for Paroxysmal Atrial Fibrillation in Elderly: Planning and Dosimetric Point of View. J Pers Med 2023; 13:jpm13040596. [PMID: 37108982 PMCID: PMC10143465 DOI: 10.3390/jpm13040596] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/13/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
Purpose: Approaching treatment for elderly patients with atrial fibrillation is difficult. A prospective phase II trial evaluating LINAC-based stereotactic arrhythmia radioablation (STAR) safety in this population started in 2021. Dosimetric and planning data were reported. Materials and Methods: A vac-lock bag was used for immobilization in the supine position and a computed tomography (CT, 1 mm) was performed. The clinical target volume (CTV) was defined as the area around the pulmonary veins. An internal target volume (ITV) was added to the CTV to compensate heart and respiratory movement. The planning target volume (PTV) was defined by adding 0–3 mm to the ITV. STAR was performed during free-breathing with a PTV prescription total dose (Dp) of 25 Gy/1 fraction. Flattening filter-free volumetric-modulated arc therapy plans were generated, optimized, and delivered by TrueBeamTM. Image-guided radiotherapy with cone-beam CT and surface-guided radiotherapy with Align-RT (Vision RT) were employed. Results: From May 2021 to March 2022, 10 elderly patients were treated. Mean CTVs, ITVs, and PTVs were 23.6 cc, 44.32 cc, and 62.9 cc, respectively; the mean prescription isodose level and D2% were 76.5% and 31.2 Gy, respectively. The average heart and left anterior descending artery (LAD) Dmean were 3.9 and 6.3 Gy, respectively; the mean Dmax for LAD, spinal cord, left and right bronchus, and esophagus were 11.2, 7.5, 14.3, 12.4, and 13.6 Gy, respectively. The overall treatment time (OTT) was 3 min. Conclusions: The data showed an optimal target coverage, sparing surrounding tissue, in 3 min of OTT. LINAC-based STAR for AF could represent a valid non-invasive alternative for elderly patients who were excluded from catheter ablation.
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18
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STereotactic Arrhythmia Radioablation: current status of the art. The old world and the new world connected. JOURNAL OF RADIOTHERAPY IN PRACTICE 2023. [DOI: 10.1017/s1460396922000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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19
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Kučera T, Jedličková K, Šramko M, Peichl P, Cvek J, Knybel L, Hurník P, Neuwirth R, Jiravský O, Voska L, Kautzner J. Inflammation and fibrosis characterize different stages of myocardial remodeling in patients after stereotactic body radiotherapy of ventricular myocardium for recurrent ventricular tachycardia. Cardiovasc Pathol 2023; 62:107488. [PMID: 36206914 PMCID: PMC9760563 DOI: 10.1016/j.carpath.2022.107488] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/29/2022] [Accepted: 09/29/2022] [Indexed: 01/03/2023] Open
Abstract
We performed a histological and immunohistochemical analysis of myocardia from 3 patients who underwent radiosurgery and died for various reasons 3 months to 9 months after radiotherapy. In Case 1 (death 3 months after radiotherapy) we observed a sharp transition between relatively intact and irradiated regions. In the myolytic foci, only scattered cardiomyocytes were left and the area was infiltrated by immune cells. Using immunohistochemistry we detected numerous inflammatory cells including CD68+/CD11c+ macrophages, CD4+ and CD8+ T-lymphocytes and some scattered CD20+ B-lymphocytes. Mast cells were diminished in contrast to viable myocardium. In Case 2 and Case 3 (death 6 and 9 months after radiotherapy, respectively) we found mostly fibrosis, infiltration by adipose tissue and foci of calcification. Inflammatory infiltrates were less pronounced. Our observations are in accordance with animal experimental studies and confirm a progress from myolysis to fibrosis. In addition, we demonstrate a role of pro-inflammatory macrophages in the earlier stages of myocardial remodeling after stereotactic radioablation for ventricular tachycardia.
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Affiliation(s)
- Tomáš Kučera
- Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Albertov 4, 120 00, Prague, Czech Republic,Corresponding author: Tomáš Kučera, MD, Ph.D. Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Albertov 4, 120 00, Prague, Czech Republic, Phone Number: +420224968130.
| | - Kristína Jedličková
- Department of Pathology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
| | - Marek Šramko
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, 17. listopadu 1790, 708 52, Ostrava, Czech Republic
| | - Lukáš Knybel
- Department of Oncology, University Hospital Ostrava, 17. listopadu 1790, 708 52, Ostrava, Czech Republic
| | - Pavel Hurník
- Institute of Clinical and Molecular Pathology and Medical Genetics, University Hospital Ostrava, 17. listopadu 1790, 708 52, Ostrava, Czech Republic
| | - Radek Neuwirth
- Faculty of Medicine, Masaryk University, Brno, Kamenice 753/5, 625 00 Brno,Agel Hospital Třinec Podlesí a.s., Konská 453, 739 61 Třinec, Czech Republic
| | - Otakar Jiravský
- Faculty of Medicine, Masaryk University, Brno, Kamenice 753/5, 625 00 Brno,Agel Hospital Třinec Podlesí a.s., Konská 453, 739 61 Třinec, Czech Republic
| | - Luděk Voska
- Department of Pathology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
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20
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Nakahara S. Catheter ablation of ventricular tachycardia associated with structural heart disease: Current status and perspectives. J Cardiol 2023; 81:57-62. [PMID: 36174816 DOI: 10.1016/j.jjcc.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 11/25/2022]
Abstract
Catheter ablation is an effective and safe treatment for ventricular tachycardia attributable to structural heart disease, reducing the risk of recurrent arrhythmias and defibrillator shock therapy. Advances in medical technology and an accumulation of data have led to the development of detailed guidelines. Successful ablation requires accurate identification of the arrhythmia substrate and effective delivery of radiofrequency energy to the target tissue. Modern practice requires use of traditional electrophysiological mapping processes such as entrainment mapping and three-dimensional activation sequence mapping in combination with newer functional mapping techniques for which there is growing support. Thorough non-invasive preoperative assessment is also necessary before an invasive procedure is undertaken. In this review, we summarize contemporary practice and recent randomized controlled trials underpinning the latest developments in mapping and ablation and discuss potential future developments in this field.
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Affiliation(s)
- Shiro Nakahara
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan.
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21
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Haskova J, Sramko M, Cvek J, Kautzner J. Stereotactic Radiotherapy in the Management of Ventricular Tachycardias: More Questions than Answers? Card Electrophysiol Clin 2022; 14:779-792. [PMID: 36396193 DOI: 10.1016/j.ccep.2022.06.010] [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] [Indexed: 06/16/2023]
Abstract
Stereotactic body radiotherapy is a recent promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias (VTs) in patients with structural heart disease. Initial clinical experience with a single radiation dose of 25 Gy shows reasonable efficacy in the reduction of VT recurrences with acceptable acute toxicity. Many unanswered questions remain, including unknown mechanism of action, variable time to effect, optimal method of substrate targeting, long-term safety, and definition of an optimal candidate for this treatment."
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Affiliation(s)
- Jana Haskova
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic.
| | - Marek Sramko
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava and Ostrava University Medical School, 17 listopadu 1790/5, Ostrava-Poruba 708 00 Czech Republic
| | - Josef Kautzner
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic; Palacky University Medical School, Olomouc, Czech Republic
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22
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Whitaker J, Zei PC, Ahmad S, Niederer S, O'Neill M, Rinaldi CA. The effect of ionizing radiation through cardiac stereotactic body radiation therapy on myocardial tissue for refractory ventricular arrhythmias: A review. Front Cardiovasc Med 2022; 9:989886. [PMID: 36186961 PMCID: PMC9520407 DOI: 10.3389/fcvm.2022.989886] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022] Open
Abstract
Cardiac stereotactic body radiation therapy (cSBRT) is a non-invasive treatment modality that has been recently reported as an effective treatment for ventricular arrhythmias refractory to medical therapy and catheter ablation. The approach leverages tools developed and refined in radiation oncology, where experience has been accumulated in the treatment of a wide variety of malignant conditions. However, important differences exist between rapidly dividing malignant tumor cells and fully differentiated myocytes in pathologically remodeled ventricular myocardium, which represent the respective radiation targets. Despite its initial success, little is known about the radiobiology of the anti-arrhythmic effect cSBRT. Pre-clinical data indicates a late fibrotic effect of that appears between 3 and 4 months following cSBRT, which may result in conduction slowing and block. However, there is clear clinical evidence of an anti-arrhythmic effect of cSBRT that precedes the appearance of radiation induced fibrosis for which the mechanism is unclear. In addition, the data to date suggests that even the late anti-arrhythmic effect of cSBRT is not fully attributable to radiation.-induced fibrosis. Pre-clinical data has identified upregulation of proteins expected to result in both increased cell-to-cell coupling and excitability in the early post cSBRT period and demonstrated an associated increase in myocardial conduction velocity. These observations indicate a complex response to radiotherapy and highlight the lack of clarity regarding the different stages of the anti-arrhythmic mechanism of cSBRT. It may be speculated that in the future cSBRT therapy could be planned to deliver both early and late radiation effects titrated to optimize the combined anti-arrhythmic efficacy of the treatment. In addition to these outstanding mechanistic questions, the optimal patient selection, radiation modality, radiation dose and treatment planning strategy are currently being investigated. In this review, we consider the structural and functional effect of radiation on myocardium and the possible anti-arrhythmic mechanisms of cSBRT. Review of the published data highlights the exciting prospects for the development of knowledge and understanding in this area in which so many outstanding questions exist.
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Affiliation(s)
- John Whitaker
- Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical Schools, Boston, MA, United States
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
- *Correspondence: John Whitaker
| | - Paul C. Zei
- Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical Schools, Boston, MA, United States
| | - Shahreen Ahmad
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
- Guy's and St. Thomas's NHS Foundation Trust, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
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23
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Herrera Siklody C, Pruvot E, Pascale P, Le Bloa M, Teres C, Domenichini G, Porretta A, Bourhis J, Schiappacasse L. Refractory ventricular tachycardia treated by a second session of stereotactic arrhythmia radioablation. Clin Transl Radiat Oncol 2022; 37:89-93. [PMID: 36118122 PMCID: PMC9478870 DOI: 10.1016/j.ctro.2022.07.005] [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: 02/26/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/05/2022] Open
Abstract
Arrhythmia radioablation (STAR) is effective in refractory ventricular tachycardia. We report the first cases of successful re-irradiation of arrhythmogenic substrate. No radiation toxicity was observed after the second STAR. Caution is advised as data on early and late toxicities remain scarce.
Purpose Stereotactic arrhythmia radioablation (STAR) is an effective treatment for refractory ventricular tachycardia (VT), but recurrences after STAR were recently published. Herein, we report two cases of successful re-irradiation of the arrhythmogenic substrate. Cases We present two cases of re-irradiation after recurrence of a previously treated VT with radioablation at a dose of 20 Gy. The VT exit was localized on the border zone of the irradiated volume, which responded positively to re-irradiation at follow-up. Conclusion These two cases show the technical feasibility of re-irradiation to control recurrent VT after a first STAR.
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24
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Shangguan W, Xu G, Wang X, Zhang N, Liu X, Li G, Tse G, Liu T. Stereotactic Radiotherapy: An Alternative Option for Refractory Ventricular Tachycardia to Drug and Ablation Therapy. J Clin Med 2022; 11:jcm11123549. [PMID: 35743614 PMCID: PMC9225049 DOI: 10.3390/jcm11123549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/01/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Abstract
Refractory ventricular tachycardia (VT) often occurs in the context of organic heart disease. It is associated with significantly high mortality and morbidity rates. Antiarrhythmic drugs and catheter ablation represent the two main treatment options for refractory VT, but their use can be associated with inadequate therapeutic responses and procedure-related complications. Stereotactic body radiotherapy (SBRT) is extensively applied in the precision treatment of solid tumors, with excellent therapeutic responses. Recently, this highly precise technology has been applied for radioablation of VT, and its early results demonstrate a favorable safety profile. This review presents the potential value of SBRT in refractory VT.
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Affiliation(s)
- Wenfeng Shangguan
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Gang Xu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Xin Wang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Nan Zhang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Xingpeng Liu
- Department of Heart Center, Beijing Chaoyang Hospital, Capital Medical University, 8th Gongtinanlu Rd., Chaoyang District, Beijing 100020, China;
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
- Kent and Medway Medical School, Canterbury CT2 7FS, UK
- Correspondence: (G.T.); (T.L.)
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
- Correspondence: (G.T.); (T.L.)
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25
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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.
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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.
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Lydiard S, Pontré B, Lowe BS, Keall P. Atrial fibrillation cardiac radioablation target visibility on magnetic resonance imaging. Phys Eng Sci Med 2022; 45:757-767. [PMID: 35687311 PMCID: PMC9448688 DOI: 10.1007/s13246-022-01141-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 05/16/2022] [Indexed: 11/27/2022]
Abstract
Magnetic resonance imaging (MRI) guided cardiac radioablation (CR) for atrial fibrillation (AF) is a promising treatment concept. However, the visibility of AF CR targets on MRI acquisitions requires further exploration and MRI sequence and parameter optimization has not yet been performed for this application. This pilot study explores the feasibility of MRI-guided tracking of AF CR targets by evaluating AF CR target visualization on human participants using a selection of 3D and 2D MRI sequences.MRI datasets were acquired in healthy and AF participants using a range of MRI sequences and parameters. MRI acquisition categories included 3D free-breathing acquisitions (3Dacq), 2D breath-hold ECG-gated acquisitions (2DECG-gated), stacks of 2D breath-hold ECG-gated acquisitions which were retrospectively interpolated to 3D datasets (3Dinterp), and 2D breath-hold ungated acquisitions (2Dreal-time). The ease of target delineation and the presence of artifacts were qualitatively analyzed. Image quality was quantitatively analyzed using signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and non-uniformity. Confident 3D target delineation was achievable on all 3Dinterp datasets but was not possible on any of the 3Dacq datasets. Fewer artifacts and significantly better SNR, CNR and non-uniformity metrics were observed with 3Dinterp compared to 3Dacq. 2Dreal-time datasets had slightly lower SNR and CNR than 2DECG-gated and 3Dinterp n datasets. AF CR target visualization on MRI was qualitatively and quantitatively evaluated. The study findings indicate that AF CR target visualization is achievable despite the imaging challenges associated with these targets, warranting further investigation into MRI-guided AF CR treatments.
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Affiliation(s)
- Suzanne Lydiard
- ACRF Image X Institute, University of Sydney, 1 Central Avenue, Eveleigh, NSW, Australia. .,Kathleen Kilgour Centre, 18 Twentieth Avenue, Tauranga South, Tauranga, New Zealand.
| | - Beau Pontré
- Department of Anatomy and Medical Imaging, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Boris S Lowe
- Green Lane Cardiovascular Service, Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand
| | - Paul Keall
- ACRF Image X Institute, University of Sydney, 1 Central Avenue, Eveleigh, NSW, Australia
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Franzetti J, Volpe S, Catto V, Conte E, Piccolo C, Pepa M, Piperno G, Camarda AM, Cattani F, Andreini D, Tondo C, Jereczek-Fossa BA, Carbucicchio C. Stereotactic Radiotherapy Ablation and Atrial Fibrillation: Technical Issues and Clinical Expectations Derived From a Systematic Review. Front Cardiovasc Med 2022; 9:849201. [PMID: 35592393 PMCID: PMC9110686 DOI: 10.3389/fcvm.2022.849201] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Aim The purpose of this study is to collect available evidence on the feasibility and efficacy of stereotactic arrhythmia radio ablation (STAR), including both photon radiotherapy (XRT) and particle beam therapy (PBT), in the treatment of atrial fibrillation (AF), and to provide cardiologists and radiation oncologists with a practical overview on this topic. Methods Three hundred and thirty-five articles were identified up to November 2021 according to preferred reporting items for systematic reviews and meta-analyses criteria; preclinical and clinical studies were included without data restrictions or language limitations. Selected works were analyzed for comparing target selection, treatment plan details, and the accelerator employed, addressing workup modalities, acute and long-term side-effects, and efficacy, defined either by the presence of scar or by the absence of AF recurrence. Results Twenty-one works published between 2010 and 2021 were included. Seventeen studies concerned XRT, three PBT, and one involved both. Nine studies (1 in silico and 8 in vivo; doses ranging from 15 to 40 Gy) comprised a total of 59 animals, 12 (8 in silico, 4 in vivo; doses ranging from 16 to 50 Gy) focused on humans, with 9 patients undergoing STAR: average follow-up duration was 5 and 6 months, respectively. Data analysis supported efficacy of the treatment in the preclinical setting, whereas in the context of clinical studies the main favorable finding consisted in the detection of electrical scar in 4/4 patients undergoing specific evaluation; the minimum dose for efficacy was 25 Gy in both humans and animals. No acute complication was recorded; severe side-effects related to the long-term were observed only for very high STAR doses in 2 animals. Significant variability was evidenced among studies in the definition of target volume and doses, and in the management of respiratory and cardiac target motion. Conclusion STAR is an innovative non-invasive procedure already applied for experimental treatment of ventricular arrhythmias. Particular attention must be paid to safety, rather than efficacy of STAR, given the benign nature of AF. Uncertainties persist, mainly regarding the definition of the treatment plan and the role of the target motion. In this setting, more information about the toxicity profile of this new approach is compulsory before applying STAR to AF in clinical practice.
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Affiliation(s)
- Jessica Franzetti
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Stefania Volpe
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- *Correspondence: Stefania Volpe, , orcid.org/0000-0003-0498-2964
| | - Valentina Catto
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Electronics, Information and Biomedical Engineering, Politecnico di Milano, Milan, Italy
| | - Edoardo Conte
- Cardiovascular Computed Tomography and Radiology Unit, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Consiglia Piccolo
- Unit of Medical Physics, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Matteo Pepa
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Gaia Piperno
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Anna Maria Camarda
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Daniele Andreini
- Cardiovascular Computed Tomography and Radiology Unit, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Corrado Carbucicchio
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
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Hayase J, Chin R, Cao M, Hu P, Shivkumar K, Bradfield JS. Non-invasive Stereotactic Body Radiation Therapy for Refractory Ventricular Arrhythmias: Venturing into the Unknown. J Innov Card Rhythm Manag 2022; 13:4894-4899. [PMID: 35251759 PMCID: PMC8887931 DOI: 10.19102/icrm.2022.130202] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and safety, but randomized data and long-term outcomes are not yet available. The primary hypothesis as to the mechanism of action for SBRT relates to the development of cardiac fibrosis in arrhythmogenic myocardial substrate; however, limited animal model data offer conflicting insights into this theory. The use of SBRT for patients with refractory ventricular arrhythmias is rapidly increasing, but ongoing translational science work and randomized clinical trials will be critical to address many outstanding questions regarding this novel therapy.
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Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Robert Chin
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Minsong Cao
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Peng Hu
- Department of Radiological Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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[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]
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Lee J, Bates M, Shepherd E, Riley S, Henshaw M, Metherall P, Daniel J, Blower A, Scoones D, Wilkinson M, Richmond N, Robinson C, Cuculich P, Hugo G, Seller N, McStay R, Child N, Thornley A, Kelland N, Atherton P, Peedell C, Hatton M. Cardiac stereotactic ablative radiotherapy for control of refractory ventricular tachycardia: initial UK multicentre experience. Open Heart 2021; 8:openhrt-2021-001770. [PMID: 34815300 PMCID: PMC8611439 DOI: 10.1136/openhrt-2021-001770] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/01/2021] [Indexed: 12/25/2022] Open
Abstract
Background Options for patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or catheter ablation remain limited. Stereotactic radiotherapy has been described as a novel treatment option. Methods Seven patients with recurrent refractory VT, deemed high risk for either first time or redo invasive catheter ablation, were treated across three UK centres with non-invasive cardiac stereotactic ablative radiotherapy (SABR). Prior catheter ablation data and non-invasive mapping were combined with cross-sectional imaging to generate radiotherapy plans with aim to deliver a single 25 Gy treatment. Shared planning and treatment guidelines and prospective peer review were used. Results Acute suppression of VT was seen in all seven patients. For five patients with at least 6 months follow-up, overall reduction in VT burden was 85%. No high-grade radiotherapy treatment-related side effects were documented. Three deaths (two early, one late) occurred due to heart failure. Conclusions Cardiac SABR showed reasonable VT suppression in a high-risk population where conventional treatment had failed.
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Affiliation(s)
- Justin Lee
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Matthew Bates
- Department of Cardiology, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Ewen Shepherd
- Department of Cardiology, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephen Riley
- Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Michael Henshaw
- Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Peter Metherall
- 3D Lab, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jim Daniel
- Department of Oncology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Alison Blower
- Department of Oncology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Scoones
- Department of Pathology, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Michele Wilkinson
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil Richmond
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Clifford Robinson
- Center for Noninvasive Cardiac Radioablation, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Phillip Cuculich
- Center for Noninvasive Cardiac Radioablation, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Geoffrey Hugo
- Center for Noninvasive Cardiac Radioablation, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Neil Seller
- Department of Cardiology, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ruth McStay
- Department of Radiology, Newcastle NHS Hospitals Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas Child
- Department of Cardiology, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Andrew Thornley
- Department of Cardiology, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Nicholas Kelland
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Philip Atherton
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Clive Peedell
- Department of Oncology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Matthew Hatton
- Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Chalkia M, Kouloulias V, Tousoulis D, Deftereos S, Tsiachris D, Vrachatis D, Platoni K. Stereotactic Arrhythmia Radioablation as a Novel Treatment Approach for Cardiac Arrhythmias: Facts and Limitations. Biomedicines 2021; 9:1461. [PMID: 34680578 PMCID: PMC8533522 DOI: 10.3390/biomedicines9101461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 09/29/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
Stereotactic ablative radiotherapy (SABR) is highly focused radiation therapy that targets well-demarcated, limited-volume malignant or benign tumors with high accuracy and precision using image guidance. Stereotactic arrhythmia radioablation (STAR) applies SABR to treat cardiac arrhythmias, including ventricular tachycardia (VT) and atrial fibrillation (AF), and has recently been a focus in research. Clinical studies have demonstrated electrophysiologic conduction blockade and histologic fibrosis after STAR, which provides a proof of principle for its potential for treating arrhythmias. This review will present the basic STAR principles, available clinical study outcomes, and how the technique has evolved since the first pre-clinical study. In addition to the clinical workflow, focus will be given on the process for stereotactic radiotherapy Quality Assurance (QA) tests, as well as the need for establishing a standardized QA protocol. Future implications and potential courses of research will also be discussed.
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Affiliation(s)
- Marina Chalkia
- Radiotherapy Unit, Second Department of Radiology, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (V.K.); (K.P.)
| | - Vassilis Kouloulias
- Radiotherapy Unit, Second Department of Radiology, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (V.K.); (K.P.)
| | - Dimitris Tousoulis
- First Department of Cardiology, ‘Hippokration’ General Hospital, Vasilissis Sofias 114, 115 27 Athens, Greece;
| | - Spyridon Deftereos
- Second Department of Cardiology, “Attikon” University Hospital, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (S.D.); (D.V.)
| | | | - Dimitrios Vrachatis
- Second Department of Cardiology, “Attikon” University Hospital, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (S.D.); (D.V.)
| | - Kalliopi Platoni
- Radiotherapy Unit, Second Department of Radiology, School of Medicine, Rimini 1, National and Kapodistrian University of Athens, 124 62 Athens, Greece; (V.K.); (K.P.)
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Cha MJ, Cuculich PS, Robinson CG, Chang JH. Tailored stereotactic radiotherapy technique using deep inspiration breath-hold to reduce stomach dose for cardiac radioablation. Radiat Oncol J 2021; 39:167-173. [PMID: 34610655 PMCID: PMC8497870 DOI: 10.3857/roj.2021.00276] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/14/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose To provide a new insight on a novel safe cardiac radioablation using deep inspiration breath-hold (DIBH) to reduce gastrointestinal dose. Materials and Methods For treating incessant ventricular tachycardia (VT) originated from left ventricle inferior scar abutting the stomach, a target delineation and treatment planning for cardiac radioablation was performed. With four different computed tomography (CT) scan protocols—DIBH, full expiration breath-hold, four-dimensional (4D) CT without and with abdominal compression, the distances between the target and the stomach were compared. Results Among the protocols, the CT scan with DIBH showed largest distance between the target and the stomach and selected for the treatment planning. The prescribed dose was 25 Gy in a single fraction, and satisfactory dosimetric parameters were achieved with the DIBH. The patient was successfully treated with the DIBH, and experienced no acute toxicity. Conclusion To gain the best benefit from cardiac radioablation, understanding the possible toxicity in the adjacent organs is crucial. By moving the heart with thoraco-diaphragmatic movement by DIBH, the target could be physically separated from the stomach.
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Affiliation(s)
- Myung-Jin Cha
- Cardiovascular Division, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Phillip S Cuculich
- Cardiovascular Division, Department of Internal Medicine, Washington University, St Louis, MO, USA
| | | | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
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Ramia P, Ollaik F, Hilal L, Jalbout W, AlJaroudi W, Al Ahmad A, Sfeir P, Jurjus A, Refaat M, Youssef B. Stereotactic Radiosurgery for Atrioventricular Node Ablation in Swine: A Study on Efficacy and Dosimetric Evaluation of Organs at Risk. Cureus 2021; 13:e18785. [PMID: 34804652 PMCID: PMC8592376 DOI: 10.7759/cureus.18785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 11/07/2022] Open
Abstract
Introduction Stereotactic radiosurgery (SRS) delivered to arrhythmogenic foci within the heart is a promising treatment modality. We dosimetrically evaluated the radiation dose to the organs at risk of four swine that were successfully treated with linear-accelerator-based SRS for atrioventricular (AV) node ablation. Materials and methods Single-chamber pacemakers were implanted in four large white breed swine. Cardiac computed tomography simulation scans were performed to localize the AV node and organs at risk. SRS (35-40 Gy) was delivered to the AV node, and the pigs were followed up with pacemaker interrogations. One-sample t-tests were used to evaluate Dmax of great vessels, esophagus, and chest wall as compared to known normal tissue constraints as per RTOG 0631 and AAPM Task Group 101. Results All pigs had disturbances of AV conduction with progressive transition into complete heart block. Macroscopic and microscopic evaluation showed fibrosis in the AV node but did not reveal any changes in non-nodal cardiac tissue or vessels. The mean Dmax±SD (p-value) of the chest wall (14.7±3.3 (0.02)), esophagus (10.7±1.1 (<0.01)) superior vena cava (3.3±4.1 (<0.01)), right pulmonary artery (16.1±6.4 (<0.01)), right pulmonary vein (15.7± 5 (<0.01)), left pulmonary artery (11.1±1.7 (<0.01)) and left pulmonary vein (14.1±2.6 (<0.01)), and the inferior vena cava (33.68±1.6 (0.026)) were significantly below the normal tissue constraint cutoffs. Mean±SD (p-value) of the ascending aorta (19.4±16.1 (0.12)) was not significantly different than normal tissue constraint cutoffs. One swine model treated at 40 Gy had small area of hotspot in the ascending aorta (40.65 (0.4 cc)). Conclusion We have demonstrated in our swine models that SRS using 35-40 Gy can be done without exceeding known human normal tissue constraints to the chest wall, esophagus, and great vessels.
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Affiliation(s)
- Paul Ramia
- Radiation Oncology, American University of Beirut, Beirut, LBN
| | - Farah Ollaik
- Radiation Oncology, American University of Beirut, Beirut, LBN
| | - Lara Hilal
- Radiation Oncology, American University of Beirut, Beirut, LBN
| | - Wassim Jalbout
- Radiation Oncology, American University of Beirut, Beirut, LBN
| | | | - Amin Al Ahmad
- Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, USA
| | - Pierre Sfeir
- Cardiothoracic Surgery, American University of Beirut, Beirut, LBN
| | - Abdo Jurjus
- Anatomy, American University of Beirut, Beirut, LBN
| | - Marwan Refaat
- Cardiovascular Disease, American University of Beirut, Beirut, LBN
| | - Bassem Youssef
- Radiation Oncology, American University of Beirut, Beirut, LBN
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Wei C, Qian PC, Boeck M, Bredfeldt JS, Blankstein R, Tedrow UB, Mak R, Zei PC. Cardiac stereotactic body radiation therapy for ventricular tachycardia: Current experience and technical gaps. J Cardiovasc Electrophysiol 2021; 32:2901-2914. [PMID: 34587335 DOI: 10.1111/jce.15259] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite advances in drug and catheter ablation therapy, long-term recurrence rates for ventricular tachycardia remain suboptimal. Cardiac stereotactic body radiotherapy (SBRT) is a novel treatment that has demonstrated reduction of arrhythmia episodes and favorable short-term safety profile in treatment-refractory patients. Nevertheless, the current clinical experience is early and limited. Recent studies have highlighted variable duration of treatment effect and substantial recurrence rates several months postradiation. Contributing to these differential outcomes are disparate approaches groups have taken in planning and delivering radiation, owing to both technical and knowledge gaps limiting optimization and standardization of cardiac SBRT. METHODS AND FINDINGS In this report, we review the historical basis for cardiac SBRT and existing clinical data. We then elucidate the current technical gaps in cardiac radioablation, incorporating the current clinical experience, and summarize the ongoing and needed efforts to resolve them. CONCLUSION Cardiac SBRT is an emerging therapy that holds promise for the treatment of ventricular tachycardia. Technical gaps remain, to be addressed by ongoing research and growing clincial experience.
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Affiliation(s)
- Chen Wei
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pierre C Qian
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michelle Boeck
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jeremy S Bredfeldt
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Usha B Tedrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raymond Mak
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Paul C Zei
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Zhang DM, Navara R, Yin T, Szymanski J, Goldsztejn U, Kenkel C, Lang A, Mpoy C, Lipovsky CE, Qiao Y, Hicks S, Li G, Moore KMS, Bergom C, Rogers BE, Robinson CG, Cuculich PS, Schwarz JK, Rentschler SL. Cardiac radiotherapy induces electrical conduction reprogramming in the absence of transmural fibrosis. Nat Commun 2021; 12:5558. [PMID: 34561429 PMCID: PMC8463558 DOI: 10.1038/s41467-021-25730-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 08/25/2021] [Indexed: 02/08/2023] Open
Abstract
Cardiac radiotherapy (RT) may be effective in treating heart failure (HF) patients with refractory ventricular tachycardia (VT). The previously proposed mechanism of radiation-induced fibrosis does not explain the rapidity and magnitude with which VT reduction occurs clinically. Here, we demonstrate in hearts from RT patients that radiation does not achieve transmural fibrosis within the timeframe of VT reduction. Electrophysiologic assessment of irradiated murine hearts reveals a persistent supraphysiologic electrical phenotype, mediated by increases in NaV1.5 and Cx43. By sequencing and transgenic approaches, we identify Notch signaling as a mechanistic contributor to NaV1.5 upregulation after RT. Clinically, RT was associated with increased NaV1.5 expression in 1 of 1 explanted heart. On electrocardiogram (ECG), post-RT QRS durations were shortened in 13 of 19 patients and lengthened in 5 patients. Collectively, this study provides evidence for radiation-induced reprogramming of cardiac conduction as a potential treatment strategy for arrhythmia management in VT patients.
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Affiliation(s)
- David M Zhang
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Rachita Navara
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Tiankai Yin
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Jeffrey Szymanski
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Uri Goldsztejn
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Camryn Kenkel
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Adam Lang
- Department of Pathology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Cedric Mpoy
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Catherine E Lipovsky
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Developmental Biology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Yun Qiao
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Stephanie Hicks
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Gang Li
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Kaitlin M S Moore
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Carmen Bergom
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Buck E Rogers
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Clifford G Robinson
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Phillip S Cuculich
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Julie K Schwarz
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Stacey L Rentschler
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Developmental Biology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
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36
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Zhang DM, Szymanski J, Bergom C, Cuculich PS, Robinson CG, Schwarz JK, Rentschler SL. Leveraging Radiobiology for Arrhythmia Management: A New Treatment Paradigm? Clin Oncol (R Coll Radiol) 2021; 33:723-734. [PMID: 34535357 DOI: 10.1016/j.clon.2021.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 08/04/2021] [Accepted: 09/01/2021] [Indexed: 01/01/2023]
Abstract
Radiation therapy is a well-established approach for safely and non-invasively treating solid tumours and benign diseases with high precision and accuracy. Cardiac radiation therapy has recently emerged as a non-invasive treatment option for the management of refractory ventricular tachycardia. Here we summarise existing clinical and preclinical literature surrounding cardiac radiobiology and discuss how these studies may inform basic and translational research, as well as clinical treatment paradigms in the management of arrhythmias.
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Affiliation(s)
- D M Zhang
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - J Szymanski
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - C Bergom
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - P S Cuculich
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - C G Robinson
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - J K Schwarz
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - S L Rentschler
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA; Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA; Department of Developmental Biology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA.
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37
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Qian PC, Quadros K, Aguilar M, Wei C, Boeck M, Bredfeldt J, Cochet H, Blankstein R, Mak R, Sauer WH, Tedrow UB, Zei PC. Substrate Modification Using Stereotactic Radioablation to Treat Refractory Ventricular Tachycardia in Patients With Ischemic Cardiomyopathy. JACC Clin Electrophysiol 2021; 8:49-58. [PMID: 34364832 DOI: 10.1016/j.jacep.2021.06.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study aimed to determine the feasibility of using radioablation for arrhythmogenic a substrate modification. BACKGROUND Stereotactic body radiation therapy (SBRT) is a promising therapy for ventricular tachycardia (VT) refractory to catheter ablation. METHODS A total of 6 male patients (median age 72 years) with ischemic cardiomyopathy (left ventricular ejection fraction 20% [interquartile range (IQR): 16%-25%]) and VT refractory to antiarrhythmic medications and catheter ablations underwent SBRT to extensive scar substrate. In addition to electroanatomical mapping, 5 of 6 patients had computed tomography segmentation using MUSIC (Institut Hospitalo-Universitaire l'Institut de Rythmologie et Modélisation Cardiaque, Bordeaux, France). Regions of wall thinning <5 mm, calcification, and intramyocardial fat were targeted for radioablation at 25 Gy. RESULTS The median planning target volume was 319 (IQR: 280-330) mL. Device-treated or sustained VT episodes were not significantly reduced by radioablation (median 42 [IQR: 19-269] to 29 [IQR: 0-81]; P = 0.438). However, a reduction in device shocks was observed from 12 (IQR: 3-19) to 0 (IQR: 0-1) (P = 0.046). Over a follow-up period of 231 (IQR: 212-311) days, 3 patients died of end-stage heart failure and 3 of 6 patients had possible adverse events (heart failure exacerbation, pneumonia, and an asymptomatic pericardial effusion). CONCLUSIONS Substrate modification using SBRT assisted by computed tomography segmentation is feasible for treatment of VT in patients with ischemic cardiomyopathy. Although a significant reduction in device shocks was observed, suboptimal VT burden reduction and significant mortality rate in this cohort of patients with advanced cardiomyopathy underscore the need to improve mechanistic understanding for antiarrhythmic effects to guide dosing and targeting of scar substrates.
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Affiliation(s)
- Pierre C Qian
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Ken Quadros
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Martin Aguilar
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Chen Wei
- Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Boeck
- Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeremy Bredfeldt
- Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hubert Cochet
- IHU Liryc, Univ. Bordeaux and Inria Sophia Antipolis, France, Université de Bordeaux, Pessac, France; Inria, Sophia Antipolis, France
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond Mak
- Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William H Sauer
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Usha B Tedrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Paul C Zei
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
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38
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The Rapidly-Developing Area of Radiocardiology: Principles, Complications and Applications of Radiotherapy on the Heart. Can J Cardiol 2021; 37:1818-1827. [PMID: 34303782 DOI: 10.1016/j.cjca.2021.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 07/02/2021] [Accepted: 07/19/2021] [Indexed: 11/21/2022] Open
Abstract
Ventricular arrhythmias are the leading cause of sudden cardiac death. Current treatment strategies for VT, including antiarrhythmic drugs and catheter ablation, have limited efficacy in patients with structural heart disease. Non-invasive ablation with the use of externally applied radiation (cardiac radio-ablation) has emerged as a promising and novel approach to treating recurrent VTs. However, the heart is generally an "organ at risk" for radiation treatments, such that very little is known on the effects of radiotherapy on cardiac ultrastructure and electrophysiological properties. Furthermore, there has been limited interaction between the fields of cardiology and radiation oncology and physics. The advent of cardiac radio-ablation will undoubtedly increase interactions between cardiologists, cardiac electrophysiologists, radiation oncologists and physicists There is an important knowledge gap separating these specialties while scientific developments, technical optimization and improvements are dependent on intense multidisciplinary collaboration. This manuscript seeks to review the basic of radiation physics and biology for cardiovascular specialists in an effort to facilitate constructive scientific and clinical collaborations to improve patient outcomes.
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39
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Kovacs B, Mayinger M, Schindler M, Steffel J, Andratschke N, Saguner AM. Stereotactic radioablation of ventricular arrhythmias in patients with structural heart disease - A systematic review. Radiother Oncol 2021; 162:132-139. [PMID: 34233215 DOI: 10.1016/j.radonc.2021.06.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/28/2021] [Accepted: 06/28/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Several studies have suggested stereotactic arrhythmia radioablation (STAR) as a treatment option for patients suffering from therapy-refractory ventricular tachycardia or fibrillation (VT/VF). MATERIAL AND METHODS We performed a systematic review of human reports of STAR for structural VT/VF to assess its effectivity and safety. All identified publications were assessed for inclusion. This study adheres to the PRISMA guidelines and was registered on PROSPERO (CRD42020183044). RESULTS Thirteen studies were included resulting in a population of 57 patients. Median age was 64 (range 34-83), 31 patients (54%) had ischemic cardiomyopathy and 50 patients (88%) had prior catheter ablation (CA) for VT/VF. A mean planned target volume of 64.4 cc (range 3.5-238) with a mean safety margin of 3.3 mm (0-5) was treated with 25 Gy. Immediately following STAR, four patients (7%) experienced an electrical storm. During a mean follow-up duration of 410 days, all patients suffering from sustained VT/VF prior to STAR (n = 55) had a reduction of their sustained VT/VF-burden after STAR, but recurrence occurred in 41 patients (75%) during follow-up. Forty-six patients (81%) had an adverse effect from therapy, but no treatment-related death occurred. Evidence of scar-formation after STAR either by imaging, invasive mapping or histopathology was found in six of nine examined patients (67%). CONCLUSION From the still very limited experience, STAR appears effective and safe in patients with structural heart disease and therapy-refractory sustained VT/VF. It is associated with a significant short-term reduction of sustained VT/VF-burden, but recurrences are common.
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Affiliation(s)
- Boldizsar Kovacs
- Department of Cardiology, University Hospital Zurich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital Zurich, Switzerland
| | | | - Jan Steffel
- Department of Cardiology, University Hospital Zurich, Switzerland
| | | | - Ardan M Saguner
- Department of Cardiology, University Hospital Zurich, Switzerland.
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40
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Chang JH, Cha MJ, Seo JW, Kim HJ, Park SY, Kim BH, Lee E, Kim MK, Yoon HS, Oh S. Feasibility study on stereotactic radiotherapy for total pulmonary vein isolation in a canine model. Sci Rep 2021; 11:12369. [PMID: 34117284 PMCID: PMC8196028 DOI: 10.1038/s41598-021-91660-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/26/2021] [Indexed: 12/27/2022] Open
Abstract
We tested the feasibility of pulmonary vein (PV) and left atrial (LA) posterior wall isolation using non-invasive stereotactic ablative body radiotherapy (SABR) and investigated pathological changes in irradiated lesions in a canine model. Seven male Mongrel dogs received single-fraction 33 Gy SABR. We designed the en-bloc circular target of total PVs and LA posterior wall to avoid the esophagus. The circular box lesion included the LA roof and ridge, low posterior wall, and posterior interatrial septum. At 6 weeks or 4 months post-SABR, electrical isolation of the SABR lesion was confirmed using LA posterior wall pacing, and histopathological review was performed. Electrical isolation of all PVs and the LA posterior wall was achieved in three of five dogs in the 4-month group. There was one target failure and one sudden death at 15 weeks. Although two dogs in the 6-week group failed to achieve electrical lesion isolation, the irradiated atrial myocardium showed diffuse hemorrhage with inflammatory cell infiltration. In successfully isolated 4-month model dogs, we observed transmural fibrotic scarring with extensive fibrosis on irradiated atrial tissue. The findings suggest that this novel circular box-design radiotherapy technique using SABR could be applied to humans after further studies are conducted to confirm safety.
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Affiliation(s)
- Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Myung-Jin Cha
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. .,Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Jeong-Wook Seo
- Department of Pathology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea.,Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - So-Yeon Park
- Department of Radiation Oncology, Veterans Health Service Medical Center, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Byoung Hyuck Kim
- Department of Radiation Oncology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Euijae Lee
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
| | - Moo-Kang Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hye-Sun Yoon
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seil Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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41
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Yugo D, Lo LW, Wu YH, Chung FP, Lin YJ, Chang SL, Hu YF, Chao TF, Liao JN, Chang TY, Lin CY, Tuan TC, Kuo L, Wu CI, Liu CM, Liu SH, Cheng WH, Lugtu IC, Jain A, Chen SA. Case series on stereotactic body radiation therapy in non-ischemic cardiomyopathy patients with recurrent ventricular tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1085-1093. [PMID: 33932305 DOI: 10.1111/pace.14254] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 04/11/2021] [Accepted: 04/25/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The efficacy of stereotactic body radiation therapy (SBRT) as an alternative treatment for recurrent ventricular tachycardia (VT) is still unclear. This study aimed to report the outcome of SBRT in VT patients with nonischemic cardiomyopathy (NICM). METHODS The determination of the target substrate for radiation was based on the combination of CMR results and electroanatomical mapping merged with the real-time CT scan image. Radiation therapy was performed by Flattening-filter-free (Truebeam) system, and afterward, patients were followed up for 13.5 ± 2.8 months. We analyzed the outcome of death, incidence of recurrent VT, ICD shocks, anti-tachycardia pacing (ATP) sequences, and possible irradiation side-effects. RESULTS A total of three cases of NICM patients with anteroseptal scar detected by CMR. SBRT was successfully performed in all patients. During the follow-up, we found that VT recurrences occurred in all patients. In one patient, it happened during a 6-week blanking period, while the others happened afterward. Re-hospitalization due to VT only appeared in one patient. Through ICD interrogation, we found that all patients have reduced VT burden and ATP therapies. All of the patients died during the follow-up period. Radiotherapy-related adverse events did not occur in all patients. CONCLUSIONS SBRT therapy reduces the number of VT burden and ATP sequence therapy in NICM patients with VT, which had a failed previous catheter ablation. However, the efficacy and safety aspects, especially in NICM cases, remained unclear.
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Affiliation(s)
- Dony Yugo
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia, Jakarta, Indonesia.,Arrhythmia Division, Pusat Jantung Nasional Harapan Kita, Jakarta, Indonesia
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuan-Hung Wu
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ting-Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-I Wu
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shin-Huei Liu
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Han Cheng
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Isaiah C Lugtu
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Heart Institute, Chinese General Hospital and Medical Center, Metro Manila, Philippines
| | - Ankit Jain
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Cardiology, Vardhman Mahavir Medical College, New Delhi, India
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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42
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Whitaker J, Mak RH, Zei PC. Non-invasive ablation of arrhythmias with stereotactic ablative radiotherapy. Trends Cardiovasc Med 2021; 32:287-296. [PMID: 33951498 DOI: 10.1016/j.tcm.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/14/2021] [Accepted: 04/25/2021] [Indexed: 12/31/2022]
Abstract
Stereotactic ablative radiotherapy (SABR), or stereotactic body radiotherapy (SBRT), has recently been applied in the field of arrhythmia management. It has been most widely assessed in the treatment of ventricular tachycardia (VT) but may also have potential in the treatment of other arrhythmias as well, often termed stereotactic arrhythmia radiotherapy (STAR). The non-invasive delivery of treatment for VT has the potential to spare an often physiologically vulnerable group of patients the burden of long catheter ablation procedures with the potential for prolonged periods of hemodynamic instability. Cardiac SABR also has the capacity to direct ablative therapy at substrate that is inaccessible using current transchatheter techniques. For these reasons cardiac SABR has generated significant enthusiasm as an emerging treatment modality for VT. We consider in review the pre-clinical data pertaining to the use of SABR in cardiac tissue and recent clinical evidence regarding the application of SABR in the field of arrhythmia management.
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Affiliation(s)
- John Whitaker
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Raymond H Mak
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Paul C Zei
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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43
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Ren XY, He PK, Gao XS, Zhao ZL, Zhao B, Bai Y, Liu SW, Li K, Qin SB, Ma MW, Zhou J, Rong Y. Dosimetric feasibility of stereotactic ablative radiotherapy in pulmonary vein isolation for atrial fibrillation using intensity-modulated proton therapy. J Appl Clin Med Phys 2021; 22:79-88. [PMID: 33817981 PMCID: PMC8130224 DOI: 10.1002/acm2.13239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate dosimetric properties of intensity‐modulated proton therapy (IMPT) for simulated treatment planning in patients with atrial fibrillation (AF) targeting left atrial‐pulmonary vein junction (LA‐PVJ), in comparison with volumetric‐modulated arc therapy (VMAT) and helical tomotherapy (TOMO). Methods Ten thoracic 4D‐CT scans with respiratory motion and one with cardiac motion were used for the study. Ten respiratory 4D‐CTs were planned with VMAT, TOMO, and IMPT for simulated AF. Targets at the LA‐PVJ were defined as wide‐area circumferential ablation line. A single fraction of 25 Gy was prescribed to all plans. The interplay effects from cardiac motion were evaluated based on the cardiac 4D‐CT scan. Dose‐volume histograms (DVHs) of the ITV and normal tissues were compared. Statistical analysis was evaluated via one‐way Repeated‐Measures ANOVA and Friedman’s test with Bonferroni’s multiple comparisons test. Results The median volume of ITV was 8.72cc. All plans had adequate target coverage (V23.75Gy ≥ 99%). Compared with VMAT and TOMO, IMPT resulted in significantly lower dose of most normal tissues. For VMAT, TOMO, and IMPT plans, Dmean of the whole heart was 5.52 ± 0.90 Gy, 5.89 ± 0.78 Gy, and 3.01 ± 0.57 Gy (P < 0.001), mean dose of pericardium was 4.74 ± 0.76 Gy, 4.98 ± 0.62 Gy, and 2.59 ± 0.44 Gy (P < 0.001), and D0.03cc of left circumflex artery (LCX) was 13.96 ± 5.45 Gy, 14.34 ± 5.91 Gy, and 8.43 ± 7.24 Gy (P < 0.001), respectively. However, no significant advantage for one technique over the others was observed when examining the D0.03cc of esophagus and main bronchi. Conclusions IMPT targeting LA‐PVJ for patients with AF has high potential to reduce dose to surrounding tissues compared to VMAT or TOMO. Motion mitigation techniques are critical for a particle‐therapy approach.
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Affiliation(s)
- Xue-Ying Ren
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Peng-Kang He
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Zhi-Lei Zhao
- Department of Radiation Oncology, Yizhou International Proton Therapy Medical Center, Hebei, China
| | - Bo Zhao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Yun Bai
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Si-Wei Liu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Kang Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Shang-Bin Qin
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Ming-Wei Ma
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Jing Zhou
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
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44
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Miszczyk M, Jadczyk T, Gołba K, Wojakowski W, Wita K, Bednarek J, Blamek S. Clinical Evidence behind Stereotactic Radiotherapy for the Treatment of Ventricular Tachycardia (STAR)-A Comprehensive Review. J Clin Med 2021; 10:jcm10061238. [PMID: 33802802 PMCID: PMC8002399 DOI: 10.3390/jcm10061238] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 12/31/2022] Open
Abstract
The electrophysiology-guided noninvasive cardiac radioablation, also known as STAR (stereotactic arrhythmia radioablation) is an emerging treatment method for persistent ventricular tachycardia. Since its first application in 2012 in Stanford Cancer Institute, and a year later in University Hospital Ostrava, Czech Republic, the authors from all around the world have published case reports and case series, and several prospective trials were established. In this article, we would like to discuss the available clinical evidence, analyze the potentially clinically relevant differences in methodology, and address some of the unique challenges that come with this treatment method.
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Affiliation(s)
- Marcin Miszczyk
- IIIrd Department of Radiotherapy and Chemotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, 44-102 Gliwice, Poland
- Correspondence: ; Tel.: +48-663-040-809
| | - Tomasz Jadczyk
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (T.J.); (W.W.)
- International Clinical Research Center, Interventional Cardiac Electrophysiology Group, St. Anne’s University Hospital Brno, 664/53 Brno, Czech Republic
| | - Krzysztof Gołba
- Upper-Silesian Heart Center, Department of Electrocardiology, 40-055 Katowice, Poland;
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, 40-055 Katowice, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (T.J.); (W.W.)
| | - Krystian Wita
- First Department of Cardiology, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Jacek Bednarek
- Department of Electrocardiology, John Paul II Hospital, 31-202 Cracow, Poland;
| | - Sławomir Blamek
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, 44-102 Gliwice, Poland;
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45
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Cha MJ, Seo JW, Kim HJ, Kim MK, Yoon HS, Jo SW, Oh S, Chang JH. Early Changes in Rat Heart After High-Dose Irradiation: Implications for Antiarrhythmic Effects of Cardiac Radioablation. J Am Heart Assoc 2021; 10:e019072. [PMID: 33660526 PMCID: PMC8174197 DOI: 10.1161/jaha.120.019072] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Noninvasive cardiac radioablation is employed to treat ventricular arrhythmia. However, myocardial changes leading to early‐period antiarrhythmic effects induced by high‐dose irradiation are unknown. This study investigated dose‐responsive histologic, ultrastructural, and functional changes within 1 month after irradiation in rat heart. Methods and Results Whole hearts of wild‐type Lewis rats (N=95) were irradiated with single fraction 20, 25, 30, 40, or 50 Gy and explanted at 1 day or 1, 2, 3, or 4 weeks’ postirradiation. Microscopic pathologic changes of cardiac structures by light microscope with immunohistopathologic staining, ultrastructure by electron microscopy, and functional evaluation by ECG and echocardiography were studied. Despite high‐dose irradiation, no myocardial necrosis and apoptosis were observed. Intercalated discs were widened and disrupted, forming uneven and twisted junctions between adjacent myocytes. Diffuse vacuolization peaked at 3 weeks, suggesting irradiation dose‐responsiveness, which was correlated with interstitial and intracellular edema. CD68 immunostaining accompanying vacuolization suggested mononuclear cell infiltration. These changes were prominent in working myocardium but not cardiac conduction tissue. Intracardiac conduction represented by PR and QTc intervals on ECG was delayed compared with baseline measurements. ST segment was initially depressed and gradually elevated. Ventricular chamber dimensions and function remained intact without pericardial effusion. Conclusions Mononuclear cell–related intracellular and extracellular edema with diffuse vacuolization and intercalated disc widening were observed within 1 month after high‐dose irradiation. ECG indicated intracardiac conduction delay with prominent ST‐segment changes. These observations suggest that early antiarrhythmic effects after cardiac radioablation result from conduction disturbances and membrane potential alterations without necrosis.
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Affiliation(s)
- Myung-Jin Cha
- Division of Cardiology Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Jeong-Wook Seo
- Departments of Pathology Seoul National University Hospital Seoul South Korea
| | - Hak Jae Kim
- Department of Radiation Oncology Seoul National University College of Medicine Seoul Korea.,Department of Radiation Oncology Seoul National University Hospital Seoul South Korea.,Cancer Research InstituteSeoul National University College of Medicine Seoul Korea
| | - Moo-Kang Kim
- Division of Cardiology Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Hye-Sun Yoon
- Division of Cardiology Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Seong Won Jo
- Seoul National University College of Medicine Seoul Korea
| | - Seil Oh
- Division of Cardiology Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology Seoul National University College of Medicine Seoul Korea.,Department of Radiation Oncology Seoul National University Hospital Seoul South Korea
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46
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Lydiard, PGDip S, Blanck O, Hugo G, O’Brien R, Keall P. A Review of Cardiac Radioablation (CR) for Arrhythmias: Procedures, Technology, and Future Opportunities. Int J Radiat Oncol Biol Phys 2021; 109:783-800. [DOI: 10.1016/j.ijrobp.2020.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 10/23/2022]
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47
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Lydiard S, Pontré B, Lowe BS, Ball H, Sasso G, Keall P. Cardiac radioablation for atrial fibrillation: Target motion characterization and treatment delivery considerations. Med Phys 2021; 48:931-941. [PMID: 33325542 DOI: 10.1002/mp.14661] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The safe delivery of cardiac radioablation (CR) for atrial fibrillation (AF) is challenged by multi-direction target motion, cardiac rate variability, target proximity to critical structures, and the importance of complete target dose coverage for therapeutic benefit. Careful selection of appropriate treatment procedures is therefore essential. This work characterizes AF cardiac radioablation target motion and target proximity to surrounding structures in both healthy and AF participants to guide optimal treatment technique and technology choice. METHODS Ten healthy participants and five participants with AF underwent MRI acquisition. Multi-slice, cardiac-gated, breath-hold cines were acquired and interpolated to create three-dimensional images for 18-30 cardiac phases. Treatment targets at the left and right pulmonary vein ostia (CTVLeft and CTVRight respectively) and adjacent cardiac structures were contoured and their displacements throughout the cardiac cycle were assessed. Target proximity to surrounding structures were measured. Free-breathing real-time two-dimensional cine images were also acquired at 4 Hz frequency for between 1- and 2-min duration. The motion of easily identifiable points within the target, diaphragm and sternum was measured to assess respiratory motion. RESULTS Target motion due to cardiac contraction was most prominent in the medial-lateral direction and of 4-5 mm magnitude. CTVRight displacements were smaller in participants with AF than healthy participants in normal sinus rhythm. Nearby cardiac structures often moved with different magnitudes and motion trajectories. CTVLeft and/or CTVRight were in direct contact with the esophagus in 73% of participants. Target motion due to respiration was most prominent in the superior-inferior direction and of 13-14 mm magnitude in both healthy and AF participants. CONCLUSION AF CR target motion and relative displacement was characterized. The combination of target motion magnitude and relative displacement to critical structures highlights the importance of personalizing motion compensation techniques for effective AF CR treatments.
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Affiliation(s)
- Suzanne Lydiard
- ACRF Image X Institute, University of Sydney, Sydney, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Beau Pontré
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
| | - Boris S Lowe
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Helen Ball
- ACRF Image X Institute, University of Sydney, Sydney, Australia
| | - Giuseppe Sasso
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand.,Cancer & Blood, Radiation Oncology, Auckland City Hospital, Auckland, New Zealand.,Department of Oncology, University of Auckland, Auckland, New Zealand
| | - Paul Keall
- ACRF Image X Institute, University of Sydney, Sydney, Australia
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48
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Chiu MH, Mitchell LB, Ploquin N, Faruqi S, Kuriachan VP. Review of Stereotactic Arrhythmia Radioablation Therapy for Cardiac Tachydysrhythmias. CJC Open 2020; 3:236-247. [PMID: 33778440 PMCID: PMC7984992 DOI: 10.1016/j.cjco.2020.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/06/2020] [Indexed: 12/04/2022] Open
Abstract
Cardiac tachyarrhythmias are a major cause of morbidity and mortality. Treatments for these tachyarrhythmias include antiarrhythmic drugs, catheter ablation, surgical ablation, cardiac implantable electronic devices, and cardiac transplantation. Each of these treatment approaches is effective in some patients but there is considerable room for improvement, particularly with respect to the most common of the tachydysrhythmias, atrial fibrillation, and the most dangerous of the tachydysrhythmias, ventricular tachycardia (VT) or ventricular fibrillation. Noninvasive stereotactic ablative radiation therapy is emerging as an effective treatment for refractory tachyarrhythmias. Animal models have shown successful ablation of arrhythmogenic myocardial substrates with minimal short-term complications. Studies of stereotactic radioablation involving patients with refractory VT have shown a reduction in VT recurrence and promising early safety data. In this review, we provide the background for the application of stereotactic arrhythmia radioablation therapy along with promising results from early applications of the technology.
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Affiliation(s)
- Michael H Chiu
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Nicolas Ploquin
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Salman Faruqi
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Vikas P Kuriachan
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
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49
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Noninvasive Radioablation of Ventricular Tachycardia. Cardiol Rev 2020; 28:283-290. [PMID: 33017363 DOI: 10.1097/crd.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ventricular tachycardia (VT) occurs most commonly in the presence of structural heart disease or myocardial scarring from prior infarction. It is associated with increased mortality, especially when it results in cardiac arrest outside of a hospital. When not due to reversible causes (such as acute ischemia/infarction), placement of an implantable cardioverter-defibrillator for prevention of future sudden death is indicated. The current standard of care for recurrent VT is medical management with antiarrhythmic agents followed by invasive catheter ablation for VT that persists despite appropriate medical therapy. Stereotactic arrhythmia radioablation (STAR) is a novel, noninvasive method of treating VT that has been shown to reduce VT burden for patients who are refractory to medical therapy and/or catheter ablation, or who are unable to tolerate catheter ablation. STAR is the term applied to the use of stereotactic body radiation therapy for the treatment of arrhythmogenic cardiac tissue and requires collaboration between an electrophysiologist and a radiation oncologist. The process involves identification of VT substrate through a combination of electroanatomic mapping and diagnostic imaging (computed tomography, magnetic resonance imaging, positron emission tomography) followed by carefully guided radiation therapy. In this article, we review currently available literature describing the utilization, efficacy, safety profile, and potential future applications of STAR for the management of VT.
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50
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Jumeau R, Pruvot É, Thariat J, Latorzeff I, Milliez PU, Champ-Rigot L, De Crevoisier R, Ferchaud V. Tachycardies ventriculaires réfractaires : quelle place pour la radiothérapie et comment ? Cancer Radiother 2020; 24:534-546. [DOI: 10.1016/j.canrad.2020.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/07/2020] [Indexed: 12/31/2022]
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