1
|
Benali K, Zei PC, Lloyd M, Kautzner J, Guenancia C, Ninni S, Rigal L, Simon A, Bellec J, Vlachos K, Sacher F, Hammache N, Sellal JM, de Crevoisier R, Da Costa A, Martins R. One-year mortality and causes of death after stereotactic radiation therapy for refractory ventricular arrhythmias: A systematic review and pooled analysis. Trends Cardiovasc Med 2024:S1050-1738(23)00122-6. [PMID: 38191005 DOI: 10.1016/j.tcm.2023.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/25/2023] [Accepted: 12/27/2023] [Indexed: 01/10/2024]
Abstract
Patients treated with cardiac stereotactic body radiation therapy (radioablation) for refractory ventricular arrhythmias are patients with advanced structural heart disease and significant comorbidities. However, data regarding 1-year mortality after the procedure are scarce. This systematic review and pooled analysis aimed at determining 1-year mortality after cardiac radioablation for refractory ventricular arrhythmias and investigating leading causes of death in this population. MEDLINE/EMBASE databases were searched up to January 2023 for studies including patients undergoing cardiac radioablation for the treatment of refractory ventricular arrhythmias. Quality of included trials was assessed using the NIH Tool for Case Series Studies (PROSPERO CRD42022379713). A total of 1,151 references were retrieved and evaluated for relevance. Data were extracted from 16 studies, with a total of 157 patients undergoing cardiac radioablation for refractory ventricular arrhythmias. Pooled 1-year mortality was 32 % (95 %CI: 23-41), with almost half of the deaths occurring within three months after treatment. Among the 157 patients, 46 died within the year following cardiac radioablation. Worsening heart failure appeared to be the leading cause of death (52 %), although non-cardiac mortality remained substantial (41 %) in this population. Age≥70yo was associated with a significantly higher 12-month all-cause mortality (p<0.022). Neither target volume size nor radiotherapy device appeared to be associated with 1-year mortality (p = 0.465 and p = 0.199, respectively). About one-third of patients undergoing cardiac stereotactic body radiation therapy for refractory ventricular arrhythmias die within the first year after the procedure. Worsening heart failure appears to be the leading cause of death in this population.
Collapse
Affiliation(s)
- Karim Benali
- Section of Cardiac Electrophysiology, Saint-Etienne University, Saint-Etienne, France; IHU LIRYC, Electrophysiology and Heart Modeling Institute, Bordeaux, France; INSERM-LTSI, U1099 Rennes, France.
| | - Paul C Zei
- Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, United States
| | - Michael Lloyd
- Section of Cardiac Electrophysiology, Emory University, Atlanta, United States
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Charles Guenancia
- Section of Cardiac Electrophysiology, Dijon University, Dijon, France
| | - Sandro Ninni
- Heart and Lung Institute, Lille University, Lille, France
| | | | | | - Julien Bellec
- Department of Radiation Oncology, Centre Eugène Marquis, Rennes, France
| | | | - Frederic Sacher
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Nefissa Hammache
- Section of Cardiac Electrophysiology, Nancy University, Nancy, France
| | - Jean-Marc Sellal
- Section of Cardiac Electrophysiology, Nancy University, Nancy, France
| | | | - Antoine Da Costa
- Section of Cardiac Electrophysiology, Saint-Etienne University, Saint-Etienne, France
| | - Raphael Martins
- INSERM-LTSI, U1099 Rennes, France; Section of Cardiac Electrophysiology, Rennes University, Rennes, France
| |
Collapse
|
2
|
Rosu-Bubulac M, Trankle CR, Mankad P, Grizzard JD, Ellenbogen KA, Jordan JH, Weiss E. Institutional experience report on the target contouring workflow in the radiotherapy department for stereotactic arrhythmia radioablation delivered on conventional linear accelerators. Strahlenther Onkol 2024; 200:83-96. [PMID: 37872398 DOI: 10.1007/s00066-023-02159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/17/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE In stereotactic arrhythmia radioablation (STAR), the target is defined using multiple imaging studies and a multidisciplinary team consisting of electrophysiologist, cardiologist, cardiac radiologist, and radiation oncologist collaborate to identify the target and delineate it on the imaging studies of interest. This report describes the workflow employed in our radiotherapy department to transfer the target identified based on electrophysiology and cardiology imaging to the treatment planning image set. METHODS The radiotherapy team was presented with an initial target in cardiac axes orientation, contoured on a wideband late gadolinium-enhanced (WB-LGE) cardiac magnetic resonance (CMR) study, which was subsequently transferred to the computed tomography (CT) scan used for treatment planning-i.e., the average intensity projection (AIP) image set derived from a 4D CT-via an axial CMR image set, using rigid image registration focused on the target area. The cardiac and the respiratory motion of the target were resolved using ciné-CMR and 4D CT imaging studies, respectively. RESULTS The workflow was carried out for 6 patients and resulted in an internal target defined in standard anatomical orientation that encompassed the cardiac and the respiratory motion of the initial target. CONCLUSION An image registration-based workflow was implemented to render the STAR target on the planning image set in a consistent manner, using commercial software traditionally available for radiation therapy.
Collapse
Affiliation(s)
- Mihaela Rosu-Bubulac
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Cory R Trankle
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Pranav Mankad
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - John D Grizzard
- Department of Radiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth A Ellenbogen
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Jennifer H Jordan
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
3
|
Benali K, Lloyd MS, Petrosyan A, Rigal L, Quivrin M, Bessieres I, Vlachos K, Hammache N, Bellec J, Simon A, Laurent G, Higgins K, Garnier F, de Crevoisier R, Martins R, Da Costa A, Guenancia C. Cardiac stereotactic radiation therapy for refractory ventricular arrhythmias in patients with left ventricular assist devices. J Cardiovasc Electrophysiol 2024; 35:206-213. [PMID: 38018417 DOI: 10.1111/jce.16139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/30/2023]
Abstract
Left ventricular assist device (LVAD) implantation is an established treatment for patients with advanced heart failure refractory to medical therapy. However, the incidence of ventricular arrhythmias (VAs) is high in this population, both in the acute and delayed phases after implantation. About one-third of patients implanted with an LVAD will experience sustained VAs, predisposing these patients to worse outcomes and complicating patient management. The combination of pre-existing myocardial substrate and complex electrical remodeling after LVAD implantation account for the high incidence of VAs observed in this population. LVAD patients presenting VAs refractory to antiarrhythmic therapy and catheter ablation procedures are not rare. In such patients, treatment options are extremely limited. Stereotactic body radiation therapy (SBRT) is a technique that delivers precise and high doses of radiation to highly defined targets, reducing exposure to adjacent normal tissue. Cardiac SBRT has recently emerged as a promising alternative with a growing number of case series reporting the effectiveness of the technique in reducing the VA burden in patients with arrhythmias refractory to conventional therapies. The safety profile of cardiac SBRT also appears favorable, even though the current clinical experience remains limited. The use of cardiac SBRT for the treatment of refractory VAs in patients implanted with an LVAD are even more scarce. This review summarizes the clinical experience of cardiac SBRT in LVAD patients and describes technical considerations related to the implementation of the SBRT procedure in the presence of an LVAD.
Collapse
Affiliation(s)
- Karim Benali
- Department of Cardiac Electrophysiology, Saint-Etienne University Hospital Center, Saint-Etienne, France
- Department of Signal Analysis, IHU LIRYC, Electrophysiology and Heart Modelling Institute, Bordeaux University, Bordeaux, France
- LTSI-UMR 1099, Rennes, France
| | - Michael S Lloyd
- Department of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andranik Petrosyan
- Department of Cardiac Surgery, Saint-Etienne University Hospital Center, Saint-Etienne, France
| | - Louis Rigal
- Department of Signal Analysis, IHU LIRYC, Electrophysiology and Heart Modelling Institute, Bordeaux University, Bordeaux, France
| | - Magali Quivrin
- Department of Radiation Oncology, Centre Georges Francois Leclerc, Dijon, France
| | - Igor Bessieres
- Department of Radiation Oncology, Centre Georges Francois Leclerc, Dijon, France
| | | | - Nefissa Hammache
- Department of Cardiac Electrophysiology, Nancy University Hospital Center, Nancy, France
| | - Julien Bellec
- Department of Radiation Oncology, Centre Eugene Marquis, Rennes, France
| | - Antoine Simon
- Department of Signal Analysis, IHU LIRYC, Electrophysiology and Heart Modelling Institute, Bordeaux University, Bordeaux, France
| | - Gabriel Laurent
- Department of Cardiac Electrophysiology, Dijon University Hospital Center, Dijon, France
| | - Kristin Higgins
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Fabien Garnier
- Department of Cardiac Electrophysiology, Dijon University Hospital Center, Dijon, France
| | | | - Raphaël Martins
- Department of Signal Analysis, IHU LIRYC, Electrophysiology and Heart Modelling Institute, Bordeaux University, Bordeaux, France
- Department of Cardiac Electrophysiology, Rennes University Hospital Center, Rennes, France
| | - Antoine Da Costa
- Department of Cardiac Electrophysiology, Saint-Etienne University Hospital Center, Saint-Etienne, France
| | - Charles Guenancia
- Department of Radiation Oncology, Centre Eugene Marquis, Rennes, France
- PEC 2 EA 7460, University of Burgundy and Franche-Comté, Dijon, France
| |
Collapse
|
4
|
Cozzi S, Bottoni N, Botti A, Trojani V, Alì E, Finocchi Ghersi S, Cremaschi F, Iori F, Ciammella P, Iori M, Iotti C. The Use of Cardiac Stereotactic Radiation Therapy (SBRT) to Manage Ventricular Tachycardia: A Case Report, Review of the Literature and Technical Notes. J Pers Med 2022; 12:jpm12111783. [PMID: 36579492 PMCID: PMC9694192 DOI: 10.3390/jpm12111783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND among cardiac arrhythmias, ventricular tachycardia (VT) is one that can lead to cardiac death, although significant progress has been made in its treatment, including the use of implantable cardioverter-defibrillators (ICD) and radiofrequency catheter ablation. Nevertheless, long-term recurrence rates remain in about half of patients and drastically impact the patient's quality of life. Moreover, recurrent ICD shocks are painful and are associated with higher mortality and worsening of heart failure. Recently, more and more experiences are demonstrating potential efficacy in the use of stereotactic body radiotherapy (SBRT) (also called cardiac radio-ablation) to treat this condition. In this paper, we report our experience in the use of cardiac radio-ablation for the treatment of refractory ventricular tachycardia with a focus on the technique used, along with a review of the literature and technical notes. CASE PRESENTATION an 81-year-old male patient with a long history of non-ischemic dilated cardiomyopathy and mechanical mitral prosthesis underwent a biventricular cardioverter defibrillator implant after atrial ventricular node ablation. At the end of 2021, the number of tachycardias increased significantly to about 10 episodes per day. After failure of medical treatment and conventional RT catheter ablation, the patient was treated with SBRT for a total dose of 25 Gy in a single session at the site of the ectopic focus. No acute toxicity was recorded. After SBRT (follow-up 7 months) no other VT episodes were recorded. CONCLUSION SBRT appears to be safe and leads to a rapid reduction in arrhythmic storms as treatment for VT without acute toxicity, representing one of the most promising methods for treating VT storms.
Collapse
Affiliation(s)
- Salvatore Cozzi
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Nicola Bottoni
- Department of Cardiology, Arrhythmology Center, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Andrea Botti
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
- Correspondence:
| | - Valeria Trojani
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Emanuele Alì
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Sebastiano Finocchi Ghersi
- Radiation Oncolgy Unit, AOU Sant’Andrea, Facoltà di Medicina e Psicologia, Università La Sapienza, 00185 Rome, Italy
| | - Federica Cremaschi
- Engineer Clinical Specialist, Biosense Webster, Pratica di Mare, Pomezia, 00071 Rome, Italy
| | - Federico Iori
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Patrizia Ciammella
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Mauro Iori
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Cinzia Iotti
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| |
Collapse
|
5
|
Mircea AA, Rusu M, Liehn EA, Bucur O. Promising Therapies for Atrial Fibrillation and Ventricular Tachycardia. Int J Mol Sci 2022; 23:ijms232012612. [PMID: 36293490 PMCID: PMC9604396 DOI: 10.3390/ijms232012612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/15/2022] [Accepted: 10/16/2022] [Indexed: 11/26/2022] Open
Abstract
Sudden cardiac death due to arrhythmias, such as atrial fibrillation or ventricular tachycardia, account for 15–20% of all deaths. Myocardial infarction increases the burden of atrial fibrillation and ventricular tachycardia by structural and electrical remodeling of the heart. The current management of new-onset atrial fibrillation includes electric cardioversion with very high conversion rates and pharmacologic cardioversion, with less a than 50% conversion rate. If atrial fibrillation cannot be converted, the focus becomes the control of the symptoms ensuring a constant rhythm and rate control, without considering other contributory factors such as autonomic imbalance. Recently, a huge success was obtained by developing ablation techniques or addressing the vagal nerve stimulation. On the other hand, ventricular tachycardia is more sensitive to drug therapies. However, in cases of non-responsiveness to drugs, the usual therapeutic choice is represented by stereotactic ablative therapy or catheter ablation. This review focuses on these newly developed strategies for treatment of arrhythmias in clinical practice, specifically on vernakalant and low-level tragus stimulation for atrial fibrillation and stereotactic ablative therapy for drug-refractory ventricular tachycardia. These therapies are important for the significant improvement of the management of atrial fibrillation and ventricular tachycardia, providing: (1) a safer profile than current therapies, (2) higher success rate than current solutions, (3) low cost of delivery.
Collapse
Affiliation(s)
- Andrei Alexandru Mircea
- Victor Babes National Institute of Pathology, 050096 Bucharest, Romania
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihaela Rusu
- Department for Cardiology, Angiology and Internal Intensive Care, Medical Faculty, RWTH Aachen University, 5207 Aachen, Germany
| | - Elisa Anamaria Liehn
- Victor Babes National Institute of Pathology, 050096 Bucharest, Romania
- Institute for Molecular Medicine, University of Southern Denmark, DK-5230 Odense, Denmark
- Correspondence: (E.A.L.); or (O.B.)
| | - Octavian Bucur
- Victor Babes National Institute of Pathology, 050096 Bucharest, Romania
- Viron Molecular Medicine Institute, Boston, MA 02108, USA
- Correspondence: (E.A.L.); or (O.B.)
| |
Collapse
|