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Lehmann HI, Deisher AJ, Takami M, Kruse JJ, Song L, Anderson SE, Cusma JT, Parker KD, Johnson SB, Asirvatham SJ, Miller RC, Herman MG, Packer DL. External Arrhythmia Ablation Using Photon Beams. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004304. [DOI: 10.1161/circep.116.004304] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 03/06/2017] [Indexed: 11/16/2022]
Abstract
Background—
This study sought to investigate external photon beam radiation for catheter-free ablation of the atrioventricular junction in intact pigs.
Methods and Results—
Ten pigs were randomized to either sham irradiation or irradiation of the atrioventricular junction (55, 50, 40, and 25 Gy). Animals underwent baseline electrophysiological evaluation, cardiac gated multi-row computed tomographic imaging for beam delivery planning, and intensity-modulated radiation therapy. Doses to the coronary arteries were optimized. Invasive follow-up was conducted ≤4 months after the irradiation. A mean volume of 2.5±0.5 mL was irradiated with target dose. The mean follow-up length after irradiation was 124.8±30.8 days. Out of 7 irradiated animals, complete atrioventricular block was achieved in 6 animals of all 4 dose groups (86%). Using the same targeting margins, ablation lesion size notably increased with the delivered dose because of volumetric effects of isodose lines around the target volume. The mean macroscopically calculated atrial lesion volume for all 4 dose groups was 3.8±1.1 mL, lesions extended anteriorly into the interventricular septum. No short-term side effects were observed. No damage was observed in the tissues of the esophagus, phrenic nerves, or trachea. However, histology revealed in-field beam effects outside of the target volume.
Conclusions—
Single-fraction doses as low as 25 Gy caused a lesion with interruption of cardiac impulse propagation using this respective target volume. With doses of ≤55 Gy, maximal point-doses to coronary arteries could be kept <7Gy, but target conformity of lesions was not fully achieved using this approach.
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Affiliation(s)
- H. Immo Lehmann
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Amanda J. Deisher
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Mitsuru Takami
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Jon J. Kruse
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Limin Song
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Sarah E. Anderson
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Jack T. Cusma
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Kay D. Parker
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Susan B. Johnson
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Samuel J. Asirvatham
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Robert C. Miller
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Michael G. Herman
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
| | - Douglas L. Packer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., M.T., K.D.P., S.B.J., S.J.A., D.L.P.) and Department of Radiation Oncology (A.J.D., J.J.K., L.S., S.E.A., J.T.C., R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; and Texas Center for Proton Therapy, Irving (L.S.)
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Lehmann HI, Richter D, Prokesch H, Graeff C, Prall M, Simoniello P, Fournier C, Bauer J, Kaderka R, Weymann A, Szabó G, Sonnenberg K, Constantinescu AM, Johnson SB, Misiri J, Takami M, Miller RC, Herman MG, Asirvatham SJ, Brons S, Jäkel O, Haberer T, Debus J, Durante M, Bert C, Packer DL. Atrioventricular node ablation in Langendorff-perfused porcine hearts using carbon ion particle therapy: methods and an in vivo feasibility investigation for catheter-free ablation of cardiac arrhythmias. Circ Arrhythm Electrophysiol 2015; 8:429-38. [PMID: 25609687 DOI: 10.1161/circep.114.002436] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/08/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Particle therapy, with heavy ions such as carbon-12 ((12)C), delivered to arrhythmogenic locations of the heart could be a promising new means for catheter-free ablation. As a first investigation, we tested the feasibility of in vivo atrioventricular node ablation, in Langendorff-perfused porcine hearts, using a scanned 12C beam. METHODS AND RESULTS Intact hearts were explanted from 4 (30-40 kg) pigs and were perfused in a Langendorff organ bath. Computed tomographic scans (1 mm voxel and slice spacing) were acquired and (12)C ion beam treatment planning (optimal accelerator energies, beam positions, and particle numbers) for atrioventricular node ablation was conducted. Orthogonal x-rays with matching of 4 implanted clips were used for positioning. Ten Gray treatment plans were repeatedly administered, using pencil beam scanning. After delivery, positron emission tomography-computed tomographic scans for detection of β(+) ((11)C) activity were obtained. A (12)C beam with a full width at half maximum of 10 mm was delivered to the atrioventricular node. Delivery of 130 Gy caused disturbance of atrioventricular conduction with transition into complete heart block after 160 Gy. Positron emission computed tomography demonstrated dose delivery into the intended area. Application did not induce arrhythmias. Macroscopic inspection did not reveal damage to myocardium. Immunostaining revealed strong γH2AX signals in the target region, whereas no γH2AX signals were detected in the unirradiated control heart. CONCLUSIONS This is the first report of the application of a (12)C beam for ablation of cardiac tissue to treat arrhythmias. Catheter-free ablation using 12C beams is feasible and merits exploration in intact animal studies as an energy source for arrhythmia elimination.
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Affiliation(s)
- H Immo Lehmann
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.).
| | - Daniel Richter
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Hannah Prokesch
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Christian Graeff
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Matthias Prall
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Palma Simoniello
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Claudia Fournier
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Julia Bauer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Robert Kaderka
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Alexander Weymann
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Gábor Szabó
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Karin Sonnenberg
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Anna M Constantinescu
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Susan B Johnson
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Juna Misiri
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Mitsuru Takami
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Robert C Miller
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Michael G Herman
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Samuel J Asirvatham
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Stephan Brons
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Oliver Jäkel
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Thomas Haberer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Jürgen Debus
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Marco Durante
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Christoph Bert
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Douglas L Packer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
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