1
|
Liulu X, Balaji P, Barber J, De Silva K, Murray T, Hickey A, Campbell T, Harris J, Gee H, Ahern V, Kumar S, Hau E, Qian PC. Radiation therapy for ventricular arrhythmias. J Med Imaging Radiat Oncol 2024. [PMID: 38698577 DOI: 10.1111/1754-9485.13662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
Ventricular arrhythmias (VA) can be life-threatening arrhythmias that result in significant morbidity and mortality. Catheter ablation (CA) is an invasive treatment modality that can be effective in the treatment of VA where medications fail. Recurrence occurs commonly following CA due to an inability to deliver lesions of adequate depth to cauterise the electrical circuits that drive VA or reach areas of scar responsible for VA. Stereotactic body radiotherapy is a non-invasive treatment modality that allows volumetric delivery of energy to treat circuits that cannot be reached by CA. It overcomes the weaknesses of CA and has been successfully utilised in small clinical trials to treat refractory VA. This article summarises the current evidence for this novel treatment modality and the steps that will be required to bring it to the forefront of VA treatment.
Collapse
Affiliation(s)
- Xingzhou Liulu
- Cardiology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Poornima Balaji
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey Barber
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Kasun De Silva
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tiarne Murray
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Andrew Hickey
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Timothy Campbell
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jill Harris
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Harriet Gee
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Verity Ahern
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Hau
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- Blacktown Hematology and Cancer Centre, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Pierre C Qian
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Kovacs B, Mayinger M, Ehrbar S, Fesslmeier D, Ahmadsei M, Sazgary L, Manka R, Alkadhi H, Ruschitzka F, Duru F, Papachristofilou A, Sticherling C, Blamek S, Gołba KS, Guckenberger M, Saguner AM, Andratschke N. Dose escalation for stereotactic arrhythmia radioablation of recurrent ventricular tachyarrhythmia - a phase II clinical trial. Radiat Oncol 2023; 18:185. [PMID: 37941012 PMCID: PMC10634182 DOI: 10.1186/s13014-023-02361-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/08/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Stereotactic arrhythmia radioablation (STAR) is delivered with a planning target volume (PTV) prescription dose of 25 Gy, mostly to the surrounding 75-85% isodose line. This means that the average and maximum dose received by the target is less than 35 Gy, which is the minimum threshold required to create a homogenous transmural fibrosis. Similar to catheter ablation, the primary objective of STAR should be transmural fibrosis to prevent heterogenous intracardiac conduction velocities and the occurrence of sustained ventricular arrhythmias (sVA) caused by reentry. We hypothesize that the current dose prescription used in STAR is inadequate for the long-term prevention of sVA and that a significant increase in dose is necessary to induce transmural scar formation. OBJECTIVE A single arm, multi-center, phase II, dose escalation prospective clinical trial employing the i3 + 3 design is being conducted to examine the safety of a radiation dose-escalation strategy aimed at inducing transmural scar formation. The ultimate objective of this trial is to decrease the likelihood of sVA recurrence in patients at risk. METHODS Patients with ischemic or non-ischemic cardiomyopathy and recurrent sVA, with an ICD and history of ≥ 1 catheter ablation for sVA will be included. This is a prospective, multicenter, one-arm, dose-escalation trial utilizing the i3 + 3 design, a modified 3 + 3 specifically created to overcome limitations in traditional dose-finding studies. A total of 15 patients will be recruited. The trial aims to escalate the ITV dose from 27.0 Gy to an ITV prescription dose-equivalent level of maximum 35.1 Gy by keeping the PTV prescription dose constant at 25 Gy while increasing the dose to the target (i.e. the VT substrate without PTV margin) by step-wise reduction of the prescribing isodose line (85% down to 65%). The primary outcome of this trial is safety measured by registered radiation associated adverse events (AE) up to 90 days after study intervention including radiation associated serious adverse events graded as at least 4 or 5 according to CTCAE v5, radiation pneumonitis or pericarditis requiring hospitalization and decrease in LVEF ≥ 10% as assessed by echocardiography or cardiac MRI at 90 days after STAR. The sample size was determined assuming an acceptable primary outcome event rate of 20%. Secondary outcomes include sVA burden at 6 months after STAR, time to first sVA recurrence, reduction in appropriate ICD therapies, the need for escalation of antiarrhythmic drugs, non-radiation associated safety and patient reported outcome measures such as SF-36 and EQ5D. DISCUSSION DEFT-STAR is an innovative prospective phase II trial that aims to evaluate the optimal radiation dose for STAR in patients with therapy-refractory sVA. The trial has obtained IRB approval and focuses on determining the safe and effective radiation dose to be employed in the STAR procedure. TRIAL REGISTRATION NCT05594368.
Collapse
Affiliation(s)
- Boldizsar Kovacs
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Stefanie Ehrbar
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Debra Fesslmeier
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Maiwand Ahmadsei
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Lorraine Sazgary
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
| | - Robert Manka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
- Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
- Center for Integrative Human Physiology, University Zurich, Zurich, Switzerland
| | - Firat Duru
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
- Center for Integrative Human Physiology, University Zurich, Zurich, Switzerland
| | | | | | - Slawomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Krzysztof S Gołba
- Department of Electrocardiology, Upper Silesian Heart Center, Medical University of Silesia, Katowice, Poland
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | | | - Ardan M Saguner
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Translational and Experimental Cardiology (CTEC), University of Zurich, Zurich, Switzerland
- Center for Integrative Human Physiology, University Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Amino M, Yamazaki M, Yoshioka K, Kawabe N, Tanaka S, Shimokawa T, Niwa R, Tomii N, Kabuki S, Kunieda E, Yagishita A, Ikari Y, Kodama I. Heavy Ion Irradiation Reduces Vulnerability to Atrial Tachyarrhythmias - Gap Junction and Sympathetic Neural Remodeling. Circ J 2023; 87:1016-1026. [PMID: 36476829 DOI: 10.1253/circj.cj-22-0527] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2024]
Abstract
BACKGROUND Low-invasive stereotactic body radiation therapy is a novel anti-arrhythmic strategy. The mechanisms underlying its effects against ventricular tachycardia/fibrillation (VT/VF) are gradually becoming clear, whereas those underlying atrial tachycardia/fibrillation (AT/AF) remain unknown. This study investigated the effects of carbon ion beam on gap junction expression and sympathetic innervation. METHODS AND RESULTS Atrial and ventricular tachyarrhythmia models was established in 26 hypercholesterolemic (HC) 3-year-old New Zealand white rabbits; 12 rabbits were irradiated with a single 15-Gy carbon ion beam (targeted heavy ion irradiation [THIR]) and 14 were not (HC group). Eight 3-month-old rabbits (Young) were used as a reference group. In vivo induction frequencies in the Young, HC, and HC+THIR groups were 0%, 9.9%, and 1.2%, respectively, for AT/AF and 0%, 7.8%, and 1.2%, respectively, for VT/VF (P<0.01). The conduction velocity of the atria and ventricles on optical mapping was significantly reduced in the HC group; this was reversed in the HC+THIR group. Connexin-40 immunolabelling in the atria was 66.1-78.7% lower in the HC than Young group; this downregulation was less pronounced in the HC+THIR group (by 23.1-44.4%; P<0.01). Similar results were obtained for ventricular connexin-43. Sympathetic nerve densities in the atria and ventricles increased by 41.9-65.3% in the HC vs. Young group; this increase was reversed in the HC+THIR group. CONCLUSIONS Heavy ion radiation reduced vulnerability to AT/AF and VT/VF in HC elderly rabbits and improved cardiac conductivity. The results suggest involvement of connexin-40/43 upregulation and suppression of sympathetic nerve sprouting.
Collapse
Affiliation(s)
- Mari Amino
- Department of Cardiology, Tokai University
- National Institute for Quantum and Radiological Science and Technology
| | - Masatoshi Yamazaki
- Department of Cardiology, Nagano Hospital
- Medical Device Development and Regulation Research Center, The University of Tokyo
| | | | | | | | - Takashi Shimokawa
- National Institute for Quantum and Radiological Science and Technology
| | - Ryoko Niwa
- Research Institute of Environmental Medicine, Nagoya University
| | - Naoki Tomii
- School of Engineering, The University of Tokyo
| | | | | | | | - Yuji Ikari
- Department of Cardiology, Tokai University
| | - Itsuo Kodama
- Research Institute of Environmental Medicine, Nagoya University
| |
Collapse
|
5
|
Guarracini F, Tritto M, Di Monaco A, Mariani MV, Gasperetti A, Compagnucci P, Muser D, Preda A, Mazzone P, Themistoclakis S, Carbucicchio C. Stereotactic Arrhythmia Radioablation Treatment of Ventricular Tachycardia: Current Technology and Evolving Indications. J Cardiovasc Dev Dis 2023; 10:jcdd10040172. [PMID: 37103051 PMCID: PMC10143260 DOI: 10.3390/jcdd10040172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 04/28/2023] Open
Abstract
Ventricular tachycardia in patients with structural heart disease is a significant cause of morbidity and mortality. According to current guidelines, cardioverter defibrillator implantation, antiarrhythmic drugs, and catheter ablation are established therapies in the management of ventricular arrhythmias but their efficacy is limited in some cases. Sustained ventricular tachycardia can be terminated by cardioverter-defibrillator therapies although shocks in particular have been demonstrated to increase mortality and worsen patients' quality of life. Antiarrhythmic drugs have important side effects and relatively low efficacy, while catheter ablation, even if it is actually an established treatment, is an invasive procedure with intrinsic procedural risks and is frequently affected by patients' hemodynamic instability. Stereotactic arrhythmia radioablation for ventricular arrhythmias was developed as bail-out therapy in patients unresponsive to traditional treatments. Radiotherapy has been mainly applied in the oncological field, but new current perspectives have developed in the field of ventricular arrhythmias. Stereotactic arrhythmia radioablation provides an alternative non-invasive and painless therapeutic strategy for the treatment of previously detected cardiac arrhythmic substrate by three-dimensional intracardiac mapping or different tools. Since preliminary experiences have been reported, several retrospective studies, registries, and case reports have been published in the literature. Although, for now, stereotactic arrhythmia radioablation is considered an alternative palliative treatment for patients with refractory ventricular tachycardia and no other therapeutic options, this research field is currently extremely promising.
Collapse
Affiliation(s)
| | - Massimo Tritto
- Electrophysiology and Cardiac Pacing Unit, Humanitas Mater Domini Hospital, 21053 Castellanza, Italy
| | - Antonio Di Monaco
- Cardiology Department, General Regional Hospital F. Miulli, 70021 Acquaviva delle Fonti, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, 00100 Rome, Italy
| | - Alessio Gasperetti
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti Umberto I-Lancisi-Salesi, 60126 Ancona, Italy
| | - Daniele Muser
- Cardiothoracic Department, University Hospital, 33100 Udine, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Patrizio Mazzone
- Cardiothoracovascular Department, Electrophysiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Sakis Themistoclakis
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell'Angelo Hospital, Mestre, 30174 Venice, Italy
| | - Corrado Carbucicchio
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| |
Collapse
|
6
|
Aras D, Çetin EHÖ, Ozturk HF, Ozdemir E, Kara M, Ekizler FA, Ozeke O, Ozcan F, Korkmaz A, Kervan U, Turhan N, Coskun N, Tezcan Y, Huang H, Aksu T, Topaloglu S. Stereotactic body radioablation therapy as an immediate and early term antiarrhythmic palliative therapeutic choice in patients with refractory ventricular tachycardia. J Interv Card Electrophysiol 2023; 66:135-143. [PMID: 36040658 PMCID: PMC9424800 DOI: 10.1007/s10840-022-01352-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/16/2022] [Indexed: 10/27/2022]
Abstract
BACKGROUND Stereotactic body radioablation therapy (SBRT) has recently been introduced with the ability to provide ablative energy noninvasively to arrhythmogenic substrate while reducing damage to normal cardiac tissue nearby and minimizing patients' procedural risk. There is still debate regarding whether SBRT has a predominant effect in the early or late period after the procedure. We sought to assess the time course of SBRT's efficacy as well as the value of using a blanking period following a SBRT session. METHODS Eight patients (mean age 58 ± 14 years) underwent eight SBRT sessions for refractory ventricular tachycardia (VT). SBRT was given using a linear accelerator device with a total dose of 25 Gy to the targeted area. RESULTS During a median follow-up of 8 months, all patients demonstrated VT recurrences; however, implantable cardioverter-defibrillator (ICD) and anti-tachycardia pacing therapies were significantly reduced with SBRT (8.46 to 0.83/per month, p = 0.047; 18.50 to 3.29/per month, p = 0.036, respectively). While analyzing the temporal SBRT outcomes, the 2 weeks to 3 months period demonstrated the most favorable outcomes. After 6 months, one patient was ICD therapy-free and the remaining patients demonstrated VT episodes. CONCLUSIONS Our findings showed that the SBRT was associated with a marked reduction in the burden of VT and ICD interventions especially during first 3 months. Although SBRT does not seem to succeed complete termination of VT in long-term period, our findings support the strategy that SBRT can be utilized for immediate antiarrhythmic palliation in critically ill patients with otherwise untreatable refractory VT and electrical storm.
Collapse
Affiliation(s)
- Dursun Aras
- grid.411781.a0000 0004 0471 9346Department of Cardiology, Istanbul Medipol University, Istanbul, Turkey
| | - Elif Hande Özcan Çetin
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Huseyin Furkan Ozturk
- grid.449874.20000 0004 0454 9762Department of Radiation Oncology, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Elif Ozdemir
- grid.449874.20000 0004 0454 9762Department of Nuclear Medicine, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Meryem Kara
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Firdevs Aysenur Ekizler
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ahmet Korkmaz
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Umit Kervan
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Nesrin Turhan
- Department of Pathology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Nazim Coskun
- Department of Nuclear Medicine, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Yilmaz Tezcan
- grid.449874.20000 0004 0454 9762Department of Radiation Oncology, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Henry Huang
- grid.262743.60000000107058297Department of Cardiology, Rush Medical College, Chicago, IL USA
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Istanbul, Istanbul, Turkey, 34100.
| | - Serkan Topaloglu
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| |
Collapse
|
7
|
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
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
van der Ree MH, Dieleman EM, Visser J, Adam JA, de Bruin-Bon RH, de Jong RM, Hoeksema WF, Mosterd A, Balt JC, Planken RN, Balgobind BV, Postema PG. Direct Clinical Effects of Cardiac Radioablation in the Treatment of a Patient With Therapy-Refractory Ventricular Tachycardia Storm. Adv Radiat Oncol 2022; 7:100992. [PMID: 35782880 PMCID: PMC9240979 DOI: 10.1016/j.adro.2022.100992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/08/2022] [Indexed: 11/25/2022] Open
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Kim JS, Choi SW, Park YG, Kim SJ, Choi CH, Cha MJ, Chang JH. Impact of High-Dose Irradiation on Human iPSC-Derived Cardiomyocytes Using Multi-Electrode Arrays: Implications for the Antiarrhythmic Effects of Cardiac Radioablation. Int J Mol Sci 2021; 23:351. [PMID: 35008778 PMCID: PMC8745341 DOI: 10.3390/ijms23010351] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiac radioablation is emerging as an alternative option for refractory ventricular arrhythmias. However, the immediate acute effect of high-dose irradiation on human cardiomyocytes remains poorly known. We measured the electrical activities of human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) upon irradiation with 0, 20, 25, 30, 40, and 50 Gy using a multi-electrode array, and cardiomyocyte function gene levels were evaluated. iPSC-CMs showed to recover their electrophysiological activities (total active electrode, spike amplitude and slope, and corrected field potential duration) within 3-6 h from the acute effects of high-dose irradiation. The beat rate immediately increased until 3 h after irradiation, but it steadily decreased afterward. Conduction velocity slowed in cells irradiated with ≥25 Gy until 6-12 h and recovered within 24 h; notably, 20 and 25 Gy-treated groups showed subsequent continuous increase. At day 7 post-irradiation, except for cTnT, cardiomyocyte function gene levels increased with increasing irradiation dose, but uniquely peaked at 25-30 Gy. Altogether, high-dose irradiation immediately and reversibly modifies the electrical conduction of cardiomyocytes. Thus, compensatory mechanisms at the cellular level may be activated after the high-dose irradiation acute effects, thereby, contributing to the immediate antiarrhythmic outcome of cardiac radioablation for refractory ventricular arrhythmias.
Collapse
Affiliation(s)
- Jae Sik Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Korea; (J.S.K.); (C.H.C.)
- Department of Radiation Oncology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
| | - Seong Woo Choi
- Department of Physiology, Dongguk University College of Medicine, Gyeongju 38066, Korea;
| | - Yun-Gwi Park
- Stem Cell Research Institute, T&R Biofab Co., Ltd., Siheung 15073, Korea;
| | - Sung Joon Kim
- Department of Physiology & Ischemic/Hypoxic Disease Institute, Seoul National University College of Medicine, Seoul 03080, Korea;
| | - Chang Heon Choi
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Korea; (J.S.K.); (C.H.C.)
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Korea
| | - Myung-Jin Cha
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Korea; (J.S.K.); (C.H.C.)
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Korea
| |
Collapse
|
12
|
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.
Collapse
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.
| |
Collapse
|
13
|
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.
Collapse
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.
| |
Collapse
|
14
|
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.
Collapse
|
15
|
Amino M, Kabuki S, Kunieda E, Yagishita A, Ikari Y, Yoshioka K. Analysis of depolarization abnormality and autonomic nerve function after stereotactic body radiation therapy for ventricular tachycardia in a patient with old myocardial infarction. HeartRhythm Case Rep 2021; 7:306-311. [PMID: 34026521 PMCID: PMC8134781 DOI: 10.1016/j.hrcr.2021.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Mari Amino
- Department of Cardiology, Tokai University, Isehara, Japan.,National Institute for Quantum and Radiological Science and Technology, QST Hospital, Inage, Japan
| | - Shigeto Kabuki
- Department of Radiation Oncology, Tokai University, Isehara, Japan
| | - Etsuo Kunieda
- Department of Radiation Oncology, Tokai University, Isehara, Japan
| | | | - Yuji Ikari
- Department of Cardiology, Tokai University, Isehara, Japan
| | | |
Collapse
|
16
|
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.
Collapse
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.
| |
Collapse
|
17
|
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]
|
18
|
The role of connexin proteins and their channels in radiation-induced atherosclerosis. Cell Mol Life Sci 2021; 78:3087-3103. [PMID: 33388835 PMCID: PMC8038956 DOI: 10.1007/s00018-020-03716-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 02/08/2023]
Abstract
Radiotherapy is an effective treatment for breast cancer and other thoracic tumors. However, while high-energy radiotherapy treatment successfully kills cancer cells, radiation exposure of the heart and large arteries cannot always be avoided, resulting in secondary cardiovascular disease in cancer survivors. Radiation-induced changes in the cardiac vasculature may thereby lead to coronary artery atherosclerosis, which is a major cardiovascular complication nowadays in thoracic radiotherapy-treated patients. The underlying biological and molecular mechanisms of radiation-induced atherosclerosis are complex and still not fully understood, resulting in potentially improper radiation protection. Ionizing radiation (IR) exposure may damage the vascular endothelium by inducing DNA damage, oxidative stress, premature cellular senescence, cell death and inflammation, which act to promote the atherosclerotic process. Intercellular communication mediated by connexin (Cx)-based gap junctions and hemichannels may modulate IR-induced responses and thereby the atherosclerotic process. However, the role of endothelial Cxs and their channels in atherosclerotic development after IR exposure is still poorly defined. A better understanding of the underlying biological pathways involved in secondary cardiovascular toxicity after radiotherapy would facilitate the development of effective strategies that prevent or mitigate these adverse effects. Here, we review the possible roles of intercellular Cx driven signaling and communication in radiation-induced atherosclerosis.
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
van der Ree MH, Blanck O, Limpens J, Lee CH, Balgobind BV, Dieleman EM, Wilde AA, Zei PC, de Groot JR, Slotman BJ, Cuculich PS, Robinson CG, Postema PG. Cardiac radioablation—A systematic review. Heart Rhythm 2020; 17:1381-1392. [DOI: 10.1016/j.hrthm.2020.03.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/13/2020] [Indexed: 12/29/2022]
|
21
|
Biological Cardiac Tissue Effects of High-Energy Heavy Ions - Investigation for Myocardial Ablation. Sci Rep 2019; 9:5000. [PMID: 30899027 PMCID: PMC6428839 DOI: 10.1038/s41598-019-41314-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/26/2019] [Indexed: 12/24/2022] Open
Abstract
Noninvasive X-ray stereotactic treatment is considered a promising alternative to catheter ablation in patients affected by severe heart arrhythmia. High-energy heavy ions can deliver high radiation doses in small targets with reduced damage to the normal tissue compared to conventional X-rays. For this reason, charged particle therapy, widely used in oncology, can be a powerful tool for radiosurgery in cardiac diseases. We have recently performed a feasibility study in a swine model using high doses of high-energy C-ions to target specific cardiac structures. Interruption of cardiac conduction was observed in some animals. Here we report the biological effects measured in the pig heart tissue of the same animals six months after the treatment. Immunohistological analysis of the target tissue showed (1.) long-lasting vascular damage, i.e. persistent hemorrhage, loss of microvessels, and occurrence of siderophages, (2.) fibrosis and (3.) loss of polarity of targeted cardiomyocytes and wavy fibers with vacuolization. We conclude that the observed physiological changes in heart function are produced by radiation-induced fibrosis and cardiomyocyte functional inactivation. No effects were observed in the normal tissue traversed by the particle beam, suggesting that charged particles have the potential to produce ablation of specific heart targets with minimal side effects.
Collapse
|
22
|
Graeff C, Bert C. Noninvasive cardiac arrhythmia ablation with particle beams. Med Phys 2018; 45:e1024-e1035. [DOI: 10.1002/mp.12595] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/05/2017] [Accepted: 09/17/2017] [Indexed: 12/31/2022] Open
Affiliation(s)
- Christian Graeff
- GSI Helmholzzentrum für Schwerionenforschung GmbH 64291 Darmstadt Germany
| | - Christoph Bert
- Department of Radiation Oncology Universitätsklinikum Erlangen Friedrich‐Alexander‐Universität 91054 Erlangen‐Nürnberg Germany
| |
Collapse
|
23
|
Amino M, Yoshioka K, Kamada T, Furusawa Y. The Potential Application of Heavy Ion Beams in the Treatment of Arrhythmia: The Role of Radiation-Induced Modulation of Connexin43 and the Sympathetic Nervous System. Int J Part Ther 2018; 5:140-150. [PMID: 31773026 DOI: 10.14338/ijpt-18-00022.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/12/2018] [Indexed: 11/21/2022] Open
Abstract
It has been known that heart disease-such as myocardial infarction (MI), cardiac hypertrophy, or heart failure-alters the molecular structure and function of the gap junction, which can lead to an abnormal heart rhythm. Radiation has been shown to modulate intercellular communication in the skin and lungs by increasing connexin43 (Cx43) expression. Understanding how Cx43 upregulation is induced in a diseased heart can help provide a new perspective to radiation therapy for arrhythmias. In a recent study with rabbits after MI, carbon ions were accelerated to 290 MeV/u and extracted in the air; a biologically (cell kill) uniform 6-cm spread-out Bragg peak beam was generated, and beam tissue depth was set to 30 mm with energy degraders to the depth position. Targeted heavy ion irradiation (THIR) with 15 Gy to the left ventricle increased Cx43 expression, improved conductivity, decreased the spatial heterogeneity of repolarization, and reduced the vulnerability of rabbit hearts to ventricular arrhythmias after MI. In clinically normal rabbits, THIR > = 10 Gy caused a significant dose-dependent increase of Cx43 protein and messenger RNA 2 weeks after irradiation. The left (irradiated) and right (nonirradiated) ventricles exhibited circumferential upregulation of Cx43 lasting for at least 1 year. There were no significant changes in electrocardiograms and echocardiograms, indicating no apparent injury for 1 year. A single exposure of 135 MeV/u THIR with 15 Gy to a dog heart attenuated vulnerability to ventricular arrhythmia after the induction of MI for at least 1 year through the modulation of Cx43 expression. This long-lasting remodeling effect on gap junctions may lay the groundwork to novel therapies against life-threatening ventricular arrhythmias in structural heart disease. To date, there have been few investigations into the effects of carbon-ion irradiation on electrophysiological properties in the human heart. Patients with mediastinum cancer were investigated for 5 years after treatment that included irradiation to the heart, and investigators found that carbon-ion beam irradiation to the heart is not immediately cardiotoxic and demonstrates consistent signals of arrhythmia reduction. Its practical application in non-cancer treatment, such as in arrhythmia treatment, is highly anticipated.
Collapse
Affiliation(s)
- Mari Amino
- Department of Cardiovascular Medicine, Tokai University, Isehara, Japan
| | - Koichiro Yoshioka
- Department of Cardiovascular Medicine, Tokai University, Isehara, Japan
| | - Tadashi Kamada
- Department of Cardiovascular Medicine, Tokai University, Isehara, Japan
| | | |
Collapse
|
24
|
Sylvester CB, Abe JI, Patel ZS, Grande-Allen KJ. Radiation-Induced Cardiovascular Disease: Mechanisms and Importance of Linear Energy Transfer. Front Cardiovasc Med 2018; 5:5. [PMID: 29445728 PMCID: PMC5797745 DOI: 10.3389/fcvm.2018.00005] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/09/2018] [Indexed: 12/24/2022] Open
Abstract
Radiation therapy (RT) in the form of photons and protons is a well-established treatment for cancer. More recently, heavy charged particles have been used to treat radioresistant and high-risk cancers. Radiation treatment is known to cause cardiovascular disease (CVD) which can occur acutely during treatment or years afterward in the form of accelerated atherosclerosis. Radiation-induced cardiovascular disease (RICVD) can be a limiting factor in treatment as well as a cause of morbidity and mortality in successfully treated patients. Inflammation plays a key role in both acute and chronic RICVD, but the underling pathophysiology is complex, involving DNA damage, reactive oxygen species, and chronic inflammation. While understanding of the molecular mechanisms of RICVD has increased, the growing number of patients receiving RT warrants further research to identify individuals at risk, plans for prevention, and targets for the treatment of RICVD. Research on RICVD is also relevant to the National Aeronautics and Space Administration (NASA) due to the prevalent space radiation environment encountered by astronauts. NASA's current research on RICVD can both contribute to and benefit from concurrent work with cell and animal studies informing radiotoxicities resulting from cancer therapy. This review summarizes the types of radiation currently in clinical use, models of RICVD, current knowledge of the mechanisms by which they cause CVD, and how this knowledge might apply to those exposed to various types of radiation.
Collapse
Affiliation(s)
- Christopher B Sylvester
- Department of Bioengineering, Rice University, Houston, TX, United States.,Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, United States
| | - Jun-Ichi Abe
- Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Zarana S Patel
- Science and Space Operations, KBRwyle, Houston, TX, United States
| | | |
Collapse
|
25
|
Amino M, Yoshioka K, Shima M, Okada T, Nakajima M, Furusawa Y, Kanda S, Inokuchi S, Tanabe T, Ikari Y, Kamada T. Changes in arrhythmogenic properties and five-year prognosis after carbon-ion radiotherapy in patients with mediastinum cancer. Ann Noninvasive Electrocardiol 2017; 23. [PMID: 28590042 DOI: 10.1111/anec.12468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/27/2017] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Carbon-ion irradiation of rabbit hearts has improved left ventricular conduction abnormalities through upregulation of gap junctions. However, to date, there has been no investigation on the effect of carbon-ion irradiation on electrophysiological properties in human. We investigated this effect in patients with mediastinum extra-cardiac cancer treated with carbon-ion radiotherapy that included irradiating the heart. METHODS AND RESULTS In April-December 2009, eight patients were prospectively enrolled (including two male, aged 72.5 ± 13.0 years). They were treated with 44-72 Gray equivalent (GyE), with their hearts exposed to 1.3-19.1 GyE. High-resolution ambulatory electrocardiography was performed before and after radiotherapy to investigate arrhythmic events, late potentials (LPs), and heart rate variability. Five patients had pre-existing premature ventricular contraction (PVC)/atrial contraction (PAC) or paroxysmal atrial fibrillation (PAF)/AF; after irradiation, this improved in four patients with PVC/PAF/AF and did not deteriorate in one patient with PAC. Ventricular LP findings did not deteriorate and improved in one patient. In eight cases with available atrial LP findings, there was no deterioration, and two patients showed improvements. The low frequency/high frequency ratio of heart rate variability improved or did not deteriorate in the six patients who received radiation exposure to the bilateral stellate ganglions. During the five-year follow-up for the prognosis, six of the eight patients died because of cancer; there was no history of hospitalization for cardiac events. CONCLUSION Although this preliminary study has several limitations, carbon-ion beam irradiation to the heart is not immediately cardiotoxic and demonstrates consistent signals of arrhythmia reduction.
Collapse
Affiliation(s)
- Mari Amino
- Department of Cardiovascular Medicine, Tokai University, Isehara, Japan
| | - Koichiro Yoshioka
- Department of Cardiovascular Medicine, Tokai University, Isehara, Japan
| | - Makiyoshi Shima
- Department of Cardiovascular Medicine, Tokai University, Isehara, Japan
| | - Tohru Okada
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mio Nakajima
- National Institute of Radiological Sciences, Inage, Japan
| | | | - Shigetaka Kanda
- Department of Cardiovascular Medicine, Tokai University, Isehara, Japan
| | - Sadaki Inokuchi
- Department of Critical Care and Medicine, Tokai University, Isehara, Japan
| | | | - Yuji Ikari
- Department of Cardiovascular Medicine, Tokai University, Isehara, Japan
| | - Tadashi Kamada
- National Institute of Radiological Sciences, Inage, Japan
| |
Collapse
|