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Balaji P, Liulu X, Sivakumar S, Chong JJH, Kizana E, Vandenberg JI, Hill AP, Hau E, Qian PC. Mechanistic insights and knowledge gaps in the effects of radiation therapy on cardiac arrhythmias. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03316-9. [PMID: 39222823 DOI: 10.1016/j.ijrobp.2024.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 08/05/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
Stereotactic body radiation therapy (SBRT) is an innovative modality for treatment of refractory ventricular arrhythmias (VA). Phase I/II clinical trials have demonstrated the remarkable efficacy of SBRT at reducing VA burden(by>85%) in patients with good short-term safety. SBRT as an option for VA treatment delivered in an ambulatory, non-sedated patient in a single fraction, during an outpatient session of 15-30 minutes, without added risks of anesthetic or surgery is clinically relevant. However, the underlying mechanism remains unclear. Currently used clinical dosing of SBRT has been derived from preclinical studies aimed to induce transmural fibrosis in the atria. The propitious clinical effects of SBRT appear earlier than the time-course for fibrosis. This review addresses the plausible mechanisms by which radiation alters the electrophysiological properties of myocytes and myocardial conduction to impart an anti-arrhythmic effect to elucidate clinical observations and point the direction for further research in this promising area.
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Affiliation(s)
- Poornima Balaji
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Xingzhou Liulu
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Sonaali Sivakumar
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - James J H Chong
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia; Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Eddy Kizana
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia; Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jamie I Vandenberg
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia
| | - Adam P Hill
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia
| | - Eric Hau
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, NSW, Westmead, Australia; Blacktown Hematology and Cancer Centre, Blacktown Hospital, NSW, Blacktown, Australia
| | - Pierre C Qian
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Mages C, Gampp H, Rahm AK, Hackbarth J, Pfeiffer J, Petersenn F, Kramp X, Kermani F, Zhang J, Pijnappels DA, de Vries AAF, Seidensaal K, Rhein B, Debus J, Ullrich ND, Frey N, Thomas D, Lugenbiel P. Cardiac stereotactic body radiotherapy to treat malignant ventricular arrhythmias directly affects the cardiomyocyte electrophysiology. Heart Rhythm 2024:S1547-5271(24)02817-0. [PMID: 38936449 DOI: 10.1016/j.hrthm.2024.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Promising as a treatment option for life-threatening ventricular arrhythmias, cardiac stereotactic body radiotherapy (cSBRT) has demonstrated early antiarrhythmic effects within days of treatment. The mechanisms underlying the immediate and short-term antiarrhythmic effects are poorly understood. OBJECTIVE We hypothesize that cSBRT has a direct antiarrhythmic effect on cellular electrophysiology through reprogramming of ion channel and gap junction protein expression. METHODS After exposure to 20 Gy of x-rays in a single fraction, neonatal rat ventricular cardiomyocytes were analyzed 24 and 96 hours postradiation to determine changes in conduction velocity, beating frequency, calcium transients, and action potential duration in both monolayers and single cells. In addition, the expression of gap junction proteins, ion channels, and calcium handling proteins was evaluated at protein and messenger RNA levels. RESULTS After irradiation with 20 Gy, neonatal rat ventricular cardiomyocytes exhibited increased beat rate and conduction velocity 24 and 96 hours after treatment. Messenger RNA and protein levels of ion channels were altered, with the most significant changes observed at the 96-hour mark. Upregulation of Cacna1c (Cav1.2), Kcnd3 (Kv4.3), Kcnh2 (Kv11.1), Kcnq1 (Kv7.1), Kcnk2 (K2P2.1), Kcnj2 (Kir2.1), and Gja1 (Cx43) was noted, along with improved gap junctional coupling. Calcium handling was affected, with increased Ryr2 ryanodin-rezeptor 2 and Slc8a1 Na+/Ca2+ exchanger expression and altered properties 96 hours posttreatment. Fibroblast and myofibroblast levels remained unchanged. CONCLUSION cSBRT modulates the expression of various ion channels, calcium handling proteins, and gap junction proteins. The described alterations in cellular electrophysiology may be the underlying cause of the immediate antiarrhythmic effects observed after cSBRT.
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Affiliation(s)
- Christine Mages
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany; Informatics4Life Consortium (Institute for Informatics Heidelberg), Heidelberg, Germany
| | - Heike Gampp
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Ann-Kathrin Rahm
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany; Informatics4Life Consortium (Institute for Informatics Heidelberg), Heidelberg, Germany
| | - Juline Hackbarth
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Pfeiffer
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Finn Petersenn
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Xenia Kramp
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany
| | - Fatemeh Kermani
- Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg, Germany
| | - Juan Zhang
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel A Pijnappels
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Antoine A F de Vries
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Bernhard Rhein
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Nina D Ullrich
- German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany; Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg, Germany; Department of Physiology, University of Bern, Bern, Switzerland
| | - Norbert Frey
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany; Informatics4Life Consortium (Institute for Informatics Heidelberg), Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Patrick Lugenbiel
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Center for Heart Rhythm Disorders (HCR), University Hospital Heidelberg, Heidelberg, Germany; German Centre for Cardiovascular Research (DZHK), Partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.
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De Lio F, Schiavone M, Mancini ME, Bianchini L, Jereczek-Fossa BA, Tondo C, Carbucicchio C. Stereotactic radioablation for recurrent or nearly incessant slow ventricular tachycardia treatment. Europace 2024; 26:euae137. [PMID: 38781453 PMCID: PMC11157459 DOI: 10.1093/europace/euae137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Affiliation(s)
- Francesca De Lio
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
| | - Marco Schiavone
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
| | - Maria Elisabetta Mancini
- Department of Periooperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Lorenzo Bianchini
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Claudio Tondo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Corrado Carbucicchio
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, 20138 Milan, Italy
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Kovacs B, Lehmann HI, Manninger M, Saguner AM, Futyma P, Duncker D, Chun J. Stereotactic arrhythmia radioablation and its implications for modern cardiac electrophysiology: results of an EHRA survey. Europace 2024; 26:euae110. [PMID: 38666444 PMCID: PMC11086561 DOI: 10.1093/europace/euae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
Stereotactic arrhythmia radioablation (STAR) is a treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in patients with structural heart disease (SHD). The current and future role of STAR as viewed by cardiologists is unknown. The study aimed to assess the current role, barriers to application, and expected future role of STAR. An online survey consisting of 20 questions on baseline demographics, awareness/access, current use, and the future role of STAR was conducted. A total of 129 international participants completed the survey [mean age 43 ± 11 years, 25 (16.4%) female]. Ninety-one (59.9%) participants were electrophysiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR, while 62 (48.1%) had treated/referred a patient for treatment. Common primary indications for STAR were recurrent VT/VF in SHD (45%), recurrent VT/VF without SHD (7.8%), or premature ventricular contraction (3.9%). Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%) and non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%). Most respondents have foreseen a future clinical role of STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively), although only a minority expected a first-line indication for it (7% and 5%, respectively). Stereotactic arrhythmia radioablation as a novel treatment option of recurrent VT appears to gain acceptance within the cardiology community. Further trials are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.
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Affiliation(s)
- Boldizsar Kovacs
- Department of Cardiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, 48109 MI, USA
- Department of Cardiology, University Heart Center Zurich, Raemistrasse 100, Zurich 8091, Switzerland
| | - Helge Immo Lehmann
- Department of Cardiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, 48109 MI, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, 55 Fruit St, Boston, 02114 MA, USA
| | - Martin Manninger
- Division of Cardiology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Ardan Muammer Saguner
- Department of Cardiology, University Heart Center Zurich, Raemistrasse 100, Zurich 8091, Switzerland
| | - Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph’s Heart Rhythm Center, Rzeszów, Poland
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Julian Chun
- Cardioangiologisches Centrum Bethanien, Agaplesion Bethanien Krankenhaus, Frankfurt, Germany
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Walls GM, McCann C, O'Connor J, O'Sullivan A, I Johnston D, McAleese J, McGarry CK, Cole AJ, Jain S, Butterworth KT, Hanna GG. Pulmonary vein dose and risk of atrial fibrillation in patients with non-small cell lung cancer following definitive radiotherapy: An NI-HEART analysis. Radiother Oncol 2024; 192:110085. [PMID: 38184145 DOI: 10.1016/j.radonc.2024.110085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Abstract
BACKGROUND AND PURPOSE Symptomatic arrhythmia is common following radiotherapy for non-small cell lung cancer (NSCLC), frequently resulting in morbidity and hospitalization. Modern treatment planning technology theoretically allows sparing of cardiac substructures. Atrial fibrillation (AF) comprises the majority of post-radiotherapy arrhythmias, but efforts to prevent this cardiotoxicity have been limited as the causative cardiac substructure is not known. In this study we investigated if incidental radiation dose to the pulmonary veins (PVs) is associated with AF. MATERIAL AND METHODS A single-centre study of patients completing contemporary (chemo)radiation for NSCLC, with modern planning techniques. Oncology, cardiology and death records were examined, and AF events were verified by a cardiologist. Cardiac substructures were contoured on planning scans for retrospective dose analysis. RESULTS In 420 eligible patients with NSCLC treated with intensity-modulated (70%) or 3D-conformal (30%) radiotherapy with a median OS of 21.8 months (IQR 10.8-35.1), there were 26 cases of new AF (6%). All cases were grade 3 except two cases of grade 4. Dose metrics for both the left (V55) and right (V10) PVs were associated with the incidence of new AF. Metrics remained statistically significant after accounting for the competing risk of death and cardiovascular covariables for both the left (HR 1.02, 95%CI 1.00-1.03, p = 0.005) and right (HR 1.01 (95%CI 1.00-1.02, p = 0.033) PVs. CONCLUSION Radiation dose to the PVs during treatment of NSCLC was associated with the onset of AF. Actively sparing the PVs during treatment planning could reduce the incidence of AF during follow-up, and screening for AF may be warranted for select cases.
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Affiliation(s)
- Gerard M Walls
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland.
| | - Conor McCann
- Department of Cardiology, Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - John O'Connor
- School of Engineering, University of Ulster, York Street, Belfast, Northern Ireland
| | - Anna O'Sullivan
- School of Medicine, University College Dublin, Belfield Dublin 4, Ireland
| | - David I Johnston
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
| | - Jonathan McAleese
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - Conor K McGarry
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
| | - Aidan J Cole
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - Suneil Jain
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
| | - Karl T Butterworth
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
| | - Gerard G Hanna
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
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Walls GM, Ghita M, Herron B, Edgar KS, Kuburas R, Watson CJ, Grieve DJ, Cole AJ, Jain S, Butterworth KT. A multimodality assessment of the protective capacity of statin therapy in a mouse model of radiation cardiotoxicity. Radiother Oncol 2024; 190:110004. [PMID: 37972738 DOI: 10.1016/j.radonc.2023.110004] [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: 05/11/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Despite technological advances in radiotherapy (RT), cardiotoxicity remains a common complication in patients with lung, oesophageal and breast cancers. Statin therapy has been shown to have pleiotropic properties beyond its lipid-lowering effects. Previous murine models have shown statin therapy can reduce short-term functional effects of whole-heart irradiation. In this study, we assessed the efficacy of atorvastatin in protecting against the late effects of radiation exposure on systolic function, cardiac conduction, and atrial natriuretic peptide (ANP) following a clinically relevant partial-heart radiation exposure. MATERIALS AND METHODS Female, 12-week old, C57BL/6j mice received an image-guided 16 Gy X-ray field to the base of the heart using a small animal radiotherapy research platform (SARRP), with or without atorvastatin from 1 week prior to irradiation until the end of the experiment. The animals were followed for 50 weeks with longitudinal transthoracic echocardiography (TTE) and electrocardiography (ECG) every 10 weeks, and plasma ANP every 20 weeks. RESULTS At 30-50 weeks, mild left ventricular systolic function impairment observed in the RT control group was less apparent in animals receiving atorvastatin. ECG analysis demonstrated prolongation of components of cardiac conduction related to the heart base at 10 and 30 weeks in the RT control group but not in animals treated with atorvastatin. In contrast to systolic function, conduction disturbances resolved at later time-points with radiation alone. ANP reductions were lower in irradiated animals receiving atorvastatin at 30 and 50 weeks. CONCLUSIONS Atorvastatin prevents left ventricular systolic dysfunction, and the perturbation of cardiac conduction following partial heart irradiation. If confirmed in clinical studies, these data would support the use of statin therapy for cardioprotection during thoracic radiotherapy.
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Affiliation(s)
- Gerard M Walls
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, UK; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK.
| | - Mihaela Ghita
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Brian Herron
- Department of Histopathology Royal Victoria Hospital, Belfast Health & Social Care Trust, Falls Road, Belfast, UK
| | - Kevin S Edgar
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Refik Kuburas
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Chris J Watson
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - David J Grieve
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Aidan J Cole
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, UK; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Suneil Jain
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, UK; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
| | - Karl T Butterworth
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, UK
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van der Ree MH, Hoeksema WF, Luca A, Visser J, Balgobind BV, Zumbrink M, Spier R, Herrera-Siklody C, Lee J, Bates M, Daniel J, Peedell C, Boda-Heggemann J, Rudic B, Merten R, Dieleman EM, Rinaldi CA, Ahmad S, Whitaker J, Bhagirath P, Hatton MQ, Riley S, Grehn M, Schiappacasse L, Blanck O, Hohmann S, Pruvot E, Postema PG. Stereotactic arrhythmia radioablation: A multicenter pre-post intervention safety evaluation of the implantable cardioverter-defibrillator function. Radiother Oncol 2023; 189:109910. [PMID: 37709052 DOI: 10.1016/j.radonc.2023.109910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Stereotactic arrhythmia radioablation (STAR) appears to be beneficial in selected patients with therapy-refractory ventricular tachycardia (VT). However, high-dose radiotherapy used for STAR-treatment may affect functioning of the patients' implantable cardioverter defibrillator (ICD) by direct effects of radiation on ICD components or cardiac tissue. Currently, the effect of STAR on ICD functioning remains unknown. METHODS A retrospective pre-post multicenter study evaluating ICD functioning in the 12-month before and after STAR was performed. Patients with (non)ischemic cardiomyopathies with therapy-refractory VT and ICD who underwent STAR were included and the occurrence of ICD-related adverse events was collected. Evaluated ICD parameters included sensing, capture threshold and impedance. A linear mixed-effects model was used to investigate the association between STAR, radiotherapy dose and changes in lead parameters over time. RESULTS In total, 43 patients (88% male) were included in this study. All patients had an ICD with an additional right atrial lead in 34 (79%) and a ventricular lead in 17 (40%) patients. Median ICD-generator dose was 0.1 Gy and lead tip dose ranged from 0-32 Gy. In one patient (2%), a reset occurred during treatment, but otherwise, STAR and radiotherapy dose were not associated with clinically relevant alterations in ICD leads parameters. CONCLUSIONS STAR treatment did not result in major ICD malfunction. Only one radiotherapy related adverse event occurred during the study follow-up without patient harm. No clinically relevant alterations in ICD functioning were observed after STAR in any of the leads. With the reported doses STAR appears to be safe.
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Affiliation(s)
- Martijn H van der Ree
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Wiert F Hoeksema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Adrian Luca
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Jorrit Visser
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Brian V Balgobind
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Michiel Zumbrink
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Raymond Spier
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - Justin Lee
- Department of Cardiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Matthew Bates
- Department of Cardiology, South Tees Hospitals NHS Foundation Trust, Middleborough, UK
| | - Jim Daniel
- Department of Radiation Oncology, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Clive Peedell
- Department of Radiation Oncology, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Boris Rudic
- Department of Cardiology, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Roland Merten
- Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Edith M Dieleman
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Cristopher A Rinaldi
- Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Shahreen Ahmad
- Department of Radiation Oncology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - John Whitaker
- Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Pranav Bhagirath
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands; Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Matthew Q Hatton
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - Stephen Riley
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Luis Schiappacasse
- Department of Radiation Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Etienne Pruvot
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pieter G Postema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.
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Kaestner L, Boda-Heggemann J, Fanslau H, Xie J, Schweikard A, Giordano FA, Blanck O, Rudic B. Electroanatomical mapping after cardiac radioablation for treatment of incessant electrical storm: a case report from the RAVENTA trial. Strahlenther Onkol 2023; 199:1018-1024. [PMID: 37698592 PMCID: PMC10598131 DOI: 10.1007/s00066-023-02136-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/07/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Electroanatomical mapping (EAM)-guided stereotactic arrhythmia radioablation (STAR) is a novel noninvasive therapy option for patients with monomorphic ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or urgent catheter ablation (CA). Data on success rates in an emergency situation such as electrical storm (ES) are rare. We present a case of a patient with an initially very poor life expectancy after extensive myocardial infarction with therapy-resistant ES, not amendable for further antiarrhythmic drug therapy, implantable cardioverter-defibrillator implantation, or repeated CA who was introduced to the radiation oncology department for emergency STAR as a bail-out therapy. METHODS Target volume definition and transfer from EAM to CT were validated and quality assured with a semi-automatic, dedicated visualization tool (CARDIO-RT). Emergency STAR was performed with 25 Gy in the framework of the RAVENTA study. The VT burden gradually decreased after STAR; however, a second VT morphology occurred, which was successfully treated with EAM-guided CA 12 days after STAR. RESULTS The second EAM-guided CA showed areas of low voltage in the irradiated segments, indicating a precise targeting and early functional response to STAR. The patient remained free of any VT recurrence or any radiation-related toxicities and in good general condition during the recent follow-up of 18 months. CONCLUSION The case highlights the possible approach, caveats, difficulties, and prognosis of a patient severely affected by therapy-resistant VT in whom CA could not lead to VT suppression. Further studies of putative mechanisms of STAR in the acute and chronic phase of this novel therapy are warranted.
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Affiliation(s)
- Lena Kaestner
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany.
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Judit Boda-Heggemann
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Hannah Fanslau
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jingyang Xie
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Frank A Giordano
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Boris Rudic
- I. Department of Medicine: Cardiology, Angiology, Hemostaseology and Intensive Care, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- DZHK (German Centre for Cardiovascular Research) partner site Mannheim, Mannheim, Germany
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9
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Herrera Siklody C, Schiappacasse L, Jumeau R, Reichlin T, Saguner AM, Andratschke N, Elicin O, Schreiner F, Kovacs B, Mayinger M, Huber A, Verhoeff JJC, Pascale P, Solana Muñoz J, Luca A, Domenichini G, Moeckli R, Bourhis J, Ozsahin EM, Pruvot E. Recurrences of ventricular tachycardia after stereotactic arrhythmia radioablation arise outside the treated volume: analysis of the Swiss cohort. Europace 2023; 25:euad268. [PMID: 37695314 PMCID: PMC10551232 DOI: 10.1093/europace/euad268] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/16/2023] [Indexed: 09/12/2023] Open
Abstract
AIMS Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of therapy-refractory ventricular tachycardia (VT). VT recurrences have been reported after STAR but the mechanisms remain largely unknown. We analysed recurrences in our patients after STAR. METHODS AND RESULTS From 09.2017 to 01.2020, 20 patients (68 ± 8 y, LVEF 37 ± 15%) suffering from refractory VT were enrolled, 16/20 with a history of at least one electrical storm. Before STAR, an invasive electroanatomical mapping (Carto3) of the VT substrate was performed. A mean dose of 23 ± 2 Gy was delivered to the planning target volume (PTV). The median ablation volume was 26 mL (range 14-115) and involved the interventricular septum in 75% of patients. During the first 6 months after STAR, VT burden decreased by 92% (median value, from 108 to 10 VT/semester). After a median follow-up of 25 months, 12/20 (60%) developed a recurrence and underwent a redo ablation. VT recurrence was located in the proximity of the treated substrate in nine cases, remote from the PTV in three cases and involved a larger substrate over ≥3 LV segments in two cases. No recurrences occurred inside the PTV. Voltage measurements showed a significant decrease in both bipolar and unipolar signal amplitude after STAR. CONCLUSION STAR is a new tool available for the treatment of VT, allowing for a significant reduction of VT burden. VT recurrences are common during follow-up, but no recurrences were observed inside the PTV. Local efficacy was supported by a significant decrease in both bipolar and unipolar signal amplitude.
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Affiliation(s)
| | - Luis Schiappacasse
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Raphaël Jumeau
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Ardan M Saguner
- Department of Cardiology, Universitätsspital Zürich, University Hospital Zürich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, Universitätsspital Zürich, University Hospital Zürich, Zurich, Switzerland
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Boldizsar Kovacs
- Department of Cardiology, Universitätsspital Zürich, University Hospital Zürich, Zurich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, Universitätsspital Zürich, University Hospital Zürich, Zurich, Switzerland
| | - Adrian Huber
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Joost J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patrizio Pascale
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Jorge Solana Muñoz
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Adrian Luca
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Giulia Domenichini
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Raphael Moeckli
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Esat M Ozsahin
- Department of Radiation Oncology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Etienne Pruvot
- Department of Cardiology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
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10
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Wang S, Luo H, Mao T, Xiang C, Hu H, Zhao J, Wang X, Wang J, Liu H, Yu L, Jiang H. Stereotactic arrhythmia radioablation: A novel therapy for cardiac arrhythmia. Heart Rhythm 2023; 20:1327-1336. [PMID: 37150313 DOI: 10.1016/j.hrthm.2023.04.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 05/09/2023]
Abstract
Cardiac arrhythmia is a global health problem, and catheter ablation has been one of its main treatments for decades. However, catheter ablation is an invasive method that cannot reach the deep myocardium, and it carries a considerable risk of side effects and recurrence. Therefore, it is necessary to explore a novel approach. Stereotactic body radiotherapy, which has been widely used in the field of radiation oncology, has recently expanded in the treatment of cardiac arrhythmia; when used in this context, it is known as stereotactic arrhythmia radioablation (STAR). As a noninvasive, effective, and well-tolerated treatment, STAR may be a suitable alternative method for patients with cardiac arrhythmia who are resistant or intolerant to catheter ablation. The main particles used to deliver energy in STAR are photons, protons, and carbon ions. Most studies have shown the short-term effectiveness of STAR, but problems such as a high long-term recurrence rate with a cumulative ventricular tachycardia-free survival rate from the published literature of 38.6% and related complications have also emerged. Therefore, in this article, we review the application of stereotactic body radiotherapy in cardiac arrhythmia, analyze its potential problems, and explore methods for improvement.
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Affiliation(s)
- Songyun Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Hao Luo
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Tianlong Mao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Chunrong Xiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Haoyuan Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Jiahui Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Xinqi Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Jiale Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Huafen Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, P.R. China; Cardiac Autonomic Nervous System Research Center of Wuhan University, Wuhan, P.R. China; Cardiovascular Research Institute, Wuhan University, Wuhan, P.R. China; Hubei Key Laboratory of Cardiology, Wuhan, P.R. China.
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11
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Guarracini F, Tritto M, Di Monaco A, Mariani MV, Gasperetti A, Compagnucci P, Muser D, Preda A, Mazzone P, Themistoclakis S, Carbucicchio C. Stereotactic Arrhythmia Radioablation Treatment of Ventricular Tachycardia: Current Technology and Evolving Indications. J Cardiovasc Dev Dis 2023; 10:jcdd10040172. [PMID: 37103051 PMCID: PMC10143260 DOI: 10.3390/jcdd10040172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 04/28/2023] Open
Abstract
Ventricular tachycardia in patients with structural heart disease is a significant cause of morbidity and mortality. According to current guidelines, cardioverter defibrillator implantation, antiarrhythmic drugs, and catheter ablation are established therapies in the management of ventricular arrhythmias but their efficacy is limited in some cases. Sustained ventricular tachycardia can be terminated by cardioverter-defibrillator therapies although shocks in particular have been demonstrated to increase mortality and worsen patients' quality of life. Antiarrhythmic drugs have important side effects and relatively low efficacy, while catheter ablation, even if it is actually an established treatment, is an invasive procedure with intrinsic procedural risks and is frequently affected by patients' hemodynamic instability. Stereotactic arrhythmia radioablation for ventricular arrhythmias was developed as bail-out therapy in patients unresponsive to traditional treatments. Radiotherapy has been mainly applied in the oncological field, but new current perspectives have developed in the field of ventricular arrhythmias. Stereotactic arrhythmia radioablation provides an alternative non-invasive and painless therapeutic strategy for the treatment of previously detected cardiac arrhythmic substrate by three-dimensional intracardiac mapping or different tools. Since preliminary experiences have been reported, several retrospective studies, registries, and case reports have been published in the literature. Although, for now, stereotactic arrhythmia radioablation is considered an alternative palliative treatment for patients with refractory ventricular tachycardia and no other therapeutic options, this research field is currently extremely promising.
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Affiliation(s)
| | - Massimo Tritto
- Electrophysiology and Cardiac Pacing Unit, Humanitas Mater Domini Hospital, 21053 Castellanza, Italy
| | - Antonio Di Monaco
- Cardiology Department, General Regional Hospital F. Miulli, 70021 Acquaviva delle Fonti, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, 00100 Rome, Italy
| | - Alessio Gasperetti
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti Umberto I-Lancisi-Salesi, 60126 Ancona, Italy
| | - Daniele Muser
- Cardiothoracic Department, University Hospital, 33100 Udine, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Patrizio Mazzone
- Cardiothoracovascular Department, Electrophysiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Sakis Themistoclakis
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell'Angelo Hospital, Mestre, 30174 Venice, Italy
| | - Corrado Carbucicchio
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
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12
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Bonaparte I, Gregucci F, Di Monaco A, Troisi F, Surgo A, Ludovico E, Carbonara R, Paulicelli E, Sanfrancesco G, De Pascali C, Vitulano N, Quadrini F, Ciliberti MP, Romanazzi I, Di Guglielmo FC, Cusumano D, Calbi R, Grimaldi M, Fiorentino A. Phase II Trial of LINAC-Based STereotactic Arrhythmia Radioablation (STAR) for Paroxysmal Atrial Fibrillation in Elderly: Planning and Dosimetric Point of View. J Pers Med 2023; 13:jpm13040596. [PMID: 37108982 PMCID: PMC10143465 DOI: 10.3390/jpm13040596] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/13/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
Purpose: Approaching treatment for elderly patients with atrial fibrillation is difficult. A prospective phase II trial evaluating LINAC-based stereotactic arrhythmia radioablation (STAR) safety in this population started in 2021. Dosimetric and planning data were reported. Materials and Methods: A vac-lock bag was used for immobilization in the supine position and a computed tomography (CT, 1 mm) was performed. The clinical target volume (CTV) was defined as the area around the pulmonary veins. An internal target volume (ITV) was added to the CTV to compensate heart and respiratory movement. The planning target volume (PTV) was defined by adding 0–3 mm to the ITV. STAR was performed during free-breathing with a PTV prescription total dose (Dp) of 25 Gy/1 fraction. Flattening filter-free volumetric-modulated arc therapy plans were generated, optimized, and delivered by TrueBeamTM. Image-guided radiotherapy with cone-beam CT and surface-guided radiotherapy with Align-RT (Vision RT) were employed. Results: From May 2021 to March 2022, 10 elderly patients were treated. Mean CTVs, ITVs, and PTVs were 23.6 cc, 44.32 cc, and 62.9 cc, respectively; the mean prescription isodose level and D2% were 76.5% and 31.2 Gy, respectively. The average heart and left anterior descending artery (LAD) Dmean were 3.9 and 6.3 Gy, respectively; the mean Dmax for LAD, spinal cord, left and right bronchus, and esophagus were 11.2, 7.5, 14.3, 12.4, and 13.6 Gy, respectively. The overall treatment time (OTT) was 3 min. Conclusions: The data showed an optimal target coverage, sparing surrounding tissue, in 3 min of OTT. LINAC-based STAR for AF could represent a valid non-invasive alternative for elderly patients who were excluded from catheter ablation.
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13
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Short-term and long-term effects of noninvasive cardiac radioablation for ventricular tachycardia: A single-center case series. Heart Rhythm O2 2023; 4:119-126. [PMID: 36873313 PMCID: PMC9975004 DOI: 10.1016/j.hroo.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Noninvasive cardiac radioablation is reported to be effective and safe for the treatment of ventricular tachycardia (VT). Objective This study aimed to analyze the acute and long-term effects of VT radioablation. Methods Patients with intractable VT or premature ventricular contraction (PVC)-induced cardiomyopathy were included in this study and treated using a single-fraction 25-Gy dose of cardiac radioablation. To quantitatively analyze the acute response after treatment, continuous electrocardiography monitoring was performed from 24 hours before to 48 hours after irradiation and at the 1-month follow-up. Long-term clinical safety and efficacy were assessed 1-year follow-up. Results From 2019 to 2020, 6 patients were treated with radioablation for ischemic VT (n = 3), nonischemic VT (n = 2), or PVC-induced cardiomyopathy (n = 1). In the short-term assessment, the total burden of ventricular beats decreased by 49% within 24 hours after radioablation and further decreased by 70% at 1 month. The VT component decreased earlier and more dramatically than the PVC component (decreased by 91% and 57% at 1 month, respectively). In the long-term assessment, 5 patients showed complete (n = 3) or partial (n = 2) remission of ventricular arrhythmias. One patient showed recurrence at 10 months, which was successfully suppressed with medical treatment. The posttreatment PVC coupling interval was prolonged (+38 ms at 1 month). Ischemic VT burden decreased more markedly than nonischemic VT burden after radioablation. Conclusion In this small case series of 6 patients, without a comparison group, cardiac radioablation appeared to decrease the intractable VT burden. A therapeutic effect was apparent within 1-2 days after treatment but was variable by etiology of cardiomyopathy.
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Kučera T, Jedličková K, Šramko M, Peichl P, Cvek J, Knybel L, Hurník P, Neuwirth R, Jiravský O, Voska L, Kautzner J. Inflammation and fibrosis characterize different stages of myocardial remodeling in patients after stereotactic body radiotherapy of ventricular myocardium for recurrent ventricular tachycardia. Cardiovasc Pathol 2023; 62:107488. [PMID: 36206914 PMCID: PMC9760563 DOI: 10.1016/j.carpath.2022.107488] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/29/2022] [Accepted: 09/29/2022] [Indexed: 01/03/2023] Open
Abstract
We performed a histological and immunohistochemical analysis of myocardia from 3 patients who underwent radiosurgery and died for various reasons 3 months to 9 months after radiotherapy. In Case 1 (death 3 months after radiotherapy) we observed a sharp transition between relatively intact and irradiated regions. In the myolytic foci, only scattered cardiomyocytes were left and the area was infiltrated by immune cells. Using immunohistochemistry we detected numerous inflammatory cells including CD68+/CD11c+ macrophages, CD4+ and CD8+ T-lymphocytes and some scattered CD20+ B-lymphocytes. Mast cells were diminished in contrast to viable myocardium. In Case 2 and Case 3 (death 6 and 9 months after radiotherapy, respectively) we found mostly fibrosis, infiltration by adipose tissue and foci of calcification. Inflammatory infiltrates were less pronounced. Our observations are in accordance with animal experimental studies and confirm a progress from myolysis to fibrosis. In addition, we demonstrate a role of pro-inflammatory macrophages in the earlier stages of myocardial remodeling after stereotactic radioablation for ventricular tachycardia.
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Affiliation(s)
- Tomáš Kučera
- Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Albertov 4, 120 00, Prague, Czech Republic,Corresponding author: Tomáš Kučera, MD, Ph.D. Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Albertov 4, 120 00, Prague, Czech Republic, Phone Number: +420224968130.
| | - Kristína Jedličková
- Department of Pathology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
| | - Marek Šramko
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, 17. listopadu 1790, 708 52, Ostrava, Czech Republic
| | - Lukáš Knybel
- Department of Oncology, University Hospital Ostrava, 17. listopadu 1790, 708 52, Ostrava, Czech Republic
| | - Pavel Hurník
- Institute of Clinical and Molecular Pathology and Medical Genetics, University Hospital Ostrava, 17. listopadu 1790, 708 52, Ostrava, Czech Republic
| | - Radek Neuwirth
- Faculty of Medicine, Masaryk University, Brno, Kamenice 753/5, 625 00 Brno,Agel Hospital Třinec Podlesí a.s., Konská 453, 739 61 Třinec, Czech Republic
| | - Otakar Jiravský
- Faculty of Medicine, Masaryk University, Brno, Kamenice 753/5, 625 00 Brno,Agel Hospital Třinec Podlesí a.s., Konská 453, 739 61 Třinec, Czech Republic
| | - Luděk Voska
- Department of Pathology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Vídeňská 1958, 140 21, Prague, Czech Republic
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15
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Haskova J, Sramko M, Cvek J, Kautzner J. Stereotactic Radiotherapy in the Management of Ventricular Tachycardias: More Questions than Answers? Card Electrophysiol Clin 2022; 14:779-792. [PMID: 36396193 DOI: 10.1016/j.ccep.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Stereotactic body radiotherapy is a recent promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias (VTs) in patients with structural heart disease. Initial clinical experience with a single radiation dose of 25 Gy shows reasonable efficacy in the reduction of VT recurrences with acceptable acute toxicity. Many unanswered questions remain, including unknown mechanism of action, variable time to effect, optimal method of substrate targeting, long-term safety, and definition of an optimal candidate for this treatment."
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Affiliation(s)
- Jana Haskova
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic.
| | - Marek Sramko
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava and Ostrava University Medical School, 17 listopadu 1790/5, Ostrava-Poruba 708 00 Czech Republic
| | - Josef Kautzner
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic; Palacky University Medical School, Olomouc, Czech Republic
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16
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Kim BH, Jung JW, Han D, Cha MJ, Chang JH. One-Week Dynamic Changes in Cardiac Proteomes After Cardiac Radioablation in Experimental Rat Model. Front Cardiovasc Med 2022; 9:898222. [PMID: 35837601 PMCID: PMC9273889 DOI: 10.3389/fcvm.2022.898222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022] Open
Abstract
Background Recently, stereotactic ablative radiotherapy (SABR) has been adopted to non-invasively treat catheter ablation-refractory ventricular tachycardia (VT). VT episodes have been dramatically reduced after SABR, within weeks; however the underlying mechanisms of these clinical effects and potential mediators of early anti-arrhythmic effect remain unclear. Methods In this study, cardiac tissue was harvested from non-irradiated control (0 Gy), conventional irradiated control (2 Gy), and radioablative test (25 Gy) rat groups after 3 and 7 days of irradiation. The samples were proteomically analyzed to identify the differentially expressed proteins (DEP) between different groups. Validation experiments were performed similar to validation in profiling where Data independent acquisition and parallel reaction monitoring methods were used. Data are available via ProteomeXchange with identifier PXD030878. Results Functional enrichment analysis of 25 Gy sample showed that among the downregulated proteins, "intracellular signal transduction" and "cell to cell adhesion" proteins were significantly affected at day 3 while "Ras protein signal transduction," "GTPase regulation," and "actin filament-based process" proteins were majorly affected at day 7. GO analysis demonstrated that most of the upregulated proteins belonged to the classes "cellular stress response," "endomembranal organization," or "endoplasmic reticulum stress response" at day 3. At day 7, 42 proteins, mainly associated with response to drug, organic substance, or radiation, were specifically upregulated in 25 Gy. DEP analysis of cardiac conduction showed Ryr2 and Cav1 upregulation and Cacna2d2, Gja3, Scnb2, and Kcnn3 downregulation in the 25 Gy group compared to 0 Gy. In validation experiments, four proteins (Gsta1, Myot, Ephx1, and Capg) were repeatedly detected with 25 Gy-specific patterns at day 7. Conclusions 25 Gy single fractional irradiation induces considerable cardiac proteome changes within the first 7 days, distinct from 2 Gy. Several candidate proteins displayed 25 Gy-specific changes and were related to oxidative stress-induced innate response or cardiac remodeling processes. Future studies should explore the specific role of these proteins upon cardiac radioablation.
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Affiliation(s)
- Byoung Hyuck Kim
- Department of Radiation Oncology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin Woo Jung
- Proteomics Core Facility, Transdisciplinary Research and Collaboration, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Dohyun Han
- Proteomics Core Facility, Transdisciplinary Research and Collaboration, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
- Transdisciplinary Department of Medicine and Advanced Technology, Seoul National University Hospital, Seoul, South Korea
| | - Myung-Jin Cha
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
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17
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Shangguan W, Xu G, Wang X, Zhang N, Liu X, Li G, Tse G, Liu T. Stereotactic Radiotherapy: An Alternative Option for Refractory Ventricular Tachycardia to Drug and Ablation Therapy. J Clin Med 2022; 11:jcm11123549. [PMID: 35743614 PMCID: PMC9225049 DOI: 10.3390/jcm11123549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/01/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Abstract
Refractory ventricular tachycardia (VT) often occurs in the context of organic heart disease. It is associated with significantly high mortality and morbidity rates. Antiarrhythmic drugs and catheter ablation represent the two main treatment options for refractory VT, but their use can be associated with inadequate therapeutic responses and procedure-related complications. Stereotactic body radiotherapy (SBRT) is extensively applied in the precision treatment of solid tumors, with excellent therapeutic responses. Recently, this highly precise technology has been applied for radioablation of VT, and its early results demonstrate a favorable safety profile. This review presents the potential value of SBRT in refractory VT.
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Affiliation(s)
- Wenfeng Shangguan
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Gang Xu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Xin Wang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Nan Zhang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Xingpeng Liu
- Department of Heart Center, Beijing Chaoyang Hospital, Capital Medical University, 8th Gongtinanlu Rd., Chaoyang District, Beijing 100020, China;
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
- Kent and Medway Medical School, Canterbury CT2 7FS, UK
- Correspondence: (G.T.); (T.L.)
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China; (W.S.); (G.X.); (X.W.); (N.Z.); (G.L.)
- Correspondence: (G.T.); (T.L.)
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18
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Haskova J, Peichl P, Šramko M, Cvek J, Knybel L, Jiravský O, Neuwirth R, Kautzner J. Case Report: Repeated Stereotactic Radiotherapy of Recurrent Ventricular Tachycardia: Reasons, Feasibility, and Safety. Front Cardiovasc Med 2022; 9:845382. [PMID: 35425817 PMCID: PMC9004321 DOI: 10.3389/fcvm.2022.845382] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/24/2022] [Indexed: 11/14/2022] Open
Abstract
Stereotactic body radiotherapy (SBRT) has been reported as an attractive option for cases of failed catheter ablation of ventricular tachycardia (VT) in structural heart disease. However, even this strategy can fail for various reasons. For the first time, this case series describes three re-do cases of SBRT which were indicated for three different reasons. The purpose in the first case was the inaccuracy of the determination of the treatment volume by indirect comparison of the electroanatomical map and CT scan. A newly developed strategy of co-registration of both images allowed precise targeting of the substrate. In this case, the second treatment volume overlapped by 60% with the first one. The second reason for the re-do of SBRT was an unusual character of the substrate–large cardiac fibroma associated with different morphologies of VT from two locations around the tumor. The planned treatment volumes did not overlap. The third reason for repeated SBRT was the large intramural substrate in the setting of advanced heart failure. The first treatment volume targeted arrhythmias originating in the basal inferoseptal region, while the second SBRT was focused on adjacent basal septum without significant overlapping. Our observations suggested that SBRT for VT could be safely repeated in case of later arrhythmia recurrences (i.e., after at least 6 weeks). No acute toxicity was observed and in two cases, no side effects were observed during 32 and 22 months, respectively. To avoid re-do SBRT due to inaccurate targeting, the precise and reproducible strategy of substrate identification and co-registration with CT image should be used.
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Affiliation(s)
- Jana Haskova
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czechia
- *Correspondence: Jana Haskova
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czechia
| | - Marek Šramko
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czechia
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czechia
- Department of Oncology, Ostrava University Medical School, Ostrava, Czechia
| | - Lukáš Knybel
- Department of Oncology, University Hospital Ostrava, Ostrava, Czechia
| | - Otakar Jiravský
- Department of Cardiology, Podlesí Hospital Trinec, Trinec, Czechia
| | - Radek Neuwirth
- Department of Cardiology, Podlesí Hospital Trinec, Trinec, Czechia
- Department of Cardiology, Masaryk University Medical School, Brno, Czechia
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czechia
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19
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Ortiz de Choudens S, Sparapani R, Narayanan J, Lohr N, Gao F, Fish BL, Zielonka M, Gasperetti T, Veley D, Beyer A, Olson J, Jacobs ER, Medhora M. Lisinopril Mitigates Radiation-Induced Mitochondrial Defects in Rat Heart and Blood Cells. Front Oncol 2022; 12:828177. [PMID: 35311118 PMCID: PMC8924663 DOI: 10.3389/fonc.2022.828177] [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: 12/03/2021] [Accepted: 01/31/2022] [Indexed: 12/20/2022] Open
Abstract
The genetic bases and disparate responses to radiotherapy are poorly understood, especially for cardiotoxicity resulting from treatment of thoracic tumors. Preclinical animal models such as the Dahl salt-sensitive (SS) rat can serve as a surrogate model for salt-sensitive low renin hypertension, common to African Americans, where aldosterone contributes to hypertension-related alterations of peripheral vascular and renal vascular function. Brown Norway (BN) rats, in comparison, are a normotensive control group, while consomic SSBN6 with substitution of rat chromosome 6 (homologous to human chromosome 14) on an SS background manifests cardioprotection and mitochondrial preservation to SS rats after injury. In this study, 2 groups from each of the 3 rat strains had their hearts irradiated (8 Gy X 5 fractions). One irradiated group was treated with the ACE-inhibitor lisinopril, and a separate group in each strain served as nonirradiated controls. Radiation reduced cardiac end diastolic volume by 9-11% and increased thickness of the interventricular septum (11-16%) and left ventricular posterior wall (14-15%) in all 3 strains (5-10 rats/group) after 120 days. Lisinopril mitigated the increase in posterior wall thickness. Mitochondrial function was measured by the Seahorse Cell Mitochondrial Stress test in peripheral blood mononuclear cells (PBMC) at 90 days. Radiation did not alter mitochondrial respiration in PBMC from BN or SSBN6. However, maximal mitochondrial respiration and spare capacity were reduced by radiation in PBMC from SS rats (p=0.016 and 0.002 respectively, 9-10 rats/group) and this effect was mitigated by lisinopril (p=0.04 and 0.023 respectively, 9-10 rats/group). Taken together, these results indicate injury to the heart by radiation in all 3 strains of rats, although the SS rats had greater susceptibility for mitochondrial dysfunction. Lisinopril mitigated injury independent of genetic background.
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Affiliation(s)
| | - Rodney Sparapani
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, United States.,Cardiovascular Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Cancer Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jayashree Narayanan
- Department of Radiation Oncology, Froedtert & the Medical College of Wisconsin, Milwaukee WI, United States
| | - Nicole Lohr
- Cardiovascular Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States
| | - Feng Gao
- Department of Radiation Oncology, Froedtert & the Medical College of Wisconsin, Milwaukee WI, United States
| | - Brian L Fish
- Department of Radiation Oncology, Froedtert & the Medical College of Wisconsin, Milwaukee WI, United States
| | - Monika Zielonka
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Tracy Gasperetti
- Department of Radiation Oncology, Froedtert & the Medical College of Wisconsin, Milwaukee WI, United States
| | - Dana Veley
- Department of Radiation Oncology, Froedtert & the Medical College of Wisconsin, Milwaukee WI, United States
| | - Andreas Beyer
- Cardiovascular Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jessica Olson
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, United States.,Cardiovascular Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Cancer Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States
| | - Elizabeth R Jacobs
- Cardiovascular Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Cancer Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Pulmonary Medicine, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Research Service, Veterans Affairs, Zablocki VA Medical Center (VAMC), Milwaukee, WI, United States
| | - Meetha Medhora
- Department of Radiation Oncology, Froedtert & the Medical College of Wisconsin, Milwaukee WI, United States.,Cardiovascular Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Cancer Center, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Pulmonary Medicine, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Research Service, Veterans Affairs, Zablocki VA Medical Center (VAMC), Milwaukee, WI, United States
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20
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Hayase J, Chin R, Cao M, Hu P, Shivkumar K, Bradfield JS. Non-invasive Stereotactic Body Radiation Therapy for Refractory Ventricular Arrhythmias: Venturing into the Unknown. J Innov Card Rhythm Manag 2022; 13:4894-4899. [PMID: 35251759 PMCID: PMC8887931 DOI: 10.19102/icrm.2022.130202] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and safety, but randomized data and long-term outcomes are not yet available. The primary hypothesis as to the mechanism of action for SBRT relates to the development of cardiac fibrosis in arrhythmogenic myocardial substrate; however, limited animal model data offer conflicting insights into this theory. The use of SBRT for patients with refractory ventricular arrhythmias is rapidly increasing, but ongoing translational science work and randomized clinical trials will be critical to address many outstanding questions regarding this novel therapy.
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Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Robert Chin
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Minsong Cao
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Peng Hu
- Department of Radiological Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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21
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Akdag O, Mandija S, van Lier AL, Borman PT, Schakel T, Alberts E, van der Heide O, Hassink RJ, Verhoeff JJ, Mohamed Hoesein FA, Raaymakers BW, Fast MF. Feasibility of cardiac-synchronized quantitative T1 and T2 mapping on a hybrid 1.5 Tesla magnetic resonance imaging and linear accelerator system. Phys Imaging Radiat Oncol 2022; 21:153-159. [PMID: 35287380 PMCID: PMC8917300 DOI: 10.1016/j.phro.2022.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/18/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose Materials and methods Results Conclusions
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Affiliation(s)
- Osman Akdag
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Corresponding author.
| | - Stefano Mandija
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Astrid L.H.M.W. van Lier
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Pim T.S. Borman
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Tim Schakel
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Eveline Alberts
- Philips Healthcare, Veenpluis 6 5684 PC Best, The Netherlands
| | - Oscar van der Heide
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Rutger J. Hassink
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Joost J.C. Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Firdaus A.A. Mohamed Hoesein
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Bas W. Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Martin F. Fast
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Corresponding author.
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22
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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.
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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
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23
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[Cardiac stereotactic radiotherapy induces electrical conduction reprogramming]. Strahlenther Onkol 2021; 198:209-211. [PMID: 34928433 PMCID: PMC8789705 DOI: 10.1007/s00066-021-01891-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 12/04/2022]
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24
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Hohmann S, Hillmann HAK, Müller-Leisse J, Eiringhaus J, Zormpas C, Merten R, Veltmann C, Duncker D. Stereotactic radioablation for ventricular tachycardia. Herzschrittmacherther Elektrophysiol 2021; 33:49-54. [PMID: 34825951 DOI: 10.1007/s00399-021-00830-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
Non-invasive stereotactic radioablation of ventricular tachycardia (VT) substrate has been proposed as a novel treatment modality for patients not eligible for catheter-based ablation or in whom this approach has failed. Initial clinical results are promising with good short-term efficacy in VT suppression and tolerable side effects. This article reviews the current clinical evidence for cardiac radioablation and gives an overview of important preclinical and translational results. Practical guidance is provided, and a cardiac radioablation planning and treatment workflow based on expert consensus and the authors' institutional experience is set out.
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Affiliation(s)
- Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Henrike A K Hillmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Johanna Müller-Leisse
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jörg Eiringhaus
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christos Zormpas
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Roland Merten
- Department of Radiotherapy, Hannover Medical School, Hannover, Germany
| | - Christian Veltmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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25
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Lee J, Bates M, Shepherd E, Riley S, Henshaw M, Metherall P, Daniel J, Blower A, Scoones D, Wilkinson M, Richmond N, Robinson C, Cuculich P, Hugo G, Seller N, McStay R, Child N, Thornley A, Kelland N, Atherton P, Peedell C, Hatton M. Cardiac stereotactic ablative radiotherapy for control of refractory ventricular tachycardia: initial UK multicentre experience. Open Heart 2021; 8:openhrt-2021-001770. [PMID: 34815300 PMCID: PMC8611439 DOI: 10.1136/openhrt-2021-001770] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/01/2021] [Indexed: 12/25/2022] Open
Abstract
Background Options for patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or catheter ablation remain limited. Stereotactic radiotherapy has been described as a novel treatment option. Methods Seven patients with recurrent refractory VT, deemed high risk for either first time or redo invasive catheter ablation, were treated across three UK centres with non-invasive cardiac stereotactic ablative radiotherapy (SABR). Prior catheter ablation data and non-invasive mapping were combined with cross-sectional imaging to generate radiotherapy plans with aim to deliver a single 25 Gy treatment. Shared planning and treatment guidelines and prospective peer review were used. Results Acute suppression of VT was seen in all seven patients. For five patients with at least 6 months follow-up, overall reduction in VT burden was 85%. No high-grade radiotherapy treatment-related side effects were documented. Three deaths (two early, one late) occurred due to heart failure. Conclusions Cardiac SABR showed reasonable VT suppression in a high-risk population where conventional treatment had failed.
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Affiliation(s)
- Justin Lee
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Matthew Bates
- Department of Cardiology, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Ewen Shepherd
- Department of Cardiology, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephen Riley
- Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Michael Henshaw
- Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Peter Metherall
- 3D Lab, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jim Daniel
- Department of Oncology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Alison Blower
- Department of Oncology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Scoones
- Department of Pathology, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Michele Wilkinson
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil Richmond
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Clifford Robinson
- Center for Noninvasive Cardiac Radioablation, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Phillip Cuculich
- Center for Noninvasive Cardiac Radioablation, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Geoffrey Hugo
- Center for Noninvasive Cardiac Radioablation, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Neil Seller
- Department of Cardiology, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ruth McStay
- Department of Radiology, Newcastle NHS Hospitals Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas Child
- Department of Cardiology, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Andrew Thornley
- Department of Cardiology, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Nicholas Kelland
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Philip Atherton
- Northern Centre for Cancer Care, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Clive Peedell
- Department of Oncology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Matthew Hatton
- Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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26
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Whitaker J, Mak RH, Zei PC. Non-invasive ablation of arrhythmias with stereotactic ablative radiotherapy. Trends Cardiovasc Med 2021; 32:287-296. [PMID: 33951498 DOI: 10.1016/j.tcm.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/14/2021] [Accepted: 04/25/2021] [Indexed: 12/31/2022]
Abstract
Stereotactic ablative radiotherapy (SABR), or stereotactic body radiotherapy (SBRT), has recently been applied in the field of arrhythmia management. It has been most widely assessed in the treatment of ventricular tachycardia (VT) but may also have potential in the treatment of other arrhythmias as well, often termed stereotactic arrhythmia radiotherapy (STAR). The non-invasive delivery of treatment for VT has the potential to spare an often physiologically vulnerable group of patients the burden of long catheter ablation procedures with the potential for prolonged periods of hemodynamic instability. Cardiac SABR also has the capacity to direct ablative therapy at substrate that is inaccessible using current transchatheter techniques. For these reasons cardiac SABR has generated significant enthusiasm as an emerging treatment modality for VT. We consider in review the pre-clinical data pertaining to the use of SABR in cardiac tissue and recent clinical evidence regarding the application of SABR in the field of arrhythmia management.
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Affiliation(s)
- John Whitaker
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Raymond H Mak
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Paul C Zei
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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27
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Cha MJ, Seo JW, Kim HJ, Kim MK, Yoon HS, Jo SW, Oh S, Chang JH. Early Changes in Rat Heart After High-Dose Irradiation: Implications for Antiarrhythmic Effects of Cardiac Radioablation. J Am Heart Assoc 2021; 10:e019072. [PMID: 33660526 PMCID: PMC8174197 DOI: 10.1161/jaha.120.019072] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Noninvasive cardiac radioablation is employed to treat ventricular arrhythmia. However, myocardial changes leading to early‐period antiarrhythmic effects induced by high‐dose irradiation are unknown. This study investigated dose‐responsive histologic, ultrastructural, and functional changes within 1 month after irradiation in rat heart. Methods and Results Whole hearts of wild‐type Lewis rats (N=95) were irradiated with single fraction 20, 25, 30, 40, or 50 Gy and explanted at 1 day or 1, 2, 3, or 4 weeks’ postirradiation. Microscopic pathologic changes of cardiac structures by light microscope with immunohistopathologic staining, ultrastructure by electron microscopy, and functional evaluation by ECG and echocardiography were studied. Despite high‐dose irradiation, no myocardial necrosis and apoptosis were observed. Intercalated discs were widened and disrupted, forming uneven and twisted junctions between adjacent myocytes. Diffuse vacuolization peaked at 3 weeks, suggesting irradiation dose‐responsiveness, which was correlated with interstitial and intracellular edema. CD68 immunostaining accompanying vacuolization suggested mononuclear cell infiltration. These changes were prominent in working myocardium but not cardiac conduction tissue. Intracardiac conduction represented by PR and QTc intervals on ECG was delayed compared with baseline measurements. ST segment was initially depressed and gradually elevated. Ventricular chamber dimensions and function remained intact without pericardial effusion. Conclusions Mononuclear cell–related intracellular and extracellular edema with diffuse vacuolization and intercalated disc widening were observed within 1 month after high‐dose irradiation. ECG indicated intracardiac conduction delay with prominent ST‐segment changes. These observations suggest that early antiarrhythmic effects after cardiac radioablation result from conduction disturbances and membrane potential alterations without necrosis.
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Affiliation(s)
- Myung-Jin Cha
- Division of Cardiology Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Jeong-Wook Seo
- Departments of Pathology Seoul National University Hospital Seoul South Korea
| | - Hak Jae Kim
- Department of Radiation Oncology Seoul National University College of Medicine Seoul Korea.,Department of Radiation Oncology Seoul National University Hospital Seoul South Korea.,Cancer Research InstituteSeoul National University College of Medicine Seoul Korea
| | - Moo-Kang Kim
- Division of Cardiology Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Hye-Sun Yoon
- Division of Cardiology Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Seong Won Jo
- Seoul National University College of Medicine Seoul Korea
| | - Seil Oh
- Division of Cardiology Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology Seoul National University College of Medicine Seoul Korea.,Department of Radiation Oncology Seoul National University Hospital Seoul South Korea
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