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van der Ree MH, Cuculich PS, van Herk M, Hugo GD, Balt JC, Bates M, Ho G, Pruvot E, Herrera-Siklody C, Hoeksema WF, Lee J, Lloyd MS, Kemme MJB, Sacher F, Tixier R, Verhoeff JJC, Balgobind BV, Robinson CG, Rasch CRN, Postema PG. Interobserver variability in target definition for stereotactic arrhythmia radioablation. Front Cardiovasc Med 2023; 10:1267800. [PMID: 37799779 PMCID: PMC10547862 DOI: 10.3389/fcvm.2023.1267800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/05/2023] [Indexed: 10/07/2023] Open
Abstract
Background Stereotactic arrhythmia radioablation (STAR) is a potential new therapy for patients with refractory ventricular tachycardia (VT). The arrhythmogenic substrate (target) is synthesized from clinical and electro-anatomical information. This study was designed to evaluate the baseline interobserver variability in target delineation for STAR. Methods Delineation software designed for research purposes was used. The study was split into three phases. Firstly, electrophysiologists delineated a well-defined structure in three patients (spinal canal). Secondly, observers delineated the VT-target in three patients based on case descriptions. To evaluate baseline performance, a basic workflow approach was used, no advanced techniques were allowed. Thirdly, observers delineated three predefined segments from the 17-segment model. Interobserver variability was evaluated by assessing volumes, variation in distance to the median volume expressed by the root-mean-square of the standard deviation (RMS-SD) over the target volume, and the Dice-coefficient. Results Ten electrophysiologists completed the study. For the first phase interobserver variability was low as indicated by low variation in distance to the median volume (RMS-SD range: 0.02-0.02 cm) and high Dice-coefficients (mean: 0.97 ± 0.01). In the second phase distance to the median volume was large (RMS-SD range: 0.52-1.02 cm) and the Dice-coefficients low (mean: 0.40 ± 0.15). In the third phase, similar results were observed (RMS-SD range: 0.51-1.55 cm, Dice-coefficient mean: 0.31 ± 0.21). Conclusions Interobserver variability is high for manual delineation of the VT-target and ventricular segments. This evaluation of the baseline observer variation shows that there is a need for methods and tools to improve variability and allows for future comparison of interventions aiming to reduce observer variation, for STAR but possibly also for catheter ablation.
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Affiliation(s)
- Martijn H. van der Ree
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, Netherlands
| | - Phillip S. Cuculich
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO, United States
| | - Marcel van Herk
- Department of Radiation Oncology, Manchester Academic Health Centre, University of Manchester, Manchester, United Kingdom
| | - Geoffrey D. Hugo
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Jippe C. Balt
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Matthew Bates
- Department of Cardiology, South Tees Hospitals NHS Foundation Trust, Middleborough, United Kingdom
| | - Gordon Ho
- Department of Medicine, Division of Cardiology Cardiac Electrophysiology, Cardiovascular Institute, University of California San Diego, San Diego, CA, United States
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claudia Herrera-Siklody
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Wiert F. Hoeksema
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, Netherlands
| | - Justin Lee
- Department of Immunity, Infection and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Michael S. Lloyd
- Section of Cardiac Electrophysiology, Emory University, Atlanta, GA, United States
| | - Michiel J. B. Kemme
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, Netherlands
- Department of Cardiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Frederic Sacher
- Cardiac Arrhythmia Department, IHU LIRYC, Bordeaux University Hospital, Bordeaux, France
| | - Romain Tixier
- Cardiac Arrhythmia Department, IHU LIRYC, Bordeaux University Hospital, Bordeaux, France
| | | | | | - Clifford G. Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | | | - Pieter G. Postema
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, Netherlands
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van der Ree MH, Dieleman EMT, Visser J, Planken RN, Boekholdt SM, de Bruin-Bon RHA, Rasch CRN, Hoeksema WF, de Jong RMAJ, Kemme MJB, Balt JC, Wilde AAM, Balgobind BV, Postema PG. Non-invasive stereotactic arrhythmia radiotherapy for ventricular tachycardia: results of the prospective STARNL-1 trial. Europace 2023; 25:1015-1024. [PMID: 36746553 PMCID: PMC10062344 DOI: 10.1093/europace/euad020] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/09/2023] [Indexed: 02/08/2023] Open
Abstract
AIMS Stereotactic arrhythmia radiotherapy (STAR) is suggested as potentially effective and safe treatment for patients with therapy-refractory ventricular tachycardia (VT). However, the current prospective knowledge base and experience with STAR is limited. In this study we aimed to prospectively evaluate the efficacy and safety of STAR. METHODS AND RESULTS The StereoTactic Arrhythmia Radiotherapy in the Netherlands no.1 was a pre-post intervention study to prospectively evaluate efficacy and safety of STAR. In patients with therapy-refractory VT, the pro-arrhythmic region was treated with a 25 Gy single radiotherapy fraction. The main efficacy measure was a reduction in the number of treated VT-episodes by ≥50%, comparing the 12 months before and after treatment (or end of follow-up, excluding a 6-week blanking period). The study was deemed positive when ≥50% of patients would meet this criterion. Safety evaluation included left ventricular ejection fraction, pulmonary function, and adverse events. Six male patients with an ischaemic cardiomyopathy were enrolled, and median age was 73 years (range 54-83). Median left ventricular ejection fraction was 38% (range 24-52). The median planning target volume was 187 mL (range 93-372). Four (67%) patients completed the 12-month follow-up, and two patients died (not STAR related) during follow-up. The main efficacy measure of ≥50% reduction in treated VT-episodes at the end of follow-up was achieved in four patients (67%). The median number of treated VT-episodes was reduced by 87%. No reduction in left ventricular ejection fraction or pulmonary function was observed. No treatment related serious adverse events occurred. CONCLUSIONS STAR resulted in a ≥ 50% reduction in treated VT-episodes in 4/6 (67%) patients. No reduction in cardiac and pulmonary function nor treatment-related serious adverse events were observed during follow-up. CLINICAL TRIAL REGISTRATION Netherlands Trial Register-NL7510.
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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
| | - Edith M T Dieleman
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jorrit Visser
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - R Nils Planken
- Amsterdam UMC location University of Amsterdam, Department of Radiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Rianne H A de Bruin-Bon
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Coen R N Rasch
- Leiden UMC, University of Leiden, Department of Radiation Oncology, Albinusdreef 2, Leiden, The Netherlands
| | - Wiert F Hoeksema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Rianne M A J de Jong
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Michiel J B Kemme
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Clinical and Experimental Cardiology, Boelelaan 1117, Amsterdam, The Netherlands
| | - Jippe C Balt
- St. Antonius Hospital, Department of Cardiology, Koekoekslaan 1, Nieuwegein, The Netherlands
| | - Arthur A M Wilde
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Brian V Balgobind
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Pieter G Postema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
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