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Petzl A, Benali K, Mbolamena N, Dyrda K, Rivard L, Seidl S, Martins R, Martinek M, Pürerfellner H, Aguilar M. Patient-specific quantification of cardiorespiratory motion for cardiac stereotactic radioablation treatment planning. Heart Rhythm O2 2024; 5:234-242. [PMID: 38690147 PMCID: PMC11056453 DOI: 10.1016/j.hroo.2024.03.006] [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] [Indexed: 05/02/2024] Open
Abstract
Background Cardiac radioablation is a new treatment for patients with refractory ventricular tachycardia (VT). The target for cardiac radioablation is subject to cardiorespiratory motion (CRM), the heart's movement with breathing and cardiac contraction. Data regarding the magnitude of target CRM are limited but are highly important for treatment planning. Objectives The study sought to assess CRM amplitude by using ablation catheter geometrical data. Methods Electroanatomic mapping data of patients undergoing catheter ablation for VT at 3 academic centers were exported. The spatial position of the ablation catheter as a function of time while in contact with endocardium was analyzed and used to quantify CRM. Results Forty-four patients with ischemic and nonischemic cardiomyopathy and VT contributed 1364 ablation lesions to the analysis. Average cardiac and respiratory excursion were 1.62 ± 1.21 mm and 12.12 ± 4.10 mm, respectively. The average ratio of respiratory to cardiac motion was approximately 11:1. CRM was greatest along the craniocaudal axis (9.66 ± 4.00 mm). Regional variations with respect to respiratory and cardiac motion were observed: basal segments had smaller displacements vs midventricular and apical segments. Patient characteristics (previous cardiac surgery, height, weight, body mass index, and left ventricular ejection fraction) had a statistically significant, albeit clinically moderate, impact on CRM. Conclusion CRM is primarily determined by respiratory displacement and is modulated by the location of the target and the patient's biometric characteristics. The patient-specific quantification of CRM may allow to decrease treatment volume and reduce radiation exposure of surrounding organs at risk while delivering the therapeutic dose to the target.
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Affiliation(s)
- Adrian Petzl
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada
| | - Karim Benali
- Department of Cardiac Electrophysiology, Saint-Etienne University Hospital, France
| | - Nicolas Mbolamena
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada
| | - Katia Dyrda
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada
| | - Léna Rivard
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada
| | - Sebastian Seidl
- Department of Internal Medicine 2/Cardiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Raphaël Martins
- Department of Cardiac Electrophysiology, Rennes University Hospital, France
| | - Martin Martinek
- Department of Internal Medicine 2/Cardiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Helmut Pürerfellner
- Department of Internal Medicine 2/Cardiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Martin Aguilar
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute and Université de Montréal, Canada
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Lydiard, PGDip S, Blanck O, Hugo G, O’Brien R, Keall P. A Review of Cardiac Radioablation (CR) for Arrhythmias: Procedures, Technology, and Future Opportunities. Int J Radiat Oncol Biol Phys 2021; 109:783-800. [DOI: 10.1016/j.ijrobp.2020.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 10/23/2022]
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Poon J, Kohli K, Deyell MW, Schellenberg D, Reinsberg S, Teke T, Thomas S. Technical Note: Cardiac synchronized volumetric modulated arc therapy for stereotactic arrhythmia radioablation - Proof of principle. Med Phys 2020; 47:3567-3572. [PMID: 32415856 DOI: 10.1002/mp.14237] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/06/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Ventricular tachycardia (VT) is a rapid, abnormal heart rhythm that can lead to sudden cardiac death. Current treatment options include antiarrhythmic drug therapy and catheter ablation, both of which have only modest efficacy and have potential complications. Cardiac radiosurgery has the potential to be a noninvasive and efficient treatment option for VT. Cardiac motion, however, must be accounted for to ensure accurate dose delivery to the target region. Cardiac synchronized volumetric modulated arc therapy (CSVMAT) aims to minimize the dose delivered to normal tissues by synchronizing beam delivery with a cardiac signal, irradiating only during the quiescent intervals of the cardiac cycle (when heart motion is minimal) and adjusting the beam delivery speed in response to heart rate changes. METHODS A CSVMAT plan was adapted from a conventional VMAT plan and delivered on a Varian TrueBeam linear accelerator. The original VMAT plan was divided into three interleaved CSVMAT phases, each consisting of alternating beam-on and beam-off segments synchronized to a sample heart rate. Trajectory log files were collected for the original VMAT and CSVMAT deliveries and the dose distributions were measured with Gafchromic EBT-XD film. RESULTS Analysis of the trajectory log files showed successful synchronization with the sample cardiac signal. Film analysis comparing the original VMAT and CSVMAT dose distributions returned a gamma passing rate of 99.14% (2%/2 mm tolerance). CONCLUSIONS The film results indicated excellent agreement between the dose distributions of the original and cardiac synchronized beam deliveries. This study demonstrates a proof of principle cardiac synchronization strategy for precise radiation treatment plan delivery and adjustment to a variable heart rate. The cardiac synchronized technique may be advantageous in radioablation for VT.
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Affiliation(s)
- Justin Poon
- Department of Physics and Astronomy, University of British Columbia, Vancouver, BC, V6T 1Z1, Canada
| | - Kirpal Kohli
- Department of Medical Physics, BC Cancer -Surrey, Surrey, BC, V3V 1Z2, Canada
| | - Marc W Deyell
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, V6E 1M7, Canada
| | - Devin Schellenberg
- Department of Radiation Oncology, BC Cancer -Surrey, Surrey, British Columbia, V3V 1Z2, Canada
| | - Stefan Reinsberg
- Department of Physics and Astronomy, University of British Columbia, Vancouver, BC, V6T 1Z1, Canada
| | - Tony Teke
- Department of Medical Physics, BC Cancer -Kelowna, Kelowna, BC, V1Y 5L3, Canada
| | - Steven Thomas
- Department of Medical Physics, BC Cancer -Vancouver, Vancouver, BC, V5Z 4E6, Canada
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Pierson C, Woods R, Nekkanti R, Arastu H, Corns R, Ju AW. Thoracic Radiation Therapy in Patients With Entirely Intracardiac Leadless Cardiovascular Implantable Electronic Devices: 2 Case Reports and a Review of the Literature. Pract Radiat Oncol 2019; 9:e620-e624. [DOI: 10.1016/j.prro.2019.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 11/30/2022]
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Ipsen S, Blanck O, Lowther NJ, Liney GP, Rai R, Bode F, Dunst J, Schweikard A, Keall PJ. Towards real-time MRI-guided 3D localization of deforming targets for non-invasive cardiac radiosurgery. Phys Med Biol 2016; 61:7848-7863. [DOI: 10.1088/0031-9155/61/22/7848] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ipsen S, Blanck O, Oborn B, Bode F, Liney G, Hunold P, Rades D, Schweikard A, Keall PJ. Radiotherapy beyond cancer: target localization in real-time MRI and treatment planning for cardiac radiosurgery. Med Phys 2015; 41:120702. [PMID: 25471947 DOI: 10.1118/1.4901414] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Atrial fibrillation (AFib) is the most common cardiac arrhythmia that affects millions of patients world-wide. AFib is usually treated with minimally invasive, time consuming catheter ablation techniques. While recently noninvasive radiosurgery to the pulmonary vein antrum (PVA) in the left atrium has been proposed for AFib treatment, precise target location during treatment is challenging due to complex respiratory and cardiac motion. A MRI linear accelerator (MRI-Linac) could solve the problems of motion tracking and compensation using real-time image guidance. In this study, the authors quantified target motion ranges on cardiac magnetic resonance imaging (MRI) and analyzed the dosimetric benefits of margin reduction assuming real-time motion compensation was applied. METHODS For the imaging study, six human subjects underwent real-time cardiac MRI under free breathing. The target motion was analyzed retrospectively using a template matching algorithm. The planning study was conducted on a CT of an AFib patient with a centrally located esophagus undergoing catheter ablation, representing an ideal case for cardiac radiosurgery. The target definition was similar to the ablation lesions at the PVA created during catheter treatment. Safety margins of 0 mm (perfect tracking) to 8 mm (untracked respiratory motion) were added to the target, defining the planning target volume (PTV). For each margin, a 30 Gy single fraction IMRT plan was generated. Additionally, the influence of 1 and 3 T magnetic fields on the treatment beam delivery was simulated using Monte Carlo calculations to determine the dosimetric impact of MRI guidance for two different Linac positions. RESULTS Real-time cardiac MRI showed mean respiratory target motion of 10.2 mm (superior-inferior), 2.4 mm (anterior-posterior), and 2 mm (left-right). The planning study showed that increasing safety margins to encompass untracked respiratory motion leads to overlapping structures even in the ideal scenario, compromising either normal tissue dose constraints or PTV coverage. The magnetic field caused a slight increase in the PTV dose with the in-line MRI-Linac configuration. CONCLUSIONS The authors' results indicate that real-time tracking and motion compensation are mandatory for cardiac radiosurgery and MRI-guidance is feasible, opening the possibility of treating cardiac arrhythmia patients completely noninvasively.
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Affiliation(s)
- S Ipsen
- Radiation Physics Laboratory, Sydney Medical School, The University of Sydney, Sydney, New South Wales 2006, Australia and Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck 23562, Germany
| | - O Blanck
- Department of Radiation Oncology, University of Luebeck and University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck 23562, Germany
| | - B Oborn
- Illawarra Cancer Care Centre (ICCC), Wollongong, New South Wales 2500, Australia and Centre for Medical Radiation Physics (CMRP), University of Wollongong, Wollongong, New South Wales 2500, Australia
| | - F Bode
- Medical Department II, University of Luebeck and University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck 23562, Germany
| | - G Liney
- Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, New South Wales 2170, Australia
| | - P Hunold
- Department of Radiology and Nuclear Medicine, University of Luebeck and University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck 23562, Germany
| | - D Rades
- Department of Radiation Oncology, University of Luebeck and University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck 23562, Germany
| | - A Schweikard
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck 23562, Germany
| | - P J Keall
- Radiation Physics Laboratory, Sydney Medical School, The University of Sydney, Sydney, New South Wales 2006, Australia
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