1
|
Zenger B, Smith TW, Hicks S, Ng S, Pavek T, Knutson N, Samson P, Zheng J, Berberet C, Ibrahim ESH, Jani V, Tabor J, Wilson L, Jordan SD, Marut L, Kumar A, Manikandan S, Javaheri A, Bergom C, Schwarz JK, Boyle PM, Hugo GD, Cuculich P, Robinson C, Zemlin C, Rentschler SL. STAR Locally Prolongs Effective Refractory Period and Increases Ventricular Tachycardia Cycle Length Without Short-Term Scar Formation or Functional Decline: Insights From a Translational Porcine Model Study. Circ Arrhythm Electrophysiol 2025:e013684. [PMID: 40391432 DOI: 10.1161/circep.124.013684] [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: 12/19/2024] [Accepted: 04/28/2025] [Indexed: 05/21/2025]
Abstract
BACKGROUND Stereotactic arrhythmia radiotherapy (STAR) has emerged as a potential therapy for treatment-refractory ventricular tachycardia (VT). However, the mechanisms underlying STAR efficacy, such as scar or other electromechanical changes, are still unclear. The goal of this study was to develop a translational porcine model of ischemic monomorphic VT treated with STAR to examine the physiological changes after a typical clinical STAR treatment. METHODS We treated a previously validated porcine model of monomorphic VT after myocardial infarction with a clinically derived STAR protocol. A dose of 25 Gy was prescribed to the planning target volume and 35 Gy to the clinical target volume (regions of scar), while controls underwent a sham STAR treatment. All investigators in the study were blinded except the treating investigator. The primary study outcome was VT inducibility at 6 weeks post-STAR. Animals underwent pre- and post-STAR cardiac magnetic resonance imaging to quantify myocardial scar and function, as well as body surface mapping. Six weeks post-STAR, animals underwent a VT induction study, and tissue was harvested for optical mapping and histological analysis. RESULTS Six animals completed the study, which ended before finishing enrollment because all animals had inducible VT. We found a significantly longer local effective refractory period in the left ventricular apex and longer VT cycle lengths in STAR-treated animals compared with controls (P<0.05). We found no difference in myocardial scar burden, mechanical function, or body surface recordings when comparing pre- and post-STAR. CONCLUSIONS Our data suggest a novel therapeutic mechanism of STAR driven by increasing the effective refractory period in locally treated areas, corresponding to increased tissue wavelength. Our results corroborate clinical case reports and anecdotal evidence that STAR increases VT cycle length. Importantly, these effects were not mediated by an increase in myocardial scar burden. However, our studies do not examine the long-term effects of STAR.
Collapse
Affiliation(s)
- Brian Zenger
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Timothy W Smith
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Stephanie Hicks
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Sherwin Ng
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Todd Pavek
- Division of Comparative Medicine, Washington University School of Medicine, St. Louis, MO. (T.P., L.W.)
| | - Nels Knutson
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO. (N.K., P.S., L.M., C. Bergom, J.K.S., G.D.H., C.R.)
| | - Pamela Samson
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO. (N.K., P.S., L.M., C. Bergom, J.K.S., G.D.H., C.R.)
| | - Jie Zheng
- Department of Radiology, Washington University School of Medicine, St. Louis, MO. (J.Z., C. Berberet)
| | - Caleb Berberet
- Department of Radiology, Washington University School of Medicine, St. Louis, MO. (J.Z., C. Berberet)
| | - El-Sayed H Ibrahim
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee (E.-S.H.I.)
| | - Vinay Jani
- Department of Bioengineering (V.J., P.M.B.)
| | - James Tabor
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Leslie Wilson
- Division of Comparative Medicine, Washington University School of Medicine, St. Louis, MO. (T.P., L.W.)
| | - Samuel D Jordan
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Luke Marut
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO. (N.K., P.S., L.M., C. Bergom, J.K.S., G.D.H., C.R.)
| | - Aryan Kumar
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Sneha Manikandan
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Ali Javaheri
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- John Cochran Veterans Affairs Hospital, St. Louis (A.J.)
| | - Carmen Bergom
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO. (N.K., P.S., L.M., C. Bergom, J.K.S., G.D.H., C.R.)
| | - Julie K Schwarz
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO. (N.K., P.S., L.M., C. Bergom, J.K.S., G.D.H., C.R.)
| | - Patrick M Boyle
- Department of Bioengineering (V.J., P.M.B.)
- eScience Institute, Institute for Stem Cell and Regenerative Medicine, Center for Cardiovascular Biology, University of Washington, Seattle (P.M.B.)
| | - Geoffrey D Hugo
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO. (N.K., P.S., L.M., C. Bergom, J.K.S., G.D.H., C.R.)
| | - Phillip Cuculich
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
| | - Cliff Robinson
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO. (N.K., P.S., L.M., C. Bergom, J.K.S., G.D.H., C.R.)
| | - Christian Zemlin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO. (C.Z.)
| | - Stacey L Rentschler
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., J.T., S.D.J., A.K., S.M., A.J., P.C., S.L.R.)
- Center for Noninvasive Cardiac Radiotherapy, Washington University School of Medicine, St. Louis, MO. (B.Z., T.W.S., S.H., S.N., N.K., P.S., J.T., S.D.J., L.M., A.K., S.M., A.J., C. Bergom, J.K.S., G.D.H., P.C., C.R., S.L.R.)
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO. (S.L.R.)
| |
Collapse
|
2
|
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 2025; 121:75-89. [PMID: 39222823 DOI: 10.1016/j.ijrobp.2024.08.040] [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: 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 the treatment of refractory ventricular arrhythmias (VAs). Phase 1/2 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 nonsedated patient in a single fraction during an outpatient session of 15 to 30 minutes, without added risks of anesthetic or surgery, is clinically relevant. However, the underlying mechanism remains unclear. Currently, the clinical dosing of SBRT has been derived from preclinical studies aimed at inducing 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 antiarrhythmic effect, elucidate clinical observations, and point the direction for further research in this promising area.
Collapse
Affiliation(s)
- Poornima Balaji
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia
| | - Xingzhou Liulu
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sonaali Sivakumar
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia
| | - James J H Chong
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Eddy Kizana
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Jamie I Vandenberg
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Adam P Hill
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Eric Hau
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia; Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, New South Wales, Australia; Blacktown Hematology and Cancer Centre, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Pierre C Qian
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
| |
Collapse
|
3
|
Benali K, Lloyd MS, Petrosyan A, Rigal L, Quivrin M, Bessieres I, Vlachos K, Hammache N, Bellec J, Simon A, Laurent G, Higgins K, Garnier F, de Crevoisier R, Martins R, Da Costa A, Guenancia C. Cardiac stereotactic radiation therapy for refractory ventricular arrhythmias in patients with left ventricular assist devices. J Cardiovasc Electrophysiol 2024; 35:206-213. [PMID: 38018417 DOI: 10.1111/jce.16139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/30/2023]
Abstract
Left ventricular assist device (LVAD) implantation is an established treatment for patients with advanced heart failure refractory to medical therapy. However, the incidence of ventricular arrhythmias (VAs) is high in this population, both in the acute and delayed phases after implantation. About one-third of patients implanted with an LVAD will experience sustained VAs, predisposing these patients to worse outcomes and complicating patient management. The combination of pre-existing myocardial substrate and complex electrical remodeling after LVAD implantation account for the high incidence of VAs observed in this population. LVAD patients presenting VAs refractory to antiarrhythmic therapy and catheter ablation procedures are not rare. In such patients, treatment options are extremely limited. Stereotactic body radiation therapy (SBRT) is a technique that delivers precise and high doses of radiation to highly defined targets, reducing exposure to adjacent normal tissue. Cardiac SBRT has recently emerged as a promising alternative with a growing number of case series reporting the effectiveness of the technique in reducing the VA burden in patients with arrhythmias refractory to conventional therapies. The safety profile of cardiac SBRT also appears favorable, even though the current clinical experience remains limited. The use of cardiac SBRT for the treatment of refractory VAs in patients implanted with an LVAD are even more scarce. This review summarizes the clinical experience of cardiac SBRT in LVAD patients and describes technical considerations related to the implementation of the SBRT procedure in the presence of an LVAD.
Collapse
Affiliation(s)
- Karim Benali
- Department of Cardiac Electrophysiology, Saint-Etienne University Hospital Center, Saint-Etienne, France
- Department of Signal Analysis, IHU LIRYC, Electrophysiology and Heart Modelling Institute, Bordeaux University, Bordeaux, France
- LTSI-UMR 1099, Rennes, France
| | - Michael S Lloyd
- Department of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andranik Petrosyan
- Department of Cardiac Surgery, Saint-Etienne University Hospital Center, Saint-Etienne, France
| | - Louis Rigal
- Department of Signal Analysis, IHU LIRYC, Electrophysiology and Heart Modelling Institute, Bordeaux University, Bordeaux, France
| | - Magali Quivrin
- Department of Radiation Oncology, Centre Georges Francois Leclerc, Dijon, France
| | - Igor Bessieres
- Department of Radiation Oncology, Centre Georges Francois Leclerc, Dijon, France
| | | | - Nefissa Hammache
- Department of Cardiac Electrophysiology, Nancy University Hospital Center, Nancy, France
| | - Julien Bellec
- Department of Radiation Oncology, Centre Eugene Marquis, Rennes, France
| | - Antoine Simon
- Department of Signal Analysis, IHU LIRYC, Electrophysiology and Heart Modelling Institute, Bordeaux University, Bordeaux, France
| | - Gabriel Laurent
- Department of Cardiac Electrophysiology, Dijon University Hospital Center, Dijon, France
| | - Kristin Higgins
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Fabien Garnier
- Department of Cardiac Electrophysiology, Dijon University Hospital Center, Dijon, France
| | | | - Raphaël Martins
- Department of Signal Analysis, IHU LIRYC, Electrophysiology and Heart Modelling Institute, Bordeaux University, Bordeaux, France
- Department of Cardiac Electrophysiology, Rennes University Hospital Center, Rennes, France
| | - Antoine Da Costa
- Department of Cardiac Electrophysiology, Saint-Etienne University Hospital Center, Saint-Etienne, France
| | - Charles Guenancia
- Department of Radiation Oncology, Centre Eugene Marquis, Rennes, France
- PEC 2 EA 7460, University of Burgundy and Franche-Comté, Dijon, France
| |
Collapse
|
4
|
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: 13] [Impact Index Per Article: 6.5] [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.
Collapse
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
| |
Collapse
|
5
|
Koulaouzidis G, Charisopoulou D, Bomba P, Stachura J, Gasior P, Harpula J, Zarifis J, Marlicz W, Hudziak D, Jadczyk T. Robotic-Assisted Solutions for Invasive Cardiology, Cardiac Surgery and Routine On-Ward Tasks: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:399. [PMID: 37754828 PMCID: PMC10532157 DOI: 10.3390/jcdd10090399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/09/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023] Open
Abstract
Robots are defined as programmable machines that can perform specified tasks. Medical robots are emerging solutions in the field of cardiology leveraging recent technological innovations of control systems, sensors, actuators, and imaging modalities. Robotic platforms are successfully applied for percutaneous coronary intervention, invasive cardiac electrophysiology procedures as well as surgical operations including minimally invasive aortic and mitral valve repair, coronary artery bypass procedures, and structural heart diseases. Furthermore, machines are used as staff-assisting tools to support nurses with repetitive clinical duties i.e., food delivery. High precision and resolution allow for excellent maneuverability, enabling the performance of medical procedures in challenging anatomies that are difficult or impossible using conventional approaches. Moreover, robot-assisted techniques protect operators from occupational hazards, reducing exposure to ionizing radiation, and limiting risk of orthopedic injuries. Novel automatic systems provide advantages for patients, ensuring device stability with optimized utilization of fluoroscopy. The acceptance of robotic technology among healthcare providers as well as patients paves the way for widespread clinical application in the field of cardiovascular medicine. However, incorporation of robotic systems is associated with some disadvantages including high costs of installation and expensive disposable instrumentations, the need for large operating room space, and the necessity of dedicated training for operators due to the challenging learning curve of robotic-assisted interventional systems.
Collapse
Affiliation(s)
- George Koulaouzidis
- Department of Biochemical Sciences, Pomeranian Medical University, 70-204 Szczecin, Poland;
| | - Dafni Charisopoulou
- Pediatric Cardiology Department, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | | | | | - Pawel Gasior
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-635 Katowice, Poland; (P.G.); (J.H.)
| | - Jan Harpula
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-635 Katowice, Poland; (P.G.); (J.H.)
| | - John Zarifis
- Cardiology Department, George Papanikolaou General Hospital, 570 10 Thessaloniki, Greece;
| | - Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, 71-455 Szczecin, Poland;
| | - Damian Hudziak
- Department of Cardiac Surgery, Upper-Silesian Heart Center, 40-635 Katowice, Poland;
| | - Tomasz Jadczyk
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-635 Katowice, Poland; (P.G.); (J.H.)
- Interventional Cardiac Electrophysiology Group, International Clinical Research Center, St. Anne’s University Hospital Brno, 602 00 Brno, Czech Republic
| |
Collapse
|
6
|
Li X, Zhu Z, Liu J, Gao Y, Xiao Y, Fang Z, Liu Q, Liu X, Hu C, Ma F, Zeng M, Liu Z, Hu L, Liu N, Xiang F, Hu X, Huang L, Zhou S. Septal radioablation therapy for patients with hypertrophic obstructive cardiomyopathy: first-in-human study. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead052. [PMID: 37503357 PMCID: PMC10371052 DOI: 10.1093/ehjopen/oead052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 07/29/2023]
Abstract
Aims There is still no non-invasive septal reduction therapy for patients with hypertrophic obstructive cardiomyopathy (HOCM). This study aimed to investigate the feasibility, safety, and efficacy of stereotactic body radiotherapy (SBRT) in patients with drug-refractory symptomatic HOCM. Methods and results The radiation target of ventricular septum was determined by multiple anatomical imaging. Stereotactic body radiotherapy was performed with standard techniques. Patients were treated with a single fraction of 25 Gy, followed up at 1, 3, 6, and 12 months by clinical visit. Five patients were enrolled and completed the 12 months follow-up. The mean radioablation time was 21.6 min, and the mean target volume was 10.5 cm3. All five patients survived and showed improvements in symptoms after SBRT. At 12 months post-SBRT, the echocardiography-derived left ventricular outflow tract gradient decreased from 88 mmHg (range, 63-105) to 52 mmHg (range, 36-66) at rest and from 101 mmHg (range, 72-121) to 74 mmHg (range, 65-100) after Valsalva. The end-diastolic thickness of the targeted septum reduced from 23.7 mm (range, 20.3-29) to 22.4 mm (range, 19.7-26.5); 6 min walking distance increased from 190.4 m (range, 50-370) to 412.0 m (range, 320-480). All patients presented with new fibrosis in the irradiated septum area. No radiation-related complications were observed during SBRT and up to 12 months post procedure. Conclusion The current study suggests that SBRT might be a feasible radioablation therapeutic option for patients with drug-refractory symptomatic HOCM. Trial registration ClinicalTrials.gov Identifier: NCT04686487.
Collapse
Affiliation(s)
| | | | - Jun Liu
- Radiology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yawen Gao
- Oncology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Zhenfei Fang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Xianling Liu
- Oncology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chunhong Hu
- Oncology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fang Ma
- Oncology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mu Zeng
- Radiology Department, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhi Liu
- Anesthesiology Department, Hunan Provincial People’s Hospital, Changsha, Hunan, China
| | - Lin Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Na Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Fan Xiang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Xinqun Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Mid-Renmin Road, Changsha, Hunan 410011, China
| | - Lihong Huang
- Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Shenghua Zhou
- Corresponding author. Tel: +86 731 85292012, Fax: +86 731 85292013,
| |
Collapse
|
7
|
Guarracini F, Tritto M, Di Monaco A, Mariani MV, Gasperetti A, Compagnucci P, Muser D, Preda A, Mazzone P, Themistoclakis S, Carbucicchio C. Stereotactic Arrhythmia Radioablation Treatment of Ventricular Tachycardia: Current Technology and Evolving Indications. J Cardiovasc Dev Dis 2023; 10:jcdd10040172. [PMID: 37103051 PMCID: PMC10143260 DOI: 10.3390/jcdd10040172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 04/28/2023] Open
Abstract
Ventricular tachycardia in patients with structural heart disease is a significant cause of morbidity and mortality. According to current guidelines, cardioverter defibrillator implantation, antiarrhythmic drugs, and catheter ablation are established therapies in the management of ventricular arrhythmias but their efficacy is limited in some cases. Sustained ventricular tachycardia can be terminated by cardioverter-defibrillator therapies although shocks in particular have been demonstrated to increase mortality and worsen patients' quality of life. Antiarrhythmic drugs have important side effects and relatively low efficacy, while catheter ablation, even if it is actually an established treatment, is an invasive procedure with intrinsic procedural risks and is frequently affected by patients' hemodynamic instability. Stereotactic arrhythmia radioablation for ventricular arrhythmias was developed as bail-out therapy in patients unresponsive to traditional treatments. Radiotherapy has been mainly applied in the oncological field, but new current perspectives have developed in the field of ventricular arrhythmias. Stereotactic arrhythmia radioablation provides an alternative non-invasive and painless therapeutic strategy for the treatment of previously detected cardiac arrhythmic substrate by three-dimensional intracardiac mapping or different tools. Since preliminary experiences have been reported, several retrospective studies, registries, and case reports have been published in the literature. Although, for now, stereotactic arrhythmia radioablation is considered an alternative palliative treatment for patients with refractory ventricular tachycardia and no other therapeutic options, this research field is currently extremely promising.
Collapse
Affiliation(s)
| | - Massimo Tritto
- Electrophysiology and Cardiac Pacing Unit, Humanitas Mater Domini Hospital, 21053 Castellanza, Italy
| | - Antonio Di Monaco
- Cardiology Department, General Regional Hospital F. Miulli, 70021 Acquaviva delle Fonti, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, 00100 Rome, Italy
| | - Alessio Gasperetti
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti Umberto I-Lancisi-Salesi, 60126 Ancona, Italy
| | - Daniele Muser
- Cardiothoracic Department, University Hospital, 33100 Udine, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Patrizio Mazzone
- Cardiothoracovascular Department, Electrophysiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Sakis Themistoclakis
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell'Angelo Hospital, Mestre, 30174 Venice, Italy
| | - Corrado Carbucicchio
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| |
Collapse
|
8
|
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: 1.0] [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.
Collapse
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
| |
Collapse
|
9
|
Cozzi S, Bottoni N, Botti A, Trojani V, Alì E, Finocchi Ghersi S, Cremaschi F, Iori F, Ciammella P, Iori M, Iotti C. The Use of Cardiac Stereotactic Radiation Therapy (SBRT) to Manage Ventricular Tachycardia: A Case Report, Review of the Literature and Technical Notes. J Pers Med 2022; 12:jpm12111783. [PMID: 36579492 PMCID: PMC9694192 DOI: 10.3390/jpm12111783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND among cardiac arrhythmias, ventricular tachycardia (VT) is one that can lead to cardiac death, although significant progress has been made in its treatment, including the use of implantable cardioverter-defibrillators (ICD) and radiofrequency catheter ablation. Nevertheless, long-term recurrence rates remain in about half of patients and drastically impact the patient's quality of life. Moreover, recurrent ICD shocks are painful and are associated with higher mortality and worsening of heart failure. Recently, more and more experiences are demonstrating potential efficacy in the use of stereotactic body radiotherapy (SBRT) (also called cardiac radio-ablation) to treat this condition. In this paper, we report our experience in the use of cardiac radio-ablation for the treatment of refractory ventricular tachycardia with a focus on the technique used, along with a review of the literature and technical notes. CASE PRESENTATION an 81-year-old male patient with a long history of non-ischemic dilated cardiomyopathy and mechanical mitral prosthesis underwent a biventricular cardioverter defibrillator implant after atrial ventricular node ablation. At the end of 2021, the number of tachycardias increased significantly to about 10 episodes per day. After failure of medical treatment and conventional RT catheter ablation, the patient was treated with SBRT for a total dose of 25 Gy in a single session at the site of the ectopic focus. No acute toxicity was recorded. After SBRT (follow-up 7 months) no other VT episodes were recorded. CONCLUSION SBRT appears to be safe and leads to a rapid reduction in arrhythmic storms as treatment for VT without acute toxicity, representing one of the most promising methods for treating VT storms.
Collapse
Affiliation(s)
- Salvatore Cozzi
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Nicola Bottoni
- Department of Cardiology, Arrhythmology Center, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Andrea Botti
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
- Correspondence:
| | - Valeria Trojani
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Emanuele Alì
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Sebastiano Finocchi Ghersi
- Radiation Oncolgy Unit, AOU Sant’Andrea, Facoltà di Medicina e Psicologia, Università La Sapienza, 00185 Rome, Italy
| | - Federica Cremaschi
- Engineer Clinical Specialist, Biosense Webster, Pratica di Mare, Pomezia, 00071 Rome, Italy
| | - Federico Iori
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Patrizia Ciammella
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Mauro Iori
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Cinzia Iotti
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| |
Collapse
|
10
|
Whitaker J, Zei PC, Ahmad S, Niederer S, O'Neill M, Rinaldi CA. The effect of ionizing radiation through cardiac stereotactic body radiation therapy on myocardial tissue for refractory ventricular arrhythmias: A review. Front Cardiovasc Med 2022; 9:989886. [PMID: 36186961 PMCID: PMC9520407 DOI: 10.3389/fcvm.2022.989886] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022] Open
Abstract
Cardiac stereotactic body radiation therapy (cSBRT) is a non-invasive treatment modality that has been recently reported as an effective treatment for ventricular arrhythmias refractory to medical therapy and catheter ablation. The approach leverages tools developed and refined in radiation oncology, where experience has been accumulated in the treatment of a wide variety of malignant conditions. However, important differences exist between rapidly dividing malignant tumor cells and fully differentiated myocytes in pathologically remodeled ventricular myocardium, which represent the respective radiation targets. Despite its initial success, little is known about the radiobiology of the anti-arrhythmic effect cSBRT. Pre-clinical data indicates a late fibrotic effect of that appears between 3 and 4 months following cSBRT, which may result in conduction slowing and block. However, there is clear clinical evidence of an anti-arrhythmic effect of cSBRT that precedes the appearance of radiation induced fibrosis for which the mechanism is unclear. In addition, the data to date suggests that even the late anti-arrhythmic effect of cSBRT is not fully attributable to radiation.-induced fibrosis. Pre-clinical data has identified upregulation of proteins expected to result in both increased cell-to-cell coupling and excitability in the early post cSBRT period and demonstrated an associated increase in myocardial conduction velocity. These observations indicate a complex response to radiotherapy and highlight the lack of clarity regarding the different stages of the anti-arrhythmic mechanism of cSBRT. It may be speculated that in the future cSBRT therapy could be planned to deliver both early and late radiation effects titrated to optimize the combined anti-arrhythmic efficacy of the treatment. In addition to these outstanding mechanistic questions, the optimal patient selection, radiation modality, radiation dose and treatment planning strategy are currently being investigated. In this review, we consider the structural and functional effect of radiation on myocardium and the possible anti-arrhythmic mechanisms of cSBRT. Review of the published data highlights the exciting prospects for the development of knowledge and understanding in this area in which so many outstanding questions exist.
Collapse
Affiliation(s)
- John Whitaker
- Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical Schools, Boston, MA, United States
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
- *Correspondence: John Whitaker
| | - Paul C. Zei
- Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical Schools, Boston, MA, United States
| | - Shahreen Ahmad
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
- Guy's and St. Thomas's NHS Foundation Trust, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom
| |
Collapse
|
11
|
Ninni S, Gallot-Lavallée T, Klein C, Longère B, Brigadeau F, Potelle C, Crop F, Rault E, Decoene C, Lacornerie T, Lals S, Kouakam C, Pontana F, Lacroix D, Klug D, Mirabel X. Stereotactic Radioablation for Ventricular Tachycardia in the Setting of Electrical Storm. Circ Arrhythm Electrophysiol 2022; 15:e010955. [PMID: 36074658 DOI: 10.1161/circep.122.010955] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy for treating refractory ventricular tachycardia (VT) despite optimal medical treatment and catheter ablation. However, data on the use of SBRT in patients with electrical storm (ES) is lacking. The aim of this study was to assess the clinical outcomes associated with SBRT in the context of ES. METHODS This retrospective study included patients who underwent SBRT in the context of ES from March 2020 to March 2021 in one tertiary center (CHU Lille). The target volume was delineated according to a predefined workflow. The efficacy was assessed with the following end points: sustained VT recurrence, VT reduced with antitachycardia pacing, and implantable cardioverter defibrillator shock. RESULTS Seventeen patients underwent SBRT to treat refractory VT in the context of ES (mean 67±12.8 age, 59% presenting ischemic heart disease, mean left ventricular ejection fraction: 33.7± 9.7%). Five patients presented with ES related to incessant VT. Among these 5 patients, the time to effectiveness ranged from 1 to 7 weeks after SBRT. In the 12 remaining patients, VT recurrences occurred in 7 patients during the first 6 weeks following SBRT. After a median 12.5 (10.5-17.8) months follow-up, a significant reduction of the VT burden was observed beyond 6 weeks (-91% [95% CI, 78-103]), P<0.0001). The incidence of implantable cardioverter defibrillator shock and antitachycardia pacing was 36% at 1 year. CONCLUSIONS SBRT is associated with a significant reduction of the VT burden in the event of an ES; however, prospective randomized control trials are needed. In patients without incessant VT, recurrences are observed in half of patients during the first 6 weeks. VT tolerance and implantable cardioverter defibrillator programming adjustments should be integrated as part of an action plan defined before SBRT for each patient.
Collapse
Affiliation(s)
- Sandro Ninni
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - Thomas Gallot-Lavallée
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - Cédric Klein
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - Benjamin Longère
- CHU Lille, Institut Cœur-Poumon, Service De Radiologie (B.L., F.P.)
| | - François Brigadeau
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | | | - Frederik Crop
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.).,Medical Physics, Centre Oscar Lambret, Lille, France (F.C., E.R., C.D., T.L.)
| | - Erwann Rault
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.).,Medical Physics, Centre Oscar Lambret, Lille, France (F.C., E.R., C.D., T.L.)
| | - Camille Decoene
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.).,Medical Physics, Centre Oscar Lambret, Lille, France (F.C., E.R., C.D., T.L.)
| | - Thomas Lacornerie
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.).,Medical Physics, Centre Oscar Lambret, Lille, France (F.C., E.R., C.D., T.L.)
| | - Séverine Lals
- University Department of Radiation Oncology, Oscar Lambret Comprehensive Cancer Center (F.C., E.R., C.D., T.L., S.L.)
| | - Claude Kouakam
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - François Pontana
- CHU Lille, Institut Cœur-Poumon, Service De Radiologie (B.L., F.P.)
| | - Dominique Lacroix
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | - Didier Klug
- CHU Lille, Institut Cœur-Poumon, Service de Cardiologie (S.N., T.G.L., C.K., F.B., C.K., D.L., D.K.)
| | | |
Collapse
|
12
|
Pavone C, Scacciavillani R, Narducci ML, Cellini F, Pelargonio G, Bencardino G, Perna F, Spera F, Pinnacchio G, Sanna T, Valentini V, Crea F. Successful ventricular tachycardia radioablation in a patient with previous chemical pleurodesis: A case report. Front Cardiovasc Med 2022; 9:937090. [PMID: 35924213 PMCID: PMC9339650 DOI: 10.3389/fcvm.2022.937090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Stereotactic arrhythmia radioablation (STAR) is a novel technique for the ablation of ventricular tachycardia in patients with contraindications to standard procedures, i.e., radiofrequency ablation. Case presentation We report the case of a 73-year-old man with non-ischemic dilated cardiomyopathy and recurrent VT episodes. Electroanatomic mapping showed VT prevalently of epicardial origin, but direct epicardial access through subxyphoid puncture could not be performed due to pleuropericardial adhesions from a past history of chemical pleurodesis. STAR was performed, with no VT recurrence at 6 months follow-up. Conclusions Previous experiences with STAR have demonstrated its importance in the management of patients with refractory VT in whom other ablation strategies were not successful. Our case report highlights the use of STAR as a second choice in a patient with an unfavorable VT anatomical location and technical limitations to an optimal radiofrequency ablation. Moreover, it confirms STAR's effectiveness in the ablation of complex transmural lesions, which are more often associated with non-ischemic structural heart disease.
Collapse
Affiliation(s)
- Chiara Pavone
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
- *Correspondence: Chiara Pavone
| | - Roberto Scacciavillani
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Maria Lucia Narducci
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
- Maria Lucia Narducci
| | - Francesco Cellini
- Unit of Oncological Radiotherapy, Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Gemma Pelargonio
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Gianluigi Bencardino
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Francesco Perna
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Francesco Spera
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Gaetano Pinnacchio
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Tommaso Sanna
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Vincenzo Valentini
- Unit of Oncological Radiotherapy, Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| |
Collapse
|
13
|
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: 1.0] [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.
Collapse
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
| |
Collapse
|
14
|
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; 11:3549. [PMID: 35743614 PMCID: PMC9225049 DOI: 10.3390/jcm11123549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [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.
Collapse
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
| | - 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.)
| |
Collapse
|
15
|
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: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and safety, but randomized data and long-term outcomes are not yet available. The primary hypothesis as to the mechanism of action for SBRT relates to the development of cardiac fibrosis in arrhythmogenic myocardial substrate; however, limited animal model data offer conflicting insights into this theory. The use of SBRT for patients with refractory ventricular arrhythmias is rapidly increasing, but ongoing translational science work and randomized clinical trials will be critical to address many outstanding questions regarding this novel therapy.
Collapse
Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Robert Chin
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Minsong Cao
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Peng Hu
- Department of Radiological Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| |
Collapse
|
16
|
Ramia P, Ollaik F, Hilal L, Jalbout W, AlJaroudi W, Al Ahmad A, Sfeir P, Jurjus A, Refaat M, Youssef B. Stereotactic Radiosurgery for Atrioventricular Node Ablation in Swine: A Study on Efficacy and Dosimetric Evaluation of Organs at Risk. Cureus 2021; 13:e18785. [PMID: 34804652 PMCID: PMC8592376 DOI: 10.7759/cureus.18785] [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] [Accepted: 10/04/2021] [Indexed: 11/07/2022] Open
Abstract
Introduction Stereotactic radiosurgery (SRS) delivered to arrhythmogenic foci within the heart is a promising treatment modality. We dosimetrically evaluated the radiation dose to the organs at risk of four swine that were successfully treated with linear-accelerator-based SRS for atrioventricular (AV) node ablation. Materials and methods Single-chamber pacemakers were implanted in four large white breed swine. Cardiac computed tomography simulation scans were performed to localize the AV node and organs at risk. SRS (35-40 Gy) was delivered to the AV node, and the pigs were followed up with pacemaker interrogations. One-sample t-tests were used to evaluate Dmax of great vessels, esophagus, and chest wall as compared to known normal tissue constraints as per RTOG 0631 and AAPM Task Group 101. Results All pigs had disturbances of AV conduction with progressive transition into complete heart block. Macroscopic and microscopic evaluation showed fibrosis in the AV node but did not reveal any changes in non-nodal cardiac tissue or vessels. The mean Dmax±SD (p-value) of the chest wall (14.7±3.3 (0.02)), esophagus (10.7±1.1 (<0.01)) superior vena cava (3.3±4.1 (<0.01)), right pulmonary artery (16.1±6.4 (<0.01)), right pulmonary vein (15.7± 5 (<0.01)), left pulmonary artery (11.1±1.7 (<0.01)) and left pulmonary vein (14.1±2.6 (<0.01)), and the inferior vena cava (33.68±1.6 (0.026)) were significantly below the normal tissue constraint cutoffs. Mean±SD (p-value) of the ascending aorta (19.4±16.1 (0.12)) was not significantly different than normal tissue constraint cutoffs. One swine model treated at 40 Gy had small area of hotspot in the ascending aorta (40.65 (0.4 cc)). Conclusion We have demonstrated in our swine models that SRS using 35-40 Gy can be done without exceeding known human normal tissue constraints to the chest wall, esophagus, and great vessels.
Collapse
Affiliation(s)
- Paul Ramia
- Radiation Oncology, American University of Beirut, Beirut, LBN
| | - Farah Ollaik
- Radiation Oncology, American University of Beirut, Beirut, LBN
| | - Lara Hilal
- Radiation Oncology, American University of Beirut, Beirut, LBN
| | - Wassim Jalbout
- Radiation Oncology, American University of Beirut, Beirut, LBN
| | | | - Amin Al Ahmad
- Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, USA
| | - Pierre Sfeir
- Cardiothoracic Surgery, American University of Beirut, Beirut, LBN
| | - Abdo Jurjus
- Anatomy, American University of Beirut, Beirut, LBN
| | - Marwan Refaat
- Cardiovascular Disease, American University of Beirut, Beirut, LBN
| | - Bassem Youssef
- Radiation Oncology, American University of Beirut, Beirut, LBN
| |
Collapse
|
17
|
Wei C, Qian PC, Boeck M, Bredfeldt JS, Blankstein R, Tedrow UB, Mak R, Zei PC. Cardiac stereotactic body radiation therapy for ventricular tachycardia: Current experience and technical gaps. J Cardiovasc Electrophysiol 2021; 32:2901-2914. [PMID: 34587335 DOI: 10.1111/jce.15259] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite advances in drug and catheter ablation therapy, long-term recurrence rates for ventricular tachycardia remain suboptimal. Cardiac stereotactic body radiotherapy (SBRT) is a novel treatment that has demonstrated reduction of arrhythmia episodes and favorable short-term safety profile in treatment-refractory patients. Nevertheless, the current clinical experience is early and limited. Recent studies have highlighted variable duration of treatment effect and substantial recurrence rates several months postradiation. Contributing to these differential outcomes are disparate approaches groups have taken in planning and delivering radiation, owing to both technical and knowledge gaps limiting optimization and standardization of cardiac SBRT. METHODS AND FINDINGS In this report, we review the historical basis for cardiac SBRT and existing clinical data. We then elucidate the current technical gaps in cardiac radioablation, incorporating the current clinical experience, and summarize the ongoing and needed efforts to resolve them. CONCLUSION Cardiac SBRT is an emerging therapy that holds promise for the treatment of ventricular tachycardia. Technical gaps remain, to be addressed by ongoing research and growing clincial experience.
Collapse
Affiliation(s)
- Chen Wei
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pierre C Qian
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michelle Boeck
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jeremy S Bredfeldt
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Usha B Tedrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raymond Mak
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Paul C Zei
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
18
|
Zhang DM, Navara R, Yin T, Szymanski J, Goldsztejn U, Kenkel C, Lang A, Mpoy C, Lipovsky CE, Qiao Y, Hicks S, Li G, Moore KMS, Bergom C, Rogers BE, Robinson CG, Cuculich PS, Schwarz JK, Rentschler SL. Cardiac radiotherapy induces electrical conduction reprogramming in the absence of transmural fibrosis. Nat Commun 2021; 12:5558. [PMID: 34561429 PMCID: PMC8463558 DOI: 10.1038/s41467-021-25730-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 08/25/2021] [Indexed: 02/08/2023] Open
Abstract
Cardiac radiotherapy (RT) may be effective in treating heart failure (HF) patients with refractory ventricular tachycardia (VT). The previously proposed mechanism of radiation-induced fibrosis does not explain the rapidity and magnitude with which VT reduction occurs clinically. Here, we demonstrate in hearts from RT patients that radiation does not achieve transmural fibrosis within the timeframe of VT reduction. Electrophysiologic assessment of irradiated murine hearts reveals a persistent supraphysiologic electrical phenotype, mediated by increases in NaV1.5 and Cx43. By sequencing and transgenic approaches, we identify Notch signaling as a mechanistic contributor to NaV1.5 upregulation after RT. Clinically, RT was associated with increased NaV1.5 expression in 1 of 1 explanted heart. On electrocardiogram (ECG), post-RT QRS durations were shortened in 13 of 19 patients and lengthened in 5 patients. Collectively, this study provides evidence for radiation-induced reprogramming of cardiac conduction as a potential treatment strategy for arrhythmia management in VT patients.
Collapse
Affiliation(s)
- David M Zhang
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Rachita Navara
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Tiankai Yin
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Jeffrey Szymanski
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Uri Goldsztejn
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Camryn Kenkel
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Adam Lang
- Department of Pathology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Cedric Mpoy
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Catherine E Lipovsky
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Developmental Biology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Yun Qiao
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Stephanie Hicks
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Gang Li
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Kaitlin M S Moore
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Carmen Bergom
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Buck E Rogers
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Clifford G Robinson
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Phillip S Cuculich
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Julie K Schwarz
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Stacey L Rentschler
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Developmental Biology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
| |
Collapse
|
19
|
Lee H, Pursley J, Lu HM, Adams J, DeLaney T, Chen YL, Jee KW. A proof of concept treatment planning study of gated proton radiotherapy for cardiac soft tissue sarcoma. Phys Imaging Radiat Oncol 2021; 19:78-84. [PMID: 34368473 PMCID: PMC8326805 DOI: 10.1016/j.phro.2021.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/23/2021] [Accepted: 06/03/2021] [Indexed: 12/25/2022] Open
Abstract
Challenges of a cardiac target due to the respiration, the heart motion and the interplay effect. Cardiac respiratory double gating with additional ECG signals for proton radiotherapy. Proton planning study with a cardiac-gated CT scan obtained at the end-expiration.
Background and Purpose Few studies on radiotherapy of cardiac targets exist, and none using a gating method according to cardiac movement. This study aimed to evaluate the dose-volume advantage of using cardiac-respiratory double gating (CRDG) in terms of target location with additional ECG signals in comparison to respiratory single gating (RSG) for proton radiotherapy of targets in the heart. Materials and Methods Cardiac motion was modeled using a cardiac-gated four-dimensional computed tomography scan obtained at the end-expiration. Plans with the prescription dose of 50 Gy (RSG and CRDG plans at diastole and systole phases) were compared in terms of clinically relevant dose-volume criteria for various target sizes and seven cardiac subsites. Potential dose sparing by utilizing CRDG over RSG was quantified in terms of surrounding organ at risk (OAR) doses while the dose coverage to the targets was fully ensured. Results The average mean dose reductions were 28 ± 10% when gated at diastole and 21 ± 12% at systole in heart and 30 ± 17% at diastole and 8 ± 9% at systole in left ventricle compared to respiratory single gating. The diastole phase was optimal for gated treatments for all target locations except right ventricle and interventricular septum. The right ventricle target was best treated at the systole phase. However, an optimal gating phase for the interventricular septum target could not be determined. Conclusions We have studied the dose-volume benefits of CRDG for each cardiac subsite, and demonstrated that CRDG may spare organs at risk better than RSG.
Collapse
Affiliation(s)
- Hyeri Lee
- Corresponding author at: Radiation Oncology, Massachusetts General Hospital, 55 Fruit Street, Lunder Building, LL 236, Boston, MA 02114, USA.
| | | | | | | | | | | | | |
Collapse
|
20
|
Chang JH, Cha MJ, Seo JW, Kim HJ, Park SY, Kim BH, Lee E, Kim MK, Yoon HS, Oh S. Feasibility study on stereotactic radiotherapy for total pulmonary vein isolation in a canine model. Sci Rep 2021; 11:12369. [PMID: 34117284 PMCID: PMC8196028 DOI: 10.1038/s41598-021-91660-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/26/2021] [Indexed: 12/27/2022] Open
Abstract
We tested the feasibility of pulmonary vein (PV) and left atrial (LA) posterior wall isolation using non-invasive stereotactic ablative body radiotherapy (SABR) and investigated pathological changes in irradiated lesions in a canine model. Seven male Mongrel dogs received single-fraction 33 Gy SABR. We designed the en-bloc circular target of total PVs and LA posterior wall to avoid the esophagus. The circular box lesion included the LA roof and ridge, low posterior wall, and posterior interatrial septum. At 6 weeks or 4 months post-SABR, electrical isolation of the SABR lesion was confirmed using LA posterior wall pacing, and histopathological review was performed. Electrical isolation of all PVs and the LA posterior wall was achieved in three of five dogs in the 4-month group. There was one target failure and one sudden death at 15 weeks. Although two dogs in the 6-week group failed to achieve electrical lesion isolation, the irradiated atrial myocardium showed diffuse hemorrhage with inflammatory cell infiltration. In successfully isolated 4-month model dogs, we observed transmural fibrotic scarring with extensive fibrosis on irradiated atrial tissue. The findings suggest that this novel circular box-design radiotherapy technique using SABR could be applied to humans after further studies are conducted to confirm safety.
Collapse
Affiliation(s)
- Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Myung-Jin Cha
- Division of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. .,Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Jeong-Wook Seo
- Department of Pathology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea.,Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - So-Yeon Park
- Department of Radiation Oncology, Veterans Health Service Medical Center, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Byoung Hyuck Kim
- Department of Radiation Oncology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Euijae Lee
- Division of Cardiology, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
| | - Moo-Kang Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hye-Sun Yoon
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seil Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
21
|
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: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/14/2021] [Accepted: 04/25/2021] [Indexed: 12/31/2022]
Abstract
Stereotactic ablative radiotherapy (SABR), or stereotactic body radiotherapy (SBRT), has recently been applied in the field of arrhythmia management. It has been most widely assessed in the treatment of ventricular tachycardia (VT) but may also have potential in the treatment of other arrhythmias as well, often termed stereotactic arrhythmia radiotherapy (STAR). The non-invasive delivery of treatment for VT has the potential to spare an often physiologically vulnerable group of patients the burden of long catheter ablation procedures with the potential for prolonged periods of hemodynamic instability. Cardiac SABR also has the capacity to direct ablative therapy at substrate that is inaccessible using current transchatheter techniques. For these reasons cardiac SABR has generated significant enthusiasm as an emerging treatment modality for VT. We consider in review the pre-clinical data pertaining to the use of SABR in cardiac tissue and recent clinical evidence regarding the application of SABR in the field of arrhythmia management.
Collapse
Affiliation(s)
- John Whitaker
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Raymond H Mak
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Paul C Zei
- Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| |
Collapse
|
22
|
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: 5.8] [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.
Collapse
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
| |
Collapse
|
23
|
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: 3.5] [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]
|
24
|
Munshi A. Ablative radiosurgery for cardiac arrhythmias - A systematic review. Cancer Radiother 2021; 25:373-379. [PMID: 33589330 DOI: 10.1016/j.canrad.2021.01.009] [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: 10/03/2020] [Revised: 01/21/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
Stereotactic body radiotherapy (SBRT) is a high precision technique that is commonly used for malignant lesions in lung, liver, pancreas and spine. Recent reports suggest promise in use of SBRT as a tool in atrial and ventricular cardiac arrhythmias. The present systematic review deals with the use of SBRT technology for this novel indication. A PubMed search was done for articles published between 1990 and 2020. All original articles, case reports, case series of treated patients were included in the analyses. Out of the 55 articles in PubMed search, our search found 1 phase I/II clinical case series, 3 clinical case reports, 3 animal studies and 4 dosimetric studies related to cardiac SBRT for arrythmias. All studies used a uniform cardiac dose of 25Gy. The available preclinical, dosimetric and clinical studies have suggested that SBRT for cardiac arrhythmias could become a potential alternative in suitable patients. Cardiac and radiation oncology community await further data and experience in this modality, including safety and outcomes.
Collapse
Affiliation(s)
- A Munshi
- Department of Radiation Oncology, Manipal Hospitals, Dwarka, New Delhi, India.
| |
Collapse
|
25
|
Chiu MH, Mitchell LB, Ploquin N, Faruqi S, Kuriachan VP. Review of Stereotactic Arrhythmia Radioablation Therapy for Cardiac Tachydysrhythmias. CJC Open 2020; 3:236-247. [PMID: 33778440 PMCID: PMC7984992 DOI: 10.1016/j.cjco.2020.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/06/2020] [Indexed: 12/04/2022] Open
Abstract
Cardiac tachyarrhythmias are a major cause of morbidity and mortality. Treatments for these tachyarrhythmias include antiarrhythmic drugs, catheter ablation, surgical ablation, cardiac implantable electronic devices, and cardiac transplantation. Each of these treatment approaches is effective in some patients but there is considerable room for improvement, particularly with respect to the most common of the tachydysrhythmias, atrial fibrillation, and the most dangerous of the tachydysrhythmias, ventricular tachycardia (VT) or ventricular fibrillation. Noninvasive stereotactic ablative radiation therapy is emerging as an effective treatment for refractory tachyarrhythmias. Animal models have shown successful ablation of arrhythmogenic myocardial substrates with minimal short-term complications. Studies of stereotactic radioablation involving patients with refractory VT have shown a reduction in VT recurrence and promising early safety data. In this review, we provide the background for the application of stereotactic arrhythmia radioablation therapy along with promising results from early applications of the technology.
Collapse
Affiliation(s)
- Michael H Chiu
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Nicolas Ploquin
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Salman Faruqi
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Vikas P Kuriachan
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| |
Collapse
|
26
|
Kiani S, Kutob L, Schneider F, Higgins KA, Lloyd MS. Histopathologic and Ultrastructural Findings in Human Myocardium After Stereotactic Body Radiation Therapy for Recalcitrant Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2020; 13:e008753. [PMID: 33031001 DOI: 10.1161/circep.120.008753] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) is a novel treatment for refractory ventricular tachycardia (VT). While outcomes have been described in small studies, histological findings after SBRT for VT are unknown. METHODS We identified 4 explanted hearts in the context of transplant that received prior SBRT as part of an 11-patient compassionate use series at our institution. Clinical VTs and computed tomography-defined target volume areas of SBRT were correlated to the anatomic specimens. Gross pathological, histological, and ultrastructural examination of tissue in the target area of SBRT was performed. RESULTS All 4 patients had nonischemic cardiomyopathy, and 3 had left ventricular assist devices. In all cases, patients had recurrent sustained VT and had failed multiple antiarrhythmics and radiofrequency ablations. Four patients underwent 5 total SBRT therapy sessions with 25-Gy single-fraction dose delivered to the area of culprit scar. The time from SBRT to explant ranged from 12 to 250 days. Histopathologic features following radiation were comparable in all patients and were characterized by areas of subendocardial necrosis surrounded by a rim of fibrosis. In 1 patient, the surrounding myocardium showed cytoplasmic vacuolization in myocytes and in another patchy interstitial fibrosis. Vascular changes consisted of myointimal thickening with prominence of endothelial cells. Electron microscopy of myocardium showed irregular, convoluted intercalated disc regions, loss of contractile elements with disrupted and haphazardly arranged myofibrils, and edematous mitochondria with loss of cisternae. CONCLUSIONS Here, we report the first series of findings in human tissue in 4 patients after SBRT. Histopathologic features were consistent across all 4 patients and were indicative of cell injury, death, and to a lesser extent, fibrosis. Electron microscopy demonstrated features consistent with acute injury. These specimens provide radiobiological mechanisms of acute cellular injury during SBRT for VT, which may have an antiarrhythmic effect before the onset of fibrosis.
Collapse
Affiliation(s)
- Soroosh Kiani
- Department of Medicine, Division of Cardiology, Section of Electrophysiology and Pacing (S.K., M.S.L.), Emory University School of Medicine, Atlanta, GA
| | - Leila Kutob
- Department of Pathology and Laboratory Medicine (L.K., F.S.), Emory University School of Medicine, Atlanta, GA
| | - Frank Schneider
- Department of Pathology and Laboratory Medicine (L.K., F.S.), Emory University School of Medicine, Atlanta, GA
| | - Kristin A Higgins
- Department of Radiation Oncology (K.A.H.), Emory University School of Medicine, Atlanta, GA
| | - Michael S Lloyd
- Department of Medicine, Division of Cardiology, Section of Electrophysiology and Pacing (S.K., M.S.L.), Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
27
|
Noninvasive Radioablation of Ventricular Tachycardia. Cardiol Rev 2020; 28:283-290. [PMID: 33017363 DOI: 10.1097/crd.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ventricular tachycardia (VT) occurs most commonly in the presence of structural heart disease or myocardial scarring from prior infarction. It is associated with increased mortality, especially when it results in cardiac arrest outside of a hospital. When not due to reversible causes (such as acute ischemia/infarction), placement of an implantable cardioverter-defibrillator for prevention of future sudden death is indicated. The current standard of care for recurrent VT is medical management with antiarrhythmic agents followed by invasive catheter ablation for VT that persists despite appropriate medical therapy. Stereotactic arrhythmia radioablation (STAR) is a novel, noninvasive method of treating VT that has been shown to reduce VT burden for patients who are refractory to medical therapy and/or catheter ablation, or who are unable to tolerate catheter ablation. STAR is the term applied to the use of stereotactic body radiation therapy for the treatment of arrhythmogenic cardiac tissue and requires collaboration between an electrophysiologist and a radiation oncologist. The process involves identification of VT substrate through a combination of electroanatomic mapping and diagnostic imaging (computed tomography, magnetic resonance imaging, positron emission tomography) followed by carefully guided radiation therapy. In this article, we review currently available literature describing the utilization, efficacy, safety profile, and potential future applications of STAR for the management of VT.
Collapse
|
28
|
Non-invasive stereotactic body radiation therapy for refractory ventricular arrhythmias: an institutional experience. J Interv Card Electrophysiol 2020; 61:535-543. [DOI: 10.1007/s10840-020-00849-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/03/2020] [Indexed: 12/31/2022]
|
29
|
van der Ree MH, Blanck O, Limpens J, Lee CH, Balgobind BV, Dieleman EM, Wilde AA, Zei PC, de Groot JR, Slotman BJ, Cuculich PS, Robinson CG, Postema PG. Cardiac radioablation—A systematic review. Heart Rhythm 2020; 17:1381-1392. [DOI: 10.1016/j.hrthm.2020.03.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/13/2020] [Indexed: 12/29/2022]
|
30
|
Park JS, Choi Y. Stereotactic Cardiac Radiation to Control Ventricular Tachycardia and Fibrillation Storm in a Patient with Apical Hypertrophic Cardiomyopathy at Burnout Stage: Case Report. J Korean Med Sci 2020; 35:e200. [PMID: 32657082 PMCID: PMC7358068 DOI: 10.3346/jkms.2020.35.e200] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/08/2020] [Indexed: 12/31/2022] Open
Abstract
Stereotactic cardiac radiation for ablation (radioablation) of life-threatening ventricular arrhythmia was recently introduced into clinical practice. A 76-year-old male patient with apical hypertrophic cardiomyopathy at burnout stage, who received defibrillator implantation for the secondary prevention of sudden arrhythmic death, was admitted for repeated defibrillator therapy. Radiofrequency catheter ablation was unsuccessful due to the induction of ventricular fibrillation (VF) and hemodynamically unstable sustained monomorphic ventricular tachycardia (VT). However, intracardiac activation mapping for the induced VT revealed the earliest ventricular activation at the apical aneurysm. Radioablation was performed to control VT and VF storm refractory to antiarrhythmic drug therapy. A total of 24 Gray was radiated, divided into three fractions around the apical aneurysm. The onset of electrical modulation was instantaneous and the antiarrhythmic effect was maintained for at least 6 months without significant radiation toxicities. This case suggests that radioablation may be considered as a rescue therapy for VT and VF storm refractory to other treatment modalities.
Collapse
Affiliation(s)
- Jong Sung Park
- Department of Cardiology, Dong-A University Hospital, Busan, Korea.
| | - Youngmin Choi
- Department of Radiation Oncology, Dong-A University Hospital, Busan, Korea
| |
Collapse
|
31
|
Fiorentino A, Gregucci F, Bonaparte I, Vitulano N, Surgo A, Mazzola R, Di Monaco A, Carbonara R, Alongi F, Langialonga T, Grimaldi M. Stereotactic Ablative radiation therapy (SABR) for cardiac arrhythmia: A new therapeutic option? Radiol Med 2020; 126:155-162. [PMID: 32405924 DOI: 10.1007/s11547-020-01218-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/27/2020] [Indexed: 11/26/2022]
Abstract
AIM Stereotactic ablative radiation therapy (SABR) is used in non-oncologic indications, recently even for cardiac arrhythmias. Thus, aim of this analysis is to review preclinical, early clinical evidences and future direction of the latter new treatment approach. METHOD A collection of available data regarding SABR and cardiac arrhythmias was made, by Pubmed research and 2 independent researchers, including preclinical and clinical data. A review of ongoing trials was conducted on ClinicalTrials.gov. RESULTS Preclinical research conducted in animal models showed that a safe and effective noninvasive treatment approach for cardiac arrhythmias could be represented by SABR with a median time of response around 2-3 months. The treatment dose plays a crucial role: the atrioventricular node would seem more radiosensitive than the other cardiac electric zones. Clinical data, such as published case series, case reports and early prospective studies, have already suggested the feasibility, efficacy and safety of SABR (25 Gy in one session) for refractory ventricular arrhythmias. CONCLUSION Considering the ongoing trials of SABR and new technological improvements in radiotherapy (e.g. hybrid magnetic resonance) and in arrhythmias noninvasive mapping systems, the future analyses will improve the reliability of those preliminary results.
Collapse
Affiliation(s)
- Alba Fiorentino
- Department of Radiation Oncology, General Regional Hospital "F. Miulli", Strada Prov 127, 70021, Acquaviva delle Fonti, Bari, Italy
| | - Fabiana Gregucci
- Department of Radiation Oncology, General Regional Hospital "F. Miulli", Strada Prov 127, 70021, Acquaviva delle Fonti, Bari, Italy.
| | - Ilaria Bonaparte
- Department of Radiation Oncology, General Regional Hospital "F. Miulli", Strada Prov 127, 70021, Acquaviva delle Fonti, Bari, Italy
| | - Nicola Vitulano
- Department of Cardiology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Alessia Surgo
- Department of Radiation Oncology, General Regional Hospital "F. Miulli", Strada Prov 127, 70021, Acquaviva delle Fonti, Bari, Italy
| | - Rosario Mazzola
- Department of Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Antonio Di Monaco
- Department of Cardiology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Roberta Carbonara
- Department of Radiation Oncology, General Regional Hospital "F. Miulli", Strada Prov 127, 70021, Acquaviva delle Fonti, Bari, Italy
| | - Filippo Alongi
- Department of Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | - Tommaso Langialonga
- Department of Cardiology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| |
Collapse
|
32
|
Clinical experience of stereotactic body radiation for refractory ventricular tachycardia in advanced heart failure patients. Heart Rhythm 2020; 17:415-422. [DOI: 10.1016/j.hrthm.2019.09.028] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Indexed: 12/31/2022]
|
33
|
Wei C, Qian P, Tedrow U, Mak R, Zei PC. Non-invasive Stereotactic Radioablation: A New Option for the Treatment of Ventricular Arrhythmias. Arrhythm Electrophysiol Rev 2020; 8:285-293. [PMID: 32685159 PMCID: PMC7358955 DOI: 10.15420/aer.2019.04] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Ventricular tachycardia (VT) is associated with significant morbidity and mortality. Radiofrequency catheter ablation can be effective for the treatment of VT but it carries a high rate of recurrence often attributable to insufficient depth of penetration for reaching critical arrhythmogenic substrates. Stereotactic body radioablation (SBRT) is a commonly used technology developed for the non-invasive treatment of solid tumours. Recent evidence suggests that it can also be effective for the treatment of VT. It is a non-invasive procedure and it has the unique advantage of delivering ablative energy to any desired volume within the body to reach sites that are inaccessible with catheter ablation. This article summarises the pre-clinical studies that have formed the evidence base for SBRT in the heart, describes the clinical approaches for SBRT VT ablation and provides perspective on next steps for this new treatment modality.
Collapse
Affiliation(s)
- Chen Wei
- Harvard Medical School, Boston, MA, US.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, US
| | - Pierre Qian
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, US
| | - Usha Tedrow
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, US
| | - Raymond Mak
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, US
| | - Paul C Zei
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, US
| |
Collapse
|
34
|
Robinson CG, Samson PP, Moore KMS, Hugo GD, Knutson N, Mutic S, Goddu SM, Lang A, Cooper DH, Faddis M, Noheria A, Smith TW, Woodard PK, Gropler RJ, Hallahan DE, Rudy Y, Cuculich PS. Phase I/II Trial of Electrophysiology-Guided Noninvasive Cardiac Radioablation for Ventricular Tachycardia. Circulation 2019; 139:313-321. [PMID: 30586734 DOI: 10.1161/circulationaha.118.038261] [Citation(s) in RCA: 302] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Case studies have suggested the efficacy of catheter-free, electrophysiology-guided noninvasive cardiac radioablation for ventricular tachycardia (VT) using stereotactic body radiation therapy, although prospective data are lacking. METHODS We conducted a prospective phase I/II trial of noninvasive cardiac radioablation in adults with treatment-refractory episodes of VT or cardiomyopathy related to premature ventricular contractions (PVCs). Arrhythmogenic scar regions were targeted by combining noninvasive anatomic and electric cardiac imaging with a standard stereotactic body radiation therapy workflow followed by delivery of a single fraction of 25 Gy to the target. The primary safety end point was treatment-related serious adverse events in the first 90 days. The primary efficacy end point was any reduction in VT episodes (tracked by indwelling implantable cardioverter defibrillators) or any reduction in PVC burden (as measured by a 24-hour Holter monitor) comparing the 6 months before and after treatment (with a 6-week blanking window after treatment). Health-related quality of life was assessed using the Short Form-36 questionnaire. RESULTS Nineteen patients were enrolled (17 for VT, 2 for PVC cardiomyopathy). Median noninvasive ablation time was 15.3 minutes (range, 5.4-32.3). In the first 90 days, 2/19 patients (10.5%) developed a treatment-related serious adverse event. The median number of VT episodes was reduced from 119 (range, 4-292) to 3 (range, 0-31; P<0.001). Reduction was observed for both implantable cardioverter defibrillator shocks and antitachycardia pacing. VT episodes or PVC burden were reduced in 17/18 evaluable patients (94%). The frequency of VT episodes or PVC burden was reduced by 75% in 89% of patients. Overall survival was 89% at 6 months and 72% at 12 months. Use of dual antiarrhythmic medications decreased from 59% to 12% ( P=0.008). Quality of life improved in 5 of 9 Short Form-36 domains at 6 months. CONCLUSIONS Noninvasive electrophysiology-guided cardiac radioablation is associated with markedly reduced ventricular arrhythmia burden with modest short-term risks, reduction in antiarrhythmic drug use, and improvement in quality of life. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT02919618.
Collapse
Affiliation(s)
- Clifford G Robinson
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Pamela P Samson
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Kaitlin M S Moore
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Geoffrey D Hugo
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Nels Knutson
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Sasa Mutic
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - S Murty Goddu
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Adam Lang
- Department of Pathology (A.L.), Washington University, St Louis, MO
| | - Daniel H Cooper
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Mitchell Faddis
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Amit Noheria
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Timothy W Smith
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Pamela K Woodard
- Mallinckrodt Institute of Radiology (P.K.W., R.J.G.), Washington University, St Louis, MO
| | - Robert J Gropler
- Mallinckrodt Institute of Radiology (P.K.W., R.J.G.), Washington University, St Louis, MO
| | - Dennis E Hallahan
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Yoram Rudy
- Departments of Biomedical Engineering, Cell Biology and Physiology, Medicine, Radiology, and Pediatrics (Y.R.), Washington University, St Louis, MO
| | - Phillip S Cuculich
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| |
Collapse
|
35
|
Abstract
The management of ventricular arrhythmias (VA) has evolved over time to an advanced discipline, incorporating many technologies in the diagnosis and treatment of the myriad types of VA. The first application of imaging is in the assessment for structural heart disease, as this has the greatest impact on prognosis. Advanced imaging has its greatest utility in the planning and execution of ablation for VA. The following review outlines the application of different imaging modalities, such as ultrasonography, magnetic resonance imaging, computed tomography, and positron emission tomography, for the treatment of VA.
Collapse
|
36
|
Sharp AJ, Mak R, Zei PC. Noninvasive Cardiac Radioablation for Ventricular Arrhythmias. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0596-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|