The electrophysiology-guided noninvasive cardiac radioablation, also known as STAR (stereotactic arrhythmia radioablation) is an emerging treatment method for persistent ventricular tachycardia. Since its first application in 2012 in Stanford Cancer Institute, and a year later in University Hospital Ostrava, Czech Republic, the authors from all around the world have published case reports and case series, and several prospective trials were established. In this article, we would like to discuss the available clinical evidence, analyze the potentially clinically relevant differences in methodology, and address some of the unique challenges that come with this treatment method.

1st Department of Cardiology Medical University of Silesia 40 055 Katowice Poland

3rd Department of Radiotherapy and Chemotherapy Maria Sklodowska Curie National Research Institute of Oncology 44 102 Gliwice Poland

Department of Cardiology and Structural Heart Diseases Medical University of Silesia 40 055 Katowice Poland

Department of Electrocardiology and Heart Failure Medical University of Silesia 40 055 Katowice Poland

Department of Electrocardiology John Paul 2 Hospital 31 202 Cracow Poland

Department of Radiotherapy Maria Sklodowska Curie National Research Institute of Oncology 44 102 Gliwice Poland

International Clinical Research Center Interventional Cardiac Electrophysiology Group St Anne's University Hospital Brno 664 53 Brno Czech Republic

Upper Silesian Heart Center Department of Electrocardiology 40 055 Katowice Poland

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Tang P.T., Shenasa M., Boyle N.G. Ventricular arrhythmias and sudden cardiac death. Card. Electrophysiol. Clin. 2017;9:693–708. doi: 10.1016/j.ccep.2017.08.004. PubMed DOI

Srinivasan N.T., Schilling R.J. Sudden cardiac death and arrhythmias. Arrhythmia Electrophysiol. Rev. 2018;7:111. doi: 10.15420/aer.2018:15:2. PubMed DOI PMC

Shivkumar K. Catheter ablation of ventricular arrhythmias. N. Engl. J. Med. 2019;380:1555–1564. doi: 10.1056/NEJMra1615244. PubMed DOI

Al-Khatib S.M., Stevenson W.G., Ackerman M.J., Bryant W.J., Callans D.J., Curtis A.B., Deal B.J., Dickfeld T., Field M.E., Fonarow G.C., et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: Executive summary: A report of the american college of cardiology/american heart association task force on clinical practice guidelines and the heart rhythm society. Heart Rhythm. 2018;15:e190–e252. PubMed

Dukkipati S.R., Koruth J.S., Choudry S., Miller M.A., Whang W., Reddy V.Y. Catheter ablation of ventricular tachycardia in structural heart disease: Indications, strategies, and outcomes-Part II. J. Am. Coll. Cardiol. 2017;70:2924–2941. doi: 10.1016/j.jacc.2017.10.030. PubMed DOI

Fernandez-Armenta J., Soto-Iglesias D., Silva E., Penela D., Jáuregui B., Linhart M., Bisbal F., Acosta J., Fernandez M., Borras R., et al. Safety and outcomes of ventricular tachycardia substrate ablation during sinus rhythm: A prospective multicenter registry. JACC Clin. Electrophysiol. 2020 doi: 10.1016/j.jacep.2020.07.028. PubMed DOI

Santangeli P., Frankel D.S., Tung R., Vaseghi M., Sauer W.H., Tzou W.S., Mathuria N., Nakahara S., Dickfeldt T.M., Lakkireddy D., et al. Early mortality after catheter ablation of ventricular tachycardia in patients with structural heart disease. J. Am. Coll. Cardiol. 2017;69:2105–2115. doi: 10.1016/j.jacc.2017.02.044. PubMed DOI

Palaniswamy C., Kolte D., Harikrishnan P., Khera S., Aronow W.S., Mujib M., Mellana W.M., Eugenio P., Lessner S., Ferrick A., et al. Catheter ablation of postinfarction ventricular tachycardia: Ten-year trends in utilization, in-hospital complications, and in-hospital mortality in the United States. Heart Rhythm. 2014 doi: 10.1016/j.hrthm.2014.07.012. PubMed DOI

Arenal Á., Hernández J., Calvo D., Ceballos C., Atéa L., Datino T., Atienza F., González-Torrecilla E., Eídelman G., Miracle Á., et al. Safety, long-term results, and predictors of recurrence after complete endocardial ventricular tachycardia substrate ablation in patients with previous myocardial infarction. Am. J. Cardiol. 2013 doi: 10.1016/j.amjcard.2012.10.031. PubMed DOI

Cuculich P.S., Schill M.R., Kashani R., Mutic S., Lang A., Cooper D., Faddis M., Gleva M., Noheria A., Smith T.W., et al. Noninvasive cardiac radiation for ablation of ventricular tachycardia. N. Engl. J. Med. 2017 doi: 10.1056/NEJMoa1613773. PubMed DOI PMC

Robinson C.G., Samson P.P., Moore K.M.S., Hugo G.D., Knutson N., Mutic S., Goddu S.M., Lang A., Cooper D.H., Faddis M., et al. Phase I/II trial of electrophysiology-guided noninvasive cardiac radioablation for ventricular tachycardia. Circulation. 2019;139:313–321. doi: 10.1161/CIRCULATIONAHA.118.038261. PubMed DOI PMC

Neuwirth R., Cvek J., Knybel L., Jiravsky O., Molenda L., Kodaj M., Fiala M., Peichl P., Feltl D., Januška J., et al. Stereotactic radiosurgery for ablation of ventricular tachycardia. EP Eur. 2019;21:1088–1095. doi: 10.1093/europace/euz133. PubMed DOI

Dickfeld T., Tian J., Ahmad G., Jimenez A., Turgeman A., Kuk R., Peters M., Saliaris A., Saba M., Shorofsky S., et al. MRI-guided ventricular tachycardia ablation integration of late gadolinium-enhanced 3D scar in patients with implantable cardioverter- defibrillators. Circ. Arrhythmia Electrophysiol. 2011 doi: 10.1161/CIRCEP.110.958744. PubMed DOI

Cochet H., Komatsu Y., Sacher F., Jadidi A.S., Scherr D., Riffaud M., Derval N., Shah A., Roten L., Pascale P., et al. Integration of merged delayed-enhanced magnetic resonance imaging and multidetector computed tomography for the guidance of ventricular tachycardia ablation: A pilot study. J. Cardiovasc. Electrophysiol. 2013 doi: 10.1111/jce.12052. PubMed DOI

Benedict S.H., Yenice K.M., Followill D., Galvin J.M., Hinson W., Kavanagh B., Keall P., Lovelock M., Meeks S., Papiez L., et al. Stereotactic body radiation therapy: The report of AAPM Task Group 101. Med. Phys. 2010 doi: 10.1118/1.3438081. PubMed DOI

Pappone C., Ciconte G., Manguso F., Vicedomini G., Mecarocci V., Conti M., Giannelli L., Pozzi P., Borrelli V., Menicanti L., et al. Assessing the malignant ventricular arrhythmic substrate in patients with brugada syndrome. J. Am. Coll. Cardiol. 2018 doi: 10.1016/j.jacc.2018.02.022. PubMed DOI

Talib A.K., Takagi M., Shimane A., Nakano M., Hayashi T., Okajima K., Kentaro M., Fukada K., Kowase S., Kurosaki K., et al. Efficacy of endocardial ablation of drug-resistant ventricular fibrillation in brugada syndrome. Circ. Arrhythma Electrophysiol. 2018 doi: 10.1161/CIRCEP.117.005631. PubMed DOI

Igarashi M., Nogami A., Kurosaki K., Hanaki Y., Komatsu Y., Fukamizu S., Morishima I., Kaitani K., Nishiuchi S., Talib A.K., et al. Radiofrequency catheter ablation of ventricular tachycardia in patients with hypertrophic cardiomyopathy and apical aneurysm. JACC Clin. Electrophysiol. 2018 doi: 10.1016/j.jacep.2017.12.020. PubMed DOI

Bogun F.M., Desjardins B., Good E., Gupta S., Crawford T., Oral H., Ebinger M., Pelosi F., Chugh A., Jongnarangsin K., et al. Delayed-enhanced magnetic resonance imaging in nonischemic cardiomyopathy. utility for identifying the ventricular arrhythmia substrate. J. Am. Coll. Cardiol. 2009 doi: 10.1016/j.jacc.2008.11.052. PubMed DOI PMC

Andreu D., Berruezo A., Ortiz-Pérez J.T., Silva E., Mont L., Borràs R., De Caralt T.M., Perea R.J., Fernández-Armenta J., Zeljko H., et al. Integration of 3D electroanatomic maps and magnetic resonance scar characterization into the navigation system to guide ventricular tachycardia ablation. Circ. Arrhythmia Electrophysiol. 2011 doi: 10.1161/CIRCEP.111.961946. PubMed DOI

Gupta S., Desjardins B., Baman T., Ilg K., Good E., Crawford T., Oral H., Pelosi F., Chugh A., Morady F., et al. Delayed-enhanced MR scar imaging and intraprocedural registration into an electroanatomical mapping system in post-infarction patients. JACC Cardiovasc. Imaging. 2012 doi: 10.1016/j.jcmg.2011.08.021. PubMed DOI PMC

Cronin E.M., Bogun F.M., Maury P., Peichl P., Chen M., Namboodiri N., Aguinaga L., Leite L.R., Al-Khatib S.M., Anter E., et al. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace. 2019 doi: 10.1093/europace/euz132. PubMed DOI PMC

Cvek J., Neuwirth R., Knybel L., Molenda L., Otahal B., Pindor J., Murárová M., Kodaj M., Fiala M., Branny M., et al. Cardiac radiosurgery for malignant ventricular tachycardia. Cureus. 2014 doi: 10.7759/cureus.190. DOI

Loo B.W., Soltys S.G., Wang L., Lo A., Fahimian B.P., Iagaru A., Norton L., Shan X., Gardner E., Fogarty T., et al. Stereotactic ablative radiotherapy for the treatment of refractory cardiac ventricular arrhythmia. Circ. Arrhythmia Electrophysiol. 2015;8:748–750. doi: 10.1161/CIRCEP.115.002765. PubMed DOI

Park J.S., 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 doi: 10.3346/jkms.2020.35.e200. PubMed DOI PMC

Jumeau R., Ozsahin M., Schwitter J., Vallet V., Duclos F., Zeverino M., Moeckli R., Pruvot E., Bourhis J. Rescue procedure for an electrical storm using robotic non-invasive cardiac radio-ablation. Radiother. Oncol. 2018;128:189–191. doi: 10.1016/j.radonc.2018.04.025. PubMed DOI

Haskova J., Peichl P., Pirk J., Cvek J., Neuwirth R., Kautzner J. Stereotactic radiosurgery as a treatment for recurrent ventricular tachycardia associated with cardiac fibroma. HeartRhythm Case Rep. 2019;5:44–47. doi: 10.1016/j.hrcr.2018.10.007. PubMed DOI PMC

Scholz E.P., Seidensaal K., Naumann P., André F., Katus H.A., Debus J. Risen from the dead: Cardiac stereotactic ablative radiotherapy as last rescue in a patient with refractory ventricular fibrillation storm. HeartRhythm Case Rep. 2019;5:329–332. doi: 10.1016/j.hrcr.2019.03.004. PubMed DOI PMC

Zeng L., Huang L., Tan H., Zhang H., Mei J., Shi H., Jiang C., Tan C., Zheng J., Liu X. Stereotactic body radiation therapy for refractory ventricular tachycardia secondary to cardiac lipoma: A case report. Pacing Clin. Electrophysiol. 2019;42:1276–1279. doi: 10.1111/pace.13731. PubMed DOI

Martí-Almor J., Jiménez-López J., Rodríguez de Dios N., Tizón H., Vallés E., Algara M. Noninvasive ablation of ventricular tachycardia with stereotactic radiotherapy in a patient with arrhythmogenic right ventricular cardiomyopathy. Rev. Esp. Cardiol. (Engl. Ed). 2019 doi: 10.1016/j.rec.2019.06.004. PubMed DOI

Bhaskaran A., Downar E., Chauhan V.S., Lindsay P., Nair K., Ha A., Hope A., Nanthakumar K. Electroanatomical mapping–guided stereotactic radiotherapy for right ventricular tachycardia storm. HeartRhythm Case Rep. 2019;5:590–592. doi: 10.1016/j.hrcr.2019.09.007. PubMed DOI PMC

Krug D., Blanck O., Demming T., Dottermusch M., Koch K., Hirt M., Kotzott L., Zaman A., Eidinger L., Siebert F.A., et al. Stereotactic body radiotherapy for ventricular tachycardia (cardiac radiosurgery): First-in-patient treatment in Germany. Strahlenther. Onkol. 2020;196:23–30. doi: 10.1007/s00066-019-01530-w. PubMed DOI

Mayinger M., Kovacs B., Tanadini-Lang S., Ehrbar S., Wilke L., Chamberlain M., Moreira A., Weitkamp N., Brunckhorst C., Duru F., et al. First magnetic resonance imaging-guided cardiac radioablation of sustained ventricular tachycardia. Radiother. Oncol. 2020 doi: 10.1016/j.radonc.2020.01.008. PubMed DOI

Lloyd M.S., Wight J., Schneider F., Hoskins M., Attia T., Escott C., Lerakis S., Higgins K.A. Clinical experience of stereotactic body radiation for refractory ventricular tachycardia in advanced heart failure patients. Heart Rhythm. 2019 doi: 10.1016/j.hrthm.2019.09.028. PubMed DOI

Chin R., Hayase J., Hu P., Cao M., Deng J., Ajijola O., Do D., Vaseghi M., Buch E., Khakpour H., et al. Non-invasive stereotactic body radiation therapy for refractory ventricular arrhythmias: An institutional experience. J. Interv. Card. Electrophysiol. 2020 doi: 10.1007/s10840-020-00849-0. PubMed DOI

Gianni C., Rivera D., Burkhardt J.D., Pollard B., Gardner E., Maguire P., Zei P.C., Natale A., Al-Ahmad A. Stereotactic arrhythmia radioablation for refractory scar-related ventricular tachycardia. Heart Rhythm. 2020 doi: 10.1016/j.hrthm.2020.02.036. PubMed DOI

Jáuregui B., Soto-Iglesias D., Zucchelli G., Penela D., Ordóñez A., Terés C., Chauca A., Acosta J., Fernández-Armenta J., Linhart M., et al. Arrhythmogenic substrate detection in chronic ischaemic patients undergoing ventricular tachycardia ablation using multidetector cardiac computed tomography: Compared evaluation with cardiac magnetic resonance. EP Eur. 2021 doi: 10.1093/europace/euaa237. PubMed DOI

Brett C., Cook J., Aboud A.A., Karim R., Stevenson W., Shinohara E.T. Novel workflow for conversion of catheter-based electroanatomic mapping to DICOM imaging for cardiac radiation ablation of ventricular tachycardia. Int. J. Radiat. Oncol. 2020 doi: 10.1016/j.ijrobp.2020.07.627. PubMed DOI

Hohmann S., Henkenberens C., Zormpas C., Christiansen H., Bauersachs J., Duncker D., Veltmann C. A novel open-source software-based high-precision workflow for target definition in cardiac radioablation. J. Cardiovasc. Electrophysiol. 2020 doi: 10.1111/jce.14660. PubMed DOI

Wang L., Fahimian B., Soltys S.G., Zei P., Lo A., Gardner E.A., Maguire P.J., Loo B.W., Jr. Stereotactic arrhythmia radioablation (STAR) of ventricular tachycardia: A treatment planning study. Cureus. 2016;8 doi: 10.7759/cureus.694. PubMed DOI PMC

Lydiard S., Hugo G., O’Brien R., Blanck O., Keall P. A review of cardiac radioablation (CR) for arrhythmias: Procedures, technology and future opportunities. Int. J. Radiat. Oncol. 2020 doi: 10.1016/j.ijrobp.2020.10.036. PubMed DOI

Sharma A., Wong D., Weidlich G., Fogarty T., Jack A., Sumanaweera T., Maguire P. Noninvasive stereotactic radiosurgery (CyberHeart) for creation of ablation lesions in the atrium. Heart Rhythm. 2010;7:802–810. doi: 10.1016/j.hrthm.2010.02.010. PubMed DOI

Maguire P.J., Gardner E., Jack A.B., Zei P., Al-Ahmad A., Fajardo L., Ladich E., Takeda P. Cardiac Radiosurgery (CyberHeartTM) for treatment of arrhythmia: Physiologic and histopathologic correlation in the porcine model. Cureus. 2012 doi: 10.7759/cureus.32. DOI

Zei P.C., Mak R. Noninvasive stereotactic radioablation for ventricular tachycardia. Circulation. 2019;139:322–324. doi: 10.1161/CIRCULATIONAHA.118.038285. PubMed DOI

Fajardo L.F., Stewart J.R. Experimental radiation-induced heart disease. I. Light microscopic studies. Am. J. Pathol. 1970;59:299–316. PubMed PMC

Kiani S., Kutob L., Schneider F., Higgins K.A., Lloyd M.S. Histopathologic and ultrastructural findings in human myocardium after stereotactic body radiation therapy for recalcitrant ventricular tachycardia. Circ. Arrhythmia Electrophysiol. 2020 doi: 10.1161/CIRCEP.120.008753. PubMed DOI

Blanck O., Bode F., Gebhard M., Hunold P., Brandt S., Bruder R., Grossherr M., Vonthein R., Rades D., Dunst J. Dose-escalation study for cardiac radiosurgery in a porcine model. Int. J. Radiat. Oncol. Biol. Phys. 2014;89:590–598. doi: 10.1016/j.ijrobp.2014.02.036. PubMed DOI

Robinson C.G., Samson P., Moore K.M.S., Hugo G.D., Knutson N., Mutic S., Goddu S.M., Cooper D.H., Faddis M., Noheria A., et al. Longer term results from a Phase I/II study of ep-guided noninvasive cardiac radioablation for treatment of ventricular tachycardia (ENCORE-VT) Int. J. Radiat. Oncol. 2019;105:682. doi: 10.1016/j.ijrobp.2019.08.032. DOI

Monroy E., Azpiri J., De La Peña C., Cardona C., Hinojosa M., Zamarripa R., Assad J. Late gadolinium enhancement cardiac magnetic resonance imaging post Robotic Radiosurgical Pulmonary Vein Isolation (RRPVI). First case in the world. Cureus. 2016;8 doi: 10.7759/cureus.738. PubMed DOI PMC

Blanck O., Buergy D., Vens M., Eidinger L., Zaman A., Krug D., Rudic B., Boda-Heggemann J., Giordano F.A., Boldt L.H., et al. Radiosurgery for ventricular tachycardia: Preclinical and clinical evidence and study design for a German multi-center multi-platform feasibility trial (RAVENTA) Clin. Res. Cardiol. 2020;109:1319–1332. doi: 10.1007/s00392-020-01650-9. PubMed DOI PMC

Boda-Heggemann J., Blanck O., Mehrhof F., Ernst F., Buergy D., Fleckenstein J., Tülümen E., Krug D., Siebert F.-A., Zaman A., et al. Interdisciplinary clinical target volume generation for cardiac radioablation: Multi-center benchmarking for the RAdiosurgery for VENtricular TAchycardia (RAVENTA) trial. Int. J. Radiat. Oncol. 2021 doi: 10.1016/j.ijrobp.2021.01.028. PubMed DOI

Robinson C.G., Kashani R., Bradley J.D., Roach M.C., Mutic S., Schill M., Cuculich P.S. Noninvasive stereotactic cardiac ablation for recurrent Ventricular Tachycardia (VT): Technical considerations and early clinical experience. Int. J. Radiat. Oncol. 2016 doi: 10.1016/j.ijrobp.2016.06.1890. DOI

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