Stereotactic body radiotherapy (SBRT) has been reported as an attractive option for cases of failed catheter ablation of ventricular tachycardia (VT) in structural heart disease. However, even this strategy can fail for various reasons. For the first time, this case series describes three re-do cases of SBRT which were indicated for three different reasons. The purpose in the first case was the inaccuracy of the determination of the treatment volume by indirect comparison of the electroanatomical map and CT scan. A newly developed strategy of co-registration of both images allowed precise targeting of the substrate. In this case, the second treatment volume overlapped by 60% with the first one. The second reason for the re-do of SBRT was an unusual character of the substrate-large cardiac fibroma associated with different morphologies of VT from two locations around the tumor. The planned treatment volumes did not overlap. The third reason for repeated SBRT was the large intramural substrate in the setting of advanced heart failure. The first treatment volume targeted arrhythmias originating in the basal inferoseptal region, while the second SBRT was focused on adjacent basal septum without significant overlapping. Our observations suggested that SBRT for VT could be safely repeated in case of later arrhythmia recurrences (i.e., after at least 6 weeks). No acute toxicity was observed and in two cases, no side effects were observed during 32 and 22 months, respectively. To avoid re-do SBRT due to inaccurate targeting, the precise and reproducible strategy of substrate identification and co-registration with CT image should be used.

Department of Cardiology Institute for Clinical and Experimental Medicine Prague Czechia

Department of Cardiology Masaryk University Medical School Brno Czechia

Department of Cardiology Podlesí Hospital Trinec Trinec Czechia

Department of Oncology Ostrava University Medical School Ostrava Czechia

Department of Oncology University Hospital Ostrava Ostrava Czechia

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Briceño DF, Romero J, Patel K, Liaqat W, Zhang XD, Alviz I, et al. . First-line ablation of ventricular tachycardia in ischemic cardiomyopathy: stratification of outcomes by left ventricular function. J Interv Card Electrophysiol. (2021) 62:391–400. 10.1007/s10840-020-00912-w PubMed DOI

Vergara P, Tung R, Vaseghi M, Brombin C, Frankel DS, Di Biase L, et al. . Successful ventricular tachycardia ablation in patients with electrical stormreduces recurrences and improves survival. Heart Rhythm. (2018) 15:48–55. 10.1016/j.hrthm.2017.08.022 PubMed DOI

Tung R, Vaseghi M, Frankel DS, Vergara P, Di Biase L, Nagashima K, et al. . Freedom from recurrent ventricular tachycardia after catheter ablation is associated with improved survival in patients with structural heart disease: An International VT Ablation Center Collaborative Group study. Heart Rhythm. (2015) 12:1997–2007. 10.1016/j.hrthm.2015.05.036 PubMed DOI PMC

Kumar S, Barbhaiya CR, Sobieszczyk P, Eisenhauer AC, Couper GS, Nagashima K, et al. . Role of alternative interventional procedures when endo- and epicardial catheter ablation attempts for ventricular arrhythmias fail. Circ Arrhythm Electrophysiol. (2015) 8:606–15. 10.1161/CIRCEP.114.002522 PubMed DOI

Tokuda M, Kojodjojo P, Tung S, Tedrow UB, Nof E, Inada K, et al. . Acute failure of catheter ablation for ventricular tachycardia due to structural heart disease: causes and significance. J Am Heart Assoc. (2013) 2:e000072. 10.1161/JAHA.113.000072 PubMed DOI PMC

Cvek J, Neuwirth R, Knybel L, Molenda L, Otahal B, Pindor J, et al. . Cardiac Radiosurgery for Malignant Ventricular Tachycardia. Cureus. (2014) 6:e190. 10.7759/cureus.190 DOI

Loo BW, Jr, Soltys SG, Wang L, Lo A, Fahimian BP, Iagaru A, et al. . Stereotactic ablative radiotherapy for the treatment of refractory cardiac ventricular arrhythmia. Circ Arrhythm Electrophysiol. (2015) 8:748–50. 10.1161/CIRCEP.115.002765 PubMed DOI

Cuculich PS, Schill MR, Kashani R, Mutic S, Lang A, Cooper D, et al. . Noninvasive cardiac radiation for ablation of ventricular tachycardia. N Engl J Med. (2017) 377:2325–36. 10.1056/NEJMoa1613773 PubMed DOI PMC

Robinson CG, Samson PP, Moore KMS, Hugo GD, Knutson N, Mutic S, et al. . Phase I/II Trial of Electrophysiology-Guided Noninvasive Cardiac Radioablation for Ventricular Tachycardia. Circulation. (2019) 139:313–21. 10.1161/CIRCULATIONAHA.118.038261 PubMed DOI PMC

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. (2018) 5:44–47. 10.1016/j.hrcr.2018.10.007 PubMed DOI PMC

Jumeau R, Ozsahin M, Schwitter J, Vallet V, Duclos F, Zeverino M, et al. . Rescue procedure for an electrical storm using robotic non-invasive cardiac radio-ablation. Radiother Oncol. (2018) 128:189–91. 10.1016/j.radonc.2018.04.025 PubMed DOI

Neuwirth R, Cvek J, Knybel L, Jiravsky O, Molenda L, Kodaj M, et al. . Stereotactic radiosurgery for ablation of ventricular tachycardia. Europace. (2019) 21:1088–95. 10.1093/europace/euz133 PubMed DOI

Scholz EP, Seidensaal K, Naumann P, André F, Katus HA, 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) 5:329–32. 10.1016/j.hrcr.2019.03.004 PubMed DOI PMC

Bhaskaran A, Downar E, Chauhan VS, Lindsay P, Nair K, Ha A, et al. . Electroanatomical mapping-guided stereotactic radiotherapy for right ventricular tachycardia storm. HeartRhythm Case Rep. (2019) 5:590–2. 10.1016/j.hrcr.2019.09.007 PubMed DOI PMC

Lloyd MS, Wight J, Schneider F, Hoskins M, Attia T, Escott C, et al. . Clinical experience of stereotactic body radiation for refractory ventricular tachycardia in advanced heart failure patients. Heart Rhythm. (2020) 17:415–22. 10.1016/j.hrthm.2019.09.028 PubMed DOI

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. 10.3346/jkms.2020.35.e200 PubMed DOI PMC

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). (2020) 73:97–9. 10.1016/j.rec.2019.06.004 PubMed DOI

Lee J, Bates M, Shepherd E, Riley S, Henshaw M, Metherall P, et al. . Cardiac stereotactic ablative radiotherapy for control of refractory ventricular tachycardia: initial UK multicentre experience. Open Heart. (2021) 8:e001770. 10.1136/openhrt-2021-001770 PubMed DOI PMC

Carbucicchio C, Andreini D, Piperno G, Catto V, Conte E, Cattani F, et al. . Stereotactic radioablation for the treatment of ventricular tachycardia: preliminary data and insights from the STRA-MI-VT phase Ib/II study. J Interv Card Electrophysiol. (2021) 62:427–39. 10.1007/s10840-021-01060-5 PubMed DOI PMC

Peichl P, Sramko M, Cvek J, Kautzner. A case report of successful elimination of recurrent ventricular tachycardia by repeated stereotactic radiotherapy: the importance of accurate target volume delineation. Eur Heart J Case Rep. (2020) 5:ytaa516. 10.1093/ehjcr/ytaa516 PubMed DOI PMC

Bergom C, Bradley JA, Ng AK, Samson P, Robinson C, Lopez-Mattei J, et al. . Past, present, and future of radiation-induced cardiotoxicity: refinements in targeting, surveillance, and risk stratification. JACC CardioOncol. (2021) 3:343–59. 10.1016/j.jaccao.2021.06.007 PubMed DOI PMC

Borkenhagen JF, Bergom C, Rapp CT, Klawikowski SJ, Rein LE, Gore EM. Dosimetric predictors of cardiotoxicity in thoracic radiotherapy for lung cancer. Clin Lung Cancer. (2019) 20:435–41. 10.1016/j.cllc.2019.05.014 PubMed DOI

van den Bogaard VA, Ta BD, van der Schaaf A, Bouma AB, Middag AM, Bantema-Joppe EJ, et al. . Validation and modification of a prediction model for acute cardiac events in patients with breast cancer treated with radiotherapy based on three-dimensional dose distributions to cardiac substructures. J Clin Oncol. (2017) 35:1171–8. 10.1200/JCO.2016.69.8480 PubMed DOI PMC

Taylor C, Correa C, Duane FK, Aznar MC, Anderson SJ, Bergh J, et al. . Early Breast Cancer Trialists' Collaborative Group. Estimating the risks of breast cancer radiotherapy: evidence from modern radiation doses to the lungs and heart and from previous randomized trials. J Clin Oncol. (2017) 35:1641–9. 10.1200/JCO.2016.72.0722 PubMed DOI PMC

Lehmann HI, Graeff C, Simoniello P, Constantinescu A, Takami M, Lugenbiel P, et al. . Feasibility study on cardiac arrhythmia ablation using high-energy heavy ion beams. Sci Rep. (2016) 6:38895. 10.1038/srep38895 PubMed DOI PMC

Suzuki A, Deisher AJ, Rettmann ME, Lehmann HI, Hohmann S, Wang S, et al. . Catheter-free arrhythmia ablation using scanned proton beams: electrophysiologic outcomes, biophysics, and characterization of lesion formation in a porcine model. Circ Arrhythm Electrophysiol. (2020) 13:e008838. 10.1161/CIRCEP.120.008838 PubMed DOI

Kautzner J, Jedlickova K, Sramko M, Peichl P, Cvek J, Knybel L, et al. . Radiation-induced changes in ventricular myocardium after stereotactic body radiotherapy for recurrent ventricular tachycardia. JACC Clin Electrophysiol. (2021) 21:S2405-500X(21)00687-3. 10.1016/j.jacep.2021.07.012 PubMed DOI

Chin R, Hayase J, Hu P, Cao M, Deng J, Ajijola O, et al. . Non-invasive stereotactic body radiation therapy for refractory ventricular arrhythmias: an institutional experience. J Interv Card Electrophysiol. (2021) 61:535–43. 10.1007/s10840-020-00849-0 PubMed DOI

Gianni C, Rivera D, Burkhardt JD, Pollard B, Gardner E, Maguire P, et al. . Stereotactic arrhythmia radioablation for refractory scar-related ventricular tachycardia. Heart Rhythm. (2020) 17:1241–8. 10.1016/j.hrthm.2020.02.036 PubMed DOI

Zhang DM, Navara R, Yin T, Szymanski J, Goldsztejn U, Kenkel C, et al. . Cardiac radiotherapy induces electrical conduction reprogramming in the absence of transmural fibrosis. Nat Commun. (2021) 12:5558. 10.1038/s41467-021-25730-0 PubMed DOI PMC

Cha MJ, Seo JW, Kim HJ, Kim MK, Yoon HS, Jo SW, et al. . Early changes in rat heart after high-dose irradiation: implications for antiarrhythmic effects of cardiac radioablation. J Am Heart Assoc. (2021) 10:e019072. 10.1161/JAHA.120.019072 PubMed DOI PMC

Abdel-Kafi S, Sramko M, Omara S, de Riva M, Cvek J., Peichl P, et al. . Accuracy of electroanatomical mapping-guided cardiac radiotherapy for ventricular tachycardia: pitfalls and solutions. Europace. (2021) 23:1989–97. 10.1093/europace/euab195 PubMed DOI

Mayinger M, Kovacs B, Tanadini-Lang S, Ehrbar S, Wilke L, Chamberlain M, et al. . First magnetic resonance imaging-guided cardiac radioablation of sustained ventricular tachycardia. Radiother Oncol. (2020) 152:203–7. 10.1016/j.radonc.2020.01.008 PubMed DOI

Patient selection, ventricular tachycardia substrate delineation, and data transfer for stereotactic arrhythmia radioablation: a clinical consensus statement of the European Heart Rhythm Association of the European Society of Cardiology and the Heart Rhythm Society

Inflammation and fibrosis characterize different stages of myocardial remodeling in patients after stereotactic body radiotherapy of ventricular myocardium for recurrent ventricular tachycardia

Repeated stereotactic radiotherapy of recurrent ventricular tachycardia

Retrograde coronary venous ethanol ablation of ventricular tachycardia in a patient after aortic valve replacement and failed both radiofrequency ablation and stereotactic radiotherapy