BACKGROUND: Stereotactic Arrhythmia Radioablation (STAR) is an emerging treatment modality for patients with sustained ventricular tachycardia (VT) and refractory to treatment with drugs and radiofrequency catheter ablation (RFA). It is believed that up to 12-17% of patients experience recurrence of VT within 1 year of follow-up; thus, novel therapeutic options are needed. The aim of this article is to present initial experience within a novel treatment modality for VT. CASE SUMMARY: Two patients with a medical history of coronary artery disease and heart failure with reduced left ventricle (LV) ejection fraction, after implantation of cardioverter-defibrillator (ICD) and previous unsuccessful RFAs owing to sustained VT were admitted to the cardiology department due to recurrence of sustained VT episodes. With electroanatomical mapping (EAM), the VT substrate in LV has been confirmed and specified. In order to determine the target volume for radioablation, contrast-enhanced computed tomography was performed and the arrhythmia substrate was contoured using EAM data. Using the Volumetric Modulated Arc Therapy technique and three 6 MeV flattening filter-free photon beam fields, a single dose of 25 Gy was delivered to the target volume structure located in the apex and anterior apical segments of LV in the first patient and in the apex, anterolateral and inferior apical segments of the second patient. In both cases, volumes of the target structures were comparable. Interrogation of the implanted ICD at follow-up visits throughout 6 months after the treatment revealed no VT episodes in the first patient and sudden periprocedural increase in VT burden with a subsequent gradual decrease of ventricular arrhythmia to only two non-sustained episodes at the end of the follow-up period in case of the second patient. A significant reduction in premature ventricular contractions burden was observed compared to the pre-treatment period. No noticeable deterioration in LV function was noted, nor any adverse effects of radiosurgery associated with the implanted device. CONCLUSION: The early response to STAR can be unpredictable and probably does not reflect the final outcome of irradiation. Close monitoring of patients, especially in the early period after irradiation is crucial to properly handle potentially harmful early reactions to STAR.

1st Department of Cardiology Medical University of Silesia Katowice Poland

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

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

Department of Electrocardiology John Paul 2 Hospital Kraków Poland

Department of Electrocardiology Prof Leszek Giec Upper Silesian Medical Centre of the Medical University of Silesia Katowice Poland

Department of Medical Physics Maria Skłodowska Curie National Research Institute of Oncology Gliwice Poland

Department of Radiotherapy Maria Skłodowska Curie National Research Institute of Oncology Gliwice Poland

Department of Radiotherapy Planning Maria Skłodowska Curie National Research Institute of Oncology Gliwice Poland

Interventional Cardiac Electrophysiology Group International Clinical Research Center St Anne's University Hospital Brno Brno Czechia

Zobrazit více v PubMed

Srinivasan NT, Schilling RJ. Sudden cardiac death and arrhythmias. Arrhythmia Electrophysiol Rev. (2018) 7:111. 10.15420/aer.2018:15:2 PubMed DOI PMC

Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, 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. Hear Rhythm. (2018) 15:e190–252. 10.1016/j.hrthm.2017.10.035 PubMed DOI

Fernandez-Armenta J, Soto-Iglesias D, Silva E, Penela D, Jáuregui B, Linhart M, et al. Safety and outcomes of ventricular tachycardia substrate ablation during sinus rhythm: a prospective multicenter registry. JACC Clin Electrophysiol. (2020) 6:1435–48. 10.1016/j.jacep.2020.07.028 PubMed 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 Arrhythmia Electrophysiol. (2015) 8:748–50. 10.1161/CIRCEP.115.002765 PubMed DOI

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

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

Miszczyk M, Jadczyk T, Gołba K, Wojakowski W, Wita K, Bednarek J, et al. Clinical evidence behind stereotactic radiotherapy for the treatment of ventricular tachycardia (STAR)—a comprehensive review. J Clin Med. (2021) 10:1238. 10.3390/JCM10061238 PubMed DOI PMC

ClinicalTrials.gov. Stereotactic Management of Arrhythmia – Radiosurgery in Treatment of Ventricular Tachycardia. (2021). Available online at: https://clinicaltrials.gov/ct2/show/NCT04642963 (accessed on October 12, 2021).

Miszczyk M, Jadczyk T, Tomasik B, Latusek T, Bednarek J, Kurzelowski R, et al. Stereotactic management of arrhythmia – radiosurgery in treatment of ventricular tachycardia (SMART-VT) – clinical trial protocol and study rationale. OncoReview. (2021) 10:123–9. 10.24292/01.OR.420010221 DOI

Tajstra M, Blamek S, Niedziela JT, Gadula-Gacek E, Przybylski A, Blicharz J, et al. Patients with cardiac implantable electronic devices undergoing radiotherapy in Poland. Expert opinion of the heart rhythm section of the polish cardiac society and the polish society of radiation oncology. Kardiol Pol. (2019) 77:1106-16. 10.33963/KP.15063 PubMed DOI

Maguire P, Gardner E, Jack AB, Zei P, Al-Ahmad A, Fajardo L, et al. Cardiac radiosurgery (CyberHeart™) for treatment of arrhythmia: physiologic and histopathologic correlation in the porcine model. Cureus. (2012) 3:e32. 10.7759/cureus.32 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

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

Bonaparte I, Gregucci F, Surgo A, Di Monaco A, Vitulano N, Ludovico E, et al. Linac-based stereotactic arrhythmia radioablation (STAR) for ventricular tachycardia: a treatment planning study. Jpn J Radiol. (2021) 39:1223–8. 10.1007/s11604-021-01159-9 PubMed DOI

Fiorentino A, Di Monaco A, Surgo A, Vitulano N, Gregucci F, Ludovico E, et al. Linac-based stereotactic arrhythmia radioablation (STAR) of ventricular tachycardia: case report and literature review. Clin Case Rep. (2020) 9:362–6. 10.1002/ccr3.3530 PubMed DOI PMC

Weidlich GA, Hacker F, Bellezza D, Maguire P, Gardner EA. Ventricular tachycardia: a treatment comparison study of the cyberknife with conventional linear accelerators. Cureus. (2018) 10:e3445. 10.7759/cureus.3445 PubMed DOI PMC

Wang L, Fahimian B, Soltys SG, Zei P, Lo A, Edward A, et al. Stereotactic arrhythmia radioablation (STAR) of ventricular tachycardia: a treatment planning study. Cureus. (2016) 8:e694. 10.7759/cureus.694 PubMed DOI PMC