Stereotactic arrhythmia radioablation (STAR) is a novel, non-invasive, and promising treatment option for ventricular arrhythmias (VAs). It has been applied in highly selected patients mainly as bailout procedure, when (multiple) catheter ablations, together with anti-arrhythmic drugs, were unable to control the VAs. Despite the increasing clinical use, there is still limited knowledge of the acute and long-term response of normal and diseased myocardium to STAR. Acute toxicity appeared to be reasonably low, but potential late adverse effects may be underreported. Among published studies, the provided methodological information is often limited, and patient selection, target volume definition, methods for determination and transfer of target volume, and techniques for treatment planning and execution differ across studies, hampering the pooling of data and comparison across studies. In addition, STAR requires close and new collaboration between clinical electrophysiologists and radiation oncologists, which is facilitated by shared knowledge in each collaborator's area of expertise and a common language. This clinical consensus statement provides uniform definition of cardiac target volumes. It aims to provide advice in patient selection for STAR including aetiology-specific aspects and advice in optimal cardiac target volume identification based on available evidence. Safety concerns and the advice for acute and long-term monitoring including the importance of standardized reporting and follow-up are covered by this document. Areas of uncertainty are listed, which require high-quality, reliable pre-clinical and clinical evidence before the expansion of STAR beyond clinical scenarios in which proven therapies are ineffective or unavailable.

AGEL Hospital Trinec Podlesi Trinec Czech Republic

Assistant Professor of Medicine Johns Hopkins Medicine Division of Cardiology Baltimore MD USA

Atrium Health Sanger Heart Vascular Institute Kenilworth Charlotte NC USA

Cardiology Department Policlinico Gemelli Rome Italy

Cardiology Department University College London London UK

Cardiology Hospital General La Paz Madrid Spain

Cardiology Institute for Clinical and Experimental Medicine Prague Czech Republic

CHU de Nancy Cardiology Institut Lorrain du Coeur et des Vaisseaux Vandoeuvre Les Nancy France

Department of Arrhythmology Centro Cardiologico Monzino IRCCS Milan Italy

Department of Cardiology Inselspital Bern University Hospital University of Bern Bern Switzerland

Department of Cardiology Lausanne University Hospital CHUV Lausanne Switzerland

Department of Cardiology Leiden University Medical Center P O Box 9600 2300 RC Leiden The Netherlands

Department of Cardiology Service de Radio Oncologie Lausanne University Hospital CHUV Lausanne Switzerland

Department of Clinical Electrophysiology and Pacing Monzino Cardiac Center Milan Italy

Department of Radiation Oncology Washington University School of Medicine St Louis MO USA

Division of Cardiology Section of Cardiac Electrophysiology University of California San Diego La Jolla CA USA

Electrophysiology Heart Center Leipzig Leipzig Germany

Electrophysiology Texas Cardiac Arrhythmia Institute Austin TX USA

Emory Electrophysiology Electrophysiology Lab Director EUH Emory University Hospital Atlanta GA USA

Faculty of Medicine Masaryk University Brno Czech Republic

Inselspital Hôpital universitaire de Berne Bern Switzerland

Professor of Medicine Cardiac Electrophysiology Brigham and Women's Hospital Harvard Medical School Boston MA USA

QEII Health Sciences Center Halifax Infirmary Site Halifax NS Canada

Radiation Oncology University of Ostrava Ostrava Czech Republic

Vanderbilt University Medical Center Nashville TN USA

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Excellent interobserver agreement and steep learning curve for target volume delineation for stereotactic arrhythmia radioablation using a commercial software