AIMS: Stereotactic arrhythmia radioablation (STAR) has emerged as bail-out treatment for ventricular tachycardia (VT). Accurate, reproducible, and easy-to-use data transfer from electroanatomical mapping (EAM) systems to radiotherapy planning CT is desirable. We aim to evaluate interobserver variability, ease of use, and learning curve for EAM based target volume (CardTV-EPinv) creation and transfer using available software packages. METHODS AND RESULTS: In patients considered for STAR, CardTV-EPinv were created using ADAS and Slicer3D for workflow comparison. Four CardTV-EPinv (clinically targeted volume and three mock targets) were created by an experienced operator and a 2nd-year medical student, based on endocardial EAM tags indicating VT substrate location. CardTV-EPinv sizes, Hausdorff distances (HDs), and workflow duration were measured to assess interobserver variability and learning curve. Agreement between CardTV-EPinv was high using ADAS and Slicer3D workflows (HD 3.64 mm [2.7-4.5]). ADAS workflow was faster and more robust (ADAS 26 min [24-29] vs. Slicer3D 65 min [61-70], P < 0.001; system crashes: ADAS 0 vs. Slicer3D 7). In 20 patients (80% non-ischaemic cardiomyopathy, LVEF 35 ± 14%), 80 CardTV-EPinv were created using ADAS. CardTV-EPinv size was similar for both observers (11.8 mL [10.1-13.7] vs. 10.7 mL [9.6-11.8], P = 0.17), with high interobserver agreement (HD 1.68 mm [1.45-1.96]; 95th percentile HD < 4.8 mm [3.5-5.7]). Linear regression showed a steep learning curve for the student (P = 0.01). CONCLUSION: CardTV-EPinv creation showed excellent interobserver agreement and was faster and more robust using ADAS than 3D slicer. The steep learning curve appears clinically relevant given the limited use of STAR even in high-volume VT ablation centres.

Department of Cardiology Institute for Clinical and Experimental Medicine Prague Czech Republic

Department of Cardiology Lausanne University Hospital Lausanne Switzerland

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

Department of Cardiology Maastricht University Medical Center Maastricht University Maastricht The Netherlands

Department of Radiation Oncology GROW Research Institute for Oncology and Reproduction Maastricht University Medical Center Maastricht The Netherlands

Department of Radiation Oncology Lausanne University Hospital Lausanne Switzerland

Department of Radiation Oncology Leiden University Medical Center Leiden The Netherlands

Willem Einthoven Center of Arrhythmia Research and Management Leiden The Netherlands Aarhus Denmark

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Zeppenfeld  K, Tfelt-Hansen  J, de Riva  M, Winkel  BG, Behr  ER, Blom  NA  et al.  ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J  2022;43:3997–4126. PubMed

Sultan  A, Futyma  P, Metzner  A, Anic  A, Richter  S, Roten  L  et al.  Management of ventricular tachycardias: insights on centre settings, procedural workflow, endpoints, and implementation of guidelines-results from an EHRA survey. Europace  2024;26:euae030. PubMed PMC

Natale  A, Zeppenfeld  K, Della Bella  P, Liu  X, Sabbag  A, Santangeli  P  et al.  Twenty-five years of catheter ablation of ventricular tachycardia: a look back and a look forward. Europace  2023;25:euad225. PubMed PMC

de Riva  M, Piers  SR, Kapel  GF, Watanabe  M, Venlet  J, Trines  SA  et al.  Reassessing noninducibility as ablation endpoint of post-infarction ventricular tachycardia: the impact of left ventricular function. Circ Arrhythm Electrophysiol  2015;8:853–62. PubMed

de Riva  M, Naruse  Y, Ebert  M, Androulakis  AFA, Tao  Q, Watanabe  M  et al.  Targeting the hidden substrate unmasked by right ventricular extrastimulation improves ventricular tachycardia ablation outcome after myocardial infarction. JACC Clin Electrophysiol  2018;4:316–27. PubMed

Avila  P, Berruezo  A, Jimenez-Candil  J, Tercedor  L, Calvo  D, Arribas  F  et al.  Bayesian analysis of the substrate ablation vs. antiarrhythmic drug therapy for symptomatic ventricular tachycardia trial. Europace  2023;25:euad181. PubMed PMC

van der Ree  MH, Dieleman  EMT, Visser  J, Planken  RN, Boekholdt  SM, de Bruin-Bon  RHA  et al.  Non-invasive stereotactic arrhythmia radiotherapy for ventricular tachycardia: results of the prospective STARNL-1 trial. Europace  2023;25:1015–24. PubMed PMC

Gupta  A, Sattar  Z, Chaaban  N, Ranka  S, Carlson  C, Sami  F  et al.  Stereotactic cardiac radiotherapy for refractory ventricular tachycardia in structural heart disease patients: a systematic review. Europace  2024;27:euae305. PubMed PMC

Kovacs  B, Lehmann  HI, Manninger  M, Saguner  AM, Futyma  P, Duncker  D  et al.  Stereotactic arrhythmia radioablation and its implications for modern cardiac electrophysiology: results of an EHRA survey. Europace  2024;26:euae110. PubMed PMC

Zeppenfeld  K. Ventricular tachycardia ablation in nonischemic cardiomyopathy. JACC Clin Electrophysiol  2018;4:1123–40. PubMed

Subramanian  M, Atreya  AR, Yalagudri  SD, Shekar  PV, Saggu  DK, Narasimhan  C. Catheter ablation for ventricular arrhythmias in hypertrophic cardiomyopathy. Card Electrophysiol Clin  2022;14:693–9. PubMed

Briceno  DF, Romero  J, Villablanca  PA, Londono  A, Diaz  JC, Maraj  I  et al.  Long-term outcomes of different ablation strategies for ventricular tachycardia in patients with structural heart disease: systematic review and meta-analysis. Europace  2018;20:104–15. PubMed

Futyma  P, Sultan  A, Zarebski  L, Imnadze  G, Maslova  V, Bordignon  S  et al.  Bipolar radiofrequency ablation of refractory ventricular arrhythmias: results from a multicentre network. Europace  2024;26:euae248. PubMed PMC

cvek  J, Neuwirth  R, Knybel  L, Molenda  L, Otahal  L, Pindor  J  et al.  Cardiac radiosurgery for malignant ventricular tachycardia. Cureus  2014;6:1–7.

Merino  JL. Aiming for the STARs: radiotherapy for ventricular tachycardia-bright future or cosmic gamble?  Europace  2024;27:euae306. PubMed PMC

Zeppenfeld  K, Rademaker  R, Al-Ahmad  A, Carbucicchio  C, De Chillou  C, Ebert  M  et al.  Patient selection, ventricular tachycardia substrate delineation and data transfer for stereotactic arrhythmia radioablation. A clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC and the Heart Rhythm Society (HRS). Europace  2024;27:euae214. PubMed PMC

Hohmann  S, Henkenberens  C, Zormpas  C, Christiansen  H, Bauersachs  J, Duncker  D  et al.  A novel open-source software-based high-precision workflow for target definition in cardiac radioablation. J Cardiovasc Electrophysiol  2020;31:2689–95. PubMed

Abdel-Kafi  S, de Ridder  M, de Riva  M, van der Geest  RJ, Rasch  C, Zeppenfeld  K. Integration of electroanatomical mapping with imaging to guide radiotherapy of VT substrates with high accuracy. JACC Clin Electrophysiol  2020;6:874–6. PubMed

Blanck  O, Buergy  D, Vens  M, Eidinger  L, Zaman  A, Krug  D  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;109:1319–32. PubMed PMC

van der Ree  MH, Visser  J, Planken  RN, Dieleman  EMT, Boekholdt  SM, Balgobind  BV  et al.  Standardizing the cardiac radioablation targeting workflow: enabling semi-automated angulation and segmentation of the heart according to the American Heart Association segmented model. Adv Radiat Oncol  2022;7:100928. PubMed 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. PubMed

Hohmann  S, Xie  J, Eckl  M, Grehn  M, Karfoul  N, Janorschke  C  et al.  Semi-automated reproducible target transfer for cardiac radioablation—a multi-center cross-validation study within the RAVENTA trial. Radiother Oncol  2024;200:110499. PubMed

Mayinger  M, Boda-Heggemann  J, Mehrhof  F, Krug  D, Hohmann  S, Xie  J  et al.  Quality assurance process within the RAdiosurgery for VENtricular TAchycardia (RAVENTA) trial for the fusion of electroanatomical mapping and radiotherapy planning imaging data in cardiac radioablation. Phys Imaging Radiat Oncol  2023;25:100406. PubMed PMC

Herrera Siklody  C, Schiappacasse  L, Jumeau  R, Reichlin  T, Saguner  AM, Andratschke  N  et al.  Recurrences of ventricular tachycardia after stereotactic arrhythmia radioablation arise outside the treated volume: analysis of the Swiss cohort. Europace  2023;25:euad268. PubMed PMC

Brett  CL, Cook  JA, Aboud  AA, Karim  R, Shinohara  ET, Stevenson  WG. Novel workflow for conversion of catheter-based electroanatomic mapping to DICOM imaging for noninvasive radioablation of ventricular tachycardia. Pract Radiat Oncol  2021;11:84–8. PubMed

Kaya  YS, Stoks  J, Hazelaar  C, van Elmpt  W, Gommers  S, Volders  PGA  et al.  3D-targeted, electrocardiographic imaging-aided stereotactic radioablation for ventricular tachycardia storm: a case report. Eur Heart J Case Rep  2024;8:ytae541. PubMed PMC

Hecko  J, Knybel  L, Rybar  M, Penhaker  M, Jiravsky  O, Neuwirth  R  et al.  Optimized target delineation procedure for the radiosurgery treatment of ventricular tachycardia: observer-independent accuracy. Rep Pract Oncol Radiother  2024;29:280–9. PubMed PMC

Grehn  M, Mandija  S, Miszczyk  M, Krug  D, Tomasik  B, Stickney  KE  et al.  STereotactic Arrhythmia Radioablation (STAR): the Standardized Treatment and Outcome Platform for Stereotactic Therapy Of Re-entrant tachycardia by a Multidisciplinary consortium (STOPSTORM.eu) and review of current patterns of STAR practice in Europe. Europace  2023;25:1284–95. PubMed PMC

Haskova  J, Wichterle  D, Kautzner  J, Sramko  M, Peichl  P, Knybel  PL  et al.  Efficacy and safety of stereotactic radiotherapy in patients with recurrent ventricular tachycardias: the Czech experience. JACC Clin Electrophysiol  2024;10:654–66. PubMed

Kluge  A, Ehrbar  S, Grehn  M, Fleckenstein  J, Baus  WW, Siebert  FA  et al.  Treatment planning for cardiac radioablation: multicenter multiplatform benchmarking for the RAdiosurgery for VENtricular TAchycardia (RAVENTA). Trial. Int J Radiat Oncol Biol Phys  2022;114:360–72. PubMed

Boda-Heggemann  J, Blanck  O, Mehrhof  F, Ernst  F, Buergy  D, Fleckenstein  J  et al.  Interdisciplinary clinical target volume generation for cardiac radioablation: multicenter benchmarking for the RAdiosurgery for VENtricular TAchycardia (RAVENTA) trial. Int J Radiat Oncol Biol Phys  2021;110:745–56. PubMed

Bentley  D. CE marking—what does it really mean?  J Tissue Viability  1999;9:11–5. PubMed

Gregoire  V, Mackie  TR. State of the art on dose prescription, reporting and recording in Intensity-Modulated Radiation Therapy (ICRU report no. 83). Cancer Radiother  2011;15:555–9. PubMed