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.

• Klíčová slova
• Ablation, Radiotherapy, Stereotactic arrhythmia radioablation (STAR), Sudden death, Ventricular tachycardia,
• MeSH
• akční potenciály MeSH
• kardiologie * normy   MeSH
• komorová tachykardie * patofyziologie   chirurgie   diagnóza   MeSH
• konsensus MeSH
• lidé MeSH
• radiochirurgie * škodlivé účinky   normy   metody   MeSH
• rizikové faktory MeSH
• výběr pacientů * MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• směrnice pro lékařskou praxi MeSH
• Geografické názvy
• Evropa MeSH

BACKGROUND: Management of hypertrophic obstructive cardiomyopathy (HOCM) is often challenging, depending on clinical manifestation. This case report illustrates the complex treatment of HOCM with associated recurrent ventricular arrhythmias. CASE SUMMARY: A 54-year-old female with HOCM diagnosed in 2012 underwent a failed attempt for alcohol septal ablation, implantation of an implantable cardioverter-defibrillator, and repeated radiofrequency ablations (including ablation of the septal bulge to reduce LV obstruction). For ventricular tachycardia (VT) recurrences, she had stereotactic arrhythmia radioablation with subsequent epicardial cryoablation from mini-thoracotomy, and endocardial ablation with pulsed field energy. The situation was finally solved by mechanical support and heart transplantation. DISCUSSION: A few important lessons can be learned from the case. First, radiofrequency ablation was used successfully to decrease left outflow tract obstruction. Second, stereotactic radiotherapy has been used after four previous endo/epicardial catheter ablations to decrease the recurrences of VT. Third, mini-thoracotomy was used after previous epicardial ablation with subsequent adhesions to modify the epicardial substrate with cryoenergy. Fourth, pulsed field ablation of atrial fibrillation resulted in an excellent therapeutic effect. Fifth, pulsed field ablation was also used to modify the substrate for VT, and was complicated by transient AV block with haemodynamic deterioration requiring mechanical support. Finally, a heart transplant was the ultimate solution in the management of recurrent VT.

• Klíčová slova
• Case report, Catheter ablation, Electroanatomical mapping, Hypertrophic cardiomyopathy, Stereotactic arrhythmia radioablation, Ventricular tachycardia,
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

BACKGROUND: Part of the current stereotactic arrythmia radioablation (STAR) workflow is transfer of findings from the electroanatomic mapping (EAM) to computed tomography (CT). Here, we analyzed inter- and intraobserver variation in a modified EAM-CT registration using automatic registration algorithms designed to yield higher robustness. MATERIALS AND METHODS: This work is based on data of 10 patients who had previously undergone STAR. Two observers participated in this study: (1) an electrophysiologist technician (cardiology) with substatial experience in EAM-CT merge, and (2) a clinical engineer (radiotherapy) with minimum experience with EAM-CT merge. EAM-CT merge consists of 3 main steps: segmentation of left ventricle from CT (CT LV), registration of the CT LV and EAM, clinical target volume (CTV) delineation from EAM specific points. Mean Hausdorff distance (MHD), Dice Similarity Coefficient (DSC) and absolute difference in Center of Gravity (CoG) were used to assess intra/interobserver variability. RESULTS: Intraobserver variability: The mean DSC and MHD for 3 CT LVs altogether was 0.92 ± 0.01 and 1.49 ± 0.23 mm. The mean DSC and MHD for 3 CTVs altogether was 0,82 ± 0,06 and 0,71 ± 0,22 mm. Interobserver variability: Segmented CT LVs showed great similarity (mean DSC of 0,91 ± 0,01, MHD of 1,86 ± 0,47 mm). The mean DSC comparing CTVs from both observers was 0,81 ± 0,11 and MHD was 0,87 ± 0,45 mm. CONCLUSIONS: The high interobserver similarity of segmented LVs and delineated CTVs confirmed the robustness of the proposed method. Even an inexperienced user can perform a precise EAM-CT merge following workflow instructions.

• Klíčová slova
• interobserver, intraobserver, radioablation, target delineation, ventricular tachycardia,
• Publikační typ
• časopisecké články MeSH

Catheter ablation (CA) has become an established treatment strategy for managing recurrent ventricular tachycardias (VTs) in patients with structural heart disease. In recent years, percutaneous mechanical circulatory support (PMCS) devices have been increasingly used intra-operatively to improve the ablation outcome. One indication would be rescue therapy for patients who develop haemodynamic deterioration during the ablation. However, more efforts are focused on identifying subjects who are at high risk of such deterioration and could benefit from the pre-emptive use of the PMCS. The third reason to use PMCS could be the inability to identify diffuse substrate, especially in non-ischaemic cardiomyopathy. This paper reviews available experiences using various types of PMCS in different clinical scenarios. Although PMCS allows mapping during VT, it does not significantly influence acute outcomes and not convincingly long-term outcomes. On the contrary, the complication rate appears to be higher in PMCS cohorts. Our data suggest that even in patients with severe left ventricular dysfunction, the substrate modification can be performed without the need for general anaesthesia and risk of haemodynamic decompensation. In end-stage heart failure associated with the electrical storm, implantation of a left ventricular assist device (or PMCS with a transition to the left ventricular assist device) might be the preferred strategy before CA. In high-risk patients who are not potential candidates for these treatment options, radiotherapy could be considered as a bail-out treatment of recurrent VTs. These approaches should be studied in prospective trials.

• Klíčová slova
• Catheter ablation, Percutaneous mechanical support, Stereotactic arrhythmia radiotherapy, Substrate modification, Ventricular tachycardia,
• MeSH
• hemodynamika MeSH
• katetrizační ablace * metody   škodlivé účinky   MeSH
• komorová tachykardie * chirurgie   patofyziologie   MeSH
• lidé MeSH
• podpůrné srdeční systémy * MeSH
• rizikové faktory MeSH
• srdeční selhání patofyziologie   terapie   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

BACKGROUND AND PURPOSE: Stereotactic arrhythmia radioablation (STAR) has been suggested as a promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias in patients with structural heart disease. Cyberknife® robotic radiosurgery system utilizing target tracking technology is one of the available STAR treatment platforms. Tracking using implantable cardioverter-defibrillator lead tip as target surrogate marker is affected by the deformation of marker-target geometry. A simple method to account for the deformation in the target definition process is proposed. METHODS: Radiotherapy planning CT series include scans at expiration and inspiration breath hold, and three free-breathing scans. All secondary series are triple registered to the primary CT: 6D/spine + 3D translation/marker + 3D translation/target surrogate-a heterogeneous structure around the left main coronary artery. The 3D translation difference between the last two registrations reflects the deformation between the marker and the target (surrogate) for the respective respiratory phase. Maximum translation differences in each direction form an anisotropic geometry deformation margin (GDM) to expand the initial single-phase clinical target volume (CTV) to create an internal target volume (ITV) in the dynamic coordinates of the marker. Alternative GDM-based target volumes were created for seven recent STAR patients and compared to the original treated planning target volumes (PTVs) as well as to analogical volumes created using deformable image registration (DIR) by MIM® and Velocity® software. Intra- and inter-observer variabilities of the triple registration process were tested as components of the final ITV to PTV margin. RESULTS: A margin of 2 mm has been found to cover the image registration observer variability. GDM-based target volumes are larger and shifted toward the inspiration phase relative to the original clinical volumes based on a 3-mm isotropic margin without deformation consideration. GDM-based targets are similar (mean DICE similarity coefficient range 0.80-0.87) to their equivalents based on the DIR of the primary target volume delineated by dedicated software. CONCLUSION: The proposed GDM method is a simple way to account for marker-target deformation-related uncertainty for tracking with Cyberknife® and better control of the risk of target underdose. The principle applies to general radiotherapy as well.

• Klíčová slova
• Cyberknife, deformation, motion management, radiotherapy, stereotactic, target definition, tracking,
• Publikační typ
• časopisecké články MeSH

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.

• Klíčová slova
• electroanatomical mapping, failed catheter ablation, safety, stereotactic body radiotherapy, ventricular tachycardia,
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

Congestive heart failure (HF) is a progressive affliction defined as the inability of the heart to sufficiently maintain blood flow. Ventricular arrhythmias (VAs) are common in patients with HF, and conversely, advanced HF promotes the risk of VAs. Management of VA in HF requires a systematic, multimodality approach that comprises optimization of medical therapy and use of implantable cardioverter-defibrillator and/or device combined with cardiac resynchronization therapy. Catheter ablation is one of the most important strategies with the potential to abolish or decrease the number of recurrences of VA in this population. It can be a curative strategy in arrhythmia-induced cardiomyopathy and may even save lives in cases of an electrical storm. Additionally, modulation of the autonomic nervous system and stereotactic radiotherapy have been introduced as novel methods to control refractory VAs. In patients with end-stage HF and refractory VAs, an institution of the mechanical circulatory support device and cardiac transplant may be considered. This review aims to provide an overview of current evidence regarding management strategies of VAs in HF with an emphasis on interventional treatment.

• Klíčová slova
• Catheter ablation, Heart failure, Implantable cardioverter-defibrillator, Sudden cardiac death, Ventricular arrhythmia,
• Publikační typ
• časopisecké články MeSH

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.

• Klíčová slova
• ablation, noninvasive, radiosurgery, stereotactic body radiation therapy, substrate ablation, ventricular tachycardia,
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

BACKGROUND: Stereotactic body radiotherapy (SBRT) has emerged recently as a novel therapeutic alternative for patients with ventricular tachycardias (VTs) resistant to convetional treatment. Nevertheless, many aspects related to SBRT are currently unknown. CASE SUMMARY: A 66-year-old man with ischaemic heart disease, a history of coronary artery bypass graft surgery and left ventricular dysfunction was referred for recurrent symptomatic episodes of slow VT (108 b.p.m.). The arrhythmia was resistant to antiarrhythmic drug therapy with amiodarone and repeated catheter ablation. The patient was scheduled to SBRT, however, the first session failed to suppress VT recurrences. After 20 months, the patient underwent re-do ablation procedure that revealed a newly developed scar with its core adjacent to the presumed critical part of the VT substrate. Catheter ablation again failed to eliminate VT and the second session of SBRT was scheduled. To improve targeting of the VT substrate for SBRT, we applied our recently developed original method for integration of data from the electroanatomical mapping system with computer tomography images. The second session of SBRT with precise targeting using the novel strategy led within 3 months to the successful elimination of VT. DISCUSSION: This case report describes a patient in whom the recurrent VT was abolished only by properly targeted SBRT. Above all, the case highlights the importance of precise identification and targeting for SBRT. Our case also documents in vivo, by electroanatomical voltage mapping, the development of SBRT-related myocardial lesion. This represents an important mechanistic proof of the concept of SBRT.

• Klíčová slova
• Case report, Catheter ablation, Stereotactic radiotherapy, Ventricular tachycardia,
• Publikační typ
• časopisecké články MeSH

We review the role of echocardiography and biomarkers in detection of radiation-induced cardiac toxicity (RICT). RICT is related to micro- and macrovascular damage which induce inflammation, endothelial dysfunction, accelerated atherosclerosis, myocyte degeneration and fibrosis. The process is cumulative dose to the heart and target volume dependent. Furthermore, the damage of the heart is frequently potentiated by the adjunctive chemotherapy. The clinical manifestations of RICT may acutely develop but most often become clinically apparent several years after irradiation. RICT clinical manifestation covers a wide spectrum of pathologies including pericarditis, coronary artery disease (CAD), myocardial infarction, valvular heart disease, rhythm abnormalities, and non-ischemic myocardial and conduction system damages. Echocardiography and cardiac markers are important diagnostic tools for the detection of RICT.

• Klíčová slova
• Cardiac troponin, Echocardiography, Natriuretic peptide, Radiation induced cardiotoxicity,
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH