Carola Gianni1, Douglas Rivera2, J David Burkhardt3, Brad Pollard2, Edward Gardner4, Patrick Maguire4, Paul C Zei5, Andrea Natale6, Amin Al-Ahmad3. 1. Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas. Electronic address: carola.gianni@gmail.com. 2. Austin CyberKnife, Dell Seton Medical Center, University of Texas, Austin, Texas. 3. Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas. 4. CyberHeart, Portola Valley, California. 5. Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. 6. Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; HCA National Medical Director of Cardiac Electrophysiology, USA; Interventional Electrophysiology, Scripps Clinic, La Jolla, California; MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Abstract
BACKGROUND: Recently, stereotactic radiosurgery has been applied to arrhythmias (stereotactic arrhythmia radioablation [STAR]), with promising results reported in patients with refractory scar-related ventricular tachycardia (VT), a cohort with known high morbidity and mortality. OBJECTIVE: Herein, we describe our experience with STAR, detailing its early and mid- to long-term results. METHODS: This is a pilot prospective study of patients undergoing STAR for refractory scar-related VT. The anatomical target for radioablation was defined on the basis of the clinical VT morphology, electroanatomic mapping, and study-specific preprocedural imaging with cardiac computed tomography. The target volume was treated with a prescription radiation dose of 25 Gy delivered in a single fraction by CyberKnife in an outpatient setting. Ventricular arrhythmias and radiation-related adverse events were monitored at follow-up to determine STAR efficacy and safety. RESULTS: Five patients (100% men; mean age 63 ± 12 years; 80% with ischemic cardiomyopathy; left ventricular ejection fraction 34% ± 15%) underwent STAR. Radioablation was delivered in 82 ± 11 minutes without acute complications. During a mean follow-up of 12 ± 2 months, all patients experienced clinically significant mid- to late-term ventricular arrhythmia recurrence; 2 patients died of complications associated with their advanced heart failure. There were no clinical or imaging evidence of radiation-induced complications in the organs at risk surrounding the scar targeted by radioablation. CONCLUSION: Despite good initial results, STAR did not result in effective arrhythmia control in the long term in a selected high-risk population of patients with scar-related VT. The safety profile was confirmed to be favorable, with no radiation-related complications observed during follow-up. Further studies are needed to explain these disappointing results.
BACKGROUND: Recently, stereotactic radiosurgery has been applied to arrhythmias (stereotactic arrhythmia radioablation [STAR]), with promising results reported in patients with refractory scar-related ventricular tachycardia (VT), a cohort with known high morbidity and mortality. OBJECTIVE: Herein, we describe our experience with STAR, detailing its early and mid- to long-term results. METHODS: This is a pilot prospective study of patients undergoing STAR for refractory scar-related VT. The anatomical target for radioablation was defined on the basis of the clinical VT morphology, electroanatomic mapping, and study-specific preprocedural imaging with cardiac computed tomography. The target volume was treated with a prescription radiation dose of 25 Gy delivered in a single fraction by CyberKnife in an outpatient setting. Ventricular arrhythmias and radiation-related adverse events were monitored at follow-up to determine STAR efficacy and safety. RESULTS: Five patients (100% men; mean age 63 ± 12 years; 80% with ischemic cardiomyopathy; left ventricular ejection fraction 34% ± 15%) underwent STAR. Radioablation was delivered in 82 ± 11 minutes without acute complications. During a mean follow-up of 12 ± 2 months, all patients experienced clinically significant mid- to late-term ventricular arrhythmia recurrence; 2 patients died of complications associated with their advanced heart failure. There were no clinical or imaging evidence of radiation-induced complications in the organs at risk surrounding the scar targeted by radioablation. CONCLUSION: Despite good initial results, STAR did not result in effective arrhythmia control in the long term in a selected high-risk population of patients with scar-related VT. The safety profile was confirmed to be favorable, with no radiation-related complications observed during follow-up. Further studies are needed to explain these disappointing results.
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