Cardiac Radiosurgery for Malignant Ventricular Tachycardia

Cvek, Jakub; Neuwirth, R; Knybel, Lukáš; Molenda, Lukas; Otahal, B.; Pindor, Jakub; Murárová, Mária; Kodaj, Michal; Fiala, Martin; Branny, Marian; Feltl, David

doi:10.7759/cureus.190

Cited by 47 publications

(107 citation statements)

References 12 publications

(12 reference statements)

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“…In general 25 Gy were applied in a single dose, and though outcome was reported, it was not conclusively linked to the treatment. 11 A similar case was reported by Loo et al 12 , also without conclusive results. Following preliminary results from a number of patients, a phase I/II study (NCT02919618) was initiated at the Washington University, St. Louis, MO, USA.…”

Section: A Photon Studies and Case Reportssupporting

confidence: 71%

“…In a number of studies radiation therapy was proposed or initially applied for the treatment of cardiac arrhythmias . The initial data show that a very high dose level of >25 Gy is required for creation of the electrophysiological endpoint if the treatment is applied in a single fraction.…”

Section: Discussionmentioning

confidence: 99%

“…In a number of studies radiation therapy was proposed or initially applied for the treatment of cardiac arrhythmias. [8][9][10][11][12][13] The initial data show that a very high dose level of >25 Gy is required for creation of the electrophysiological endpoint if the treatment is applied in a single fraction. As this high dose is delivered to a target moving intrafractionally due to heart beat and respiration, a number of challenges are raised.…”

Section: Discussionmentioning

confidence: 99%

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Noninvasive cardiac arrhythmia ablation with particle beams

Graeff

Bert

2018

Medical Physics

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Cardiac arrhythmias are a major health burden, associated with reduced quality of life and substantial morbidity and mortality. Current therapy includes moderately effective medication and catheter‐based ablation of arrhythmogenic substrates in the heart. Catheter interventions frequently have to be repeated due to recurrent arrhythmia, can have rare but severe side‐effects and are less suited especially for potentially lethal left ventricular tachycardia. Noninvasive alternatives are therefore warranted. Photon and ion beam radiotherapy has been studied in animal models and first patient cases have been reported using photons. Ion beams might offer the possibility to greatly reduce dose to surrounding healthy tissue, including critical cardiac substructures. Based on a recently conducted animal study, we report advantages and disadvantages of 4D‐ion beam therapy, and strategies necessary for a clinical transition. Motion management of both respiration and heartbeat are discussed, as well as range uncertainty resulting from both regular motion and interfractional anatomic changes. Image guidance both in 3D and 4D has to be employed for a safe irradiation, but also population‐based data on motion variability and time behavior of interfractional changes are necessary. Range verification could play a crucial role at least during development of clinical protocols. For clinical realization, it appears necessary to suppress or conformally mitigate the large respiratory motion to avoid normal tissue complications. Cardiac motion has to be incorporated into treatment planning, either through adequate range‐considering internal margins or through more conformal strategies such as ECG‐based gating or even 4D‐optimization. The latter strategies would necessitate online 4D image guidance.

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Section: A Photon Studies and Case Reportssupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Noninvasive cardiac arrhythmia ablation with particle beams

Graeff

Bert

2018

Medical Physics

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“…The first group used CyberKnife to ablate an arrhythmogenic lesion in the left ventricle of a patient with advanced dilated cardiomyopathy and recurrent VT and arrhythmic storms. This resulted in the reduction of PVCs from 9% to 10% to 1% to 3% in 10 days . The other group used stereotactic arrhythmia ablation protocol to ablate a VT substrate in a patient with long‐standing coronary artery disease, advanced heart failure, refractory VT, and several other comorbidities.…”

Section: Discussionmentioning

confidence: 99%

“…This resulted in the reduction of PVCs from 9% to 10% to 1% to 3% in 10 days. 13 The other group used stereotactic arrhythmia ablation protocol to ablate a VT substrate in a patient with long-standing coronary artery disease, advanced heart failure, refractory VT, and several other comorbidities. The procedure was well tolerated, and there was a significant reduction in the number of VT episodes 9 months following the stereotactic arrhythmia ablation procedure.…”

Section: Discussionmentioning

confidence: 99%

Swine Atrioventricular Node Ablation Using Stereotactic Radiosurgery: Methods and In Vivo Feasibility Investigation for Catheter‐Free Ablation of Cardiac Arrhythmias

Refaat

Ballout

Zakka

et al. 2017

JAHA

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BackgroundLinear accelerator–based stereotactic radiosurgery delivered to cardiac arrhythmogenic foci could be a promising catheter‐free ablation modality. We tested the feasibility of in vivo atrioventricular (AV) node ablation in swine using stereotactic radiosurgery.Methods and ResultsFive Large White breed swine (weight 40–75 kg; 4 females) were studied. Single‐chamber St Jude pacemakers were implanted in each pig. The pigs were placed under general anesthesia, and coronary/cardiac computed tomography simulation scans were performed to localize the AV node. Cone beam computed tomography was used for target positioning. Stereotactic radiosurgery doses ranging from 35 to 40 Gy were delivered by a linear accelerator to the AV node, and the pigs were followed up with weekly pacemaker interrogations to observe for potential electrocardiographic changes. Once changes were observed, the pigs were euthanized, and pathology specimens of various tissues, including the AV node and tissues surrounding the AV node, were taken to study the effects of radiation. All 5 pigs had disturbances of AV conduction with progressive transition into complete heart block. Macroscopic inspection did not reveal damage to the myocardium, and pigs had preserved systolic function on echocardiography. Immunostaining revealed fibrosis in the target region of the AV node, whereas no fibrosis was detected in the nontargeted regions.ConclusionsCatheter‐free radioablation using linear accelerator–based stereotactic radiosurgery is feasible in an intact swine model.

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Dosimetric feasibility of stereotactic ablative radiotherapy in pulmonary vein isolation for atrial fibrillation using intensity‐modulated proton therapy

Ren

Gao

et al. 2021

J Applied Clin Med Phys

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Purpose: To evaluate dosimetric properties of intensity-modulated proton therapy (IMPT) for simulated treatment planning in patients with atrial fibrillation (AF) targeting left atrial-pulmonary vein junction (LA-PVJ), in comparison with volumetric-modulated arc therapy (VMAT) and helical tomotherapy (TOMO).Methods: Ten thoracic 4D-CT scans with respiratory motion and one with cardiac motion were used for the study. Ten respiratory 4D-CTs were planned with VMAT, TOMO, and IMPT for simulated AF. Targets at the LA-PVJ were defined as wide-area circumferential ablation line. A single fraction of 25 Gy was prescribed to all plans. The interplay effects from cardiac motion were evaluated based on the cardiac 4D-CT scan. Dose-volume histograms (DVHs) of the ITV and normal tissues were compared. Statistical analysis was evaluated via one-way Repeated-Measures ANOVA and Friedman's test with Bonferroni's multiple comparisons test. Results:The median volume of ITV was 8.72cc. All plans had adequate target coverage (V 23.75Gy ≥ 99%). Compared with VMAT and TOMO, IMPT resulted in significantly lower dose of most normal tissues. For VMAT, TOMO, and IMPT plans, D mean of the whole heart was 5.52 ± 0.90 Gy, 5.89 ± 0.78 Gy, and 3.01 ± 0.57 Gy (P < 0.001), mean dose of pericardium was 4.74 ± 0.76 Gy, 4.98 ± 0.62 Gy, and 2.59 ± 0.44 Gy (P < 0.001), and D 0.03cc of left circumflex artery (LCX) was 13.96 ± 5.45 Gy, 14.34 ± 5.91 Gy, and 8.43 ± 7.24 Gy (P < 0.001), respectively. However, no significant advantage for one technique over the others was observed when examining the D 0.03cc of esophagus and main bronchi.Conclusions: IMPT targeting LA-PVJ for patients with AF has high potential to reduce dose to surrounding tissues compared to VMAT or TOMO. Motion mitigation techniques are critical for a particle-therapy approach.

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Cardiac Radiosurgery for Malignant Ventricular Tachycardia

Cited by 47 publications

References 12 publications

Noninvasive cardiac arrhythmia ablation with particle beams

Noninvasive cardiac arrhythmia ablation with particle beams

Swine Atrioventricular Node Ablation Using Stereotactic Radiosurgery: Methods and In Vivo Feasibility Investigation for Catheter‐Free Ablation of Cardiac Arrhythmias

Dosimetric feasibility of stereotactic ablative radiotherapy in pulmonary vein isolation for atrial fibrillation using intensity‐modulated proton therapy

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