Direct Clinical Effects of Cardiac Radioablation in the Treatment of a Patient With Therapy-Refractory Ventricular Tachycardia Storm

Ree, Martijn H. van der; Dieleman, Edith; Visser, Jelle; Adam, Judit A.; Bruin-Bon, Rianne H.A. de; Jong, Rianne M A J de; Hoeksema, Wiert F.; Mosterd, Arend; Balt, Jippe C.; Planken, R. Nils; Balgobind, Brian V.; Postema, Pieter G.

doi:10.1016/j.adro.2022.100992

Cited by 5 publications

(3 citation statements)

References 21 publications

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“…In the two cases described here, we chose 7 and 14 days post-cRA, respectively, for the initial attempt at rhythm restoration; however, this was without success in both described cases. To the best of our knowledge, there have been no reports of cRA procedures during running slow VT. Few case reports by Scholz and colleagues [ 32 ], Jumeau and colleagues [ 33 ], and also van der Ree and colleagues [ 34 ] describe rescue procedures for patients in repeated electrical storm. However, at the time of the cRA procedure, a normal heart rhythm could be established, and successful retention of normalized heart rhythm was reported for all cases for a period of up to 4 months with only very few episodes of non-sustained VT.…”

Section: Discussionmentioning

confidence: 99%

Cardiac radioablation of incessant ventricular tachycardia in patients with terminal heart failure under permanent left ventricular assist device therapy—description of two cases

et al. 2023

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Purpose Cardiac radioablation (cRA) using a stereotactic single-session radioablative approach has recently been described as a possible treatment option for patients with otherwise untreatable recurrent ventricular tachycardia (VT). There is very limited experience in cRA for patients undergoing left ventricular assist device (LVAD) therapy. We present clinical experiences of two patients treated with cRA for incessant VT under long-term LVAD therapy. Methods Two male patients (54 and 61 years old) with terminal heart failure under LVAD therapy (both patients for 8 years) showed incessant VT despite extensive antiarrhythmic drug therapy and repeated catheter ablation. cRA with a single dose of 25 Gy was applied as a last resort strategy under compassionate use in both patients following an electroanatomical mapping procedure. Results Both patients displayed ongoing VT during and after the cRA procedure. Repeated attempts at post-procedural rhythm conversion failed in both patients; however, one patient was hemodynamically stabilized and could be discharged home for several months before falling prey to a fatal bleeding complication. The second patient initially stabilized for a few days following cRA before renewed acceleration of running VT required bilateral ablation of the stellate ganglion; the patient died 50 days later. No immediate side effects of cRA were detected in either patient. Conclusion cRA might serve as a last resort strategy for patients with terminal heart failure undergoing LVAD therapy and displaying incessant VT. Intermediate- and long-term outcomes of these seriously ill patients often remain poor; therefore, best supportive care strategies should also be evaluated as long as no clear beneficial effects of cRA procedures can be shown. For patients treated with cRA under running ventricular rhythm abnormality, strategies for post-procedural generation of stabilized rhythm have to be established.

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Section: Discussionmentioning

confidence: 99%

Cardiac radioablation of incessant ventricular tachycardia in patients with terminal heart failure under permanent left ventricular assist device therapy—description of two cases

et al. 2023

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“…STAR is associated with a relatively durable reduction in VT episodes and a mostly mild acute toxicity profile in patients in patients during the first year. 3-10 Longer term follow-up is currently accumulating.…”

Section: Introductionmentioning

confidence: 99%

Interobserver Variability in Target Definition for Stereotactic Arrhythmia Radioablation

Ree

Cuculich

Herk

et al. 2023

Preprint

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BackgroundStereotactic arrhythmia radioablation (STAR) is emerging as a potential new therapy for patients with refractory ventricular tachycardia (VT). The arrhythmogenic substrate (target) is synthesized from clinical and electro-anatomical information. This study was designed to evaluate the baseline interobserver variability in target delineation for STAR.MethodsDelineation software designed for research purposes was used. The study was split into three phases. Firstly, electrophysiologists (observers) delineated a well-defined structure in three patients (spinal canal). Secondly, observers delineated the arrhythmogenic cardiac VT target in three patients previously treated with STAR based on case descriptions. To evaluate baseline performance, a basic workflow approach was used, no advanced techniques were allowed (e.g. image integration). Thirdly, observers delineated three predefined segments from the cardiac 17-segment model. Interobserver variability was evaluated by assessing volumes, variation in distance to the median volume as expressed by the root-mean-square of the observer standard deviation (RMS SD) over the target volume, and the Dice coefficient.ResultsTen electrophysiologists completed the study. For the first phase (spinal canal delineation), interobserver variability was low as indicated by low variation in distance to the median volume (RMS SD range: 0.02-0.02cm) and high Dice coefficients (mean: 0.97±0.01). In the second phase (VT-target delineation), distance to the median volume was large (RMS SD range: 0.52-1.02cm) and the Dice coefficients low (mean: 0.40±0.15). In the third phase (segment delineation), similar results were observed (RMS SD range: 0.51-1.55cm, Dice coefficient mean: 0.31±0.21)ConclusionsInterobserver variability is high for manual delineation of the VT-target and ventricular segments. Difficulties in cardiac anatomical orientation on traditional radiation oncology CT scans appear to be an important driver of variability. This evaluation of the baseline observer variation shows that there is a need for methods and tools to improve variability and allows for future comparison of interventions aiming to reduce observer variation.

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“…In STAR, the ventricular arrhythmogenic substrate is treated by applying ionizing radiation. STAR is associated with a relatively durable reduction in VT episodes and a mostly mild acute toxicity profile in patients in patients during the first year ( 3 – 10 ). Longer term follow-up is currently accumulating.…”

Section: Introductionmentioning

confidence: 99%

Interobserver variability in target definition for stereotactic arrhythmia radioablation

van der Ree,

Cuculich,

van Herk

et al. 2023

Front. Cardiovasc. Med.

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BackgroundStereotactic arrhythmia radioablation (STAR) is a potential new therapy for patients with refractory ventricular tachycardia (VT). The arrhythmogenic substrate (target) is synthesized from clinical and electro-anatomical information. This study was designed to evaluate the baseline interobserver variability in target delineation for STAR.MethodsDelineation software designed for research purposes was used. The study was split into three phases. Firstly, electrophysiologists delineated a well-defined structure in three patients (spinal canal). Secondly, observers delineated the VT-target in three patients based on case descriptions. To evaluate baseline performance, a basic workflow approach was used, no advanced techniques were allowed. Thirdly, observers delineated three predefined segments from the 17-segment model. Interobserver variability was evaluated by assessing volumes, variation in distance to the median volume expressed by the root-mean-square of the standard deviation (RMS-SD) over the target volume, and the Dice-coefficient.ResultsTen electrophysiologists completed the study. For the first phase interobserver variability was low as indicated by low variation in distance to the median volume (RMS-SD range: 0.02–0.02 cm) and high Dice-coefficients (mean: 0.97 ± 0.01). In the second phase distance to the median volume was large (RMS-SD range: 0.52–1.02 cm) and the Dice-coefficients low (mean: 0.40 ± 0.15). In the third phase, similar results were observed (RMS-SD range: 0.51–1.55 cm, Dice-coefficient mean: 0.31 ± 0.21).ConclusionsInterobserver variability is high for manual delineation of the VT-target and ventricular segments. This evaluation of the baseline observer variation shows that there is a need for methods and tools to improve variability and allows for future comparison of interventions aiming to reduce observer variation, for STAR but possibly also for catheter ablation.

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Direct Clinical Effects of Cardiac Radioablation in the Treatment of a Patient With Therapy-Refractory Ventricular Tachycardia Storm

Cited by 5 publications

References 21 publications

Cardiac radioablation of incessant ventricular tachycardia in patients with terminal heart failure under permanent left ventricular assist device therapy—description of two cases

Cardiac radioablation of incessant ventricular tachycardia in patients with terminal heart failure under permanent left ventricular assist device therapy—description of two cases

Interobserver Variability in Target Definition for Stereotactic Arrhythmia Radioablation

Interobserver variability in target definition for stereotactic arrhythmia radioablation

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