Oesophagopericardial fistula as a late complication of stereotactic radiotherapy for recurrent ventricular tachycardia

Haskova, Jana; Jedlickova, Kristina; Cvek, Jakub; Knybel, Lukáš; Neuwirth, Radek; Kautzner, Josef

doi:10.1093/europace/euab326

Cited by 13 publications

(7 citation statements)

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“… 23 , 29 However, many aspects of the treatment are yet to be elucidated, e.g. optimum dose, timing of effect, long(er)-term safety, observer variation in in target delineation, before this therapy can be more progressively implemented as therapeutic option for patients with recurrent VT. 22 , 36 , 37 Therefore, in our centre STAR is still considered a last-resort therapy for patients with therapy refractory VT. Notably, we have experienced that VT-recurrence after STAR was amenable to repeat catheter VT-ablation as opposed to pre-treatment VTs in these patients.…”

Section: Discussionmentioning

confidence: 99%

Non-invasive stereotactic arrhythmia radiotherapy for ventricular tachycardia: results of the prospective STARNL-1 trial

et al. 2023

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Aims Stereotactic arrhythmia radiotherapy (STAR) is suggested as potentially effective and safe treatment for patients with therapy-refractory ventricular tachycardia (VT). However, the current prospective knowledge base and experience with STAR is limited. In this study we aimed to prospectively evaluate the efficacy and safety of STAR. Methods and results The StereoTactic Arrhythmia Radiotherapy in the Netherlands no.1 was a pre-post intervention study to prospectively evaluate efficacy and safety of STAR. In patients with therapy-refractory VT, the pro-arrhythmic region was treated with a 25 Gy single radiotherapy fraction. The main efficacy measure was a reduction in the number of treated VT-episodes by ≥50%, comparing the 12 months before and after treatment (or end of follow-up, excluding a 6-week blanking period). The study was deemed positive when ≥50% of patients would meet this criterion. Safety evaluation included left ventricular ejection fraction, pulmonary function, and adverse events. Six male patients with an ischaemic cardiomyopathy were enrolled, and median age was 73 years (range 54–83). Median left ventricular ejection fraction was 38% (range 24–52). The median planning target volume was 187 mL (range 93–372). Four (67%) patients completed the 12-month follow-up, and two patients died (not STAR related) during follow-up. The main efficacy measure of ≥50% reduction in treated VT-episodes at the end of follow-up was achieved in four patients (67%). The median number of treated VT-episodes was reduced by 87%. No reduction in left ventricular ejection fraction or pulmonary function was observed. No treatment related serious adverse events occurred. Conclusions STAR resulted in a ≥ 50% reduction in treated VT-episodes in 4/6 (67%) patients. No reduction in cardiac and pulmonary function nor treatment-related serious adverse events were observed during follow-up. Clinical trial registration Netherlands Trial Register—NL7510.

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Section: Discussionmentioning

confidence: 99%

Non-invasive stereotactic arrhythmia radiotherapy for ventricular tachycardia: results of the prospective STARNL-1 trial

et al. 2023

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“…Beyond 90 days, there were three probable treatment-related serious adverse events: two cases of pericarditis (each grade 3) and one case of gastropericardial fistula (grade 4) occurring more than 2 years after treatment. The Czech group recently reported another case of esophagopericardial fistula, ultimately resulting in death of the patient 9 months after cardiac SBRT [ 26 ]. These serious complications demonstrate the necessity for careful procedural planning and thorough follow-up within clinical trials.…”

Section: Discussionmentioning

confidence: 99%

Radiosurgery for ventricular tachycardia (RAVENTA): interim analysis of a multicenter multiplatform feasibility trial

et al. 2023

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Background Single-session cardiac stereotactic radiation therapy (SBRT) has demonstrated promising results for patients with refractory ventricular tachycardia (VT). However, the full safety profile of this novel treatment remains unknown and very limited data from prospective clinical multicenter trials are available. Methods The prospective multicenter multiplatform RAVENTA (radiosurgery for ventricular tachycardia) study assesses high-precision image-guided cardiac SBRT with 25 Gy delivered to the VT substrate determined by high-definition endocardial and/or epicardial electrophysiological mapping in patients with refractory VT ineligible for catheter ablation and an implanted cardioverter defibrillator (ICD). Primary endpoint is the feasibility of full-dose application and procedural safety (defined as an incidence of serious [grade ≥ 3] treatment-related complications ≤ 5% within 30 days after therapy). Secondary endpoints comprise VT burden, ICD interventions, treatment-related toxicity, and quality of life. We present the results of a protocol-defined interim analysis. Results Between 10/2019 and 12/2021, a total of five patients were included at three university medical centers. In all cases, the treatment was carried out without complications. There were no serious potentially treatment-related adverse events and no deterioration of left ventricular ejection fraction upon echocardiography. Three patients had a decrease in VT episodes during follow-up. One patient underwent subsequent catheter ablation for a new VT with different morphology. One patient with local VT recurrence died 6 weeks after treatment in cardiogenic shock. Conclusion The interim analysis of the RAVENTA trial demonstrates early initial feasibility of this new treatment without serious complications within 30 days after treatment in five patients. Recruitment will continue as planned and the study has been expanded to further university medical centers. Trial registration number NCT03867747 (clinicaltrials.gov). Registered March 8, 2019. Study start: October 1, 2019.

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“…To the best of our knowledge, in literature few severe adverse events, definitely correlated to STAR, are reported. In particular, one patient died of esophagopericardial fistula after 9 months from STAR: of note, the patient had previous bypass surgery with a gastroepiploic artery that might have contributed to this severe adverse event ( 79 ); few clinically relevant or symptomatic radiation-induced pericarditis and pericardial effusion and a gastropericardial fistula 2 years after STAR were recorded ( 80 ).…”

Section: Discussionmentioning

confidence: 99%

Stereotactic Radiotherapy Ablation and Atrial Fibrillation: Technical Issues and Clinical Expectations Derived From a Systematic Review

Franzetti

Volpe²,

Catto³

et al. 2022

Front. Cardiovasc. Med.

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AimThe purpose of this study is to collect available evidence on the feasibility and efficacy of stereotactic arrhythmia radio ablation (STAR), including both photon radiotherapy (XRT) and particle beam therapy (PBT), in the treatment of atrial fibrillation (AF), and to provide cardiologists and radiation oncologists with a practical overview on this topic.MethodsThree hundred and thirty-five articles were identified up to November 2021 according to preferred reporting items for systematic reviews and meta-analyses criteria; preclinical and clinical studies were included without data restrictions or language limitations. Selected works were analyzed for comparing target selection, treatment plan details, and the accelerator employed, addressing workup modalities, acute and long-term side-effects, and efficacy, defined either by the presence of scar or by the absence of AF recurrence.ResultsTwenty-one works published between 2010 and 2021 were included. Seventeen studies concerned XRT, three PBT, and one involved both. Nine studies (1 in silico and 8 in vivo; doses ranging from 15 to 40 Gy) comprised a total of 59 animals, 12 (8 in silico, 4 in vivo; doses ranging from 16 to 50 Gy) focused on humans, with 9 patients undergoing STAR: average follow-up duration was 5 and 6 months, respectively. Data analysis supported efficacy of the treatment in the preclinical setting, whereas in the context of clinical studies the main favorable finding consisted in the detection of electrical scar in 4/4 patients undergoing specific evaluation; the minimum dose for efficacy was 25 Gy in both humans and animals. No acute complication was recorded; severe side-effects related to the long-term were observed only for very high STAR doses in 2 animals. Significant variability was evidenced among studies in the definition of target volume and doses, and in the management of respiratory and cardiac target motion.ConclusionSTAR is an innovative non-invasive procedure already applied for experimental treatment of ventricular arrhythmias. Particular attention must be paid to safety, rather than efficacy of STAR, given the benign nature of AF. Uncertainties persist, mainly regarding the definition of the treatment plan and the role of the target motion. In this setting, more information about the toxicity profile of this new approach is compulsory before applying STAR to AF in clinical practice.

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Oesophagopericardial fistula as a late complication of stereotactic radiotherapy for recurrent ventricular tachycardia

Cited by 13 publications

References 0 publications

Non-invasive stereotactic arrhythmia radiotherapy for ventricular tachycardia: results of the prospective STARNL-1 trial

Non-invasive stereotactic arrhythmia radiotherapy for ventricular tachycardia: results of the prospective STARNL-1 trial

Radiosurgery for ventricular tachycardia (RAVENTA): interim analysis of a multicenter multiplatform feasibility trial

Stereotactic Radiotherapy Ablation and Atrial Fibrillation: Technical Issues and Clinical Expectations Derived From a Systematic Review

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