Stereotactic Radioablation for Ventricular Tachycardia in the Setting of Electrical Storm

Abstract

Background: Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy for treating refractory ventricular tachycardia (VT) despite optimal medical treatment and catheter ablation. However, data on the use of SBRT in patients with electrical storm (ES) is lacking. The aim of this study was to assess the clinical outcomes associated with SBRT in the context of ES. Methods: This retrospective study included patients who underwent SBRT in the context of ES from March 2020 to March 2021 in one tertiary center (CHU Lille). The target volume was delineated according to a predefined workflow. The efficacy was assessed with the following end points: sustained VT recurrence, VT reduced with antitachycardia pacing, and implantable cardioverter defibrillator shock. Results: Seventeen patients underwent SBRT to treat refractory VT in the context of ES (mean 67±12.8 age, 59% presenting ischemic heart disease, mean left ventricular ejection fraction: 33.7± 9.7%). Five patients presented with ES related to incessant VT. Among these 5 patients, the time to effectiveness ranged from 1 to 7 weeks after SBRT. In the 12 remaining patients, VT recurrences occurred in 7 patients during the first 6 weeks following SBRT. After a median 12.5 (10.5–17.8) months follow-up, a significant reduction of the VT burden was observed beyond 6 weeks (−91% [95% CI, 78–103]), P <0.0001). The incidence of implantable cardioverter defibrillator shock and antitachycardia pacing was 36% at 1 year. Conclusions: SBRT is associated with a significant reduction of the VT burden in the event of an ES; however, prospective randomized control trials are needed. In patients without incessant VT, recurrences are observed in half of patients during the first 6 weeks. VT tolerance and implantable cardioverter defibrillator programming adjustments should be integrated as part of an action plan defined before SBRT for each patient.

Emergency Management of Electrical Storm: A Practical Overview

“…Stereotactic radioablation (SBRT) therapy has been emerging as a therapy for refractory VAs despite optimal medical therapy and CA. Ninni et al demonstrated that SBRT significantly reduces the VT burden during ES (mean VT burden reduction: −91% [95% CI, 78–103]; p < 0.0001), but with a transient recurrence in the first 6 weeks, probably linked to the inflammatory response with the necessity of VT tolerance and ICD reprogramming [ 110 ].…”

Solving the Reach Problem: A Review of Present and Future Approaches for Addressing Ventricular Arrhythmias Arising from Deep Substrate

“…Solving the Reach Problem: A Review of Present and Future Approaches for Addressing Ventricular Arrhythmias Arising from Deep Substrate Lower VA burden and ICD therapy 63 Improved quality of life in multiple small studies [63][64][65] Non-invasive mapping and Lower procedure time Modification of operator strategy in 43% of cases 45 High correlation of between image identified substrate and critical isthmus/LAVA 46 Imaging processing performed at external site Lead time may be required Advances in ablation catheter technologies include the use of higher impedance irrigation, changes in the energy source used for ablation, and pre-ablation cardiac imaging which has been introduced to improve the efficacy of catheter ablation for VT. 9,10…”

Multimodal fusion workflow for target delineation in cardiac radioablation of ventricular tachycardia

“…The described steps were integrated into a single software, named CardioMerge, that makes use of the state-of -the-art C++ libraries insight toolkit (ITK) 3 and VTK. 3 https://itk.org/…”

“…Cardiac radioablation (CR) recently appeared as a promising technique for treatment of refractory ventricular tachycardia (VT). [1][2][3] Also known as Stereotactic arrhythmia radiotherapy (STAR), 4 or cardiac stereotactic body radiotherapy (cardiac SBRT), 2 this treatment consists in delivering a high radiation dose (20 to 25Gy), in a single treatment session, to the myocardium tissues identified as the source of the VT. Patients suffering from VT undergo a series of treatments, including medications, implantation of an implantable cardioverter-defibrillator (ICD), and invasive catheter radiofrequency ablation (CRF), that constitutes the standard medical care.…”

“…Cardiac radioablation (CR) recently appeared as a promising technique for treatment of refractory ventricular tachycardia (VT) 1–3 . Also known as Stereotactic arrhythmia radiotherapy (STAR), 4 or cardiac stereotactic body radiotherapy (cardiac SBRT), 2 this treatment consists in delivering a high radiation dose (20 to 25Gy), in a single treatment session, to the myocardium tissues identified as the source of the VT.…”