Treatment Planning for Cardiac Radioablation: Multicenter Multiplatform Benchmarking for the RAdiosurgery for VENtricular TAchycardia (RAVENTA) Trial

Kluge, Anne; Ehrbar, Stefanie; Grehn, Melanie; Fleckenstein, Jens; Baus, Wolfgang; Siebert, Frank‐André; Schweikard, Achim; Andratschke, Nicolaus; Mayinger, Michael; Boda-Heggemann, Judit; Buergy, Daniel; Celik, Eren; Krug, David; Kovacs, Boldizsar; Saguner, Ardan M.; Rudic, Boris; Bergengruen, Paula; Boldt, Leif-Hendrik; Stauber, Annina; Zaman, Adrian; Bonnemeier, Hendrik; Dunst, Jürgen; Budach, Volker; Blanck, Oliver; Mehrhof, Felix

doi:10.1016/j.ijrobp.2022.06.056

Cited by 8 publications

(3 citation statements)

References 46 publications

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“…Metal-related artefacts may hamper these efforts in patients bearing a LVAD and therefore menace treatment success. cRA has been shown to be feasible with robotic arm and C‑arm LINAC systems with comparable plan quality [ 29 ]; treatment planning depends on dose specification and platform capabilities, with consequences for the method of motion management.…”

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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“…Based on the radiotherapy system and respiratory motion compensation technique, a residual motion ITV was generated and a standardized treatment planning volume (PTV) margin (3–5 mm) was added to encompass treatment uncertainties. Treatment planning was based on the RAVENTA study benchmark [ 24 ] and the previously published study protocol [ 20 ]. Briefly, a single-fraction dose of 25 Gy was prescribed to the PTV (PTV D 95% ≥ 25 Gy).…”

Section: Methodsmentioning

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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“…At first, the VT exit site was transferred manually from the EAM to the CT. Additionally, a quality assessment was performed via the semi-automatic CTV transfer tool CARDIO-RT (CARDIO-RT is available free of charge upon request from the authors; [ 3 ]). A CTV-to-PTV (planning target volume) margin of 7 mm was applied, and a STAR plan was calculated (Monaco V, Elekta, Stockholm, Sweden) considering the dose and constraint recommendations of the RAVENTA study protocol [ 10 ]. A single fraction of 25 Gy prescribed to 95% of the PTV with 6 MV flattening-filter-free (FFF) beams with previous cone-beam CT-based image guidance was delivered on a linear accelerator (Versa HD, Elekta, Stockholm, Sweden).…”

Section: Case Reportmentioning

confidence: 99%

Electroanatomical mapping after cardiac radioablation for treatment of incessant electrical storm: a case report from the RAVENTA trial

Kaestner,

Boda-Heggemann,

Fanslau

et al. 2023

Strahlenther Onkol

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Background Electroanatomical mapping (EAM)-guided stereotactic arrhythmia radioablation (STAR) is a novel noninvasive therapy option for patients with monomorphic ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or urgent catheter ablation (CA). Data on success rates in an emergency situation such as electrical storm (ES) are rare. We present a case of a patient with an initially very poor life expectancy after extensive myocardial infarction with therapy–resistant ES, not amendable for further antiarrhythmic drug therapy, implantable cardioverter-defibrillator implantation, or repeated CA who was introduced to the radiation oncology department for emergency STAR as a bail-out therapy. Methods Target volume definition and transfer from EAM to CT were validated and quality assured with a semi-automatic, dedicated visualization tool (CARDIO-RT). Emergency STAR was performed with 25 Gy in the framework of the RAVENTA study. The VT burden gradually decreased after STAR; however, a second VT morphology occurred, which was successfully treated with EAM-guided CA 12 days after STAR. Results The second EAM-guided CA showed areas of low voltage in the irradiated segments, indicating a precise targeting and early functional response to STAR. The patient remained free of any VT recurrence or any radiation-related toxicities and in good general condition during the recent follow-up of 18 months. Conclusion The case highlights the possible approach, caveats, difficulties, and prognosis of a patient severely affected by therapy-resistant VT in whom CA could not lead to VT suppression. Further studies of putative mechanisms of STAR in the acute and chronic phase of this novel therapy are warranted.

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Treatment Planning for Cardiac Radioablation: Multicenter Multiplatform Benchmarking for the RAdiosurgery for VENtricular TAchycardia (RAVENTA) Trial

Cited by 8 publications

References 46 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

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

Electroanatomical mapping after cardiac radioablation for treatment of incessant electrical storm: a case report from the RAVENTA trial

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