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Strahlentherapie und Onkologie
Published in: Strahlentherapie und Onkologie 1/2020

01-01-2020 | Ventricular Tachycardia | Case Study

Stereotactic body radiotherapy for ventricular tachycardia (cardiac radiosurgery)

First-in-patient treatment in Germany

Authors: Dr. med. David Krug, MD, Oliver Blanck, PhD, Thomas Demming, MD, Matthias Dottermusch, MD, Karoline Koch, MD, Markus Hirt, PhD, Laura Kotzott, MD, Adrian Zaman, MD, Lina Eidinger, Frank-Andre Siebert, PhD, Jürgen Dunst, MD, Hendrik Bonnemeier, MD

Published in: Strahlentherapie und Onkologie | Issue 1/2020

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Abstract

Purpose

Single-session cardiac stereotactic body radiotherapy, called cardiac radiosurgery (CRS) or radioablation (RA), may offer a potential treatment option for patients with refractory ventricular tachycardia (VT) and electrical storm who are otherwise ineligible for catheter ablation. However, there is only limited clinical experience. We now present the first-in-patient treatment using (CRS/RA) for VT in Germany.

Methods

A 78-year-old male patient with dilated cardiomyopathy and significantly reduced ejection fraction (15%) presented with monomorphic VT refractory to poly-anti-arrhythmic medication and causing multiple implantable cardioverter-defibrillator (ICD) interventions over the course of several weeks, necessitating prolonged treatment on an intensive care unit. Ultra-high-resolution electroanatomical voltage mapping (EVM) revealed a re-entry circuit in the cardiac septum inaccessible for catheter ablation. Based on the EVM, CRS/RA with a single session dose of 25 Gy (83% isodose) was delivered to the VT substrate (8.1 cc) using a c-arm-based high-precision linear accelerator on November 30, 2018.

Results

CRS/RA was performed without incident and dysfunction of the ICD was not observed. Following the procedure, a significant reduction in monomorphic VT from 5.0 to 1.6 episodes per week and of ICD shock interventions by 81.2% was observed. Besides periprocedural nausea with a single episode of vomiting, no treatment-associated side effects were noted. Unfortunately, the patient died 57 days after CRS/RA due to sepsis-associated cardiac circulatory failure after Clostridium difficile-associated colitis developed during rehabilitation. Histopathologic examination of the heart as part of a clinical autopsy revealed diffuse fibrosis on most sections of the heart without apparent differences between the target area and the posterior cardiac wall serving as a control.

Conclusion

CRS/RA appears to be a possible treatment option for otherwise untreatable patients suffering from refractory VT and electrical storm. A relevant reduction in VT incidence and ICD interventions was observed, although long-term outcome and consequences of CRS/RA remain unclear. Clinical trials are strongly warranted and have been initiated.
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Metadata
Title
Stereotactic body radiotherapy for ventricular tachycardia (cardiac radiosurgery)
First-in-patient treatment in Germany
Authors
Dr. med. David Krug, MD
Oliver Blanck, PhD
Thomas Demming, MD
Matthias Dottermusch, MD
Karoline Koch, MD
Markus Hirt, PhD
Laura Kotzott, MD
Adrian Zaman, MD
Lina Eidinger
Frank-Andre Siebert, PhD
Jürgen Dunst, MD
Hendrik Bonnemeier, MD
Publication date
01-01-2020
Publisher
Springer Berlin Heidelberg
Published in
Strahlentherapie und Onkologie / Issue 1/2020
Print ISSN: 0179-7158
Electronic ISSN: 1439-099X
DOI
https://doi.org/10.1007/s00066-019-01530-w

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