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Stereotactic body radiotherapy for ventricular tachycardia (cardiac radiosurgery)

First-in-patient treatment in Germany

  • Case Study
  • Published:
Strahlentherapie und Onkologie Aims and scope Submit manuscript

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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Acknowledgements

The authors would like to thank Dr. Annette Rogge (Clinical Ethics Committee, Kiel, Germany) for ethical counseling in the context of the treatment of the patient.

Author information

Authors and Affiliations

  1. Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany

    David Krug MD, Oliver Blanck PhD, Markus Hirt PhD, Lina Eidinger, Frank-Andre Siebert PhD & Jürgen Dunst MD

  2. Klinik für Innere Medizin III, Kardiologie, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany

    Thomas Demming MD, Laura Kotzott MD, Adrian Zaman MD, Lina Eidinger & Hendrik Bonnemeier MD

  3. Institut für Pathologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany

    Matthias Dottermusch MD

  4. Institut für Pathologie – Sektion für Hämatopathologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany

    Karoline Koch MD

Authors
  1. David Krug MD
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  2. Oliver Blanck PhD
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  3. Thomas Demming MD
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  4. Matthias Dottermusch MD
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  5. Karoline Koch MD
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  6. Markus Hirt PhD
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  7. Laura Kotzott MD
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  8. Adrian Zaman MD
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  9. Lina Eidinger
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  10. Frank-Andre Siebert PhD
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  11. Jürgen Dunst MD
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  12. Hendrik Bonnemeier MD
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Corresponding author

Correspondence to David Krug MD.

Ethics declarations

Conflict of interest

D. Krug received honoraria from Merck Sharp & Dohme (MSD) outside of the submitted work. H. Bonnemeier received honoraria from Boston Scientific (BSC) outside of the submitted work. O. Blanck, T. Demming, M. Dottermusch, K. Koch, M. Hirt, L. Kotzott, A. Zaman, L. Eidinger, F.-A. Siebert, and J. Dunst declare that they have no competing interests.

Ethical standards

Before informing the patient about the possibility of CRS/RA, the clinical ethics committee was consulted. During the discussion of CRS/RA with the patient, a representative of the clinical ethics committee was present. The patient gave his written informed consent for collection and analysis of clinical data for this case report.

Additional information

David Krug and Oliver Blanck contributed equally. Jürgen Dunst and Hendrik Bonnemeier are shared senior authors.

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Krug, D., Blanck, O., Demming, T. et al. Stereotactic body radiotherapy for ventricular tachycardia (cardiac radiosurgery). Strahlenther Onkol 196, 23–30 (2020). https://doi.org/10.1007/s00066-019-01530-w

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  • DOI: https://doi.org/10.1007/s00066-019-01530-w

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