用于室性心动过速消融的非侵入性心脏放射治疗。
Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia.
作者信息
Cuculich Phillip S, Schill Matthew R, Kashani Rojano, Mutic Sasa, Lang Adam, Cooper Daniel, Faddis Mitchell, Gleva Marye, Noheria Amit, Smith Timothy W, Hallahan Dennis, Rudy Yoram, Robinson Clifford G
机构信息
From the Department of Internal Medicine, Cardiovascular Division (P.S.C., D.C., M.F., M.G., A.N., T.W.S.), and the Departments of Surgery (M.R.S.), Radiation Oncology (R.K., S.M., D.H., C.G.R.), Pathology (A.L.), and Cell Biology and Physiology, Medicine, Radiology, and Pediatrics (Y.R.), School of Medicine, and the Department of Biomedical Engineering, School of Engineering and Applied Science (Y.R.), Washington University in St. Louis, St. Louis.
出版信息
N Engl J Med. 2017 Dec 14;377(24):2325-2336. doi: 10.1056/NEJMoa1613773.
BACKGROUND
Recent advances have enabled noninvasive mapping of cardiac arrhythmias with electrocardiographic imaging and noninvasive delivery of precise ablative radiation with stereotactic body radiation therapy (SBRT). We combined these techniques to perform catheter-free, electrophysiology-guided, noninvasive cardiac radioablation for ventricular tachycardia.
METHODS
We targeted arrhythmogenic scar regions by combining anatomical imaging with noninvasive electrocardiographic imaging during ventricular tachycardia that was induced by means of an implantable cardioverter-defibrillator (ICD). SBRT simulation, planning, and treatments were performed with the use of standard techniques. Patients were treated with a single fraction of 25 Gy while awake. Efficacy was assessed by counting episodes of ventricular tachycardia, as recorded by ICDs. Safety was assessed by means of serial cardiac and thoracic imaging.
RESULTS
From April through November 2015, five patients with high-risk, refractory ventricular tachycardia underwent treatment. The mean noninvasive ablation time was 14 minutes (range, 11 to 18). During the 3 months before treatment, the patients had a combined history of 6577 episodes of ventricular tachycardia. During a 6-week postablation "blanking period" (when arrhythmias may occur owing to postablation inflammation), there were 680 episodes of ventricular tachycardia. After the 6-week blanking period, there were 4 episodes of ventricular tachycardia over the next 46 patient-months, for a reduction from baseline of 99.9%. A reduction in episodes of ventricular tachycardia occurred in all five patients. The mean left ventricular ejection fraction did not decrease with treatment. At 3 months, adjacent lung showed opacities consistent with mild inflammatory changes, which had resolved by 1 year.
CONCLUSIONS
In five patients with refractory ventricular tachycardia, noninvasive treatment with electrophysiology-guided cardiac radioablation markedly reduced the burden of ventricular tachycardia. (Funded by Barnes-Jewish Hospital Foundation and others.).
背景
近年来的进展使得利用心电图成像技术对心律失常进行无创标测，以及利用立体定向体部放射治疗（SBRT）实现精确消融辐射的无创递送成为可能。我们将这些技术相结合，对室性心动过速进行无导管、电生理引导的无创心脏射频消融治疗。
方法
在通过植入式心律转复除颤器（ICD）诱发室性心动过速期间，我们将解剖成像与无创心电图成像相结合，以靶向致心律失常瘢痕区域。SBRT模拟、计划和治疗均采用标准技术。患者在清醒状态下接受单次25 Gy的照射。通过计算ICD记录的室性心动过速发作次数来评估疗效。通过系列心脏和胸部成像评估安全性。
结果
2015年4月至11月，5例高危、难治性室性心动过速患者接受了治疗。平均无创消融时间为14分钟（范围为11至18分钟）。在治疗前的3个月期间，患者共有6577次室性心动过速发作史。在消融后的6周“空白期”（由于消融后炎症可能发生心律失常），有680次室性心动过速发作。在6周空白期后，在接下来的46个患者月中有4次室性心动过速发作，较基线减少了99.9%。所有5例患者的室性心动过速发作次数均减少。平均左心室射血分数在治疗后未降低。在3个月时，相邻肺野出现与轻度炎症改变一致的模糊影，至1年时已消退。
结论
在5例难治性室性心动过速患者中，电生理引导的无创心脏射频消融治疗显著减轻了室性心动过速的负担。（由巴恩斯-犹太医院基金会等资助。）
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