Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
Klinik für Innere Medizin III, Kardiologie, Abteilung für Elektrophysiologie und Rhythmologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.
Strahlenther Onkol. 2020 Jan;196(1):23-30. doi: 10.1007/s00066-019-01530-w. Epub 2019 Oct 31.
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.
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.
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.
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.
单次心脏立体定向体部放射治疗，称为心脏放射外科（CRS）或放射消融（RA），可能为因其他原因不适合导管消融的难治性室性心动过速（VT）和电风暴患者提供一种潜在的治疗选择。然而，目前临床经验有限。我们现在报告德国首例使用（CRS/RA）治疗 VT 的患者。
一名 78 岁男性患者患有扩张型心肌病，射血分数明显降低（15%），患有单形性 VT，对多抗心律失常药物治疗无效，并在数周内多次导致植入式心脏复律除颤器（ICD）干预，需要在重症监护病房长时间治疗。超高分辨率电解剖电压图（EVM）显示心脏间隔内存在一个无法进行导管消融的折返环。基于 EVM，于 2018 年 11 月 30 日，使用基于 C 臂的高精度直线加速器对 VT 底物（8.1 cc）进行单次 25 Gy（83%等剂量）的 CRS/RA。
CRS/RA 无并发症进行，未观察到 ICD 功能障碍。在该操作后，观察到单形性 VT 从每周 5.0 次显著减少到 1.6 次，ICD 电击干预减少了 81.2%。除了单次呕吐引起的围手术期恶心外，未发现其他与治疗相关的副作用。不幸的是，患者在 CRS/RA 后 57 天因艰难梭菌相关性结肠炎引起的败血症相关心脏循环衰竭死亡。作为临床尸检一部分的心脏组织病理学检查显示，心脏的大部分切片均存在弥漫性纤维化，目标区域与用作对照的心脏后壁之间无明显差异。
CRS/RA 似乎是一种可能的治疗选择，适用于其他无法治疗的难治性 VT 和电风暴患者。观察到 VT 发生率和 ICD 干预的显著减少，尽管 CRS/RA 的长期结果和后果尚不清楚。强烈需要并已启动临床试验。
