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Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02087-y |
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| Elimination of refractory ventricular tachycardia storm and fibrillation using stereotactic radiotherapy | ||
| A. Wutzler1, B. Tiedke2, M. Osman1, N. Mahrous1, R. Wurm1 | ||
| 1Medizinische Klinik II - Kardiologie, Klinikum Frankfurt/Oder, Frankfurt (Oder); 2MVZ des Klinikums Frankfurt (Oder), Frankfurt (Oder); | ||
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56-year- old male
patient with a history of myocardial infarction and heart failure presented to
our hospital with cardiac arrest due to a vt storm that degenerated to
ventricular fibrillation. the vt storm was refractory to pharmacotherapy. the
patient experienced a previous episode of vf ten years ago, following which he
underwent multiple revascularizations of the left anterior descending (lad)
coronary artery. he had a left ventricular aneurysm ever since with decreased
left ventricular ejection fraction (lvef) (15%). he underwent ICD implantation 7 years ago. icd interrogation revealed multiple vt and vf episodes. after
resuscitation and stabilization, the patient underwent coronary angiography and
the patient had a proximal lad lesion as well as in-stent restenosis. we implanted two stents and drug-eluting
balloon dilatation was performed. antiarrhythmic therapy with lidocaine and
amiodarone was begun. The hemodynamically- unstable ventricular
tachycardias persisted and we decided to perform catheter ablation of the vt.
electroanatomical mapping revealed anterior, septal, and apical extensive scar
areas in the left ventricle with multiple areas of late potentials.
catheter ablation was performed and substrate modification as well as ablation
of two ventricular tachycardia morphologies, was performed. the
first vt was ablated at the inferior apical area of the left ventricle and was
rendered non-inducible. we induced a second morphology that was ablated at the
mid- anterior wall. this tachycardia degenerated into a different morphology
during ablation. the latter was terminated with burst stimulation. finally, the
vts were non-inducible. our goal was to
decrease the vt burden as well as the number of adequate shocks. nonetheless,
the vt recurred after three months. due to therapy- refractoriness, extensive
substrate, and involvement of the septum, sbrt was performed.
we performed a series of ct scans with a free-breathing ct and respiration-correlated ct. the 12- lead ecg, 4d ct, and electroanatomic mapping were used to determine the planning target volume (ptv), which consisted of the gross target volume (gtv), the internal target volume (itv) as well as 2 mm as an additional safety using the treatment planning system (tps) iplan rt® (brainlab, feldkirchen, germany). after the scar tissue was delineated (gtv), an additional area was added to account for the motion resulting from breathing as well as cardiac motion (itv). the ptv created using the tps was targeted with a single dose of (25 gy) high precision- sbrt achieving maximal precision while sparing the surrounding organs at risk (oat) such as lungs, esophagus, and surrounding myocardial tissue. sbrt was delivered using novalis tx® (varian medical systems, palo alto, ca) using a dynamic conformal arc technique (6 mv-srs, 1000 mu/min). the patient was positioned on the linear accelerator using exac trac® (brainlab, feldkirchen, germany) x-ray 6d system as well as cone beam ct using a 6d verification threshold for translation of 0.5mm and rotation of 0.5°. sbrt was performed without complications or icd dysfunction. during a one-year follow-up via icd telemonitoring as well as outpatient clinic assessments, no need for adequate shocks, after a massive pre-interventional vt burden. the lvef improved to 31%. no complications related to sbrt were detected. the patient remained on amiodarone, ß-blockers, platelet inhibitor, diuretics and a sacubitril/valsartan combination.f |
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https://dgk.org/kongress_programme/ht2022/aP283.html |