Abstract
Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and safety, but randomized data and long-term outcomes are not yet available. The primary hypothesis as to the mechanism of action for SBRT relates to the development of cardiac fibrosis in arrhythmogenic myocardial substrate; however, limited animal model data offer conflicting insights into this theory. The use of SBRT for patients with refractory ventricular arrhythmias is rapidly increasing, but ongoing translational science work and randomized clinical trials will be critical to address many outstanding questions regarding this novel therapy.
Highlights
Modern techniques and technology for the catheter ablation of ventricular tachycardia (VT) continue to improve and remain a cornerstone of therapy for the management of these life-threatening arrhythmias.[1]
Many patients may require multiple procedures. Patients with these arrhythmias often suffer from multiple comorbid conditions, further increasing the peri-procedural risk
In the longerterm report of the ENCORE-VT trial, which is the largest series to date consisting of 19 patients, at a median follow-up of 23.5 months, 1 patient developed pericarditis within 90 days, 2 patients developed pericardial effusions >2 years after stereotactic body radiation therapy (SBRT), and 1 patient developed a gastropericardial fistula 2.4 years after SBRT which required surgical correction.[25]
Summary
Modern techniques and technology for the catheter ablation of ventricular tachycardia (VT) continue to improve and remain a cornerstone of therapy for the management of these life-threatening arrhythmias.[1]. Until more data about long-term safety and efficacy become available, it is prudent to limit this novel, palliative therapy to patients who have exhausted options of traditional, proven therapies for ventricular arrhythmias, including heart failure optimization, anti-arrhythmic medications, catheter ablation, and autonomic modulation. In the longerterm report of the ENCORE-VT trial, which is the largest series to date consisting of 19 patients, at a median follow-up of 23.5 months, 1 patient developed pericarditis within 90 days, 2 patients developed pericardial effusions >2 years after SBRT, and 1 patient developed a gastropericardial fistula 2.4 years after SBRT which required surgical correction.[25] These toxicities, both cardiac and non-cardiac, will be important to keep in mind as more long-term data become available on patients receiving SBRT for cardiac arrhythmias. This might serve as a potential explanation for the early benefits of SBRT reported in certain studies.[2,6] These findings are supported by histopathologic findings of 3 patients after explantation during heart transplant showing minimal fibrosis but significant compromise of intercalated discs.[7] This might serve as a potential explanation for the early benefits of SBRT reported in certain studies.[2,6] These findings are supported by histopathologic findings of 3 patients after explantation during heart transplant showing minimal fibrosis but significant compromise of intercalated discs.[7]
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