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EP News: Case Reports

  • T. Jared Bunch
    Correspondence
    Address reprint requests and correspondence: Dr T. Jared Bunch, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132.
    Affiliations
    Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Published:February 05, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.02.002
      Noninvasive radiotherapy is emerging as an alternative therapy for medically refractory ventricular tachycardia (VT) that is not amenable to catheter ablation because of either anatomy or patient stability/health. The long-term outcomes and potential consequences with this therapy are an area of active investigation, particularly in patients with prolonged survival. No data describing the use, efficacy, and potential implications of radiotherapy for VT in pediatric populations are available. Lee et al (https://doi.org/10.1016/j.hrcr.2020.12.009) share the case of an 11-year-old boy with nonischemic cardiomyopathy, ejection fraction (EF) <10% (3% by magnetic resonance imaging), and incessant monomorphic VT despite multiple attempts at catheter ablation. He was admitted for decompensated heart failure with sustained VT. Another attempt at catheter ablation was performed with localization to the right ventricular free wall. One hour after the ablation, VT recurred. He was stabilized on mexiletine and low-dose intravenous lidocaine. A dual-chamber implantable cardioverter-defibrillator (ICD) was inserted. The decision was made to pursue radiotherapy. The patient received a single fraction of 25 Gy using a total of 5 arc beams, including 4 noncoplanar beams. There was a delayed response with a measured VT burden of 98% nine days after radioablation, 95% after 5 weeks, and 61% after 6 weeks. At 6 weeks, bilateral stellate ganglion blockade was performed, with further burden reduction to 24%. After 6 months, his VT was completely resolved, although his cardiac function remained severely reduced (EF 15%). This case shows an approach to radiotherapy in a boy in whom other options were largely exhausted. The long-term safety of focal cardiac radiotherapy will need to be carefully monitored and studied in this boy who is still actively growing, and the results should be reported.
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