Stereotactic radioablation of ventricular arrhythmias in patients with structural heart disease – A systematic review

•Systematic review of stereotactic arrhythmia radioablation to treat ventricular arrhythmias.•Safety of radioablation in selected patients with structural heart disease could be demonstrated.•Short-term reduction in ventricular arrhythmia burden is pronounced, but recurrences are common.•High recurrence rate could be related to low radiation dose applied in all investigated patients. Several studies have suggested stereotactic arrhythmia radioablation (STAR) as a treatment option for patients suffering from therapy-refractory ventricular tachycardia or fibrillation (VT/VF). We performed a systematic review of human reports of STAR for structural VT/VF to assess its effectivity and safety. All identified publications were assessed for inclusion. This study adheres to the PRISMA guidelines and was registered on PROSPERO (CRD42020183044). Thirteen studies were included resulting in a population of 57 patients. Median age was 64 (range 34–83), 31 patients (54%) had ischemic cardiomyopathy and 50 patients (88%) had prior catheter ablation (CA) for VT/VF. A mean planned target volume of 64.4 cc (range 3.5–238) with a mean safety margin of 3.3 mm (0–5) was treated with 25 Gy. Immediately following STAR, four patients (7%) experienced an electrical storm. During a mean follow-up duration of 410 days, all patients suffering from sustained VT/VF prior to STAR (n = 55) had a reduction of their sustained VT/VF-burden after STAR, but recurrence occurred in 41 patients (75%) during follow-up. Forty-six patients (81%) had an adverse effect from therapy, but no treatment-related death occurred. Evidence of scar-formation after STAR either by imaging, invasive mapping or histopathology was found in six of nine examined patients (67%). From the still very limited experience, STAR appears effective and safe in patients with structural heart disease and therapy-refractory sustained VT/VF. It is associated with a significant short-term reduction of sustained VT/VF-burden, but recurrences are common.