Stereotactic arrhythmia radioablation and its implications for modern cardiac electrophysiology: results of an EHRA survey

Abstract Stereotactic arrhythmia radioablation (STAR) is a treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in patients with structural heart disease (SHD). The current and future role of STAR as viewed by cardiologists is unknown. The study aimed to assess the current role, barriers to application, and expected future role of STAR. An online survey consisting of 20 questions on baseline demographics, awareness/access, current use, and the future role of STAR was conducted. A total of 129 international participants completed the survey [mean age 43 ± 11 years, 25 (16.4%) female]. Ninety-one (59.9%) participants were electrophysiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR, while 62 (48.1%) had treated/referred a patient for treatment. Common primary indications for STAR were recurrent VT/VF in SHD (45%), recurrent VT/VF without SHD (7.8%), or premature ventricular contraction (3.9%). Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%) and non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%). Most respondents have foreseen a future clinical role of STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively), although only a minority expected a first-line indication for it (7% and 5%, respectively). Stereotactic arrhythmia radioablation as a novel treatment option of recurrent VT appears to gain acceptance within the cardiology community. Further trials are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.


Introduction
STereotactic Arrhythmia Radioablation and its place in modern cardiac ElectroPhysiology * 1. GDPR Disclaimer We will not disclose your identity to any third party.
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Please confirm that you have read the above and agree to participate in this survey.13.Based on my current knowledge and experience 14.In your opinion, which are the why STAR may not be adopted as an 3D electroanatomic data created using invasive mapping catheters Cross-sectional imaging (computed tomography, cardiac magnetic resonance imaging, etc.)

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STereotactic Arrhythmia Radioablation and its place in modern cardiac ElectroPhysiology

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experimental) treatment ?(multiple choice) Lack of knowledge about this treatment Lack of reliable outcomes data on STAR I do not believe this treatment works Concern of toxicity and side effects I do not know where the next centre is which offers STAR to patients Other (please specify) * 15.Which further studies/publications would you like to see to facilitate your clinical decisions-making regarding STAR? (please put in order of priority -1 most important, 5 least important) EHRA (or ESC) consensus document and expert recommendations on clinical use of STAR Prospective clinical outcome data demonstrating safety (>2 years follow-up) Randomized clinical trial in treatment naïve patients with VT/VF comparing STAR to ablation therapy and/or antiarrhythmic drug therapy Randomized clinical trial in patients with recurrent VT/VF after ablation therapy and/or antiarrhythmic therapy comparing STAR to repeat ablation therapy/escalation of antiarrhythmic drug therapy Other type of publication * 16.Which inclusion criteria would you consider necessary for STAR ?(multiple choice) Structural heart diseases (ischemic cardiomyopathy or non-ischemic cardiomyopathy) Placement of an ICD Recurrent monomorphic VT (>3 episodes in the previous 3 months) Electrical strom Optimal antiarrhythmic medication One or more previous catheter ablation procedures or contraindication against ablation Other (please specify) * 17.Which exclusion criteria would you consider prohibitive STAR? (multiple choice) In your opinion, where should STAR be performed?Any hospital that offers this form of radiotherapy (stereotactic body radiotherapy) and has the radiation oncology expertise Any hospital that has the expertise in both VT ablation and expertise to perform stereotactic body radiotherapy Any hospital that has the expertise in both VT ablation and specifically STAR STAR should only be performed in an academic (i.e.research) setting STAR should not be performed anywhere Future of STAR in cardiology and electrophysiology STereotactic Arrhythmia Radioablation and its place in modern cardiac ElectroPhysiology 19.How would you rank the possible advantages of STAR? (please put in order of priority -1 most important, 6 least important) Higher efficacy than other available treatment options (ablation, antiarrhythmic drug therapy, etc.) Non-invasive treatment approach with overall low expected acute and short-term procedural risks Short treatment time (~20-40 minutes) Efficacy for arrhythmias that are not amenable to either catheter ablation or antiarrhythmic drugs Shorter expected recovery time from procedure allowing early (e.g.same day) discharge as compared to ablation Reduction of antiarrhythmic drug dosage 20.What in your opinion is the most appropriate way to determine the myocardial tissue that should be targeted with STAR for the treatment of ventricular arrhythmia (multiple choice)

thank you for completing the STAR in EP survey. Your input is very much appreciated and will help us to evaluate the current role and future of STAR in Cardiology and Electrophysiology. Please spread the word among your Cardiology and EP colleagues to answer this survey (https://www.surveymonkey.com/r/_S_T_A_R). It is not restricted to EHRA/ESC members or physicians practicing in Europe. If you have any comments or questions on the survey, feel free to contact us: boldizsar.kovacs@usz.ch Thanks again for your contribution, Boldizsar Kovacs, H. Immo Lehmann on behalf of the EHRA Scientific Initiatives Committee.
21. Currently STAR is mainly considered a 'last resort' treatment for sustained VT/VF in structural heart disease.In your opinion, what will be the MOST LIKELY clinical role of STAR in the next 5-10 years in the following arrhythmias: *