2017.12.13 11:04
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Rapid, erratic heartbeats — called ventricular tachycardia — can lead to sudden death. An experimental radiation treatment has eased the condition in five patients.
2017.12.13 11:47
2017.12.14 01:29
ORIGINAL ARTICLE
Phillip S. Cuculich, M.D., Matthew R. Schill, M.D., Rojano Kashani, Ph.D., Sasa Mutic, Ph.D., Adam Lang, M.D., Daniel Cooper, M.D., Mitchell Faddis, M.D., Ph.D., Marye Gleva, M.D., Amit Noheria, M.B., B.S., Timothy W. Smith, M.D., D.Phil., Dennis Hallahan, M.D., Yoram Rudy, Ph.D., and Clifford G. Robinson, M.D.
N Engl J Med 2017; 377:2325-2336December 14, 2017DOI: 10.1056/NEJMoa1613773
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Recent advances have enabled noninvasive mapping of cardiac arrhythmias with electrocardiographic imaging and noninvasive delivery of precise ablative radiation with stereotactic body radiation therapy (SBRT). We combined these techniques to perform catheter-free, electrophysiology-guided, noninvasive cardiac radioablation for ventricular tachycardia.
We targeted arrhythmogenic scar regions by combining anatomical imaging with noninvasive electrocardiographic imaging during ventricular tachycardia that was induced by means of an implantable cardioverter–defibrillator (ICD). SBRT simulation, planning, and treatments were performed with the use of standard techniques. Patients were treated with a single fraction of 25 Gy while awake. Efficacy was assessed by counting episodes of ventricular tachycardia, as recorded by ICDs. Safety was assessed by means of serial cardiac and thoracic imaging.
From April through November 2015, five patients with high-risk, refractory ventricular tachycardia underwent treatment. The mean noninvasive ablation time was 14 minutes (range, 11 to 18). During the 3 months before treatment, the patients had a combined history of 6577 episodes of ventricular tachycardia. During a 6-week postablation “blanking period” (when arrhythmias may occur owing to postablation inflammation), there were 680 episodes of ventricular tachycardia. After the 6-week blanking period, there were 4 episodes of ventricular tachycardia over the next 46 patient-months, for a reduction from baseline of 99.9%. A reduction in episodes of ventricular tachycardia occurred in all five patients. The mean left ventricular ejection fraction did not decrease with treatment. At 3 months, adjacent lung showed opacities consistent with mild inflammatory changes, which had resolved by 1 year.
In five patients with refractory ventricular tachycardia, noninvasive treatment with electrophysiology-guided cardiac radioablation markedly reduced the burden of ventricular tachycardia. (Funded by Barnes–Jewish Hospital Foundation and others.)
Supported by a grant from the Barnes–Jewish Hospital Foundation (to Dr. Cuculich), by Washington University (the Department of Radiation Oncology, to Dr. Robinson; and the Cardiovascular Division of the Department of Medicine, to Dr. Cuculich), and by a grant (R01 HL033343, to Dr. Rudy) from the National Institutes of Health.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
From the Department of Internal Medicine, Cardiovascular Division (P.S.C., D.C., M.F., M.G., A.N., T.W.S.), and the Departments of Surgery (M.R.S.), Radiation Oncology (R.K., S.M., D.H., C.G.R.), Pathology (A.L.), and Cell Biology and Physiology, Medicine, Radiology, and Pediatrics (Y.R.), School of Medicine, and the Department of Biomedical Engineering, School of Engineering and Applied Science (Y.R.), Washington University in St. Louis, St. Louis.
Address reprint requests to Dr. Cuculich at Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8086, St. Louis, MO 63110, or at pcuculic@wustl.edu.
2017.12.14 09:36
Yes, This is truly remarkable achievement from the prestigious insitution and "the game changer" as commented.
Glad to see a name of a surgeon in the paper.
Personally, it brings me the memories of erlier days of electrophysiology and EP surgery, the "Pennsylvania peel-operation(endocardial resection)"(Mark Josephson who recently passed away and the surgical colleague/teacher Alden Harken) in late 70's and number of workshops I attended at the Barnes Hospital during the earlier days of surgical implantation of defibrillator patches or surgical WPW or Maze operations for atrial fibrillation.
Most of these procedures became ,more or less, non surgical procedures these days.
In addition to the caliber of researches at Barnes, I was always impressed by the animal labs at Barns, which were much better than operationg rooms of my hospital in early-mid 80's.
For another thought, if you want some investment for quick return(??), might be worthwhile to look into these companies---
---the immobilization device(body FIX,Elekta) or 4 dimensional CT scanner---ㅎㅎㅎ
This is incredible!
This is an example of a revolutionary idea of a physician solely dedicated to
his patient's well being that turned out to be working like a miracle.
I can just picture what might have been going through this doctor's mind
when he came up with this idea and how desperately he felt in trying to help
his patient with intractable ventricular tachycardia that was causing numerous
DC shocks by the implanted defibrillator and was incapacitating him each episode.
I had a few such patients and still remember spending practically a whole day
at the bedside of the one patient with intractable VT.
Besides electric shocks, you usually try IV amiodarone, lidocaine, beta-blockers
while loading the patient with oral amiodarone as well.
But VT still can recur and you do not know what to do.
You become just as desperate as the patient or sometimes more desperate than the patient
because often times the patient keeps on thanking you with beautiful smiles,
which makes you feel very inadequate as his physician.
Cardiology community certainly is congratulating him.
On the other hand the history of medicine and Cardiology shows numerous such examples
of history making events which helped advance medicine in all its fronts for the benefit
of mankind.
It seems that only the dedicated physician knows and is convinced that
the most beautiful thing among all creations and among all life forms
is indeed a human life and being a physician is the holiest, highest calling,
indeed. It is such a privilege as taught by Hippocrates so long ago.