Education: Minimally Invasive Cardiac Arrhythmia Ablation: Use of Radiosurgery

Education: Minimally Invasive Cardiac Arrhythmia Ablation: Use of Radiosurgery

Patrick Maguire, MD, PhD and Thomas Fogarty, MD
CyberHeart Incorporated, Portola Valley, California Stanford University, Stanford, California. USA

Ablation of cardiac arrhythmias has progressed over the last decade and the technology is now accepted and utilized internationally. A variety of energy sources are used including radiofrequency, cryothermy, laser energy, etc., all with varying degrees of success. Most current therapies are catheter based and involve the use of sophisticated techniques, including intra-cardiac manipulation of catheters by experienced clinicians. Improvements in outcomes are noted, yet long term relief of arrhythmia in the case of atrial fibrillation and ventricular tachycardia is elusive. New ablation technology (radiosurgery), used initially in the field of oncology, is minimally invasive, and can provides accurate placement of beam energy that is guided by imaging. Ablation lesions can be created even in consideration of target motion.1,2 Secondly, the energy delivery is highly focused so as to minimize any possible long term radiation effect on other structures nearby. Radiosurgery has been previously used to treat the heart, albeit in oncology applications (tumors metastatic to the heart).3,4 CyberHeart Inc. (Portola Valley, CA) has developed 3-D treatment planning software and technology to allow the precise targeting and delivery of ablation to anatomic targets associated with arrhythmia.5 The concept of this non- to minimally invasive energy delivery is intriguing, and has the potential to reduce patient procedural risk, reduce peri-procedural discomfort and achieve equivalent efficacy. The technology involves use of a radiosurgery system, such as the Cyberknife (Accuray Inc., Sunnyvale, CA) that has the ability to plan accurate radiation dose delivery (<1.5 mm accuracy with motion) and subsequent energy delivery. The addition Figure 1. Typical room set-up of the cyberknife radiosurgery of three-dimensional cardiac planning software enables this technology to ablate the myocardium in a precise fashion. Figure 1 shows the instrument and patient set-up. The enabling software (CardioPlan, CyberHeart, Portola Valley, CA) gives the planning clinician the ability to: 1- direct ablation volume placement; 2- examine the placement of dose relative to nearby structures to preserve safety; and 3-visualize this in 3-dimensions before ever treating the patient. (Figure 2). Once a target volume has been constructed, other organs can be protected by not allowing energy beams to traverse while being Figure 2. Panel to the right demonstrates the target (blue line) of the proposed ablation plan to directed at the clinical target volume. create pulmonary vein isolation in 3-D. One can see the relationship ofPanel (red) toleft shows critical structures, such as esophagus (green) and bronchi (light blue). dose on the the other (Figure 3). this treatment plan translated to the 2-D CT scan.

Education: Minimally Invasive Cardiac Arrhythmia Ablation: Use of Radiosurgery

The requirements of this, or any new technology are efficacy and a safety profile that fits the benefit-risk profile of the individual and the disease condition. In order to accomplish this, evidence of electrical conduction block with correlating histologic change had to be documented. In pre-clinical studies, lesion creation had to be shown to correlate with known anatomic lesion sets that are used for the treatment of arrhythmia. Electrical conduction block has been documented in the cavotricuspid isthmus, the AV node and the pulmonary vein-left atrial junction with corresponding tissue change of contiguous and transmural fibrosis. (Figure 4 and Figure 5).

Figure 3. Typical Treatment Plan of the left atrium to create pulmonary vein isolation. Screen shot demonstrates an axial slice view showing ablation volumes.

Figure 4. Hematoxylin-eosin stain of the left atrium following radiosurgical delievery of 25 Gy.

In addition, this technology may have Figure 5. Decapolar electrode recordings from a Lasso catheter in the Right Superior showing dissociation (block) of conduction from a 10 mA electrical pulse particular application in difficult or refractory Pulmonary Veincardiac electrogram post ablation. to any intrinsic situations, such as the treatment of drug and catheter-refractory ventricular tachycardia. This new technology can be used to treat when endo- and epicardial techniques have failed, and the causative substrate is inaccessible. Cardiac radiosurgical ablation allows for the creation of a plan and energy delivery to a defined area that can encompass data from functional imaging tests (PET, positron emission tomography). (Figure 6) The ability to deliver non-minimally invasive cardiac ablation may have inherent advantages over catheter energy delivery, which rely on perfect tissue contact for contiguity. The ability to reliably control and predict lesion size for an individual patients anatomy can offer clinicians a less invasive option to treat this growing patient population with its health care cost burden.

References
1. Van der Voort van Zyp NC, Prevost JB, Hoogeman MS, et al: Stereotactic radiotherapy with real-time tumor tracking for non-small cell lung cancer; clinical outcome. Radiother Oncol 2009; 91(3): 296-300. 2. Dieterich S, Cleary K, DSouza W, et al: Locating and targeting moving tumors with radiation beams. International J of Radiation Oncology Biology Physics. 2010; 78:122 3. Martin AGR, Coltart DJ, Plowman PN: Images in CyberKnife

Figure 6. Superimposed PET scan image on CardioPlan contouring software. View is from above looking into the apex of the left ventricle. Blue line documents location of planned ablation for ventricular tachycardia.

radiosurgery for an intracardiac metastasis. BMJ Case Reports 2011; doi;10.1136/bcr.072010.3197 4. Soltys SG, Kalani MY, Cheshier SH, et al: Stereotactic Radiosurgery for a Cardiac Sarcoma: A Case Report. Technol Cancer Res Treat 2008; 7 (5). 5. Sharma A, Wong D, Weidlich G, et al: Non-invasive stereotactic radiosurgery (CyberHeart) for the creation of ablation lesion in the atrium. Heart Rhythm J 2010, 7:802-810.