<div>Alexander Wutzler<sup>a,b</sup>, Borris
Tiedke<sup>a</sup>, Mohamed Osman<sup>a</sup>, Noha
Mahrous<sup>a</sup>, Wurm R<sup>c</sup></div><div>aDepartment of Cardiology, Klinikum Frankfurt (Oder), Germany</div><div>bCardiovascular Center, St. Josef Hospital, University Hospital of the
Ruhr-University Bochum</div><div>cDepartment of Radiation Oncology, Klinikum Frankfurt (Oder), Germany</div><div>Corresponding Author:</div><div>Mahrous, Noha</div><div>Department of Cardiology</div><div>Klinikum Frankfurt (Oder), Müllroser Chaussee 7</div><div>15236 Frankfurt (Oder)</div><div>Email: Noha.Mahrous@klinikumffo.de</div><div>Phone: +49 1784188268</div><div>Fax: +49 335 548 4652</div><div>All authors declare no conflict of interest.</div><div>Funding: none to declare</div><div>Introduction</div><div>Ventricular tachycardia (VT) storms
and ventricular fibrillation (VF) are arrhythmias with limited and
unsatisfactory treatment options and are associated with high mortality.
Failed catheter ablation poses a fourfold increased risk of death in
patients with VT/VF. Furthermore, heart failure and adequate implantable
cardioverter defibrillator (ICD) shocks are associated with impaired
prognosis <sup>[1]</sup>. Stereotactic body radiotherapy
(SBRT) has been proposed as a last resort in patients with VT storm and
VF refractory to medical therapy and catheter ablation<sup>[2]</sup>.</div><div>Case report</div><div>A 56-year- old male patient with history of myocardial infarction and
heart failure presented to our hospital with cardiac arrest due to VT
storm that degenerated to ventricular fibrillation. The VT storm was
refractory to pharmacotherapy. The patient experienced a previous
episode of VF ten years ago, following which he underwent multiple
revascularizations of the left anterior descending (LAD) coronary
artery. He had ever since a left ventricular aneurysm with decreased
left ventricular ejection fraction (LVEF) (15%). He underwent ICD
implantation seven years ago. ICD Interrogation revealed multiple VT and
VF episodes within the last 6 Weeks, which were treated with ATP or
adequate ICD shocks. After resuscitation and stabilization, the patient
underwent catheter ablation of VT. Electroanatomical mapping revealed an
anterior and antero-septal scar area in the left ventricle. Catheter
ablation was performed. Nonetheless, the VT recurred after three months.
Due to therapy- refractoriness, extensive substrate, and involvement of
the septum, SBRT was performed. Cardiac radiotherapy was delivered in a
single dose of (25 Gy) high precision- SBRT based on the electroanatomic
mapping.</div><div>SBRT was performed without complications or ICD dysfunction. During a
one- year follow up via ICD telemonitoring as well as outpatient clinic
assessments, no recurrence of any VT was documented, after a massive
periinterventional VT burden. The LVEF improved to 31%. No
complications related to SBRT were detected. The patient remained on
Amiodarone, ß-blockers, platelet inhibitor, diuretics and a
Sacubitril/valsartan combination.</div><div>Conclusion</div><div>Radiotherapy offers a feasible, safe and effective therapy to VT storms
and VF refractory to pharmacotherapy and ablation. We report a patient
in whom radiotherapy was safely performed leading to complete
elimination of ventricular arrhythmia during mid-term follow up. Our
results should be confirmed in a prospective multi-center trial.</div><div>References</div><div>1- Nayyar S, Ganesan AN, Brooks AG, Sullivan T, Roberts-Thomson KC,
Sanders P. Venturing into ventricular arrhythmia storm: a systematic
review and meta-analysis. European heart journal. 2013 Feb
21;34(8):560-71.</div><div>2- Scholz EP, Seidensaal K, Naumann P, André F, Katus HA, Debus J. Risen
from the dead: Cardiac stereotactic ablative radiotherapy as last rescue
in a patient with refractory ventricular fibrillation storm. HeartRhythm
case reports. 2019 Jun 1;5(6):329-32.</div>