May 7, 2021 by John Fernandez
Pioneering Procedure: Radiation Therapy Targets Heart Rhythm Disorder in Critically Ill Patient
The relatively new procedure, performed for the first time in Florida by a multidisciplinary team from Baptist Health’s Miami Cardiac & Vascular Institute and Miami Cancer Institute, has put a 77-year-old, critically ill heart patient on the road to a full recovery.
The procedure, stereotactic body radiation therapy (SBRT), also known as radioablation, is a commonly used technology for the non-invasive treatment of solid tumors. It uses targeted, image-guided beams of radiation. And it’s a standard radiation treatment at Miami Cancer Institute.
(Watch now: Hear from patient Jose Manuel Garcia and his team of specialists from Baptist Health’s Miami Cardiac & Vascular Institute and Miami Cancer Institute. Video by Anthony Vivian.)
Previously, a team of specialists from Washington University School of Medicine in St. Louis has utilized SBRT to successfully treat a potentially fatal heart arrhythmia known as ventricular tachycardia, or VT. Before their landmark procedure, the Baptist Health team consulted with colleagues at Washington University.
SBRT is quite common in radiation oncology, explains Rupesh Kotecha, M.D., a radiation oncologist and chief of radiosurgery at Miami Cancer Institute. “We do this for hundreds of cancer patients for a range of tumors in the body. We can use stereotactic radiation therapy to deliver high-precision radiation treatment. And it’s also called stereotactic radiosurgery — so, it’s like doing surgery but without the invasive component.”
A heart normally beats about 60 to 100 times a minute when a person is at rest. In most patients with VT, the heart beats 150 times a minute or higher, even at rest. VT is a heart rhythm disorder, or arrhythmia, caused by abnormal electrical signals in the lower chambers of the heart (ventricles). The lower chambers beat so fast that they fall out of sync with the upper chambers, raising the risk of sudden cardiac death.
The critically ill heart patient, Jose Manuel Garcia, was experiencing dizziness, some shortness of breath, and recurrent episodes of passing out before undergoing the SBRT procedure, said Mario Pascual, M.D., a cardiologist and cardiac electrophysiologist at Miami Cardiac & Vascular Institute. Prior to the procedure, Mr. Garcia’s cardiology team at Miami Cardiac & Vascular Institute was led by Jonathan Fialkow, M.D., deputy medical director and chief of cardiology, and Sandra Chaparro, M.D., cardiologist and director of the Advanced Heart Failure Program.
“This procedure is extremely revolutionary, both in terms of the intersection between a technology that’s generally in a oncology world and then the cardiovascular expertise,” said Dr. Fialkow. “And bringing those two disciplines together through a technology which allows for a better patient outcome with less invasiveness, less recuperation.”
Making Sure Patient was ‘Rock Stable’
“The arrhythmia was coming frequently and that it was very difficult to live with because you have to you measure everything that you do,” recalls the patient, Mr. Garcia. “And when you get the symptoms, a lot of times you have to call the rescue.” Then the medical team sat down with Mr. Garcia and detailed the potential benefits of the radioablation procedure targeting his VT.
Drs. Pascual and Kotecha both explained what they were going to do,” recalls the patient, Mr. Garcia. “I still had apprehension because it was going to be the first one. But they explained it so thoroughly that, once I got home, we decided to do it.”
In the weeks prior to the procedure, Mr. Garcia had to be stabilized with drug therapies after experiencing cardiogenic shock, a serious condition when the heart cannot pump enough blood and oxygen to the brain, kidneys, and other vital organs, explains Dr. Chaparro. His VT and congestive heart failure had contributed to a left ventricular ejection fraction (LVEF) of 10 percent. The normal LVEF range is from 55 to 70 percent. During his procedure, Mr. Garcia had to be medically stable, and remain awake and alert to follow directions from physicians.
“We were seeing him very frequently in the outpatient setting to make sure he was rock stable so we could proceed with the radioablation,” said Dr. Chaparro. “The procedure is amazing; it takes about 15 minutes. But there was a lot of planning and a lot of meetings to make sure everything was in place because, obviously, this was the first case.”
Procedure is Rarely Done Worldwide
Applying radioablation to a heart patient with VT is still rarely done in the U.S. and worldwide, according to Drs. Kotecha and Pascual who led the team that performed the landmark SBRT procedure. Elliott Elias, M.D., a cardiologist with a focus on interventional echocardiography, was also a key member of the team.
Worldwide, an estimated 30 to 40 patients have undergone this procedure to treat VT. Patients with VT are at an extremely high risk of suffering sudden cardiac death, especially in those patients who have not responded to other standard treatments or medications.
“When we talk about sudden cardiac death — that’s what ventricular tachycardia is — and it’s actually the No. 1 cause of death in this country,” said Dr. Pascual. “Ventricular tachycardia is very common. The No. 1 cause of ventricular tachycardia is going to be underlying heart disease. So, it’s patients with a cardiomyopathy or a weak heart or patients with underlying coronary artery disease.”
Multidisciplinary Approach is Critical
The complexity of performing SBRT on patients with ventricular tachycardia stems from the multidisciplinary nature of the procedure.
“Doing stereotactic radiation therapy for an arrhythmia is done very infrequently in the world,” says Dr. Kotecha. “That’s because you need to have a good cardiac team, a good cardiac imaging team, and then you have to have the radiation therapy team. Cardiac and radiation oncology teams don’t typically interact together, and VT is not a common indication for radiation treatment — given that it’s a non-malignant indication. So, this really requires a synergy among three services.”
The standard treatments for VT patients include implantation of defibrillators that shock the heart back into a normal rhythm. These patients are also treated often with “catheter ablation” procedures, in which a catheter is inserted into the heart and manipulated to create scars in the part of the damaged heart muscle that is responsible for the misfiring of electrical signals. But a catheter ablation is invasive and requires many hours under general anesthesia. For many patients it is not a permanent solution. The rapid heart rhythm returns in about half of such patients.
Outpatient Procedure with Quick Recovery
In sharp contrast to catheter ablation, SBRT to treat ventricular tachycardia is a noninvasive outpatient procedure that involves the use of electrocardiograms and computed tomography scans of a patient’s heart. This helps the medical team pinpoint the origin of the arrhythmia. The 3D visual of the heart works as a guide for the radiation therapy. Doctors target the area of the heart causing the arrhythmia with a single, high-dose treatment of radiation therapy that often takes just a few minutes to administer, and requires no anesthesia or hospitalization.
The patient, Mr. Garcia, that underwent the SBRT had previously had two open-heart surgeries. The latest surgery had included a surgical ablation procedure to address the VT. But the condition persisted and he continued to take medications that are not meant for long-term use. “Medications for ventricular tachycardia have a list of long-term toxicities,” says Dr. Pascual. “Patients just can’t remain on these medications for many years.”
Compared to the standard catheter ablation, the recovery time for VT patients from SBRT is remarkably fast.
“If we look at our standard catheter ablation, I know this patient would have had a prolonged ICU (intensive care unit) stay,” explains Dr. Pascual. “But the day we did the SBRT, he literally got off the table and we walked him to a room and talked to him for about 20 minutes to make sure he was okay. He went home and had dinner. Since then, he’s just continued to feel better and better. He has not had any side effects whatsoever, and we’re hopeful that we can soon start to withdraw some of those anti-arrhythmic medications to get rid of those toxicities associated with the medications.”
The patient, Mr. Garcia, says his swift recovery began in the moments following the procedure. And his life is practically back to normal.
“I couldn’t believe it … this is a miracle,” he says. “The difference is like night and day. I don’t have any more arrhythmia and the medicine has been decreased slowly …”
Before performing its procedure, the Baptist Health team consulted with colleagues at Washington University School of Medicine in St. Louis. They had performed more of these procedures on VT patients than any other single medical team in the world. “It was so important to meet with our colleagues at Washington University,” said Dr. Pascual. “They had so much experience with this. We made a case presentation and they assured us that we were on the same page. This was very helpful.”
From now on, the teams at both Miami Cardiac & Vascular Institute and Miami Cancer Institute will evaluate VT patients who may have exhausted other treatments and could benefit from this landmark procedure.
“If a patient can derive clinical benefit from this treatment, then the entire cardiology team will evaluate any future potential patients to ensure that they would be a good candidate for this procedure,” said Dr. Kotecha. “Then we will work to develop a radiation plan together, just like we did for this first patient.”