Key result
STAR shows immediate termination of refractory electrical storm with no VT recurrence over 6 months.
Why the study?
Catheter ablation for drug-refractory ventricular tachycardia may be contraindicated with a left ventricular thrombus, highlighting the need for non-invasive rescue options such as stereotactic arrhythmia radiotherapy.
Does stereotactic arrhythmia radiotherapy (STAR) terminate electrical storm in a patient with ischemic cardiomyopathy and LV thrombus where catheter ablation is contraindicated?
Case Report (n=1)
Does stereotactic arrhythmia radiotherapy (STAR) terminate electrical storm in a patient with ischemic cardiomyopathy and LV thrombus where catheter ablation is contraindicated?
Stereotactic arrhythmia radiotherapy (STAR) may serve as an effective non-invasive rescue therapy for refractory electrical storm when catheter ablation is contraindicated.
Hypothesis-generating for STAR as rescue when ablation contraindicated due to LV thrombus; prospective trials needed before clinical adoption.
Background Electrical storm in patients with structural heart disease is associated with high morbidity and mortality. Catheter ablation is recommended for drug-refractory ventricular tachycardia (VT), but may be contraindicated in the presence of a left ventricular (LV) thrombus due to increased thromboembolic risk. Stereotactic arrhythmia radiotherapy (STAR) has emerged as a non-invasive treatment option for refractory VT. This case highlights the potential role of STAR as a rescue therapy when conventional approaches are not feasible. Case summary An 80-year-old man with advanced ischemic cardiomyopathy presented after out-of-hospital cardiac arrest due to monomorphic VT. Evaluation revealed severe LV dysfunction (LVEF 15%), an anteroapical LV aneurysm and a newly detected LV thrombus. Catheter ablation was deferred due to embolic risk. Eleven weeks later, the patient was admitted with recurrent VT and developed electrical storm refractory to antiarrhythmic drug therapy, overdrive pacing, and bilateral stellate ganglion blockade. Non-invasive target delineation using contrast-enhanced cardiac computed tomography with scar characterization and ECG-based localization was performed. A single fraction of 25 Gy stereotactic arrhythmia radiotherapy was delivered to the suspected VT substrate. Electrical storm terminated immediately after treatment, and no further VT episodes occurred during hospitalization or during six months of follow-up. Discussion This case demonstrates that stereotactic arrhythmia radiotherapy may provide an effective non-invasive rescue strategy for electrical storm when catheter ablation is contraindicated. Integration of advanced cardiac imaging with ECG-based localization enables target definition in the absence of invasive electroanatomical mapping.
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Lemoine et al. (2026) conducted a case report in Electrical storm in ischemic cardiomyopathy with left ventricular thrombus (n=1). Stereotactic arrhythmia radiotherapy (STAR) was evaluated on Termination of electrical storm and recurrence of ventricular tachycardia. A single 25 Gy fraction of stereotactic arrhythmia radiotherapy immediately terminated refractory electrical storm, with no ventricular tachycardia recurrence over 6 months of follow-up.
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