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Pulmonary vein isolation by radiosurgery: implications for non-invasive treatment of atrial fibrillation

Frank Bode, Oliver Blanck, Maximilian Gebhard, Peter Hunold, Martin Grossherr, Sebastian Brandt, Reinhard Vonthein, Holger Thiele, Juergen Dunst, Dirk Rades
DOI: http://dx.doi.org/10.1093/europace/euu406 1868-1874 First published online: 3 March 2015


Aims Electrical isolation of the pulmonary veins (PVs) has been established in clinical routine as a curative treatment for atrial fibrillation (AF). While catheter ablation carries procedural risks, radiosurgery might be able to non-invasively induce lesions at the PV ostia to block veno-atrial electrical conduction. This porcine feasibility and dose escalation study determined the effect of radiosurgery on electrophysiologic properties of the left atrial–PV junction.

Methods and results Eight adult Goettingen mini-pigs underwent electrophysiological voltage mapping in the left atrium and the upper right PV. Radiation was delivered with a conventional linear accelerator. A single homogeneous dose ranging from 22.5 to 40 Gy was applied circumferentially to the target vein antrum. Six months after radiosurgery, electrophysiological mapping was repeated and a histological examination performed. Voltage mapping consistently showed electrical potentials in the upper right PV at baseline. Pacing the target vein prompted atrial excitation, thus proving veno-atrial electrical conduction. After 6 months, radiation had reduced PV electrogram amplitudes. This was dose dependent with a mean interaction effect of −5.8%/Gy. Complete block of atrio-venous electrical conduction occurred after 40 Gy dose application. Histology revealed transmural scarring of the targeted PV musculature with doses >30 Gy. After 40 Gy, it spanned the entire circumference in accordance with pulmonary vein isolation.

Conclusion Pulmonary vein isolation to treat AF can be achieved by radiosurgery with a conventional linear accelerator. Yet, it requires a high radiation dose which might limit clinical applicability.

  • Atrial fibrillation
  • Ablation
  • Pulmonary vein isolation
  • Radiation
  • Radiosurgery
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