Stereotactic radiosurgery targeting the stellate ganglion for refractory ventricular arrhythmias: A first-in-human case report with 18-month follow-up.

Abstract

We present the first-in-human application of stereotactic radiosurgery (SRS) targeting the left stellate ganglion (LSG) as a non-invasive neuromodulatory strategy for treating polymorphic ventricular tachycardia/ventricular fibrillation (VT/VF). A 69-year-old man with mixed-etiology cardiomyopathy (LVEF 28 %) experienced 27 VT/VF episodes over three months. This resulted in 18 implantable cardioverter-defibrillator (ICD) shocks and nine anti-tachycardia pacing therapies, despite optimal pharmacotherapy, catheter ablation and two temporary LSG blocks. Using CyberKnife, we delivered 40 Gy in a single fraction to a 0.386 mL LSG planning target under CT guidance utilizing Xsight Spine tracking. Arrhythmia burden, ICD interventions and adverse effects were prospectively recorded for 18 months. After SRS procedure, only four self-terminating, non-sustained VT episodes were documented, representing an 85.2% reduction in arrhythmic events. There were no further ICD shocks or anti-tachycardia pacing episodes required. The therapeutic effect manifested as a 75% reduction in arrhythmic events within the first post-treatment month (3 events vs. 12 pre-treatments monthly average), and this benefit remained stable throughout the 18-month follow-up. We observed no acute or late radiation-related toxicities, such as Horner's syndrome, neuropathic pain, dysphagia or vascular injury. The patient reported the elimination of syncope and ICD discharges, allowing him to return to his daily activities. Single-fraction SRS of the LSG was feasible, well tolerated, and produced long-lasting suppression of refractory VT/VF in a high-risk patient.