Open in new tab Tables of advices...

Patient selection, monitoring, and safety	Strength of evidence
Advised TO DO
It is advised to consider STAR in the context of an approved investigational trial for patients with VT refractory to AAD (due to recurrence, intolerance, or contraindications) and RFCA performed in an expert centre.
It is appropriate to discuss all patients considered for STAR with a multi-disciplinary team, including an electrophysiologist highly experienced in the invasive treatment of VA, a radiation oncologist, a heart failure specialist, a specialist in cardiac imaging, and a cardiac surgeon (for treatment alternatives and options in case of deterioration of cardiac function).
It is advised to use standard reporting criteria for patient selection and patient follow-up.
It is advised to capture and report all early and late recurrences of VA from the time of treatment, without any blanking period together with concomitant treatment in clinical trials.
It is advised to systematically evaluate and report acute and long-term toxicities of STAR before the routine use of STAR.
It is advised to evaluate radiation-induced toxicity according to at least the Common Terminology Criteria for Adverse Events (CTCAE) version 6.0.
It is advised to perform regular clinical follow-up including a careful history of new or aggravated symptoms, ICD interrogation, and 12-lead ECGs to evaluate acute and long-term toxicities.
It is advised to perform regular echocardiography for cardiac and valvular function, in particular if valves were in close proximity to the CardTV.
May be appropriate TO DO
STAR may be appropriate with appropriate institutional approval after failure of AAD treatment and catheter ablation by experienced operators that included available techniques to enhance lesion size and transmurality (e.g. half-saline, bipolar ablation, and TCEA) to define and reach the VT substrate.
STAR may be appropriate if mechanical valves or LV thrombi preclude conventional catheter ablation provided that the VT substrate can be localized.
It may be appropriate to perform cardiac ischaemia detection after 2–4 years if major coronary arteries were near and/or inside the CardTV.
Areas of uncertainty
It is unknown whether STAR is appropriate in patients with terminal end-stage heart failure whose dominant problem is heart failure arising from different aetiologies and not scar-related VT.
The role of STAR to acutely control recurrent VT or an ongoing ES is unclear.
Optimal strategies to reduce acute and long-term side effects, apart from reducing radiation of organs at risk are unknown, e.g. the efficacy of PPI to reduce oesophageal or gastric toxicity is unknown.
It is unknown if patients with interstitial lung disease are at higher risk, supporting a careful benefit-risk assessment.

Patient selection, monitoring, and safety

Strength of evidence

Advised TO DO

It is advised to consider STAR in the context of an approved investigational trial for patients with VT refractory to AAD (due to recurrence, intolerance, or contraindications) and RFCA performed in an expert centre.

It is appropriate to discuss all patients considered for STAR with a multi-disciplinary team, including an electrophysiologist highly experienced in the invasive treatment of VA, a radiation oncologist, a heart failure specialist, a specialist in cardiac imaging, and a cardiac surgeon (for treatment alternatives and options in case of deterioration of cardiac function).

It is advised to use standard reporting criteria for patient selection and patient follow-up.

It is advised to capture and report all early and late recurrences of VA from the time of treatment, without any blanking period together with concomitant treatment in clinical trials.

It is advised to systematically evaluate and report acute and long-term toxicities of STAR before the routine use of STAR.

It is advised to evaluate radiation-induced toxicity according to at least the Common Terminology Criteria for Adverse Events (CTCAE) version 6.0.

It is advised to perform regular clinical follow-up including a careful history of new or aggravated symptoms, ICD interrogation, and 12-lead ECGs to evaluate acute and long-term toxicities.

It is advised to perform regular echocardiography for cardiac and valvular function, in particular if valves were in close proximity to the CardTV.

May be appropriate TO DO

STAR may be appropriate with appropriate institutional approval after failure of AAD treatment and catheter ablation by experienced operators that included available techniques to enhance lesion size and transmurality (e.g. half-saline, bipolar ablation, and TCEA) to define and reach the VT substrate.

STAR may be appropriate if mechanical valves or LV thrombi preclude conventional catheter ablation provided that the VT substrate can be localized.

It may be appropriate to perform cardiac ischaemia detection after 2–4 years if major coronary arteries were near and/or inside the CardTV.

Areas of uncertainty

It is unknown whether STAR is appropriate in patients with terminal end-stage heart failure whose dominant problem is heart failure arising from different aetiologies and not scar-related VT.

The role of STAR to acutely control recurrent VT or an ongoing ES is unclear.

Optimal strategies to reduce acute and long-term side effects, apart from reducing radiation of organs at risk are unknown, e.g. the efficacy of PPI to reduce oesophageal or gastric toxicity is unknown.

It is unknown if patients with interstitial lung disease are at higher risk, supporting a careful benefit-risk assessment.

Patient selection, monitoring, and safety	Strength of evidence
Advised TO DO
It is advised to consider STAR in the context of an approved investigational trial for patients with VT refractory to AAD (due to recurrence, intolerance, or contraindications) and RFCA performed in an expert centre.
It is appropriate to discuss all patients considered for STAR with a multi-disciplinary team, including an electrophysiologist highly experienced in the invasive treatment of VA, a radiation oncologist, a heart failure specialist, a specialist in cardiac imaging, and a cardiac surgeon (for treatment alternatives and options in case of deterioration of cardiac function).
It is advised to use standard reporting criteria for patient selection and patient follow-up.
It is advised to capture and report all early and late recurrences of VA from the time of treatment, without any blanking period together with concomitant treatment in clinical trials.
It is advised to systematically evaluate and report acute and long-term toxicities of STAR before the routine use of STAR.
It is advised to evaluate radiation-induced toxicity according to at least the Common Terminology Criteria for Adverse Events (CTCAE) version 6.0.
It is advised to perform regular clinical follow-up including a careful history of new or aggravated symptoms, ICD interrogation, and 12-lead ECGs to evaluate acute and long-term toxicities.
It is advised to perform regular echocardiography for cardiac and valvular function, in particular if valves were in close proximity to the CardTV.
May be appropriate TO DO
STAR may be appropriate with appropriate institutional approval after failure of AAD treatment and catheter ablation by experienced operators that included available techniques to enhance lesion size and transmurality (e.g. half-saline, bipolar ablation, and TCEA) to define and reach the VT substrate.
STAR may be appropriate if mechanical valves or LV thrombi preclude conventional catheter ablation provided that the VT substrate can be localized.
It may be appropriate to perform cardiac ischaemia detection after 2–4 years if major coronary arteries were near and/or inside the CardTV.
Areas of uncertainty
It is unknown whether STAR is appropriate in patients with terminal end-stage heart failure whose dominant problem is heart failure arising from different aetiologies and not scar-related VT.
The role of STAR to acutely control recurrent VT or an ongoing ES is unclear.
Optimal strategies to reduce acute and long-term side effects, apart from reducing radiation of organs at risk are unknown, e.g. the efficacy of PPI to reduce oesophageal or gastric toxicity is unknown.
It is unknown if patients with interstitial lung disease are at higher risk, supporting a careful benefit-risk assessment.

Patient selection, monitoring, and safety

Strength of evidence

Advised TO DO

It is advised to use standard reporting criteria for patient selection and patient follow-up.

It is advised to capture and report all early and late recurrences of VA from the time of treatment, without any blanking period together with concomitant treatment in clinical trials.

It is advised to systematically evaluate and report acute and long-term toxicities of STAR before the routine use of STAR.

It is advised to evaluate radiation-induced toxicity according to at least the Common Terminology Criteria for Adverse Events (CTCAE) version 6.0.

It is advised to perform regular clinical follow-up including a careful history of new or aggravated symptoms, ICD interrogation, and 12-lead ECGs to evaluate acute and long-term toxicities.

It is advised to perform regular echocardiography for cardiac and valvular function, in particular if valves were in close proximity to the CardTV.

May be appropriate TO DO

STAR may be appropriate if mechanical valves or LV thrombi preclude conventional catheter ablation provided that the VT substrate can be localized.

It may be appropriate to perform cardiac ischaemia detection after 2–4 years if major coronary arteries were near and/or inside the CardTV.

Areas of uncertainty

It is unknown whether STAR is appropriate in patients with terminal end-stage heart failure whose dominant problem is heart failure arising from different aetiologies and not scar-related VT.

The role of STAR to acutely control recurrent VT or an ongoing ES is unclear.

It is unknown if patients with interstitial lung disease are at higher risk, supporting a careful benefit-risk assessment.

Technical aspects	Strength of evidence
Advised TO DO
STAR for VA requires a standardized workflow allowing accurate integration of electrophysiological and anatomical data into planning by a multi-disciplinary team.
It is advised to use uniform reporting criteria for constraints on OAR and measured dose on CardTV and OARs.
It is advised to provide the technical details and choice of margins for the delineation of the planning target volume.
Areas of uncertainty
To date, there are no data suggesting the superiority of a specific SBRT system for STAR.
The optimal dose, the exact response, and time to effect of STAR in diseased human myocardium of various aetiologies is unclear.
Whether scar homogenization can be achieved by STAR is unknown.
It is uncertain if patients benefit from STAR if dose constraints on OAR lead to dose reduction to the arrhythmia substrate.

Technical aspects

Strength of evidence

Advised TO DO

STAR for VA requires a standardized workflow allowing accurate integration of electrophysiological and anatomical data into planning by a multi-disciplinary team.

It is advised to use uniform reporting criteria for constraints on OAR and measured dose on CardTV and OARs.

It is advised to provide the technical details and choice of margins for the delineation of the planning target volume.

Areas of uncertainty

To date, there are no data suggesting the superiority of a specific SBRT system for STAR.

The optimal dose, the exact response, and time to effect of STAR in diseased human myocardium of various aetiologies is unclear.

Whether scar homogenization can be achieved by STAR is unknown.

It is uncertain if patients benefit from STAR if dose constraints on OAR lead to dose reduction to the arrhythmia substrate.

Technical aspects	Strength of evidence
Advised TO DO
STAR for VA requires a standardized workflow allowing accurate integration of electrophysiological and anatomical data into planning by a multi-disciplinary team.
It is advised to use uniform reporting criteria for constraints on OAR and measured dose on CardTV and OARs.
It is advised to provide the technical details and choice of margins for the delineation of the planning target volume.
Areas of uncertainty
To date, there are no data suggesting the superiority of a specific SBRT system for STAR.
The optimal dose, the exact response, and time to effect of STAR in diseased human myocardium of various aetiologies is unclear.
Whether scar homogenization can be achieved by STAR is unknown.
It is uncertain if patients benefit from STAR if dose constraints on OAR lead to dose reduction to the arrhythmia substrate.

Definition and delineation of the target	Strength of evidence
Advised TO DO
It is advised to use uniform definitions for CardTV in the context of STAR.
It is advised to describe in detail the methods and criteria used to determine the CardTV.
It is advised to incorporate invasive mapping data relevant to the arrhythmia for the determination of CardTV-EP until data are available showing reliability of the usage of only non-invasive methods such as ECGI.
It is advised to specify the image modality and the applied methods and thresholds to define and delineate scar or fibrosis.
For the electrophysiologist, for the CardTV, it is advised to include only safety margins that exclude areas with healthy functioning myocardium, as identified by voltage mapping or advanced CMR imaging (T1 mapping and LGE-CMR), and avoid unnecessary margins.
For the radiation oncologist, it is advised to avoid unnecessary safety margins that include viable, functioning myocardium when planning the PTV.
It is advised to obtain detailed EAM covering the surface of the chamber of interest with anatomical marking of at least 3 chambers/distinct landmarks in preparation of CardTV-EP_in whenever possible.
It is advised to indicate sites based on activation mapping, pace mapping, RF response, and functional information that are considered relevant by the EP on the electroanatomical mapping in patients who are considered candidates for STAR.
May be appropriate TO DO
It may be appropriate to exclude areas with BV >2.1 mV or BV 3.0 mV for remodelled or normal remote myocardium, respectively (recorded with 3.5 mm tip electrode) from CardTV-EP_inv in patients with ICM.
It may be appropriate to deliver STAR to limited scar areas based on LGE-CMR in patients with prior MI.
Advised NOT TO DO
It is not advised to deliver STAR only based on LGE-CMR in patients with non-ischaemic fibrosis.
It is not advised to deliver STAR to an entire LV segment of the standard 17-segment LV model, if the CardTV-EP determined by mapping involves only part of that segment; irradiation of viable myocardium should be minimized.
Areas of uncertainty
It is unknown whether considering undocumented inducible VT morphologies for STAR treatment planning impacts outcomes.
The reliability of ECGI only for defining the CardTV-EP is not known.

Definition and delineation of the target

Strength of evidence

Advised TO DO

It is advised to use uniform definitions for CardTV in the context of STAR.

It is advised to describe in detail the methods and criteria used to determine the CardTV.

It is advised to incorporate invasive mapping data relevant to the arrhythmia for the determination of CardTV-EP until data are available showing reliability of the usage of only non-invasive methods such as ECGI.

It is advised to specify the image modality and the applied methods and thresholds to define and delineate scar or fibrosis.

For the electrophysiologist, for the CardTV, it is advised to include only safety margins that exclude areas with healthy functioning myocardium, as identified by voltage mapping or advanced CMR imaging (T1 mapping and LGE-CMR), and avoid unnecessary margins.

For the radiation oncologist, it is advised to avoid unnecessary safety margins that include viable, functioning myocardium when planning the PTV.

It is advised to obtain detailed EAM covering the surface of the chamber of interest with anatomical marking of at least 3 chambers/distinct landmarks in preparation of CardTV-EP_in whenever possible.

It is advised to indicate sites based on activation mapping, pace mapping, RF response, and functional information that are considered relevant by the EP on the electroanatomical mapping in patients who are considered candidates for STAR.

May be appropriate TO DO

It may be appropriate to exclude areas with BV >2.1 mV or BV 3.0 mV for remodelled or normal remote myocardium, respectively (recorded with 3.5 mm tip electrode) from CardTV-EP_inv in patients with ICM.

It may be appropriate to deliver STAR to limited scar areas based on LGE-CMR in patients with prior MI.

Advised NOT TO DO

It is not advised to deliver STAR only based on LGE-CMR in patients with non-ischaemic fibrosis.

It is not advised to deliver STAR to an entire LV segment of the standard 17-segment LV model, if the CardTV-EP determined by mapping involves only part of that segment; irradiation of viable myocardium should be minimized.

Areas of uncertainty

It is unknown whether considering undocumented inducible VT morphologies for STAR treatment planning impacts outcomes.

The reliability of ECGI only for defining the CardTV-EP is not known.

Definition and delineation of the target	Strength of evidence
Advised TO DO
It is advised to use uniform definitions for CardTV in the context of STAR.
It is advised to describe in detail the methods and criteria used to determine the CardTV.
It is advised to incorporate invasive mapping data relevant to the arrhythmia for the determination of CardTV-EP until data are available showing reliability of the usage of only non-invasive methods such as ECGI.
It is advised to specify the image modality and the applied methods and thresholds to define and delineate scar or fibrosis.
For the electrophysiologist, for the CardTV, it is advised to include only safety margins that exclude areas with healthy functioning myocardium, as identified by voltage mapping or advanced CMR imaging (T1 mapping and LGE-CMR), and avoid unnecessary margins.
For the radiation oncologist, it is advised to avoid unnecessary safety margins that include viable, functioning myocardium when planning the PTV.
It is advised to obtain detailed EAM covering the surface of the chamber of interest with anatomical marking of at least 3 chambers/distinct landmarks in preparation of CardTV-EP_in whenever possible.
It is advised to indicate sites based on activation mapping, pace mapping, RF response, and functional information that are considered relevant by the EP on the electroanatomical mapping in patients who are considered candidates for STAR.
May be appropriate TO DO
It may be appropriate to exclude areas with BV >2.1 mV or BV 3.0 mV for remodelled or normal remote myocardium, respectively (recorded with 3.5 mm tip electrode) from CardTV-EP_inv in patients with ICM.
It may be appropriate to deliver STAR to limited scar areas based on LGE-CMR in patients with prior MI.
Advised NOT TO DO
It is not advised to deliver STAR only based on LGE-CMR in patients with non-ischaemic fibrosis.
It is not advised to deliver STAR to an entire LV segment of the standard 17-segment LV model, if the CardTV-EP determined by mapping involves only part of that segment; irradiation of viable myocardium should be minimized.
Areas of uncertainty
It is unknown whether considering undocumented inducible VT morphologies for STAR treatment planning impacts outcomes.
The reliability of ECGI only for defining the CardTV-EP is not known.

Open in new tab

Tables of advices

Patient selection, monitoring, and safety	Strength of evidence
Advised TO DO
It is advised to consider STAR in the context of an approved investigational trial for patients with VT refractory to AAD (due to recurrence, intolerance, or contraindications) and RFCA performed in an expert centre.
It is appropriate to discuss all patients considered for STAR with a multi-disciplinary team, including an electrophysiologist highly experienced in the invasive treatment of VA, a radiation oncologist, a heart failure specialist, a specialist in cardiac imaging, and a cardiac surgeon (for treatment alternatives and options in case of deterioration of cardiac function).
It is advised to use standard reporting criteria for patient selection and patient follow-up.
It is advised to capture and report all early and late recurrences of VA from the time of treatment, without any blanking period together with concomitant treatment in clinical trials.
It is advised to systematically evaluate and report acute and long-term toxicities of STAR before the routine use of STAR.
It is advised to evaluate radiation-induced toxicity according to at least the Common Terminology Criteria for Adverse Events (CTCAE) version 6.0.
It is advised to perform regular clinical follow-up including a careful history of new or aggravated symptoms, ICD interrogation, and 12-lead ECGs to evaluate acute and long-term toxicities.
It is advised to perform regular echocardiography for cardiac and valvular function, in particular if valves were in close proximity to the CardTV.
May be appropriate TO DO
STAR may be appropriate with appropriate institutional approval after failure of AAD treatment and catheter ablation by experienced operators that included available techniques to enhance lesion size and transmurality (e.g. half-saline, bipolar ablation, and TCEA) to define and reach the VT substrate.
STAR may be appropriate if mechanical valves or LV thrombi preclude conventional catheter ablation provided that the VT substrate can be localized.
It may be appropriate to perform cardiac ischaemia detection after 2–4 years if major coronary arteries were near and/or inside the CardTV.
Areas of uncertainty
It is unknown whether STAR is appropriate in patients with terminal end-stage heart failure whose dominant problem is heart failure arising from different aetiologies and not scar-related VT.
The role of STAR to acutely control recurrent VT or an ongoing ES is unclear.
Optimal strategies to reduce acute and long-term side effects, apart from reducing radiation of organs at risk are unknown, e.g. the efficacy of PPI to reduce oesophageal or gastric toxicity is unknown.
It is unknown if patients with interstitial lung disease are at higher risk, supporting a careful benefit-risk assessment.

Patient selection, monitoring, and safety	Strength of evidence
Advised TO DO
It is advised to consider STAR in the context of an approved investigational trial for patients with VT refractory to AAD (due to recurrence, intolerance, or contraindications) and RFCA performed in an expert centre.
It is appropriate to discuss all patients considered for STAR with a multi-disciplinary team, including an electrophysiologist highly experienced in the invasive treatment of VA, a radiation oncologist, a heart failure specialist, a specialist in cardiac imaging, and a cardiac surgeon (for treatment alternatives and options in case of deterioration of cardiac function).
It is advised to use standard reporting criteria for patient selection and patient follow-up.
It is advised to capture and report all early and late recurrences of VA from the time of treatment, without any blanking period together with concomitant treatment in clinical trials.
It is advised to systematically evaluate and report acute and long-term toxicities of STAR before the routine use of STAR.
It is advised to evaluate radiation-induced toxicity according to at least the Common Terminology Criteria for Adverse Events (CTCAE) version 6.0.
It is advised to perform regular clinical follow-up including a careful history of new or aggravated symptoms, ICD interrogation, and 12-lead ECGs to evaluate acute and long-term toxicities.
It is advised to perform regular echocardiography for cardiac and valvular function, in particular if valves were in close proximity to the CardTV.
May be appropriate TO DO
STAR may be appropriate with appropriate institutional approval after failure of AAD treatment and catheter ablation by experienced operators that included available techniques to enhance lesion size and transmurality (e.g. half-saline, bipolar ablation, and TCEA) to define and reach the VT substrate.
STAR may be appropriate if mechanical valves or LV thrombi preclude conventional catheter ablation provided that the VT substrate can be localized.
It may be appropriate to perform cardiac ischaemia detection after 2–4 years if major coronary arteries were near and/or inside the CardTV.
Areas of uncertainty
It is unknown whether STAR is appropriate in patients with terminal end-stage heart failure whose dominant problem is heart failure arising from different aetiologies and not scar-related VT.
The role of STAR to acutely control recurrent VT or an ongoing ES is unclear.
Optimal strategies to reduce acute and long-term side effects, apart from reducing radiation of organs at risk are unknown, e.g. the efficacy of PPI to reduce oesophageal or gastric toxicity is unknown.
It is unknown if patients with interstitial lung disease are at higher risk, supporting a careful benefit-risk assessment.

Technical aspects	Strength of evidence
Advised TO DO
STAR for VA requires a standardized workflow allowing accurate integration of electrophysiological and anatomical data into planning by a multi-disciplinary team.
It is advised to use uniform reporting criteria for constraints on OAR and measured dose on CardTV and OARs.
It is advised to provide the technical details and choice of margins for the delineation of the planning target volume.
Areas of uncertainty
To date, there are no data suggesting the superiority of a specific SBRT system for STAR.
The optimal dose, the exact response, and time to effect of STAR in diseased human myocardium of various aetiologies is unclear.
Whether scar homogenization can be achieved by STAR is unknown.
It is uncertain if patients benefit from STAR if dose constraints on OAR lead to dose reduction to the arrhythmia substrate.

Technical aspects	Strength of evidence
Advised TO DO
STAR for VA requires a standardized workflow allowing accurate integration of electrophysiological and anatomical data into planning by a multi-disciplinary team.
It is advised to use uniform reporting criteria for constraints on OAR and measured dose on CardTV and OARs.
It is advised to provide the technical details and choice of margins for the delineation of the planning target volume.
Areas of uncertainty
To date, there are no data suggesting the superiority of a specific SBRT system for STAR.
The optimal dose, the exact response, and time to effect of STAR in diseased human myocardium of various aetiologies is unclear.
Whether scar homogenization can be achieved by STAR is unknown.
It is uncertain if patients benefit from STAR if dose constraints on OAR lead to dose reduction to the arrhythmia substrate.

Definition and delineation of the target	Strength of evidence
Advised TO DO
It is advised to use uniform definitions for CardTV in the context of STAR.
It is advised to describe in detail the methods and criteria used to determine the CardTV.
It is advised to incorporate invasive mapping data relevant to the arrhythmia for the determination of CardTV-EP until data are available showing reliability of the usage of only non-invasive methods such as ECGI.
It is advised to specify the image modality and the applied methods and thresholds to define and delineate scar or fibrosis.
For the electrophysiologist, for the CardTV, it is advised to include only safety margins that exclude areas with healthy functioning myocardium, as identified by voltage mapping or advanced CMR imaging (T1 mapping and LGE-CMR), and avoid unnecessary margins.
For the radiation oncologist, it is advised to avoid unnecessary safety margins that include viable, functioning myocardium when planning the PTV.
It is advised to obtain detailed EAM covering the surface of the chamber of interest with anatomical marking of at least 3 chambers/distinct landmarks in preparation of CardTV-EP_in whenever possible.
It is advised to indicate sites based on activation mapping, pace mapping, RF response, and functional information that are considered relevant by the EP on the electroanatomical mapping in patients who are considered candidates for STAR.
May be appropriate TO DO
It may be appropriate to exclude areas with BV >2.1 mV or BV 3.0 mV for remodelled or normal remote myocardium, respectively (recorded with 3.5 mm tip electrode) from CardTV-EP_inv in patients with ICM.
It may be appropriate to deliver STAR to limited scar areas based on LGE-CMR in patients with prior MI.
Advised NOT TO DO
It is not advised to deliver STAR only based on LGE-CMR in patients with non-ischaemic fibrosis.
It is not advised to deliver STAR to an entire LV segment of the standard 17-segment LV model, if the CardTV-EP determined by mapping involves only part of that segment; irradiation of viable myocardium should be minimized.
Areas of uncertainty
It is unknown whether considering undocumented inducible VT morphologies for STAR treatment planning impacts outcomes.
The reliability of ECGI only for defining the CardTV-EP is not known.

Definition and delineation of the target	Strength of evidence
Advised TO DO
It is advised to use uniform definitions for CardTV in the context of STAR.
It is advised to describe in detail the methods and criteria used to determine the CardTV.
It is advised to incorporate invasive mapping data relevant to the arrhythmia for the determination of CardTV-EP until data are available showing reliability of the usage of only non-invasive methods such as ECGI.
It is advised to specify the image modality and the applied methods and thresholds to define and delineate scar or fibrosis.
For the electrophysiologist, for the CardTV, it is advised to include only safety margins that exclude areas with healthy functioning myocardium, as identified by voltage mapping or advanced CMR imaging (T1 mapping and LGE-CMR), and avoid unnecessary margins.
For the radiation oncologist, it is advised to avoid unnecessary safety margins that include viable, functioning myocardium when planning the PTV.
It is advised to obtain detailed EAM covering the surface of the chamber of interest with anatomical marking of at least 3 chambers/distinct landmarks in preparation of CardTV-EP_in whenever possible.
It is advised to indicate sites based on activation mapping, pace mapping, RF response, and functional information that are considered relevant by the EP on the electroanatomical mapping in patients who are considered candidates for STAR.
May be appropriate TO DO
It may be appropriate to exclude areas with BV >2.1 mV or BV 3.0 mV for remodelled or normal remote myocardium, respectively (recorded with 3.5 mm tip electrode) from CardTV-EP_inv in patients with ICM.
It may be appropriate to deliver STAR to limited scar areas based on LGE-CMR in patients with prior MI.
Advised NOT TO DO
It is not advised to deliver STAR only based on LGE-CMR in patients with non-ischaemic fibrosis.
It is not advised to deliver STAR to an entire LV segment of the standard 17-segment LV model, if the CardTV-EP determined by mapping involves only part of that segment; irradiation of viable myocardium should be minimized.
Areas of uncertainty
It is unknown whether considering undocumented inducible VT morphologies for STAR treatment planning impacts outcomes.
The reliability of ECGI only for defining the CardTV-EP is not known.

This Feature Is Available To Subscribers Only