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JACC. Clinical Electrophysiology Jun 2023There is variability in treatment modalities for premature ventricular complexes (PVCs), including use of antiarrhythmic drug (AAD) therapy or catheter ablation (CA).... (Review)
Review
There is variability in treatment modalities for premature ventricular complexes (PVCs), including use of antiarrhythmic drug (AAD) therapy or catheter ablation (CA). This study reviewed evidence comparing CA vs AADs for the treatment of PVCs. A systematic review was performed from the Medline, Embase, and Cochrane Library databases, as well as the Australian and New Zealand Clinical Trials Registry, U.S. National Library of Medicine ClinicalTrials database, and the European Union Clinical Trials Register. Five studies (1 randomized controlled trial) enrolling 1,113 patients (57.9% female) were analyzed. Four of five studies recruited mainly patients with outflow tract PVCs. There was significant heterogeneity in AAD choice. Electroanatomic mapping was used in 3 of 5 studies. No studies documented intracardiac echocardiography or contact force-sensing catheter use. Acute procedural endpoints varied (2 of 5 targeted elimination of all PVCs). All studies had significant potential for bias. CA seemed superior to AADs for PVC recurrence, frequency, and burden. One study reported long-term symptoms (CA superior). Quality of life or cost-effectiveness was not reported. Complication and adverse event rates were 0% to 5.6% for CA and 9.5% to 21% for AADs. Future randomized controlled trials will assess CA vs AADs for patients with PVCs without structural heart disease (ECTOPIA [Elimination of Ventricular Premature Beats with Catheter Ablation versus Optimal Antiarrhythmic Drug Treatment]), with impaired LVEF (PAPS [Prospective Assessment of Premature Ventricular Contractions Suppression in Cardiomyopathy] Pilot), and with structural heart disease (CAT-PVC [Catheter Ablation Versus Amiodarone for Therapy of Premature Ventricular Contractions in Patients With Structural Heart Disease]). In conclusion, CA seems to reduce recurrence, burden, and frequency of PVCs compared with AADs. There is a lack of data on patient- and health care-specific outcomes such as symptoms, quality of life, and cost-effectiveness. Several upcoming trials will offer important insights for management of PVCs.
Topics: Female; United States; Male; Humans; Anti-Arrhythmia Agents; Prospective Studies; Quality of Life; Ventricular Premature Complexes; Australia; Heart Diseases; Catheter Ablation
PubMed: 37380322
DOI: 10.1016/j.jacep.2023.01.035 -
Clinical Cardiology Jan 2024Hypertrophic cardiomyopathy (HCM) is a common contemporary, treatable, genetic disorder that can be compatible with normal longevity. While current medical therapies are... (Review)
Review
Hypertrophic cardiomyopathy (HCM) is a common contemporary, treatable, genetic disorder that can be compatible with normal longevity. While current medical therapies are ubiquitous, they are limited by a lack of solid evidence, are often inadequate, poorly tolerated, and do not alter the natural disease course. As such, there has long been a need for effective, evidence-based, and targeted disease-modifying therapies for HCM. In this review, we redefine HCM as a treatable condition, evaluate current strategies for therapeutic intervention, and discuss novel myosin inhibitors. The majority of patients with HCM have elevated left ventricular outflow tract gradients, which predicts worse symptoms and adverse outcomes. Conventional pharmacological therapies for symptomatic HCM can help improve symptoms but are often inadequate and poorly tolerated. Septal reduction therapies (surgical myectomy and alcohol septal ablation) can safely and effectively reduce refractory symptoms and improve outcomes in patients with obstructive HCM. However, they require expertise that is not universally available and are not without risks. Currently, available therapies do not alter the disease course or the progressive cardiac remodeling that ensues, nor subsequent heart failure and arrhythmias. This has been regarded as an unmet need in the care of HCM patients. Novel targeted pharmacotherapies, namely cardiac myosin inhibitors, have emerged to reverse key pathophysiological changes and alter disease course. Their favorable outcomes led to the early Food and Drug Administration approval of mavacamten, a first-in-class myosin modulator, changing the paradigm for the pharmacological treatment of HCM.
Topics: United States; Humans; Cardiomyopathy, Hypertrophic; Heart; Disease Progression; Heart Failure; Myosins
PubMed: 38269637
DOI: 10.1002/clc.24207 -
The Cochrane Database of Systematic... Nov 2021Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different... (Review)
Review
BACKGROUND
Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, in the last decade renal sympathetic ablation (renal denervation) has been proposed as a possible therapeutic alternative to treat this condition.
OBJECTIVES
We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile and kidney function, as well as the potential adverse events related to the procedure.
SEARCH METHODS
For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to 3 November 2020: Cochrane Hypertension's Specialised Register, CENTRAL (2020, Issue 11), Ovid MEDLINE, and Ovid Embase. The World Health Organization International Clinical Trials Registry Platform (via CENTRAL) and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov were searched for ongoing trials. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.
SELECTION CRITERIA
We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction.
DATA COLLECTION AND ANALYSIS
Two authors independently extracted data and assessed study risk of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI). Certainty of evidence has been assessed using the GRADE approach.
MAIN RESULTS
We found 15 eligible studies (1416 participants). In four studies, renal denervation was compared to sham procedure; in the remaining studies, renal denervation was tested against standard or intensified antihypertensive therapy. Most studies had unclear or high risk of bias for allocation concealment and blinding. When compared to control, there was low-certainty evidence that renal denervation had little or no effect on the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (5 studies, 892 participants; RR 0.98, 95% CI 0.33 to 2.95), unstable angina (3 studies, 270 participants; RR 0.51, 95% CI 0.09 to 2.89) or hospitalisation (3 studies, 743 participants; RR 1.24, 95% CI 0.50 to 3.11). Based on moderate-certainty evidence, renal denervation may reduce 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (9 studies, 1045 participants; MD -5.29 mmHg, 95% CI -10.46 to -0.13), ABPM diastolic BP (8 studies, 1004 participants; MD -3.75 mmHg, 95% CI -7.10 to -0.39) and office diastolic BP (8 studies, 1049 participants; MD -4.61 mmHg, 95% CI -8.23 to -0.99). Conversely, this procedure had little or no effect on office systolic BP (10 studies, 1090 participants; MD -5.92 mmHg, 95% CI -12.94 to 1.10). Moderate-certainty evidence suggested that renal denervation may not reduce serum creatinine (5 studies, 721 participants, MD 0.03 mg/dL, 95% CI -0.06 to 0.13) and may not increase the estimated glomerular filtration rate (eGFR) or creatinine clearance (6 studies, 822 participants; MD -2.56 mL/min, 95% CI -7.53 to 2.42). AUTHORS' CONCLUSIONS: In patients with resistant hypertension, there is low-certainty evidence that renal denervation does not improve major cardiovascular outomes and renal function. Conversely, moderate-certainty evidence exists that it may improve 24h ABPM and diastolic office-measured BP. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardised procedural methods are necessary to clarify the utility of this procedure in this population.
Topics: Antihypertensive Agents; Blood Pressure; Denervation; Humans; Hypertension; Kidney
PubMed: 34806762
DOI: 10.1002/14651858.CD011499.pub3 -
ESC Heart Failure Dec 2021While the interplay between heart failure (HF) and atrial fibrillation (AF) has been extensively studied, little is known regarding HF and atrial flutter (AFL), which... (Review)
Review
While the interplay between heart failure (HF) and atrial fibrillation (AF) has been extensively studied, little is known regarding HF and atrial flutter (AFL), which may be managed differently. We reviewed the incidence, prevalence, and predictors of HF in AFL and vice versa, and the outcomes of treatment of AFL in HF. A systematic literature review of PubMed/Medline and EMBASE yielded 65 studies for inclusion and qualitative synthesis. No study described the incidence or prevalence of AFL in unselected patients with HF. Most cohorts enrolled patients with AF/AFL as interchangeable diagnoses, or highly selected patients with tachycardia-induced cardiomyopathy. The prevalence of HF in AFL ranged from 6% to 56%. However, the phenotype of HF was never defined by left ventricular ejection fraction (LVEF). No studies reported the predictors, phenotype, and prognostic implications of AFL in HF. There was significant variation in treatments studied, including the proportion that underwent ablation. When systolic dysfunction was tachycardia-mediated, catheter ablation demonstrated LVEF normalization in up to 88%, as well as reduced cardiovascular mortality. In summary, AFL and HF often coexist but are understudied, with no randomized trial data to inform care. Further research is warranted to define the epidemiology and establish optimal management.
Topics: Atrial Flutter; Catheter Ablation; Heart Failure; Humans; Stroke Volume; Ventricular Function, Left
PubMed: 34505352
DOI: 10.1002/ehf2.13526 -
Journal of Geriatric Cardiology : JGC Nov 2020Catheter ablation for ventricular tachycardia (VT) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) has significantly evolved over the past...
BACKGROUND
Catheter ablation for ventricular tachycardia (VT) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) has significantly evolved over the past decade. However, different ablation strategies showed inconsistency in acute and long-term outcomes.
METHODS
We searched the databases of Medline, Embase and Cochrane Library through October 17, 2019 for studies describing the clinical outcomes of VT ablation in ARVC. Data including VT recurrence, all-cause mortality, acute procedural efficacy and major procedural complications were extracted. A meta-analysis with trial sequential analysis was further performed in comparative studies of endo-epicardial versus endocardial-only ablation.
RESULTS
A total of 24 studies with 717 participants were enrolled. The literatures of epicardial ablation were mainly published after 2010 with total ICD implantation of 73.7%, acute efficacy of 89.8%, major complication of 5.2%, follow-up of 28.9 months, VT freedom of 75.3%, all-cause mortality of 1.1% and heart transplantation of 0.6%. Meta-analysis of 10 comparative studies revealed that compared with endocardial-only approach, epicardial ablation significantly decreased VT recurrence (OR: 0.50; 95% CI: 0.30-0.85; = 0.010), but somehow increased major procedural complications (OR: 4.64; 95% CI: 1.28-16.92; = 0.02), with not evident improvement of acute efficacy (OR: 2.74; 95% CI: 0.98-7.65; = 0.051) or all-cause mortality (OR: 0.87; 95% CI: 0.09-8.31; = 0.90).
CONCLUSION
Catheter ablation for VT in ARVC is feasible and effective. Epicardial ablation is associated with better long-term VT freedom, but with more major complications and unremarkable survival or acute efficacy benefit.
PubMed: 33343648
DOI: 10.11909/j.issn.1671-5411.2020.11.001 -
Clinical Research in Cardiology :... Dec 2023Patients with Brugada syndrome (BrS) may experience recurrent ventricular arrhythmias (VAs). Catheter ablation is becoming an emerging paradigm for treatment of BrS.
BACKGROUND
Patients with Brugada syndrome (BrS) may experience recurrent ventricular arrhythmias (VAs). Catheter ablation is becoming an emerging paradigm for treatment of BrS.
OBJECTIVE
To assess the efficacy and safety of catheter ablation in BrS in an updated systematic review.
METHODS
We comprehensively searched the databases of Pubmed/Medline, EMBASE, and Cochrane Central Register of Controlled Trials from inception to 11th of August 2021.
RESULTS
Fifty-six studies involving 388 patients were included. A substrate-based strategy was used in 338 cases (87%), and a strategy of targeting premature ventricular complex (PVCs)/ventricular tachycardias (VTs) that triggered ventricular fibrillation (VF) in 47 cases (12%), with combined abnormal electrogram and PVC/VT ablation in 3 cases (1%). Sodium channel blocker was frequently used to augment the arrhythmogenic substrate in 309/388 cases (80%), which included a variety of agents, of which ajmaline was most commonly used. After ablation procedure, the pooled incidence of non-inducibility of VA was 87.1% (95% confidence interval [CI], 73.4-94.3; I = 51%), and acute resolution of type I ECG was seen in 74.5% (95% CI [52.3-88.6]; I = 75%). Over a weighted mean follow up of 28 months, 7.6% (95% CI [2.1-24]; I = 67%) had recurrence of type I ECG either spontaneously or with drug challenge and 17.6% (95% CI [10.2-28.6]; I = 60%) had recurrence of VA.
CONCLUSION
Catheter ablation appears to be an efficacious strategy for elimination of arrhythmias or substrate associated with BrS. Further study is needed to identify which patients stand to benefit, and optimal provocation protocol for identifying ablation targets.
Topics: Humans; Brugada Syndrome; Ventricular Fibrillation; Ventricular Premature Complexes; Catheter Ablation; Tachycardia, Ventricular; Treatment Outcome; Electrocardiography
PubMed: 35451610
DOI: 10.1007/s00392-022-02020-3 -
American Heart Journal Plus :... Dec 2022Hypertrophic cardiomyopathy (HCM) is a genetic disease that can cause left ventricular outflow tract (LVOT) obstruction. This study analyzed the efficacy of... (Review)
Review
STUDY OBJECTIVE
Hypertrophic cardiomyopathy (HCM) is a genetic disease that can cause left ventricular outflow tract (LVOT) obstruction. This study analyzed the efficacy of radiofrequency ablation (RA) in improving clinical and hemodynamic factors in patients receiving obstructive HCM refractory treatment. This evaluation was necessary because of the small number of studies on the effectiveness of this technique for obstructive HCM in the existing literature.
DESIGN
We used the PubMed, Embase, and Science Direct databases to identify randomized clinical trials and observational studies addressing the clinical and hemodynamic outcomes before and after RA in patients with HCM.
PARTICIPANTS
We selected six articles published between 2011 and 2022, comprising 304 patients (mean age: 45 years).
INTERVENTIONS
We performed a bias assessment using the ROBINS I tool, and meta-analysis processing was performed using the STATA program (v.16.0).
RESULTS
The left ventricular outflow tract (LVOT) gradient at rest and with stimulation decreased by 58.78 mmHg ( = 0.001) and 70.38 mmHg (total effect Z = 21.62; < 0.0001), respectively. Additionally, the New York Heart Association (NYHA) functional class decreased by 0.43 ( = 0.001), indicating symptomatic and hemodynamic improvements. Furthermore, we observed a significant reduction in septal thickness (by 4 mm; = 0.001).
CONCLUSIONS
RA improved the NYHA functional class and LVOT gradient at rest and with stimulation and reduced septal thickness. These results suggest that RA is effective in patients refractory to pharmacological therapy and unsuitable for alcohol septal ablation or myectomy. However, more studies, including randomized clinical trials, should be conducted to define the role of RA in interventional therapies.
PubMed: 38560638
DOI: 10.1016/j.ahjo.2022.100229 -
Pacing and Clinical Electrophysiology :... Apr 2022Catheter ablation of papillary muscle ventricular arrhythmias (PM-VAs) has been associated with unsatisfactory results. Features that may affect acute and long-term...
BACKGROUND
Catheter ablation of papillary muscle ventricular arrhythmias (PM-VAs) has been associated with unsatisfactory results. Features that may affect acute and long-term procedural outcomes are not well established.
OBJECTIVE
To systematically review the available data in the literature assessing efficacy and safety of PM-VAs catheter ablation.
METHODS
An online search of PubMed, Cochrane Registry, Web of Science, Scopus and EMBASE libraries (from inception to March 1, 2021) was performed, in addition to manual screening. Twenty-one observational noncontrolled case-series were considered eligible for the systematic review, including 536 patients.
RESULTS
Postero-medial PM harbored 60.8% of PM-VAs, while antero-lateral PM and right ventricular PMs 34.9% and 4.3% of cases, respectively. The mean acute success rate of the index ablation procedure was 88.1% (95% CI 82.8% to 91.9%, p < .001, I 0%). After a mean follow-up period of 15.5 ± 17.4 months, pooled long-term arrhythmia-free rate was 69.2%, while the pooled long-term success rate after multiple ablation procedure was 84.9%. Overall, procedure complications occurred in nine patients (1.7%) and no procedure-related deaths were reported. The use of intracardiac echocardiography (ICE) as well as contact force sensing (CFS) and irrigated catheters during ablation was associated with higher rates of arrhythmia-freedom at long-term follow-up.
CONCLUSIONS
Catheter ablation is an effective and safe strategy for PM-VAs, with an acute success rate of 88.1%, a long-term success rate of 69.2%, with a relatively low procedural complication rate. The use of ICE, irrigated catheters and catheters with CFS capability was associated with higher rates of arrhythmia-freedom at long-term follow-up.
Topics: Catheter Ablation; Heart Ventricles; Humans; Papillary Muscles; Tachycardia, Ventricular; Treatment Outcome; Ventricular Premature Complexes
PubMed: 35147225
DOI: 10.1111/pace.14462 -
The Cochrane Database of Systematic... Feb 2017Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications, or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, renal sympathetic ablation (renal denervation) has been recently proposed as a possible therapeutic alternative to treat this condition.
OBJECTIVES
We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile, and kidney function, as well as the potential adverse events related to the procedure.
SEARCH METHODS
We searched the following databases to 17 February 2016 using relevant search terms: the Cochrane Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ClinicalTrials.gov SELECTION CRITERIA: We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction.
DATA COLLECTION AND ANALYSIS
Two authors independently extracted data and assessed study risks of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI).
MAIN RESULTS
We found 12 eligible studies (1149 participants). In four studies, renal denervation was compared to sham procedure; one study compared a proximal ablation to a complete renal artery denervation; in the remaining, renal denervation was tested against standard or intensified antihypertensive therapy.None of the included trials was designed to look at hard clinical end points as primary outcomes.When compared to control, there was low quality evidence that renal denervation did not reduce the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (4 studies, 823 participants; RR 1.15, 95% CI 0.36 to 3.72), or unstable angina (2 studies, 201 participants; RR 0.63, 95% CI 0.08 to 5.06), and moderate quality evidence that it had no effect on 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (5 studies, 797 participants; MD 0.28 mmHg, 95% CI -3.74 to 4.29), diastolic BP (4 studies, 756 participants; MD 0.93 mmHg, 95% CI -4.50 to 6.36), office measured systolic BP (6 studies, 886 participants; MD -4.08 mmHg, 95% CI -15.26 to 7.11), or diastolic BP (5 studies, 845 participants; MD -1.30 mmHg, 95% CI -7.30 to 4.69). Furthermore, low quality evidence suggested that this procedure produced no effect on either serum creatinine (3 studies, 736 participants, MD 0.01 mg/dL; 95% CI -0.12 to 0.14), estimated glomerular filtration rate (eGFR), or creatinine clearance (4 studies, 837 participants; MD -2.09 mL/min, 95% CI -8.12 to 3.95). Based on low-quality evidence, renal denervation significantly increased bradycardia episodes compared to control (3 studies, 220 participants; RR 6.63, 95% CI 1.19 to 36.84), while the risk of other adverse events was comparable or not assessable.Data were sparse or absent for all cause mortality, hospitalisation, fatal cardiovascular events, quality of life, atrial fibrillation episodes, left ventricular hypertrophy, sleep apnoea severity, need for renal replacement therapy, and metabolic profile.The quality of the evidence was low for cardiovascular outcomes and adverse events and moderate for lack of effect on blood pressure and renal function.
AUTHORS' CONCLUSIONS
In patients with resistant hypertension, there is low quality evidence that renal denervation does not change major cardiovascular events, and renal function. There was moderate quality evidence that it does not change blood pressure and and low quality evidence that it caused an increaseof bradycardia episodes. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardized procedural methods are necessary to clarify the utility of this procedure in this population.
Topics: Angina, Unstable; Antihypertensive Agents; Blood Pressure Determination; Drug Resistance; Humans; Hypertension; Kidney; Myocardial Infarction; Stroke; Sympathectomy
PubMed: 28220472
DOI: 10.1002/14651858.CD011499.pub2 -
Frontiers in Cardiovascular Medicine 2022The purpose of this study is to collect available evidence on the feasibility and efficacy of stereotactic arrhythmia radio ablation (STAR), including both photon...
AIM
The purpose of this study is to collect available evidence on the feasibility and efficacy of stereotactic arrhythmia radio ablation (STAR), including both photon radiotherapy (XRT) and particle beam therapy (PBT), in the treatment of atrial fibrillation (AF), and to provide cardiologists and radiation oncologists with a practical overview on this topic.
METHODS
Three hundred and thirty-five articles were identified up to November 2021 according to preferred reporting items for systematic reviews and meta-analyses criteria; preclinical and clinical studies were included without data restrictions or language limitations. Selected works were analyzed for comparing target selection, treatment plan details, and the accelerator employed, addressing workup modalities, acute and long-term side-effects, and efficacy, defined either by the presence of scar or by the absence of AF recurrence.
RESULTS
Twenty-one works published between 2010 and 2021 were included. Seventeen studies concerned XRT, three PBT, and one involved both. Nine studies (1 and 8 ; doses ranging from 15 to 40 Gy) comprised a total of 59 animals, 12 (8 , 4 ; doses ranging from 16 to 50 Gy) focused on humans, with 9 patients undergoing STAR: average follow-up duration was 5 and 6 months, respectively. Data analysis supported efficacy of the treatment in the preclinical setting, whereas in the context of clinical studies the main favorable finding consisted in the detection of electrical scar in 4/4 patients undergoing specific evaluation; the minimum dose for efficacy was 25 Gy in both humans and animals. No acute complication was recorded; severe side-effects related to the long-term were observed only for very high STAR doses in 2 animals. Significant variability was evidenced among studies in the definition of target volume and doses, and in the management of respiratory and cardiac target motion.
CONCLUSION
STAR is an innovative non-invasive procedure already applied for experimental treatment of ventricular arrhythmias. Particular attention must be paid to safety, rather than efficacy of STAR, given the benign nature of AF. Uncertainties persist, mainly regarding the definition of the treatment plan and the role of the target motion. In this setting, more information about the toxicity profile of this new approach is compulsory before applying STAR to AF in clinical practice.
PubMed: 35592393
DOI: 10.3389/fcvm.2022.849201