Stereotactic arrhythmia radioablation (STAR)-A systematic review and meta-analysis of prospective trials on behalf of the STOPSTORM.eu consortium.

Abstract

Stereotactic arrhythmia radioablation (STAR) is a noninvasive treatment of refractory ventricular tachycardia (VT). In this study, we aimed to systematically review prospective trials on STAR and pool harmonized outcome measures in a meta-analysis. After registration in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023439666), we searched OVID Medline, OVID Embase, Web of Science Core Collection, the Cochrane Central Register of Controlled Trials, and Google Scholar on November 9, 2023, to identify reports describing results of prospective trials evaluating STAR for VT. Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool. Meta-analysis was performed using generalized linear mixed models. We identified 10 prospective trials in which 82 patients were treated with STAR between 2016 and 2022. The 90-day rate of treatment-related grade ≥3 adverse events was 0.10 (95% confidence interval [CI] 0.04-0.2). The proportions of patients achieving given VT burden reductions were 0.61 (95% CI 0.45-0.74) for ≥95%, 0.80 (95% CI 0.62-0.91) for ≥75%, and 0.9 (95% CI 0.77-0.96) for ≥50% in 63 evaluable patients. The 1-year overall survival rate was 0.73 (95% CI 0.61-0.83) in 81 patients, 1-year freedom from recurrence was 0.30 (95% CI 0.16-0.49) in 61 patients, and 1-year recurrence-free survival was 0.21 in 60 patients (95% CI 0.08-0.46). Limitations include methodological heterogeneity across studies and moderate to significant risk of bias. In conclusion, STAR is a promising treatment method, characterized by moderate toxicity. We observed 1-year mortality of ≈27% in this population of critically ill patients suffering from refractory VT. Most patients experience a significant reduction in VT burden; however, 1-year recurrence rates are high. STAR should still be considered an investigational approach and recommended to patients primarily within the context of prospective trials.