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Phillip Cuculich, MD, and Clifford Robinson, MD

A Game Changer in Cardiac Medicine

The best ideas are always the what if. What if ablation wasn’t so difficult? What if it wasn’t so risky? What if we could actually make it a little more effective, and what if it was a little less invasive along the way?

Phillip Cuculich, MD

Noninvasive Cardiac Radiosurgery

Leading edge physicians discuss a game changer in the way deadly heart rhythms are treated. 

The unlikely pairing of a cardiologist and radiation oncologist led to a game changer in the treatment of ventricular tachycardia, an irregular heart rhythm that can lead to sudden cardiac arrest.

Gary Robertson was a healthy, athletic 31-year-old man playing racquetball when he experienced his first bout of irregular heartbeats. The frightening episode proved to be just the beginning of a future afflicted with blackouts, ambulance trips, invasive procedures and hospitalizations. The cause was ventricular tachycardia (VT), a fast heart rate that is the leading cause of sudden cardiac arrest.

He truly believed he had reached the end of his road. But then, he was referred to Phillip Cuculich, MD, and Clifford Robinson, MD, trailblazers who combined their disparate specialties of cardiology and radiation oncology to bring a new noninvasive treatment to patients who do not respond to standard treatments.

A Novel Approach to VT

Many years before that lifesaving meeting, Gary had received an implantable cardioverter defibrillator (ICD) that rescued him more than 500 times. He also underwent four attempts to control his VT with invasive catheter ablations, a procedure in which a thin, flexible tube is guided through the femoral vein up to the heart where a tiny electrode tip is used to burn off cells causing the irregular heartbeat.

I was in and out of the hospital so much, I just kept a bag packed,” says Gary, who is now 58. “I lost confidence in myself. I wouldn’t be left alone with my grandson. I was afraid something would happen to me.”

Then in December 2016, his life completely changed. He was referred to Dr. Cuculich, a Washington University cardiologist who specializes in heart rhythms. Dr. Cuculich told Gary about an ongoing trial of an experimental procedure employing stereotactic radiation, a high-powered beam typically used to blast away cancer cells. However, in this unique use of radiation, the high-energy particle stream is aimed directly at VT patients’ hearts to destroy cells causing the irregular beats.

Because this was a new use of the radiation, the long-term effects on the heart were unknown—but Gary decided it was worth the risk.

A Unique Collaboration

Dr. Robinson, a Washington University radiation oncologist at Barnes-Jewish Hospital, recalls quite clearly the day that Dr. Cuculich approached him with the radical idea of hitting the heart with a high-precision radiation stream.

It was exactly what Dr. Robinson had tried to avoid during his career. “I thought, it sounds amazing, but I also had an instant feeling of heartburn,” says Dr. Robinson, who had just finished writing an article about the risk of toxicity to the heart from radiation exposure. “I remember thinking, are we really going to consider this?”

“Cliff didn’t say no right away,” says Dr. Cuculich. “But it took months of meetings and discussions and learning each other’s language before we felt confident enough to move forward with this idea.”

Move ahead, they did, and today their noninvasive radiotherapy procedure is what many experts believe will be a game changer in the way irregular heartbeats, called arrhythmias, are treated. The results from the first five patients were published in the New England Journal of Medicine in December 2017 and received widespread media coverage.

Drs. Cuculich and Robinson have completed a prospective trial, confirming the short-term safety of the procedure and assessing its ability to stop lethal heart rhythms. As an essential next step, this team is planning a multicenter trial involving centers in the Unites States and across the world. But the size and timing of the trial depends on whether they can attract sufficient financial backing.

“The next necessary step is a big one and that requires funding,” says Dr. Cuculich. “Unfortunately, the process of applying for grants from the federal government is rather slow. We wouldn’t be able to start the trial until 2020 at the earliest. That gap leaves us spinning our wheels.”

The Future of Noninvasive Radiotherapy

Currently, Drs. Cuculich and Robinson are treating VT, a leading cause for sudden cardiac arrest, which kills an estimated 325,000 Americans annually. The team has already begun planning ways to evolve the treatment to target the most common irregular heartbeat, called atrial fibrillation, or Afib. At least 2.7 million Americans are living with atrial fibrillation, and Afib increases the chances for blood clots, stroke, heart failure and other heart-related complications.

The overwhelmingly positive international response to the recent studies by Drs. Cuculich and Robinson demonstrates the concern about the numerous patients in need and a field looking for new advances to such common treatments as catheter ablations that are invasive, require hospitalization with a long recovery period and don’t always work.

For example, there’s a 40 to 70 percent success rate with catheter ablations and the procedure takes four to 10 hours followed by a required two-day stay in the hospital.

In comparison, a noninvasive radiotherapy ablation takes about 10 minutes and patients are able to leave the hospital in less than a half hour.

“It was very short. I was amazed,” says Gary. “I got off the table, got in my vehicle and drove home.”

He said the procedure changed his life. In the more than 30 months since undergoing radiation, Gary is now able to walk more than five miles and has had only one episode of VT.

"It’s like night and day. I would not be living now or wouldn’t have the quality of life,” he says. “I’m not scared of anything anymore. I can play with my grandson now. In fact, I’m leaving now to pick him up from school.”

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