Non invasive ablation is where I think the whole field of electrophysiology is going to be in the next 25 years. Maybe, catheter based ablation will still maintain a niche role!
Phillip Cuculich and colleagues at Wash U in St. Louis have pioneered this technique.
Here is their article in NEJM.
In simplistic terms, their workflow is:
For electrocardiographic imaging, patients wore a vest of 256 electrodes (BioSemi) and underwent chest CT scanning. Patients were then brought to the electrophysiology laboratory and underwent noninvasive programmed stimulation with the use of an indwelling ICD to induce ventricular tachycardia. Data for electrocardiographic imaging maps were obtained, and the ICD was used to terminate ventricular tachycardia overdrive pacing. Electrocardiographic imaging maps were created to identify the site of earliest electrical activation during ventricular tachycardia (the “exit site”).
Additional cardiac imaging was used to identify regions of anatomical scarring with either resting single-photon emission CT (SPECT) or contrast-enhanced cardiac MRI.
Before treatment, patients underwent a planning CT scan, which included immobilization of the entire body from thorax to legs with the use of a vacuum-assisted device (BodyFIX, Elekta) and acquisition of a respiration-correlated CT scan (4D CT) to assess cardiac and pulmonary motion. A final target (planning target volume) was developed.
A total dose of 25 Gy in a single fraction was administered to the planning target volume.
Following the pilot trial, the authors have begun enrolling in the Encore VT trial.