Anyone who thinks of radiotherapy, also known as radiation therapy, immediately makes a connection to cancer. But the technique can also be used against other conditions. Gijs Donker, meanwhile, knows all about it. He has struggled with a heart rhythm disorder since 2010. Last year, doctors at the UMC Utrecht decided he was eligible for a first: the first patient with a cardiac arrhythmia to undergo radiotherapy in our hospital. Nine months later, satisfaction prevails. The 84-year-old walks and cycles again and his ICD, a device that intervenes in dangerous cardiac arrhythmias, is activated significantly less often than before treatment.
“This morning my wife laughingly asked if it wasn’t about time to stop working in the garden. I had been working for a couple of hours.” So says Gijs Donker. The Zaltbommel resident feels better and is much more active since receiving radiotherapy at the UMC Utrecht for his heart arrhythmia.
Such a disorder means that the heartbeat is irregular, too fast or just too slow. Those who have it often feel tired, are short of breath and, because of low blood pressure, are at a higher risk of sometimes losing consciousness. If left untreated, the disorder can worsen and eventually lead to more serious problems: heart failure or death.
“Together with Mr. Donker, we decided on radiotherapy in his case because the usual treatment options proved ineffective,” explains cardiologist-electrophysiologist Rutger Hassink. “Medication is the first treatment choice for a cardiac arrhythmia. Sometimes this does not work, for example because the body becomes resistant to the drugs. It can also happen that the side effects are too adverse. Then we consider the second treatment option: ablation.”
Rutger continues: “Ablation is a procedure in which we insert catheters through the groin and guide them to the heart. With an electrode, we then burn away the piece of heart tissue that is causing the disorder. We turn this active area into a scar. Then no more arrhythmias can occur from this area. But sometimes we cannot reach the affected piece of heart tissue with a catheter, for example because the arrhythmia originates from a spot in the middle of the heart muscle. That muscle is a centimeter or more thick in some places; if the source of the disorder is deep in there, it is too far away to be burned away.”
This was exactly the flaw in Gijs Donker’s case, as was revealed during the ablation Rutger and colleagues performed on him in the fall of 2021. Shortly after the patient came out of anesthesia, the cardiologist-electrophysiologist told about a treatment that UMC Utrecht wanted to perform in the future: radiotherapy for cardiac arrhythmias. Radiotherapist Joost Verhoeff had previously initiated a study into the possibilities of this approach. As project leader, Joost had received a Horizon 2020 grant for the so-called stopstorm.eu-project. Last year, knowledge and expertise in the UMC Utrecht had reached such a level that the time was ripe to treat the first patient.
Gijs: “I immediately told Dr. Hassink that I wanted to be considered for this. Pretty soon after that I got a call at home: was I still interested? I was invited for interviews with cardiologists Meine and Hassink and radiotherapists Verhoeff and Van de Pol. At the end I said: I will do it, but only on the condition that my wife and two sons agree. They turned out to agree as well. It was actually quite easy: the treatment was my only option to get a better quality of life.”
The procedure was performed on Dec. 9 under the direction of radiotherapist Sandrine van de Pol. She says, “The radiation itself took only a few minutes. Much more time we spent on the preparation. You want to know exactly which part of the heart tissue should be irradiated, so that you avoid damage in other areas and can proceed as safely as possible. Therefore, a CT scan and MRI scan were first made of Mr. Donker’s heart while he was lying in the position in which he would be irradiated. We were also guided by the information about the heart that Rutger had gathered during the ablation. Thus, we arrived at an area 6.5 centimeters wide and 5 centimeters long. Within that was the part of heart tissue that caused the disorder and we eliminated that with radiation.”
Exciting and a bit special. That’s how Sandrine experienced the scoop. “Normally we treat cancer patients and make a radiation plan that leaves the heart unaffected. Now the goal was precisely to target part of the heart. We did that with stereotactic radiotherapy: a treatment with a very high radiation dose. We have been using this technique for years in all kinds of different parts of the body, but now for the first time in the heart.”
Gijs Donker: “Doctor Van de Pol had told me that I would not feel better in the first weeks after radiotherapy. The irradiated piece of heart tissue would slowly die off, so the effect would take a while. But in time, things did indeed improve. Not only did I notice that I was less tired, but I also saw it in the data from my ICD, my implantable cardioverter-defibrillator.”
He explains: “An ICD comes into action when a heart rhythm is dangerous. In my case, it then delivers five pulses. UMC Utrecht remotely keeps track of how often my ICD is activated. I can also track this, via the hospital’s patient portal. In December and January I still had fifteen to twenty activations per month, but in February it started to decrease. Now I have two to four every month.”
Gijs has had quite a history of illness, so he is happy with the new situation. “Since 2010, I have undergone open-heart surgery and received a pacemaker and a stent, among other things. From May 2021, I was taken by ambulance to the emergency room several times because of cardiac arrhythmias. My heart rate at those times was 130 or higher and I felt hot, tired and restless. Compare that to how I am doing now: I can walk for three quarters of an hour to an hour and ride my e-bike for an hour. I have nothing but praise for the doctors and nurses at UMC Utrecht. Not only because of their medical expertise, but also because of the personal attention they gave me.”
Now that the first treatment has gone well, UMC Utrecht wants to use radiotherapy on more patients with cardiac arrhythmia. Eligible for this – as yet experimental – treatment are people for whom medication and ablation do not provide relief and who are carrying an ICD.
The UMC Utrecht is the third medical center in the Netherlands where radiotherapy is used to treat a cardiac arrhythmia. The study is called ProSTAR, where STAR stands for: Stereotactic arrhythmia radioablation. The name of the Horizon2020 project is STOPSTORM.eu: Standardized Treatment and Outcome Platform for Stereotactic Therapy Of Re-entry tachycardia by a Multidisciplinary consortium.
