Stereotactic arrhythmia radioablation for refractory ventricular tachycardia: A narrative review and pooled analysis of clinical outcomes and treatment delivery approaches

PURPOSE: Stereotactic arrhythmia radioablation (STAR) has emerged as a noninvasive salvage therapy for refractory ventricular tachycardia (VT), particularly in patients ineligible for catheter ablation (CA). This narrative review and pooled analysis evaluates STAR's efficacy, safety, and technical characteristics, integrating evidence from preclinical studies, case reports, case series, and clinical trials. METHODS: A comprehensive literature search identified 88 studies published between 2015 and 2025, comprising 13 preclinical investigations, 50 case reports, 18 case series, and 7 clinical trials. Study-level data were extracted for pooled analyses of 6- and 12-month mortality, VT burden reduction, and Grade 3+ acute toxicity. Subgroup analyses were performed by delivery modality, age, left ventricular ejection fraction (LVEF), and cardiomyopathy type. RESULTS: = 98.8%). Grade 3+ acute toxicity occurred in 7% (95% CI: 4%-10%), most commonly heart-failure decompensation or pneumonitis. Subgroup analyses indicated more favorable outcomes in younger patients, non-ischemic cardiomyopathy (NICM), and those with higher baseline LVEF. CONCLUSIONS: STAR achieves meaningful VT suppression with acceptable acute toxicity across multiple delivery modalities. However, wide inter-study heterogeneity underscores the need for standardized endpoint definitions, dosimetric and motion-management protocols, and prospective follow-up registries. Translational preclinical data and emerging clinical evidence collectively support STAR's continued development as a biologically informed cardiac radiotherapy paradigm.