{
  "abstract": "Background: Stereotactic Arrhythmia Radiotherapy (STAR) offers a non-invasive alternative for ventricular tachycardia ablation, yet motion management remains a critical challenge. While respiratory gating is established, cardiac gating requires a dedicated workflow and gating device.\n\nMethods: This study establishes and validates an end-to-end workflow for cardiorespiratory gated proton STAR in six healthy swine. Key innovations include a novel pencil-beam scanning (PBS) controller enabling mid-spot beam pausing and resumption, and the integration of CardioKit, an ultrasound-based image-guidance system for real-time soft-tissue tracking. The workflow was evaluated by comparing single-gated (respiratory only) and dual-gated (cardiorespiratory) delivery strategies, assessing system latency, dosimetric accuracy on dynamic phantoms, and motion tracking fidelity against 4D-CT benchmarks.\n\nResults: The upgraded PBS system demonstrated a gate response latency of <550 µs, effectively mitigating interplay effects in dynamic phantom measurements through gated beam deliveries. CardioKit provided respiratory motion traces highly correlated with 4D-CT data (Pearson r > 0.97) and responded to arrhythmic events within 5 ms. In vivo , dual-gating restricted delivery to the diastolic window (70–100% R–R), which resulted in a reduction in the Internal Target Volume (ITV) expansion by a mean of 45% compared to single-gating (19% vs. 64%), thereby substantially sparing healthy myocardium. Although dual-gating increased total beam-on time, the mid-spot interrupt capability ensured robust dose accumulation without treatment aborts.\n\nConclusion: The workflow for imaging, treatment planning, and cardiorespiratory-gated beam delivery was viable for treating all six subjects. The PBS system responded to gating commands < 550 µs and CardioKit responded to irregularities in heartbeat in <5 ms. Cardiorespiratory gating enabled an average 45% reduction in target expansion due to cardiac motion. Comparison of CardioKit respiratory motion traces with respiratory 4D-CT yielded differences of 1.1-1.4 mm in total motion amplitude and 0.97-0.99 Pearson correlation factor. These findings are valuable for establishing a workflow for cardiorespiratory-gated STAR treatment with CardioKit.",
  "abstract_shown": true,
  "affiliations": [
    "Mass General Brigham, Harvard Medical School",
    "Yale University",
    "EBAMed SA",
    "Massachusetts Institute of Technology",
    "Pyramid Technical Consultants",
    "University of Utah"
  ],
  "article_type": null,
  "arxiv": null,
  "author_total": 19,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Nicolas Depauw"
    },
    {
      "affs": [
        0,
        1
      ],
      "name": "Felicitas Bijari"
    },
    {
      "affs": [
        0
      ],
      "name": "Ethan Cascio"
    },
    {
      "affs": [
        0
      ],
      "name": "Evan Driscoll"
    },
    {
      "affs": [
        2
      ],
      "name": "Adriano Garonna"
    },
    {
      "affs": [
        0
      ],
      "name": "Jagdip Kang"
    },
    {
      "affs": [
        0
      ],
      "name": "Helen Deng"
    },
    {
      "affs": [
        0,
        3
      ],
      "name": "Hyeongseok Kim"
    },
    {
      "affs": [
        0
      ],
      "name": "Marina Macdonald-Soccorso"
    },
    {
      "affs": [
        4
      ],
      "name": "Willian Nett"
    },
    {
      "affs": [
        1
      ],
      "name": "Marc Normandin"
    },
    {
      "affs": [
        2
      ],
      "name": "Matthieu Pellissier-Tanon"
    },
    {
      "affs": [
        0
      ],
      "name": "Rebecca Woodcock"
    },
    {
      "affs": [
        0
      ],
      "name": "Koushiar Yaghoubian"
    },
    {
      "affs": [
        1
      ],
      "name": "Georges El Fakhri"
    },
    {
      "affs": [
        0
      ],
      "name": "Robert Levine"
    },
    {
      "affs": [
        0,
        5
      ],
      "name": "H.Immo Lehmann"
    },
    {
      "affs": [
        0
      ],
      "name": "Yen-Lin Chen"
    },
    {
      "affs": [
        0
      ],
      "name": "Kyung-Wook Jee"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/cbkrpe550j4x2.bib",
  "cited_by": 0,
  "doi": "10.3389/fonc.2026.1923998",
  "fulltext_url": "https://www.frontiersin.org/articles/10.3389/fonc.2026.1923998/full",
  "id": "cbkrpe550j4x2",
  "issns": [
    "2234-943X"
  ],
  "landing_url": "https://www.frontiersin.org/articles/10.3389/fonc.2026.1923998/full",
  "language": "en",
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "lcc",
      "RC254-282"
    ],
    [
      "openalex",
      "3108|Advanced Radiotherapy Techniques"
    ]
  ],
  "openalex": "W7223298944",
  "pdf_url": "https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2026.1923998/pdf",
  "pmcid": null,
  "pmid": null,
  "published": "2026-10-23",
  "publisher": "Frontiers Media SA",
  "ris": "https://research.draconitic.com/paper/cbkrpe550j4x2.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:20:13Z",
      "native_id": "10.3389/fonc.2026.1923998",
      "source": "crossref",
      "url": "https://www.frontiersin.org/articles/10.3389/fonc.2026.1923998/full"
    },
    {
      "first_seen": "2026-10-30T13:43:11Z",
      "native_id": "4c6e157abb4e4f26b325402e825a1226",
      "source": "doaj",
      "url": "https://doi.org/10.3389/fonc.2026.1923998"
    }
  ],
  "subjects": [
    {
      "field": "physics",
      "origin": "openalex:3108|Advanced Radiotherapy Techniques",
      "subfield": "applied-instrumentation"
    }
  ],
  "title": "Cardio-respiratory-gated proton pencil beam scanning for cardiac ablation: workflow and end-to-end validation",
  "title_text": "Cardio-respiratory-gated proton pencil beam scanning for cardiac ablation: workflow and end-to-end validation",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T13:43:11Z",
  "url": "https://research.draconitic.com/paper/cbkrpe550j4x2",
  "venue": "Frontiers in Oncology",
  "versions": []
}