Elsevier

Heart Rhythm

Volume 17, Issue 9, September 2020, Pages 1510-1518
Heart Rhythm

Clinical
Ventricular Tachycardia
Efficacy and safety of combined endocardial/epicardial catheter ablation for ventricular tachycardia in Chagas disease: A randomized controlled study

https://doi.org/10.1016/j.hrthm.2020.02.009Get rights and content

Background

Epicardial mapping and ablation are frequently necessary to eliminate ventricular tachycardia (VT) in patients with Chagas disease. Nonetheless, there are no randomized controlled trials demonstrating the role of this strategy.

Objective

We conducted this randomized controlled trial to evaluate the efficacy and safety of combined epicardial ablation in patients with Chagas disease.

Methods

We randomized patients with Chagas disease and VT in a 1:1 fashion to either the endocardial (endo) mapping and ablation group or the combined endocardial/epicardial (endo/epi) mapping and ablation group. The efficacy end points were measured by VT inducibility and all-ventricular arrhythmia recurrence. Safety was assessed by the rate of periprocedural complications.

Results

Thirty patients were enrolled, and most were male. The median age was 67 (Q1: 58; Q3: 70) years in the endo group and 58 (Q1: 43; Q3: 66) years in the endo/epi group. The left ventricular ejection fraction was 33.0% ± 9.5% and 35.2% ± 11.5%, respectively P = .13. Acute success (non-reinducibility of clinical VT) was obtained in 13 patients (86%) in the endo/epi group and in 6 patients (40%) in the endo-only group (P = .021). There were 12 patients with VT recurrence (80%) in the endo-only group and 6 patients (40%) in the endo/epi group (P = .02) (by intention-to-treat analysis). Epicardial ablation was ultimately performed in 9 patients (60%) in the endo-only group because of an absence of endocardial scar or maintenance of VT inducibility. There was no difference in complications between the groups.

Conclusion

Combining endo/epi VT catheter ablation in patients with Chagas disease significantly increases short- and long-term freedom from all-ventricular arrhythmias. Epicardial access did not increase periprocedural complication rates.

Introduction

Chagas disease is an infectious disease caused by the parasite Trypanosoma cruzi (T cruzi). It is estimated that 8–10 million people worldwide are infected by T cruzi, mostly in Latin America, where the disease is endemic.1,2 The main areas of scar tissue and wall thinning in patients with Chagas disease are the apical, basal inferior, and lateral walls of the left ventricle (LV). Ventricular tachycardia (VT) in Chagas disease usually has transmural or subepicardial substrates. Because of the epicardial distribution of the VT circuits in this entity, an epicardial mapping and ablation approach was initially proposed >2 decades ago.3 Nevertheless, it has not yet become the standard of care worldwide because of safety concerns about epicardial access technique and lack of prospective randomized data on clinical outcomes. Endocardial (endo) ablation has remained the initial approach with the perception that with new developments in catheter ablation technology (ie, open irrigation and contact force sensing), larger and deeper lesions can be created from the endocardial surface that could theoretically reach the mid-myocardial or epicardial substrates.

Consequently, we conducted this prospective randomized controlled trial to evaluate the efficacy and safety of endocardial/epicardial (endo/epi) mapping and ablation in comparison to the conventional endo approach.

Section snippets

Study design

This was a single-center, open-label, randomized controlled trial of patients with Chagas disease with recurrent VT despite the use of antiarrhythmic drugs. All procedures were performed in the electrophysiology laboratory between April 2014 and July 2017 at the Heart Institute (InCor) of the University of São Paulo Medical School by 2 operators (C.F.P. and M.S.). Patients were randomly assigned to undergo either endo/epi mapping and ablation (ie, endo/epi group) or endo-only mapping and

Results

The baseline characteristics are presented in Table 1 and Online Supplemental Table S1. Most patients were male; the mean LV ejection fraction was 33.0% ± 9.5% and 35.2% ± 11.5% for the endo group and the endo/epi group, respectively (P = .13). There was a median of 3 (Q1: 2; Q3: 7.5) and 6 (Q1: 4; Q3: 11) VT episodes before the procedure for the endo group and endo/epi group, respectively (P = .15). Most patients were on amiodarone before the procedure (97%). Four patients (26.7%) in the endo

Discussion

This is the randomized controlled trial evaluating the safety and efficacy of a combined endo/epi ablation strategy in patients with recurrent sustained VT and Chagas disease. The main finding of this study is that conventional endo ablation failed to eliminate clinical VT in most (60%) patients with Chagas disease even when using irrigated-tip catheters with contact force–sensing capabilities. Likewise, combined endo/epi mapping resulted in less ablation failure (13.3%). Furthermore, partial

Conclusion

The combined endo/epi mapping and ablation approach for VT in patients with Chagas disease is associated with lower short- and long-term failure rates as compared with endo-only ablation. In most of the patients who underwent an initial endo approach, a combined endo/epi procedure was necessary because of clinical VT recurrence. The combined endo/epi approach showed similar safety to the conventional endo-only approach.

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  • Cited by (23)

    • Advanced Therapies for Ventricular Arrhythmias in Patients With Chagasic Cardiomyopathy: JACC State-of-the-Art Review

      2021, Journal of the American College of Cardiology
      Citation Excerpt :

      Since then, the epicardial access technique has been widely adopted and refined with the use of different access needles, pressure sensors, and integration of multiple imaging modalities (82). Epicardial scars have been reported to be significantly larger than endocardial scars, according to voltage mapping in patients with CCC referred for VT ablation (76,83,84). A cohort of 19 patients with CCC in Colombia referred for VT ablation showed that 79% of endocardial scars with the use of bipolar voltage (≤1.5 mV) converged with epicardial scars (≤1.0 mV) (83).

    View all citing articles on Scopus

    This study was sponsored by Biosense Webster.

    Drs Pisani, Hardy, Chokr, and Scanavacca serve on speakers’ bureau for Biosense Webster. Dr Di Biase serves as a consultant for Biosense Webster, Stereotaxis, Boston Scientific, and Abbott and receives speaker honoraria/travel support from Medtronic, AtriCure, Pfizer, Bristol-Meyers Squibb, and Biotronik. The rest of the authors report no conflicts of interest.

    This study is the final document of the PhD thesis of Dr Pisani.

    ClinicalTrials.gov identifier: NCT02072707.

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