ClinicalVentricular TachycardiaEfficacy and safety of combined endocardial/epicardial catheter ablation for ventricular tachycardia in Chagas disease: A randomized controlled study
Graphical abstract
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)
Feasibility of Transatrial Access for Epicardial Ablation: Evaluation of 2 Different Techniques in Swine
2023, JACC: Clinical ElectrophysiologySustained Apnea for Epicardial Access With Right Ventriculography: The SAFER Epicardial Approach
2023, JACC: Clinical ElectrophysiologyPatient Selection, Techniques, and Complication Mitigation for Epicardial Ventricular Tachycardia Ablation
2022, Cardiac Electrophysiology ClinicsAdvanced management of ventricular arrhythmias in chronic Chagas cardiomyopathy
2021, Heart Rhythm O2Advanced Therapies for Ventricular Arrhythmias in Patients With Chagasic Cardiomyopathy: JACC State-of-the-Art Review
2021, Journal of the American College of CardiologyCitation 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).
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.