Advanced management of ventricular arrhythmias in chronic Chagas cardiomyopathy

David Santacruz; Fernando Rosas; Carina Abigail Hardy; Diego Ospina; Andrea Nathalie Rosas; Juan Manuel Camargo; Juan José Bermúdez; Juan Felipe Betancourt; Víctor Manuel Velasco; Mario D González

doi:10.1016/j.hroo.2021.10.010

Advanced management of ventricular arrhythmias in chronic Chagas cardiomyopathy

Heart Rhythm O2. 2021 Dec 17;2(6Part B):807-818. doi: 10.1016/j.hroo.2021.10.010. eCollection 2021 Dec.

Authors

David Santacruz^{1

2}, Fernando Rosas^{1

2}, Carina Abigail Hardy³, Diego Ospina², Andrea Nathalie Rosas⁴, Juan Manuel Camargo^{1

2}, Juan José Bermúdez², Juan Felipe Betancourt^{1

2}, Víctor Manuel Velasco^{1

2}, Mario D González⁵

Affiliations

¹ Department of Cardiac Electrophysiology, Fundación Clínica Shaio, Bogotá, Colombia.
² Training Program in Cardiac Electrophysiology, Pontificia Universidad Javeriana, Bogotá, Colombia.
³ Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil.
⁴ Medicine Training Program, Universidad del Rosario, Bogotá, Colombia.
⁵ Clinical Electrophysiology, Hershey Medical Center, Penn State University, Hershey, Pennsylvania.

Abstract

Chagas cardiomyopathy is a parasitic infection caused by Trypanosoma cruzi. Structural and functional abnormalities are the result of direct myocardial damage by the parasite, immunological reactions, dysautonomia, and microvascular alterations. Chronic Chagas cardiomyopathy (CCC) is the most serious and important manifestation of the disease, affecting up to 30% of patients in the chronic phase. It results in heart failure, arrhythmias, thromboembolism, and sudden cardiac death. As in other cardiomyopathies, scar-related reentry frequently results in ventricular tachycardia (VT). The scars typically are located in the inferior and lateral aspects of the left ventricle close to the mitral annulus extending from endocardium to epicardium. The scars may be more prominent in the epicardium than in the endocardium, so epicardial mapping and ablation frequently are required. Identification of late potentials during sinus rhythm and mid-diastolic potentials during hemodynamically tolerated VT are the main targets for ablation. High-density mapping during sinus rhythm can identify late isochronal regions that are then targeted for ablation. Preablation cardiac magnetic resonance imaging with late enhancement can identify potentials areas of arrhythmogenesis. Therapeutic alternatives for VT management include antiarrhythmic drugs and modulation of the cardiac autonomic nervous system.

Keywords: Antiarrhythmic treatment; Cardiomyopathy; Catheter ablation; Chagas disease; Endo-epicardial approach; Implantable cardioverter-defibrillator; Neuraxial modulation; Ventricular tachycardia.