Endocardial Unipolar Voltage Maps to Identify Epicardial Circuits During Ventricular Tachycardia Ablation in Chagasic Cardiomyopathy: When the Pot of Gold May Not Be at the Other End of the Rainbow

See Article by Soto-Becerra et al Chagas’ disease has become a global concern.1 Endemic in Latin America, where it affects ≈6 million individuals according to the World Health Organization 2015 report.2 The disease has recently spread worldwide because of increasing human migration. It has been estimated that >200 000 individuals were living with the disease in the United States in 2012, most of which were unaware of the diagnosis.3 Up to one third (20%–30%) of individuals develop cardiomyopathy during the chronic stages of the disease, typically 20 to 30 years after initial contact.4 Among these patients, sudden death accounts for 55% to 65% of deaths5 and is usually because of ventricular arrhythmias.3 The relative rate of sudden death as cause of death is even higher in asymptomatic patients in early stages of the disease.6 This results in increased mortality for relatively young patients, both with and without an implantable cardioverter-defibrillator: in the first group, mortality is thought to be related to heart failure acutely worsened by frequent implantable cardioverter-defibrillator shocks while in the latter it is secondary to sudden death.7 Given that the natural course of Chagasic cardiomyopathy often includes development of ventricular tachycardia (VT), these patients frequently undergo catheter ablation procedures. Because VT in Chagasic patients characteristically arises from transmural circuits from fibrotic areas located in the …