The Effectiveness of Arrhythmic Substrate Ablation in The Treatment of Brugada Syndrome Has Been Confirmed

In 2015 the research team led by Professor Carlo Pappone, Director of the Department of Arrhythmology and Electrophysiologyat IRCCS Policlinico San Donato, changed the history of Brugada Syndrome treatment forever, thanks to a crucial discovery of the  arrhythmic substrate. 

For the first time in the world, a group of cells expressing abnormal electrical potentials was identified on the outer (epicardial) surface of the heart at the level of the right ventricle, forming an area that is associated with the clinical presentation of the disease and the risk of suffering from a more aggressive form of the disease associated with the development of malignant ventricular arrhythmias.

The identification of disease mechanisms led to the definition of ablation of the arrhythmic substrate of Brugada syndrome as a therapeutic strategy that could effectively treat the condition. In light of new research led by Professor Carlo Pappone, Giuseppe Ciconte, Gabriele Vicedomini, Luigi Anastasia and Vincenzo Santinelli, of the Department of Arrhythmology at IRCCS Policlinico San Donato, this treatment finally becomes a stable and lasting chance for cure. 

Today, in fact, the study confirms the role of the extension of the arrhythmogenic substrate of Brugada Syndrome, the group of abnormal cells on the outer (epicardial) surface of the heart, at the level of the right ventricle, as a crucial prognostic factor for recurrent ventricular fibrillation events, and validates the safety and efficacy of epicardial ablation with radiofrequency in eliminating all abnormal electrical signals located on the epicardium, pathognomonic of BrS. 

The results of the study also emphasize the importance of using ajmaline, a drug capable of latently eliminating latent electrical abnormalities of the heart, to better define the area to be exposed to radiofrequency when mapping the epicardial surface under study. This finding sets the stage for further exploration of non-invasive methods to guide informed clinical decisions. 

A total of 257 selected patients with symptomatic Brugada Syndrome with defibrillator implantation (ICD) were included in the long-term investigative prospective study. Among them:

• first group of 206 patients who underwent epicardial radiofrequency ablation (RFA) and were monitored for more than 5 years post-ablation;
• second group of 51 patients who received only ICD implantation while refusing RFA. 

Primary endpoints included risk factors for pre-ablation ventricular fibrillation (VF) events and freedom from post-ablation VF events. In the RFA group, BrS substrates were identified on the epicardial surface of the right ventricle. 

During the pre-RFA follow-up period (median of 27 months), there were episodes of fibrillation in 53 patients. In the post-RFA follow-up period (median 40 months), the group undergoing ablation demonstrated superior results compared with the control group and without major procedure-related complications.

This study shows that ablation of Brugada Syndrome can free patients from a disease that can undermine their lives every day. In addition, it is not ruled out in the near future that this therapeutic technique may be a viable alternative to implanting a defibrillator, which would make young patients limited in their daily lives, both sports and social.

The same researchers announce the imminent publication of the results of a randomized trial showing that this technique unequivocally saves patients otherwise destined to die suddenly when suffering from a severe form of the disease.

Finally, the same group is about to provide a major breakthrough aimed at screening the general population for early detection of patients unaware they have Brugada Syndrome. These results so promising for the future of all patients will also be announced soon.