Chagas Cardiomyopathy – ABC CARDIOL

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Research Letter

16-Year Evolution of Acute Orally Transmitted Chagas Disease: Report of an Autochthonous Case Progressing to Chagasic Cardiomyopathy

Monica Regina Hosannah Silva e Silva et al. Jorge Augusto de Oliveira Guerra Jessica Vanina Ortiz Matheus Martins Monteiro … Katia do Nascimento Couceiro Maria das Graças Vale Barbosa Guerra João Marcos Bemfica Barbosa Ferreira

Introduction

Chagas disease (CD) is caused by Trypanosoma cruzi, a protozoan with a complex life cycle found in dozens of species of triatomine insects (kissing bugs) and mammals. The World Health Organization (WHO) included CD among the neglected tropical diseases in 2006.

Humans can become infected through contact with insect feces containing T. cruzi or through other mechanisms, including the ingestion of contaminated food. The clinical presentation of CD varies between its two phases: acute and chronic. In the acute phase, individuals are usually oligosymptomatic, presenting with nonspecific signs and symptoms. However, a minority may develop more severe manifestations such as hepatosplenomegaly, myocarditis, or meningoencephalitis. The chronic phase comprises three well-defined clinical forms: indeterminate, cardiac, and digestive.^–

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Original Article

Implantation of Pacemakers in Patients with Chagas disease: A Case-Control Study of Associated Contextual Factors and Prognosis

Sâmara Fernandes Leite et al. Maria Carmo Pereira Nunes Cesar Augusto Taconeli Mathaus Henrique Reis Silva … Dardiane Santos Cruz Lea Campos Oliveira Ester Cerdeira Sabino Marco Paulo Tomáz Barbosa Antonio Luis Pinho Ribeiro Ariela Mota Ferreira Desirée Sant’Ana Haikal

Abstract

Background

Chronic Chagas cardiomyopathy (CCC) is the most severe manifestation of Chagas disease and may present with bradyarrhythmias requiring pacemaker (PM) implantation.

Objective

1. To identify contextual factors associated with PM implantation among individuals with CCC. 2. To assess the prognosis (death) in these groups over a 4-year follow-up period.

Method

1. Nested case-control study within the SaMi-Trop cohort. We matched cases (patients with CCC who had a PM implanted between waves 1 and 2 of the study) with controls at a 1:3 ratio, considering equivalence in baseline cardiac severity. Independent variables related to the municipal context were considered. Binary logistic regression was conducted. 2. Survival analysis to evaluate the prognosis of these groups, adjusted for clinical variables (Cox regression), considering death as the outcome. Conclusions were based on a significance level of 5%.

Results

The study included 46 cases and 138 controls. The odds of PM implantation were higher among individuals residing in municipalities with: larger population (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.3 to 9.6), higher coverage of the Family Health Strategy (OR: 5.3; 95% CI: 1.8 to 15.8), and with a lower number of electrocardiographs per thousand inhabitants (OR: 2.6; 95% CI: 1.0 to 6.6). Considering 4 years of follow-up, death was observed in 32.6% of cases and 21.2% of controls. Only ejection fraction affected survival (relative risk: 7.2; 95% CI: 3.6 to 14.2).

Conclusion

Contextual factors interfered with PM implantation. However, PM implantation did not influence death over 4 years of follow-up, which was associated only with ejection fraction.

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Original Article

Acute Heart Failure in Patients with Chagas Cardiomyopathy: Results of the I Brazilian Heart Failure Registry (BREATHE)

Pedro Gabriel Melo de Barros e Silva et al. Denilson Campos Albuquerque Renato Delascio Lopes Paulo Roberto Nogueira … Aguinaldo F Freitas Jr Carlos Vieira Nascimento Charles Mady Elizabete Silva dos Santos Mauro Esteves Hernandes Maria Alayde Mendonça Rivera João David de Souza Neto Alvaro Rabelo Manoel Fernandes Canesin Helder Reis Anderson da Costa Armstrong Conrado Hoffmann Renato Hideo Nakagawa Santos Isabella de Andrade Jesuino Luis Eduardo Rohde Lidia Zytinsky Moura Fabiana Goulart Marcondes-Braga Evandro Tinoco Mesquita José Albuquerque de Figueiredo Neto Ricardo Mourilhe-Rocha Luís Beck-da-Silva Mucio Tavares Oliveira Junior Marcus Vinicius Simões

Abstract

Background

Although the clinical features of chronic Chagas’ cardiomyopathy (CCC) have been well established, clinical data about the patients are scarce.

Objectives

The current analysis reports the results of the I Brazilian Heart Failure Registry (BREATHE) assessing baseline characteristics and clinical outcomes of patients with acute heart failure due to CCC.

Methods

BREATHE enrolled a total of 3,013 adult patients hospitalized with acute heart failure. We analyzed comparatively 261 (8.7%) patients with chronic CCC and 2,752 (91.3%) patients with other etiologies. Clinical and demographic information, cardiac structure/function data on echocardiogram and outcomes during the hospital stay and after discharge were assessed in both groups. Uni and multivariate tests were performed and a p-value <0.05 was considered statistically significant.

Results

Patients with CCC presented lower systolic blood pressure (108.3 ± 26.1 vs 128.3 ± 30.3 mmHg, p<0.001) and left ventricle ejection fraction (25.4 [19 – 36]% vs 37 [27 – 54] %, p<0.001) with higher rates of jugular vein distension (54.8% vs 38.9%, p<0.001), hepatomegaly (47.9% vs 25.6%, p<0.001), and “cold and wet” clinical hemodynamic profile (27.2% vs 10.6%, p<0.001). Patients with CCC presented higher rate of the composite death or heart transplantation (17.4% vs. 11.1%, p=0.004), and higher cumulative incidence of death after 3 months (16.5% vs 10.8%, p=0.017), 6 months (25.3% vs 17.2%, p=0.006), and 12 months (39.4% vs 26.6%, p<0.001). Besides, CCC was independently associated with 12-month mortality risk with odds ratio = 2.02 (95% IC: 1.47-2.77).

Conclusion

Patients with CCC, hospitalized due to acute heart failure, in comparison to other etiologies, presented a higher risk profile that was associated with a poorer outcome during hospital stay and after discharge.

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Original Article

Decreased Insulin Levels in Patients with Acute Chagas Disease from Brazilian Amazon treated with Benznidazole

João Marcos Barbosa-Ferreira et al. Jessica Vanina Ortiz Fernanda Gallinaro Pessoa Maria das Graças Vale Barbosa … Jorge Augusto de Oliveira Guerra Kátia do Nascimento Couceiro Mônica Regina Hosannah Silva e Silva Matheus Martins Monteiro Keila Cardoso Barbosa Fonseca Felix Alvarez Ramires Barbara Maria Ianni Charles Mady Fábio Fernandes

Abstract

Background

In the Amazon region, there has been a significant increase in the number of acute Chagas disease (ACD) leading to electrocardiographic and echocardiographic abnormalities. The main pathophysiological mechanisms involved in Chagas cardiomyopathy (CCM) are microvascular dysfunction, Autonomic Nervous System (ANS) dysfunction, direct parasite aggression, and inflammatory activity. Chagas disease (CD) is a perfect example of inflammatory cardiomyopathy that might influence changes in metabolic parameters and ANS. Studies on the measurement of adipocytokines and insulin levels in humans with ACD are scarce.

Objective

To evaluate adiponectin, leptin and insulin levels before and after the treatment of ACD with benznidazole and to correlate with ANS and cardiac function.

Methods

Twenty-eight subjects were divided into groups: control group (CG), with 15 subjects, and ACD group, with 13 subjects. All subjects underwent a standard 12-lead ECG, comprehensive transthoracic echocardiographic, evaluation of autonomic function and serum adiponectin, insulin and leptin levels. A level of significance of 5% (p-value < 0,05) was used.

Results

Insulin levels were lower in the ACD group both before and after the treatment when compared to the control group and lower in the post-treatment phase when compared to the pre-treatment phase. Adipocytokine, leptin and adiponectin levels showed no differences between groups.

Conclusion

Insulin levels were lower in the ACD group both before and after the treatment when compared to the control group and lower in the post-treatment phase when compared to the pre-treatment phase. There was no significant correlation between adipocytokine and insulin levels with cardiac function and the ANS parameters.

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Original Article

Prognostic Evaluation of Chagasic and Non-Chagasic Patients Undergoing Pacemaker Implantation and Cardiac Resynchronization in a Tertiary Center

Laís Toledo de Vasconcelos et al. Larissa Natany Almeida Martins Anna Terra França Fábio Morato de Castilho Antônio Luiz Pinho Ribeiro

Abstract

Background:

Chagas cardiomyopathy (ChCC) is one of the causes of the implantation of pacemakers (PM) in many patients and has been associated with an adverse prognosis.

Objectives:

To compare the prognosis of the chagasic and non-chagasic populations undergoing PM and cardiac resynchronizer implantation.

Methods:

Observational, retrospective study, which analyzed a cohort of patients who underwent implantation of these devices, in a tertiary center, from October 2007 to December 2017, comparing the chagasic group with non-chagasic patients. The non-parametric Kaplan-Meier method was used to calculate patient survival. The significance level adopted in the statistical analysis was 5%. The primary outcome was mortality from any cause, while the secondary outcomes were the occurrence of hospitalization and the combination of hospitalization and death.

Results:

A total of 911 patients were included, of which 23.4% had ChCC. In a Cox analysis adjusted for sex and age, Chagas disease (ChD) was not associated with an increased risk of death (HR: 1.14, CI:95%, 0.86-1.51, p=0.365), hospitalization (HR: 0.79, CI:95%, 0.61-1.04, p=0.09) or combined outcome of death and hospitalization (HR: 0.90, CI:95%, 0.72-1 .12, p=0.49).

Conclusions:

ChD was not associated with an increased risk of death, hospitalization, or combined outcome of death and hospitalization, even after adjustment for sex and age. These results contrast with those of previous studies and suggest changes in the quality of care of patients with cardiomyopathy.

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Original Article

Left Ventricular Function and Myocardial Longitudinal Strain Analysis in Patients With Chagas Disease: Case Series and Systematic Literature Review

José Victor da Nóbrega Borges et al. Samira Abdel Correia Leila Manuella Guedes da Nóbrega Machado Kiran Sooraj Thirukonda Jegadeesh Babu … Karma Jashvantbhai Patel Kavya Hiteshkumar Shah Mahitha Reddy Takkasila Abdul Majid Shaik Muhammad Ahmed Shaikh Ninad Khandekar Sahithi Burra

Abstract

Introduction:

Left ventricular dysfunction as an independent predictor of mortality in Chagas disease. Global longitudinal strain (GLS) is an emerging echocardiographic modality with possible incremental value in early detection of cardiac involvement.

Objective:

Compare left ventricular function with multiple echocardiographic parameters between patients with the indeterminate and chronic forms of Chagas, and perform a literature review.

Methods:

In this observational study, 11 patients with a confirmed diagnosis of Chagas disease were evaluated. Individuals were distributed as follows: five with the indeterminate and six with the chronic forms. Conventional echocardiographic evaluation was followed by GLS measurement.

Results:

The mean left ventricle ejection fraction left ventricular ejection fraction (LVEF) was 33 ± 2.88, and the mean GLS of the left ventricle was −10.76 ± 2.20 in the chronic form as compared to 57.80 ± 6.49 and −17.34 ± 3.82, respectively in the indeterminate group. Contractility was reduced in segments of the inferior, inferoseptal and anteroseptal walls in both groups. These segmental alterations in the indeterminate group may be attributed to early myocardial damage from inflammation and fibrosis, even before significant left ventricular dysfunction is evident.

Conclusion:

Analysis of longitudinal strain in the indeterminate form has potential incremental value to the conventional analysis of ejection fraction when compared to patients with chronic Chagas cardiomyopathy, especially with individual segmental analysis, but the impact and clinical significance of these techniques are still unknown.

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Original Article

Exercise Training Reduces Inflammation and Fibrosis and Preserves Myocardial Function and Perfusion in a Model of Chronic Chagas Cardiomyopathy

Thayrine R. Damasceno et al. Denise M. Tanaka Enrico F. Magnani Rafael D. B. Oliveira … Danielle A. G. Pereira Ildernandes Vieira-Alves Virginia S. Lemos Jorge M. Cabeza Camila G. Fabricio Alessandra A. Resende Dawit A. P. Gonçalves Gustavo de Oliveira Zanetti Eduardo E. Vieira de Carvalho Marcus V. Simões Luciano F. L. Oliveira

Abstract

Background:

Chronic Chagas cardiomyopathy (CCC) is caused by an inflammatory process induced by Trypanosoma cruzi, which leads to myocarditis with reactive and reparative fibrosis. CCC progresses with myocardial perfusion abnormalities and histopathological events that affect cardiorespiratory fitness (CRF).

Objectives:

We evaluated the effects of aerobic physical training (APT) on myocardial perfusion and on morphological and functional impairments related with inflammation and fibrosis in Syrian hamsters with CCC. As a secondary objective, we analyzed the cross-sectional areas of the skeletal muscle.

Methods:

Hamsters with CCC and their respective controls were divided into four groups: CCC sedentary, CCC-APT, sedentary control and APT control. Seven months after infection, the animals underwent echocardiography, myocardial perfusion scintigraphy and cardiopulmonary exercise testing. Moderate-intensity APT was performed for fifty minutes, five times a week, for eight weeks. Subsequently, the animals were reassessed. Histopathological analysis was conducted after the above-mentioned procedures. The level of significance was set at 5% in all analyses (p<0.05).

Results:

CCC sedentary animals presented worse myocardial perfusion defects (MPD) over time, reduced left ventricle ejection fraction (LVEF) and showed more inflammation and fibrosis when compared to other groups (mixed ANOVA analysis). Conversely, APT was able to mitigate the progression of MPD, ameliorate inflammation and fibrosis and improve CRF efficiency in CCC-APT animals.

Conclusions:

Our study demonstrated that APT ameliorated cardiac dysfunction, MPD, and reduced inflammation and fibrosis in CCC hamster models. Additionally, CCC-SED animals presented skeletal muscle atrophy while CCC-APT animals showed preserved skeletal muscle CSA. Understanding APT’s effects on CCC’s pathophysiological dimensions is crucial for future research and therapeutic interventions.

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Original Article

De Novo Versus Upgrade Cardiac Resynchronization Therapy in Patients with Heart Failure: A Cohort Study

William Carvalho et al. Luíz Carlos Santana Passos Tainá Teixeira Viana Gustavo Pinheiro Santana … Jackson Pedro Barros-Pereira Fernanda Pinheiro Martin Tapioca Caio Rebouças Fonseca Cafezeiro

Abstract

Background:

Cardiac resynchronization therapy (CRT) is beneficial for patients with heart failure (HF) who have left bundle branch block. However, the benefits of CRT in patients with prior cardiac stimulation remain uncertain.

Objective:

Compare short-term mortality between upgrade and de novo CRT implantation.

Methods:

This prospective cohort study included patients with HF indicated for CRT with left ventricular ejection fraction (LVEF) below 35%. Overall survival was assessed using the Kaplan–Meier method, and multivariate analysis was performed using a Cox regression model.

Results:

A total of 412 patients were evaluated, with a mean follow-up of 59 ± 8 months. Of these, 104 patients were in the upgrade group, while 308 patients were included in the de novo group. Chagas disease was the most prevalent cause of HF, accounting for 148 cases (36%). While the de novo group progressed with an increase in LVEF (from 25% ± 6.7% to 28% ± 16.3%, p = 0.005), patients who underwent upgrade did not show a statistically significant difference in LVEF at 6 months (from 27.5% ± 6.9% to 27.5% ± 15.5%, p = 0.6). Overall mortality at 1 year was 122 cases (29.6%). In multivariate analysis, only LVEF and CRT upgrade remained independently associated with the outcome (hazard ratio: 0.93, confidence interval: 0.90 to 0.97, p = 0.001 and hazard ratio: 2.90, confidence interval: 1.21 to 7.10, p = 0.002, respectively).

Conclusion:

In this population with HF, the upgrade group was associated with higher 1-year mortality when compared with the de novo group.

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Editorial

Revisiting ICD Use in Chagas Cardiomyopathy: Current Evidence and Future Directions

André Carmo et al. Antônio Luiz Pinho Ribeiro

Chagas cardiomyopathy (ChC) is a chronic infectious heart disease that has recently been considered an infectious arrhythmogenic cardiomyopathy according to the HRS statement on this subject. After an acute phase, patients become chronically infected, displaying a wide range of presentations concerning heart disease, including heart failure, stroke, conduction abnormalities, atrial fibrillation, and ventricular arrhythmia. Sudden death is a mode of death of most patients with ChC, and implantable cardioverter-defibrillator (ICD) has been used as a preferred therapy, at least for secondary prevention, following recommendations similar to those of other cardiovascular diseases.

All information on the use of ICD in ChC comes from observational studies and, regarding death rates, two meta-analyses have evaluated this topic in different populations. The first meta-analysis, conducted by our group, found an annual mortality rate of 9.7% (95% CI: 5.7 to 13.7) in a population with ICD implanted exclusively for secondary prevention. The second meta-analysis, evaluating a mixed population of primary and secondary prevention, revealed a pooled annual all-cause mortality rate of 9.0%. These findings highlight the significant mortality risk in patients with ChC who have ICDs, emphasizing the importance of careful monitoring and management in this population.

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Giant Megacolon in Chagasic Cardiomyopathy: A Challenging Combination

Anderson Oliveira Estevan et al. Aguinaldo Freitas Jr.

This case concerns a 62-year-old man diagnosed with chagasic cardiomyopathy, presenting with a dilated and arrhythmogenic form, showing significant ventricular dysfunction, and currently undergoing cardiac resynchronization therapy with a previously implanted implantable cardioverter defibrillator. In the outpatient setting prior to admission, the patient’s medical records indicate recurrent ventricular arrhythmias and multiple appropriate shocks from the device over recent years.

Upon admission to the emergency department, the patient complained of severe asthenia, abdominal pain, postprandial vomiting, and choking persisting for a week. His current medication regimen included losartan 100 mg/day, carvedilol 50 mg/day, spironolactone 25 mg/day, empagliflozin 25 mg/day, furosemide 80 mg/day, acetylsalicylic acid 100 mg/day, and atorvastatin 40 mg/day. During the physical examination upon admission, a significant drop in general condition, cachexia, blood pressure of 84×57 mmHg, and heart rate of 93 bpm were observed. In addition to hypotension, cold extremities and prolonged capillary refill time were noted. There were no peripheral edema, jugular distension or pulmonary congestion. In addition, there was significant abdominal distension and pain on palpation. Based on the patient’s clinical history and physical examination findings, a diagnosis of acute obstructive abdomen and decompensated heart failure (HF) with an L-profile was determined.

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ABCIC

Review Article

Use of Three-Dimensional Echocardiography in the Analysis of Ventricular Function in Chagas Disease

Antonio Carlos Leite de Barros Filho et al. Minna Moreira Dias Romano

Abstract

Chagas disease is recognized as a global public health issue, capable of causing cardiac, digestive, and neurological manifestations. The echocardiogram is a fundamental complementary exam in assessing patients with cardiac involvement, evaluating various parameters of cardiac structure and function. This review aims to discuss the use of three-dimensional echocardiography in analyzing ventricular function in patients with Chagas disease.

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Case Report

Left Bundle Branch Area Pacing for Resynchronization in Chagasic Patient and Dependent on Artificial Cardiac Pacing. Case Report

Raoni de Castro Galvão et al. João Paulo Velasco Pucci Ofir Gomes Vieira Edvagner Leite Sérgio de Carvalho … Winder Marconsini Soares Guilherme Cunha dos S. Teles

Introduction

Persistent monosytic pacing of the right ventricle can cause deleterious effects on ventricular function. Patients with Chagas cardiomyopathy (CCM) with ventricular dysfunction, requiring artificial heart stimulation (AHS) may accelerate the progression to heart failure (HF) due to the underlying disease and the consequent ventricular dyssynchrony.

For over 20 years, cardiac resynchronization therapy (CRT) has been an established alternative in cardiology for the treatment of heart failure with reduced ejection fraction (LVEF) with intraventricular conduction disorder (especially LBBB).^, However, the effect of CRT on Chagas patients may not be as clear in relation to other heart diseases. The high degree of myocardial fibrosis, especially in the left ventricle (LV) lateral wall or other target regions for electrode placement, may be one of the factors that would explain this poor response to CRT.

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Editorial

Noninvasive Cardiac Radioablation for Chagas Heart Disease

Philip C. Wiener et al. Kaitlin M.S. Moore Carlos Contreras Clifford G. Robinson Phillip S. Cuculich

Chagas heart disease is a common cause of nonischemic cardiomyopathy in Latin America. It is caused by Trypanosoma cruzi, a parasite that causes acute myopericarditis and a more chronic fibrosing cardiomyopathy. In most studies, the most common overall cause of death is sudden cardiac arrest from arrhythmias (55–60%), followed by heart failure (25–30%) and embolic events (10–15%). implantable cardioverter-defibrillator (ICD) shocks save lives from ventricular arrhythmias but are painful and associated with accelerated patterns of heart failure and death. Catheter ablation can be an effective stop-gap therapy for many patients to minimize ICD shocks from ventricular tachycardia (VT). Because of the transmural patchy nature of scar associated with Chagas disease, the best results are achieved with mapping and ablating the scar from both the endocardial and epicardial surfaces in an effort to homogenize the scar. And, yet, for many patients, VT recurs, and with it comes more ICD shocks. Recurrences of VT can be the result of incompletely treated circuits within the scar or new circuits forming over time.

Scanavacca et al. here report the first use of an entirely noninvasive treatment by means of focused radiation in a patient with Chagas to minimize, then eliminate, VT. This therapy, known as stereotactic body radiation therapy (SBRT), has revolutionized the way that many patients with cancers are treated. SBRT is an ablative radiation modality employing advanced imaging technologies capable of accurately damaging a target tissue with a high dose of radiation, while sparing nearby normal tissues. Cardiac SBRT, or cardiac radioablation, requires close collaboration between heart rhythm, radiation oncology, and medical physics teams to develop precise and safe treatment plans within parts of scarred myocardium while avoiding healthy nearby structures. Recently, this technology has been used to treat patients with recurrent VT with promising results in patients with ischemic and various forms of nonischemic cardiomyopathies.^,

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Editorial

Defibrillation Threshold in Patients with Chronic Chagas’ Heart Disease: Are There Benefits or not Worth the Risk?

Ricardo Alkmim Teixeira

The implantable cardioverter-defibrillator (ICD) is the best therapeutic option to prevent sudden cardiac death for several high-risk groups of patients. Basically, the ICD can recognize and stop ventricular tachycardia (VT) and ventricular fibrillation (VF) by triggering anti-tachycardia pacing (ATP) or shock therapy. The defibrillation threshold (DT) is the minimum shock energy required to terminate VF.

Historically, testing the ICD function via induction and termination of VF was considered mandatory to ensure that the ICD could properly detect and stop the arrhythmic event.

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Original Article

Defibrillation Threshold Testing and Long-term Follow-up in Chagas Disease

Marco Paulo Cunha Campos et al. Luiz Fernando Gouveia Bernardes João Paulo Chaves de Melo Lucas Corsino dos Santos … Cristiano Honório Ribeiro Teixeira Maria Licia Ribeiro Cury Pavão Elerson Arfelli Adilson Scorzoni Filho Anis Rassi Jr José A. Marin-Neto André Schmidt

Abstract

Background

Sudden cardiac death is the most common cause of death in chronic Chagas cardiomyopathy (CCC). Because most CCC patients who are candidates for implantable cardioverter-defibrillators (ICD) meet criteria for high defibrillation threshold values, a defibrillator threshold test (DTT) is suggested.

Objectives

We investigated the use of DTT in CCC patients, focusing on deaths related to ICD and arrhythmic events, as well as treatment during long-term follow-up.

Methods

We retrospectively evaluated 133 CCC patients who received an ICD mainly for secondary prevention. Demographic, clinical, laboratory data, Rassi score, and DTT data were collected, with p < 0.05 considered significant.

Results

The mean patient age was 61 (SD, 13) years and 72% were men. The baseline left ventricular ejection fraction was 40 (SD, 15%) and the mean Rassi score was 10 (SD, 4). No deaths occurred during DTT and no ICD failures were documented. There was a relationship between higher baseline Rassi scores and higher DTT scores (ANOVA = 0.007). The mean time to first shock was 474 (SD, 628) days, although shock was only necessary for 28 (35%) patients with ventricular tachycardia, since most cases resolved spontaneously or through antitachycardia pacing. After a mean clinical follow-up of 1728 (SD, 1189) days, 43 deaths occurred, mainly related to progressive heart failure and sepsis.

Conclusions

A routine DTT may not be necessary for CCC patients who receive an ICD for secondary prevention. High DTT values seem to be unusual and may be related to high Rassi scores.

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Original Article

The Volume-Time Curve by Three-Dimensional Echocardiography in Chagas Cardiomyopathy: Insights into the Mechanism of Hemodynamic Adaptations

Airandes de Sousa Pinto et al. Maria Carmo Pereira Nunes Carlos Alberto Rodrigues Bráulio Muzzi Ribeiro de Oliveira … João da Rocha Medrado Neto Timothy C. Tan Manoel Otavio da Costa Rocha

Abstract

Background

Three-dimensional echocardiography (3D ECHO) allows the generation of a volume-time curve representative of changes in the left ventricular (LV) volume throughout the entire cardiac cycle.

Objective

This study aims to demonstrate the hemodynamic adaptations present in Chagas cardiomyopathy (CC) by means of the volume and flow measurements obtained by the volume-time curve by 3D ECHO.

Methods

Twenty patients with CC and 15 healthy subjects were prospectively enrolled in a cross-sectional design study. 3D ECHO was performed in all subjects and the volume over time curves of the LV was generated. The flow was obtained by the first derivative of the volume-time curve using the software MATLAB. Statistical significance was set at p<0.05.

Results

Although CC patients had lower LV ejection fraction compared to the control group (29.8±7.5 vs. 57.7±6.1, p<0.001), stroke volume (61.5±25.2 vs. 53.8±21.0, p=0.364) and maximum ejection flow during systole (-360.3±147.5 vs. -305.6±126.0, p=0.231) were similar between the groups. Likewise, the maximum flow in the early diastolic filling phase and during atrial contraction was similar between groups. An increase in preload expressed by LV end diastolic volume (204.8±79.4 vs. 93.0±32.6), p<0.001) may maintain the flow and stroke volumes similar to the controls.

Conclusion

Using a non-invasive tool, we demonstrated that an increase in LV end-diastolic volume may be the main adaptation mechanism that maintains the flow and stroke volumes in the setting of severe LV systolic dysfunction.

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Case Report

Young Patient with Chagas Disease Presenting Initially as Acute Chest Pain and Treated for Acute Coronary Syndrome

Jakson Ferreira Neto et al. Dannyl Roosevelt de Vasconcelos Lima Pedro Vinicius Amorim de Medeiros Patriota João Helbert Costa e Silva … Antônio Marconi Leandro da Silva Anderson da Costa Armstrong

Introduction

Chagas disease, a chronic and endemic condition in 21 countries within the Americas, affects approximately 6 million people. The northeast region has always been particularly important for the disease. According to data from the Mortality Information System (Sistema de Informação sobre Mortalidade), between 1980 and 2007, Brazil registered 156,224 deaths from Chagas disease; of them, 20,472 were in the northeast region and 3,144 occurred in Pernambuco.

Classic symptoms of Chagas disease can include chest pain, commonly typical for angina. Records of Chagas patients usually relate typical acute anginal pain to superimposed coronary artery disease. However, microcirculation disease has also been suggested as a chest pain trigger. Despite the high prevalence of Chagas heart disease in inland northeastern Brazil, coronary artery disease remains the main cause of heart failure and acute coronary syndromes.

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Editorial

The Importance of Assessing Malnutrition and Cachexia in Chagas Cardiomyopathy

Salvador Rassi et al. Daniela do Carmo Rassi Aguinaldo Figueiredo Freitas Júnior

Chagas cardiomyopathy, described by Carlos Chagas more than 100 years ago, is still a cause of significant morbidity and mortality, and has a negative effect on socioeconomic status of Latin America countries, including Brazil.

Malnutrition and cachexia in heart failure (HF), especially in Chagas disease patients, has a multifactorial etiology. Decreased food intake may be caused either by a reduced supply of foods to these usually underprivileged patients or by anorexia, which is common in this syndrome. Many factors may be involved in anorexia and weight loss, including tasteless food (mainly due to the low sodium diet) and due to visceral (mainly hepatic and intestinal) congestion. Hepatomegaly, usually dense, causes gastric discomfort due to left lobe enlargement and compression of the stomach. Pain in the right hypochondrium is caused by stretching of the liver capsule. Intestinal mucosal edema causes protein and fat malabsorption, ultimately affecting nutrition. Neuroendocrine and immunological changes are also involved in the development of cachexia in HF patients. Patients with cachexia have increased plasma levels of tumor necrosis factor-alpha (TNF-α) and other inflammatory cytokines, particularly interleukin (IL)-6 and IL-1. This results from bacterial translocation, in which abnormalities of the gastrointestinal tract are involved in the development of cachexia and systemic inflammation. Effects of these cytokines include proteolysis and loss of skeletal muscle mass, with aggravation of cachexia.

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Original Article

Undernutrition and Cachexia in Patients with Decompensated Heart Failure and Chagas Cardiomyopathy: Occurrence and Association with Hospital Outcomes

Larissa Candido Alves Tavares et al. Silvia Helena Gelás Lage Edimar Alcides Bocchi Victor Sarli Issa

Abstract

Background

Nutritional disorders are common among patients with heart failure (HF) and associated with poor prognosis. Importantly, some populations of patients, like the ones with Chagas disease, are frequently excluded from most analyses.

Objective

We sought to study the occurrence of undernutrition and cachexia in patients with Chagas disease during episodes of decompensated HF (DHF) as compared to other etiologies, and to investigate the influence of these findings on hospital outcomes.

Methods

We performed a consecutive case series study with patients hospitalized with DHF. Patients underwent the Subjective Global Assessment of nutritional status (SGA), besides anthropometric and laboratorial measures, and were evaluated for the occurrence of cachexia, low muscle mass and strength. We studied the occurrence of death or urgent heart transplantation during hospitalization.

Results

Altogether, 131 patients were analyzed and 42 (32.1%) had Chagas disease. Patients with Chagas disease had lower Body Mass Index (BMI) (22.4 kg/m²[19.9-25.3] vs. 23.6 kg/m2 [20.8-27.3], p=0.03), higher frequency of undernutrition (76.2% vs 55.1%, p=0.015) and higher occurrence of death or transplant (83.3% vs. 41.6%, p<0.001). We found that, in patients with Chagas etiology, the occurrence of death or cardiac transplantation were associated with undernutrition (3 [42.9%] patients with hospital discharge vs 29 [82.9%] patients with death or heart transplant, p=0.043).

Conclusions

Taken together, our results indicate that patients with Chagas disease hospitalized with DHF often present with nutritional disorders, especially undernutrition; importantly, this finding was associated with the occurrence of death and heart transplant during hospitalization.

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Case Report

Single Coronary Artery in Transplanted Heart: An Unusual Association

Thaís Rossana Cruz de Souza et al. Arthur Luiz Norte Gomes Pereira Araruna Cláudia do Nascimento Silva Fernandes Roberto Moreno Mendonça … Epitácio de Oliveira Belém Neto Robson Macedo

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Editorial

Diagnostic and Prognostic Importance of Functional Capacity in the Different Evolutionary Forms of Chagas Disease

João Marcos Barbosa-Ferreira et al. Charles Mady Fábio Fernandes

The manuscript published by Silva et al. in this issue brings us an important reflection on the evolution of the different forms of Chagas disease (CD), by demonstrating that patients with the indeterminate form (IF) have similar functional capacity, measured through peak oxygen uptake (VO₂peak), to healthy individuals without CD. On the other hand, patients with Chagas’ heart disease without ventricular dysfunction had similar functional capacity to patients with ventricular dysfunction.

The IF of CD has been studied under different aspects for several years. Some studies in asymptomatic patients that are included in the definition of IF for not presenting electrocardiographic and chest X-ray alterations, demonstrated incipient alterations in complementary exams that may suggest the possibility of evolution to the more severe forms of CD over the years. Evaluations made through echocardiography showed alterations in variables such as tissue Doppler and study of myocardial deformity through two-dimensional strain.^, There has also been demonstration of changes in the Autonomic Nervous System, especially in the parasympathetic branch, which can be potential pathways for worsening in the stage disease over the years.^, Studies performed with magnetic resonance have demonstrated the presence of myocardial fibrosis in 12% of patients with IF of the disease. However, despite these small changes, the long-term evolution of these patients has been shown favorable and similar to that of healthy individuals without CD. Ianni et al. studied patients with the IF based on ECG findings for 8 years and concluded that the IF of CD represents a benign condition with a favorable long-term prognosis. However, in a small group of patients, there may be evolution for chronic Chagas cardiopathy (CCC) or digestive tract disease in about 10 to 20 years after acute infection. Sabino et al., in a 10-year retrospective cohort study, suggested a rate of progression to cardiomyopathy of 1.85% per year in patients with FI of the disease. Therefore, studies that identify markers that can predict the possibility of this evolution are needed and the evaluation of the functional capacity of these patients is important in this aspect.

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Original Article

Cardiac Fibrosis and Changes in Left Ventricle Function in Patients with Chronic Chagas Heart Disease

João Bosco de Figueiredo Santos et al. Ilan Gottlieb Eduardo Marinho Tassi Gabriel Cordeiro Camargo … Jacob Atié Sérgio Salles Xavier Roberto Coury Pedrosa Roberto Magalhães Saraiva

Abstract

Background

Chagas heart disease (CHD) is a slow progressing condition with fibrosis as the main histopathological finding.

Objectives

To study if cardiac fibrosis increases over time and correlates with increase in left ventricular (LV) size and reduction of ejection fraction (EF) in chronic CHD.

Methods

Retrospective study that included 20 individuals (50% men; 60±10 years) with chronic CHD who underwent two cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement with a minimum interval of four years between tests. LV volume, EF, and fibrosis mass were determined by cardiac MRI. Associations of fibrosis mass at the first cardiac MRI and changes in LV volume and EF at the second cardiac MRI were tested using logistic regression analysis. P values <0.05 were considered significant.

Results

Patients were classified as follows: A (n=13; changes typical of CHD in the electrocardiogram and normal global and segmental LV systolic function) and B1 (n=7; LV wall motion abnormality and EF≥45%). Mean time between cardiac MRI studies was 5.4±0.5 years. LV fibrosis (in %LV mass) increased from 12.6±7.9% to 18.0±14.1% between MRI studies (p=0.02). Cardiac fibrosis mass at baseline was associated with decrease in >5 absolute units in LV EF from the first to the second MRI (OR 1.48, 95% CI 1.03-2.13, p=0.03). LV fibrosis mass was larger and increased between MRI studies in the group that presented decrease in LV EF between the tests.

Conclusions

Even patients at an initial stage of CHD show an increase in myocardial fibrosis over time, and the presence of LV fibrosis at baseline is associated with a decrease in LV systolic function.

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Original Article

Determinants of Functional Capacity in Patients with Chagas Disease

Whesley Tanor Silva et al. Henrique Silveira Costa Pedro Henrique Scheidt Figueiredo Márcia Maria Oliveira Lima … Vanessa Pereira Lima Fábio Silva Martins da Costa Matheus Ribeiro Ávila Vanessa Amaral Mendonça Ana Cristina Rodrigues Lacerda Maria Carmo Pereira Nunes Manoel Otávio Costa Rocha

Abstract

Background:

Chagas disease leads to reduced functional capacity. However, the stage at which functional impairment is detectable remains unclear.

Objectives:

The present study was addressed to compare the functional capacity of patients at different stages of Chagas disease and healthy individuals and to verify the determinants of peak oxygen uptake (VO2peak).

Methods:

In a cross-sectional study, 160 individuals were selected, 35 healthy and 125 with Chagas disease. In the Chagasic group, 61 (49%) were in the indeterminate form of the disease, 45 (36%) with Chagas cardiomyopathy (ChC) and preserved cardiac function and 19 (15%) with cardiac dysfunction and dilated ChC. The data were analyzed using univariate and multivariate regression analysis. Statistical significance was set at 5%.

Results:

Patients in the indeterminate form of disease showed similar functional capacity to healthy individuals (p>0.05). Patients with ChC and preserved cardiac function had lower VO2peak than patients in the indeterminate form (p<0.05), but showed similar VO2peak values than dilated ChC (p=0.46). The age, male sex, NYHA functional class, diastolic blood pressure, ratio of the early diastolic transmitral flow velocity to early diastolic mitral annular velocity, left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter were associated with functional capacity. However, only age, male sex, LVEF and NYHA functional class, remained associated with VO2peak in the final model (adjusted R2=0.60).

Conclusion:

Patients with ChC had lower functional capacity than patients in the indeterminate form. LVEF, age, male sex and NYHA functional class were determinants with VO2peak in patients with Chagas disease.

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Special Article

Chagas Disease: Are Kissing Bugs the Only Culprit?

Abilio Augusto Fragata Filho

Preface

Chagas disease, first described by Carlos Chagas in 1909, is caused by a single-celled parasite (Trypanosoma cruzi). Throughout history, the main mechanism of transmission has been via contact with the feces of an insect infected with the parasite. This insect, known as the “kissing bug” in English, is popularly known as “barbeiro,” “chupão,” or “chupança” in Brazil. The “kissing bugs” are not born with the parasite in their intestine; rather, they acquire it by feeding on the blood of infected mammals. (This disease only affects mammals). When taking a blood meal, the insects eliminate feces, where the parasites are present, and the parasites can contaminate the bite, allowing the parasite to enter the organism. In this manner, the disease begins. The kissing bugs mainly make their nests in cracks in clay walls of houses made in a style known as “pau-a-pique” in Brazil. These houses are very common in diverse regions of Brazil, especially throughout the sertão of the Northeast Region. Other mechanisms of transmission can occur, for example, via blood transfusion, organ donation, mother-to-child transmission, ingestion of contaminated foods, etc.

During the acute phase of the disease, complaints may be mild or even non-existent. They may include general manifestations, such as low fever, malaise or more severe ones, such as shortness of breath and swelling. As bites from kissing bugs usually occur on the face, swelling of the eyebrows, known as the Romaña sign, may occur. As the years pass, generally after 10 years or more, cardiac complaints appear in one third of patients, such as fatigue, shortness of breath, and swelling in the body (heart failure). In some cases, the electrical system of the heart may be compromised, with alterations in cardiac rhythm, fainting, and even sudden death. Dilatation of the esophagus and the colon can also occur, with progressive difficulty in swallowing food and defecating.

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