Schistosomiasis – ABC CARDIOL

ABCIC

Editorial

The Use of Echocardiography in Schistosomiasis

Schistosomiasis, a neglected tropical disease, affects 240 million people worldwide, with more than 90% of cases reported in Africa, according to the World Health Organization. The disease is endemic to South America, the Caribbean, Southeast Asia, and Africa, in areas with little infrastructure, especially lack of drinking water and basic sanitation. The infection is caused by helminths of the genus Schistosoma. Contamination occurs through contact with water where host snails are present. After penetrating human skin, the worms can migrate and produce eggs in the liver, lungs, and intestines.

During the acute phase, patients may be asymptomatic or develop myocarditis and pericarditis related to an allergic reaction to the schistosomes, in which eosinophils play an important role. Myocardial ischemia may rarely occur, and the exact mechanism remains unknown.

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ABCIC

Original Article

Long-Term Evolution of Patients with Important Pulmonary Hypertension due to Schistosomiasis

José Maria Del Castillo et al. Katarina Barros de Oliveira Rafael Ricardo de Oliveira Travassos Ângela Maria Pontes Bandeira … Carlos Antônio da Mota Silveira Djair Brindeiro Filho

Abstract

Introduction

Hepatosplenic schistosomiasis mansoni, associated with pulmonary arterial hypertension (PAH), causes cardiac chamber remodeling. Little is known about its long-term evolution.

Objective

To evaluate the alterations caused by PAH in patients with schistosomiasis and analyze the clinical and echocardiographic evolution over a period of 10 years.

Methods

The study included 60 patients with PAH due to schistosomiasis and 50 healthy control patients. Clinical and echocardiographic data were evaluated, including dimensions, parietal thickness, function of the right and left chambers, and parameters of myocardial strain. Patients in the group with PAH due to schistosomiasis were followed for 10 years. Data were compared using Student’s t test for unpaired samples with significance level of < 5%.

Results

Patients with PAH had smaller left ventricular dimension without alteration in the ejection fraction, but with decreased left ventricular global longitudinal strain and left atrial reservoir strain. The right ventricular dimensions and parietal thickness were increased, and the parameters of systolic function (tricuspid annular plane systolic excursion, fractional area change, tricuspid s’ wave, and the right ventricular global longitudinal strain) were significantly reduced. During the follow-up period, 18 patients (32%) died, and death was associated with higher functional class, decreased right ventricular longitudinal strain, larger right ventricular size, decreased fractional area change, and decreased tricuspid annular s’ wave velocity.

Conclusion

PAH related to schistosomiasis causes remodeling of the right chambers, with decreased parameters of systolic function and myocardial strain. The long-term evolution, with elevated mortality, presents with larger right ventricular dimensions, lower fractional area change, lower tricuspid annular systolic velocity, lower right ventricular global longitudinal strain, and more advanced functional class.

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Original Article

Schistosomiasis & Heart – On Behalf of the Neglected Tropical Diseases and other Infectious Diseases affecting the Heart (the NET-Heart Project)

Edith Liliana Posada-Martínez et al. Luis Gerardo Gonzalez-Barrera Kiera Liblik Juan Esteban Gomez-Mesa … Clara Saldarriaga Juan Maria Farina Josefina Parodi Zier Zhou Manuel Martinez-Selles Adrian Baranchuk

Abstract

Background

Schistosomiasis is a Neglected Tropical Disease which may lead to cardiovascular (CV) complications. However, the CV involvement in schistosomiasis has yet to be fully elucidated due to the limited number of cases and lack of reliable evidence, as schistosomiasis typically occurs in locations without adequate infrastructure for robust data collection.

Objective

This systematic review aims to assess cardiovascular implications of schistosomiasis, including in the diagnosis and treatment, and propose an algorithm for screening of CV manifestations.

Methods

A systematic review was performed in the MEDLINE/PubMed and LILACS databases of articles on the CV involvement in schistosomiasis.

Results

Thirty-three records were considered for this review: six review articles, one systematic review, one clinical trial, 14 observational studies, seven case reports, and four cases series. CV involvement includes a wide spectrum of clinical conditions, such as myocardial ischemia, ventricular dysfunction, myocarditis, pulmonary arterial hypertension, and pericarditis.

Conclusions

Cardiac complications of schistosomiasis may cause long-term disability and death. Clinical monitoring, physical examination, early electrocardiogram, and echocardiogram should be considered as key measures to detect CV involvement. Due to the lack of effective treatment of complications, sanitation and education in endemic areas are necessary for the elimination of this global health problem.

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Editorial

Transesophageal Echocardiogram with Contrast in Pulmonary Intravascular Dilation in Hepatosplenic Schistosomiasis

Sandra Nívea dos Reis Saraiva Falcão

The Hepatopulmonary syndrome (HPS) is defined as a defect in arterial oxygenation induced by intrapulmonary vascular dilation (IPVD) associated with liver disease. The vascular component includes diffuse or localized capillary dilation and, less commonly, pulmonary arteriovenous malformations.

A sensitive approach for the early detection of altered arterial oxygenation is the calculation of the alveolar-arterial oxygen pressure difference (PA-aO₂). This difference can be elevated before arterial oxygen pressure becomes abnormal. At sea level, PA-aO₂ ≥ 15 mmHg is considered abnormal (it changes to 20 mmHg in individuals over 64 years).

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Original Article

Value of Contrast Transesophageal Echocardiography in the Detection of Intrapulmonary Vascular Dilatations in Hepatosplenic Schistosomiasis

Aparecida de Gouvea et al. Claudio Henrique Fischer Jaquelina Sonoe Ota Arakaki Frederico José Mancuso … Paulo Brant Valdir Ambrósio Moisés Orlando Campos Filho

Abstract

Background:

Hepatopulmonary syndrome (HPS), found in cirrhotic patients, has been little studied in hepatosplenic schistosomiasis (HSS) and includes the occurrence of intrapulmonary vascular dilatations (IPVD). Contrast transesophageal echocardiography (cTEE) with microbubbles is more sensitive than contrast transthoracic echocardiography (cTTE) with microbubbles in the detection of IPVD in cirrhosis.

Objective:

To assess the performance of the cTEE, compared with that of cTTE, in detecting IPVD for the diagnosis of HPS in patients with HSS.

Methods:

cTEE and cTTE for investigation of IPVD and laboratory tests were performed in 22 patients with HSS. Agitated saline solution was injected in peripheral vein during the cTEE and cTTE procedures. Late appearance of the microbubbles in the left chambers indicated the presence of IPVD. Results of the two methods were compared by the Student’s t-test and the chi-square test (p < 0.05).

Results:

cTEE was performed in all patients without complications. Three patients were excluded due to the presence of patent foramen ovale (PFO). The presence of IPVD was confirmed in 13 (68%) of 19 patients according to the cTEE and in only six (32%, p < 0.01) according to the cTTE. No significant differences in clinical or laboratory data were found between the groups with and without IPVD, including the alveolar-arterial gradient. The diagnosis of HPS (presence of IPVD with changes in the arterial blood gas analysis) was made in five patients by the cTEE and in only one by the cTTE (p = 0.09).

Conclusion:

In HSS patients, cTEE was safe and superior to cTTE in detecting IPVD and allowed the exclusion of PFO.

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Artigo Original

Pulmonary artery pressure, gender, menopause, and pregnancy in schistosomiasis-associated pulmonary hypertension

Anderson C. Armstrong et al. Ângela M. P. Bandeira Luis C. L. Correia Humberto C. O. Melo … Carlos A. M. Silveira Eugênio Albuquerque Jeová C. Moraes Jr Antônio M. L. Silva João A. C. Lima Dário C. Sobral Filho

BACKGROUND: Schistosomiasis-associated pulmonary arterial hypertension (SPAH) is a major concern worldwide. However, the role of gender-specific contributing factors in SPAH is unknown. OBJECTIVE: We investigated how systolic pulmonary artery pressure (SPAP) values and the presence of severe SPAP relate to gender, menopausal status, and pregnancy history in SPAH patients. METHODS: Seventy-nine patients diagnosed with SPAH from 2000 to 2009 were assessed and 66 were enrolled in the study. Information about age, menopausal status, pregnancy, echocardiography-derived SPAP, and invasive mean pulmonary artery pressure (mPAP) was collected from medical records. The relation between values of SPAP and mPAP and their agreement for severe disease were assessed. Regression models assessed the association of gender, menopausal status, and pregnancy history with SPAP values and the presence of severe SPAP. RESULTS: Moderate correlation and good agreement for severe disease were found between mPAP and SPAP. Mean SPAP values were similar for men and women. A trend toward higher values of SPAP was found for non-menopausal women compared to men. Higher SPAP values were found for menopausal compared to non-menopausal women; the values were non-significant after adjustment for age. Pregnancy history had no association with SPAP. Menopause and positive pregnancy had no association with severe SPAP. CONCLUSION: In SPAH patients, neither gender, nor menopausal status, nor pregnancy history showed independent correlation with SPAP values assessed by echocardiography.

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Review Article

Echocardiography in chronic liver disease: systematic review

Vitor Gomes Mota et al. Brivaldo Markman Filho

BACKGROUND: Doppler echocardiography (Echo) is a non-invasive method of excellent accuracy to screen portopulmonary hypertension (PPH) and to assess intrapulmonary shunts (IPS) in chronic liver disease (CLD). In the past decade, Echo proved to play a fundamental role in the diagnosis of cirrhotic cardiomyopathy (CCM). OBJECTIVE: To perform a systematic review of relevant articles on the subject ‘Echo in CLD’. METHODS: In November 2011, a systematic review was performed in the PubMed, LILACS and SciELO databases, and the characteristics of the studies selected were reported. RESULTS: The search based on descriptors and free terms obtained 204 articles (179 in Pubmed, 21 in LILACS, and 1 in SciELO). Of those 204 articles, 22 were selected for systematic review. A meta-analysis could not be performed because of the heterogeneity of the articles. CONCLUSIONS: Echo should be part of CLD stratification for screening PPH, IPS and CCM, because, most of the time, such complications are diagnosed only when patients are already waiting for a liver transplant.

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Artigo Original

Hemodynamic profile of severity at pulmonary vasoreactivity test in schistosomiasis patients

Flávio A. A. Japyassú et al. Adriano A. Mendes Ângela P. Bandeira Flávio R. A. Oliveira Dário Sobral Filho

BACKGROUND: The pulmonary vasoreactivity rate of Schistosomal Pulmonary Artery Hypertension (SPAH) is not known. Hemodynamic data obtained by cardiac catheterization are associated with the most commonly used clinical criteria of severity. OBJECTIVE: To estimate the percentage of positive vasoreactivity to nitric oxide in schistosomal pulmonary arterial hypertension and verify the association of hemodynamic parameters with WHO functional classification and the six-minute walk test in these patients. METHODS: A total of 84 patients with schistosomal pulmonary hypertension were selected from a database, who had been submitted to the right and left cardiac catheterization and pulmonary vasoreactivity test with nitric oxide. Data on WHO functional classification and six-minute walk test were collected for comparison with invasive data. RESULTS: Of the 84 patients with SPAH, 3 (3.5%) had positive criteria for pulmonary vasoreactivity. The increase in pulmonary vascular resistance was significantly associated with lower exercise capacity measured by the six-minute walk test (p = 0.045) and greater symptom severity by higher functional classifications (WHO class III/IV) (p = 0.013). The decrease in oxygen saturation in the pulmonary artery was significantly associated with higher functional classifications (p = 0.041). CONCLUSION: The pulmonary response rate to the vasodilation test of schistosomiasis patients is below the values found for idiopathic pulmonary hypertension. Pulmonary vascular resistance and oxygen saturation in the pulmonary artery are hemodynamic data that can be used as markers of severity in schistosomal pulmonary hypertension.

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Artigo Original

Etiological frequency of pulmonary hypertension in a reference outpatient clinic in Bahia, Brazil

Cesar Machado et al. Ísis Brito Denile Souza Luis Cláudio Correia

BACKGROUND: Pulmonary hypertension (PH) results from several etiologies, with possible geographic influences; however, few studies have described the etiological frequency of PH, especially in our country. It is not clear whether there is an association between etiology and pulmonary pressure level or symptom intensity. OBJECTIVES: 1) to describe the etiological prevalence of PH in the state of Bahia, Brazil; 2) to evaluate whether the etiology is a determinant factor for the pulmonary pressure level; 3) to evaluate whether the etiology is a determinant factor for functional class; 4) to identify the other predictors of pulmonary pressure level and functional class. METHODS: The present was an observational, cross-sectional study that analyzed individuals with PH treated at the Magalhaes Neto Outpatient Clinic, between June 2005 and December 2007. PH was defined as pulmonary artery systolic pressure (PASP) > 40 mmHg measure at the echocardiogram. Patients with chronic obstructive pulmonary disease or ventricular disease were excluded from the study. RESULTS: A total of 48 patients with PASP = 86 ± 24 mmHg were studied. Regarding the etiology, 42% of the patients were classified as idiopathic, followed by 25% as schistosomatic, 19% as congenital cardiopathy and 10% of chronic pulmonary embolism. A longer time of disease predicted higher pressures in patients with cardiopathy. Individuals with schistosomiasis had the best functional performance when compared to the others (456 ± 58 vs. 299 ± 138 meters, p=0.005). The schistosomatic etiology and younger age presented better functional class. CONCLUSIONS: 1) the idiopathic classification is the most prevalent, with schistosomiasis being the most frequent specific cause in our country; 2) patients with schistosomatic etiology and of younger age present better functional class. 3) the congenital cardiopathy results in a higher pressure level in the pulmonary artery, probably due to the longer duration of the disease.

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