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Furquim SR, Galbiati LC, Avila MS, Marcondes-Braga FG, Fukushima J, Mangini S, Seguro LFBDC, Campos IWD, Strabelli TMV, Barone F, Paulo ARDSAD, Ohe LA, Galante MC, Gaiotto FA, Bacal F. Survival of Heart Transplant Patients with Chagas' Disease Under Different Antiproliferative Immunosuppressive Regimens. Arq Bras Cardiol 2023; 120:e20230133. [PMID: 37909604 PMCID: PMC10586812 DOI: 10.36660/abc.20230133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/06/2023] [Accepted: 08/16/2023] [Indexed: 11/03/2023] Open
Abstract
Chagas' disease (CD) is an important cause of heart transplantation (HT). The main obstacle is Chagas' disease reactivation (CDR), usually associated to high doses of immunosuppressants. Previous studies have suggested an association of mycophenolate mofetil with increased CDR. However, mortality predictors are unknown. To identify mortality risk factors in heart transplant patients with CD and the impact of antiproliferative regimen on survival. Retrospective study with CD patients who underwent HT between January 2004 and September 2020, under immunosuppression protocol that prioritized azathioprine and change to mycophenolate mofetil in case of rejection. We performed univariate regression to identify mortality predictors; and compared survival, rejection and evidence of CDR between who received azathioprine, mycophenolate mofetil and those who changed from azathioprine to mycophenolate mofetil after discharge ("Change" group). A p-value < 0.05 was considered statistically significant. Eighty-five patients were included, 54.1% men, median age 49 (39-57) years, and 91.8% were given priority in waiting list. Nineteen (22.4%) used azathioprine, 37 (43.5%) mycophenolate mofetil and 29 (34.1%) switched therapy; survival was not different between groups, 2.9 (1.6-5.0) x 2.9 (1.8-4.8) x 4.2 (2.0-5.0) years, respectively; p=0.4. There was no difference in rejection (42%, 73% and 59% respectively; p=0.08) or in CDR (T. cruzi positive by endomyocardial biopsy 5% x 11% x 7%; p=0.7; benznidazole use 58% x 65% x 69%; p=0.8; positive PCR for T. cruzi 20% x 68% x 42% respectively; p=0.1) rates. This retrospective study did not show difference in survival in heart transplant patients with CD receiving different antiproliferative regimens. Mycophenolate mofetil was not associated with statistically higher rates of CDR or graft rejection in this cohort. New randomized clinical trials are necessary to address this issue.
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Affiliation(s)
- Silas Ramos Furquim
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Luana Campoli Galbiati
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Monica S Avila
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Fabiana G Marcondes-Braga
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Julia Fukushima
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Sandrigo Mangini
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Iascara Wozniak de Campos
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Tania Mara Varejão Strabelli
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Fernanda Barone
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Luciana Akutsu Ohe
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Mariana Cappelletti Galante
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Fabio Antonio Gaiotto
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Fernando Bacal
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
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2
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Marin-Neto JA, Rassi A, Oliveira GMM, Correia LCL, Ramos Júnior AN, Luquetti AO, Hasslocher-Moreno AM, Sousa ASD, Paola AAVD, Sousa ACS, Ribeiro ALP, Correia Filho D, Souza DDSMD, Cunha-Neto E, Ramires FJA, Bacal F, Nunes MDCP, Martinelli Filho M, Scanavacca MI, Saraiva RM, Oliveira Júnior WAD, Lorga-Filho AM, Guimarães ADJBDA, Braga ALL, Oliveira ASD, Sarabanda AVL, Pinto AYDN, Carmo AALD, Schmidt A, Costa ARD, Ianni BM, Markman Filho B, Rochitte CE, Macêdo CT, Mady C, Chevillard C, Virgens CMBD, Castro CND, Britto CFDPDC, Pisani C, Rassi DDC, Sobral Filho DC, Almeida DRD, Bocchi EA, Mesquita ET, Mendes FDSNS, Gondim FTP, Silva GMSD, Peixoto GDL, Lima GGD, Veloso HH, Moreira HT, Lopes HB, Pinto IMF, Ferreira JMBB, Nunes JPS, Barreto-Filho JAS, Saraiva JFK, Lannes-Vieira J, Oliveira JLM, Armaganijan LV, Martins LC, Sangenis LHC, Barbosa MPT, Almeida-Santos MA, Simões MV, Yasuda MAS, Moreira MDCV, Higuchi MDL, Monteiro MRDCC, Mediano MFF, Lima MM, Oliveira MTD, Romano MMD, Araujo NNSLD, Medeiros PDTJ, Alves RV, Teixeira RA, Pedrosa RC, Aras Junior R, Torres RM, Povoa RMDS, Rassi SG, Alves SMM, Tavares SBDN, Palmeira SL, Silva Júnior TLD, Rodrigues TDR, Madrini Junior V, Brant VMDC, Dutra WO, Dias JCP. SBC Guideline on the Diagnosis and Treatment of Patients with Cardiomyopathy of Chagas Disease - 2023. Arq Bras Cardiol 2023; 120:e20230269. [PMID: 37377258 PMCID: PMC10344417 DOI: 10.36660/abc.20230269] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Affiliation(s)
- José Antonio Marin-Neto
- Universidade de São Paulo , Faculdade de Medicina de Ribeirão Preto , Ribeirão Preto , SP - Brasil
| | - Anis Rassi
- Hospital do Coração Anis Rassi , Goiânia , GO - Brasil
| | | | | | | | - Alejandro Ostermayer Luquetti
- Centro de Estudos da Doença de Chagas , Hospital das Clínicas da Universidade Federal de Goiás , Goiânia , GO - Brasil
| | | | - Andréa Silvestre de Sousa
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | | | - Antônio Carlos Sobral Sousa
- Universidade Federal de Sergipe , São Cristóvão , SE - Brasil
- Hospital São Lucas , Rede D`Or São Luiz , Aracaju , SE - Brasil
| | | | | | | | - Edecio Cunha-Neto
- Universidade de São Paulo , Faculdade de Medicina da Universidade, São Paulo , SP - Brasil
| | - Felix Jose Alvarez Ramires
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Fernando Bacal
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | - Martino Martinelli Filho
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Maurício Ibrahim Scanavacca
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Roberto Magalhães Saraiva
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | | | - Adalberto Menezes Lorga-Filho
- Instituto de Moléstias Cardiovasculares , São José do Rio Preto , SP - Brasil
- Hospital de Base de Rio Preto , São José do Rio Preto , SP - Brasil
| | | | | | - Adriana Sarmento de Oliveira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | - Ana Yecê das Neves Pinto
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | | | - Andre Schmidt
- Universidade de São Paulo , Faculdade de Medicina de Ribeirão Preto , Ribeirão Preto , SP - Brasil
| | - Andréa Rodrigues da Costa
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | - Barbara Maria Ianni
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | - Carlos Eduardo Rochitte
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
- Hcor , Associação Beneficente Síria , São Paulo , SP - Brasil
| | | | - Charles Mady
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Christophe Chevillard
- Institut National de la Santé Et de la Recherche Médicale (INSERM), Marselha - França
| | | | | | | | - Cristiano Pisani
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | | | | | - Edimar Alcides Bocchi
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Evandro Tinoco Mesquita
- Hospital Universitário Antônio Pedro da Faculdade Federal Fluminense , Niterói , RJ - Brasil
| | | | | | | | | | | | - Henrique Horta Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
| | - Henrique Turin Moreira
- Hospital das Clínicas , Faculdade de Medicina de Ribeirão Preto , Universidade de São Paulo , Ribeirão Preto , SP - Brasil
| | | | | | | | - João Paulo Silva Nunes
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
- Fundação Zerbini, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | | | | | | | | | - Luiz Cláudio Martins
- Universidade Estadual de Campinas , Faculdade de Ciências Médicas , Campinas , SP - Brasil
| | | | | | | | - Marcos Vinicius Simões
- Universidade de São Paulo , Faculdade de Medicina de Ribeirão Preto , Ribeirão Preto , SP - Brasil
| | | | | | - Maria de Lourdes Higuchi
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | - Mauro Felippe Felix Mediano
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brasil
| | - Mayara Maia Lima
- Secretaria de Vigilância em Saúde , Ministério da Saúde , Brasília , DF - Brasil
| | | | | | | | | | - Renato Vieira Alves
- Instituto René Rachou , Fundação Oswaldo Cruz , Belo Horizonte , MG - Brasil
| | - Ricardo Alkmim Teixeira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | - Roberto Coury Pedrosa
- Hospital Universitário Clementino Fraga Filho , Instituto do Coração Edson Saad - Universidade Federal do Rio de Janeiro , RJ - Brasil
| | | | | | | | | | - Silvia Marinho Martins Alves
- Ambulatório de Doença de Chagas e Insuficiência Cardíaca do Pronto Socorro Cardiológico Universitário da Universidade de Pernambuco (PROCAPE/UPE), Recife , PE - Brasil
| | | | - Swamy Lima Palmeira
- Secretaria de Vigilância em Saúde , Ministério da Saúde , Brasília , DF - Brasil
| | | | | | - Vagner Madrini Junior
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP - Brasil
| | | | | | - João Carlos Pinto Dias
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz , Rio de Janeiro , RJ - Brasil
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Long-term Survival Following Heart Transplantation for Chagas Versus Non-Chagas Cardiomyopathy: A Single-center Experience in Northeastern Brazil Over 2 Decades. Transplant Direct 2022; 8:e1349. [PMID: 35774419 PMCID: PMC9236606 DOI: 10.1097/txd.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/06/2022] [Indexed: 11/25/2022] Open
Abstract
Data on post–heart transplant (HT) survival of patients with Chagas cardiomyopathy (CC) are scarce. We sought to evaluate post-HT survival in patients with CC as compared with other causes of heart failure across different eras of HT.
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Pino-Marín A, Medina-Rincón GJ, Gallo-Bernal S, Duran-Crane A, Arango Duque ÁI, Rodríguez MJ, Medina-Mur R, Manrique FT, Forero JF, Medina HM. Chagas Cardiomyopathy: From Romaña Sign to Heart Failure and Sudden Cardiac Death. Pathogens 2021; 10:505. [PMID: 33922366 PMCID: PMC8145478 DOI: 10.3390/pathogens10050505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 12/16/2022] Open
Abstract
Despite nearly a century of research and accounting for the highest disease burden of any parasitic disease in the Western Hemisphere, Chagas disease (CD) is still a challenging diagnosis, primarily due to its poor recognition outside of Latin America. Although initially considered endemic to Central and South America, globalization, urbanization, and increased migration have spread the disease worldwide in the last few years, making it a significant public health threat. The international medical community's apparent lack of interest in this disease that was previously thought to be geographically restricted has delayed research on the complex host-parasite relationship that determines myocardial involvement and its differential behavior from other forms of cardiomyopathy, particularly regarding treatment strategies. Multiple cellular and molecular mechanisms that contribute to degenerative, inflammatory, and fibrotic myocardial responses have been identified and warrant further research to expand the therapeutic arsenal and impact the high burden attributed to CD. Altogether, cardiac dysautonomia, microvascular disturbances, parasite-mediated myocardial damage, and chronic immune-mediated injury are responsible for the disease's clinical manifestations, ranging from asymptomatic disease to severe cardiac and gastrointestinal involvement. It is crucial for healthcare workers to better understand CD transmission and disease dynamics, including its behavior on both its acute and chronic phases, to make adequate and evidence-based decisions regarding the disease. This review aims to summarize the most recent information on the epidemiology, pathogenesis, clinical presentation, diagnosis, screening, and treatment of CD, emphasizing on Chagasic cardiomyopathy's (Ch-CMP) clinical presentation and pathobiological mechanisms leading to sudden cardiac death.
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Affiliation(s)
- Antonia Pino-Marín
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 110131, Colombia; (G.J.M.-R.); (S.G.-B.); (M.J.R.); (J.F.F.); (H.M.M.)
| | - Germán José Medina-Rincón
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 110131, Colombia; (G.J.M.-R.); (S.G.-B.); (M.J.R.); (J.F.F.); (H.M.M.)
| | - Sebastian Gallo-Bernal
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 110131, Colombia; (G.J.M.-R.); (S.G.-B.); (M.J.R.); (J.F.F.); (H.M.M.)
- Division of Cardiology, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia; (R.M.-M.); (F.T.M.)
| | - Alejandro Duran-Crane
- Internal Medicine Residency Program, Cleveland Clinic Foundation, Cleveland, OH 44195, USA;
| | - Álvaro Ignacio Arango Duque
- Department of Infectious Diseases, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia;
| | - María Juliana Rodríguez
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 110131, Colombia; (G.J.M.-R.); (S.G.-B.); (M.J.R.); (J.F.F.); (H.M.M.)
- Division of Cardiology, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia; (R.M.-M.); (F.T.M.)
| | - Ramón Medina-Mur
- Division of Cardiology, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia; (R.M.-M.); (F.T.M.)
| | - Frida T. Manrique
- Division of Cardiology, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia; (R.M.-M.); (F.T.M.)
| | - Julian F. Forero
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 110131, Colombia; (G.J.M.-R.); (S.G.-B.); (M.J.R.); (J.F.F.); (H.M.M.)
- Division of Radiology, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia
| | - Hector M. Medina
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 110131, Colombia; (G.J.M.-R.); (S.G.-B.); (M.J.R.); (J.F.F.); (H.M.M.)
- Division of Cardiology, Fundación Cardio-Infantil-Instituto de Cardiología, Bogotá 110131, Colombia; (R.M.-M.); (F.T.M.)
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Bouton J, Ferreira de Almeida Fiuza L, Cardoso Santos C, Mazzarella MA, Soeiro MDNC, Maes L, Karalic I, Caljon G, Van Calenbergh S. Revisiting Pyrazolo[3,4- d]pyrimidine Nucleosides as Anti- Trypanosoma cruzi and Antileishmanial Agents. J Med Chem 2021; 64:4206-4238. [PMID: 33784107 DOI: 10.1021/acs.jmedchem.1c00135] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Chagas disease and visceral leishmaniasis are two neglected tropical diseases responsible for numerous deaths around the world. For both, current treatments are largely inadequate, resulting in a continued need for new drug discovery. As both kinetoplastid parasites are incapable of de novo purine synthesis, they depend on purine salvage pathways that allow them to acquire and process purines from the host to meet their demands. Purine nucleoside analogues therefore constitute a logical source of potential antiparasitic agents. Earlier optimization efforts of the natural product tubercidin (7-deazaadenosine) involving modifications to the nucleobase 7-position and the ribofuranose 3'-position led to analogues with potent anti-Trypanosoma brucei and anti-Trypanosoma cruzi activities. In this work, we report the design and synthesis of pyrazolo[3,4-d]pyrimidine nucleosides with 3'- and 7-modifications and assess their potential as anti-Trypanosoma cruzi and antileishmanial agents. One compound was selected for in vivo evaluation in an acute Chagas disease mouse model.
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Affiliation(s)
- Jakob Bouton
- Laboratory for Medicinal Chemistry (Campus Heymans), Ghent University, Ottergemsesteenweg 460, B-9000 Gent, Belgium
| | - Ludmila Ferreira de Almeida Fiuza
- Laboratório de Biologia Celular, Instituto Oswaldo Cruz (FIOCRUZ), Fundação Oswaldo Cruz, Rio de Janeiro, Avenida Brasil 4365, Manguinhos, 21040-360 Rio de Janeiro, Brazil
| | - Camila Cardoso Santos
- Laboratório de Biologia Celular, Instituto Oswaldo Cruz (FIOCRUZ), Fundação Oswaldo Cruz, Rio de Janeiro, Avenida Brasil 4365, Manguinhos, 21040-360 Rio de Janeiro, Brazil
| | - Maria Angela Mazzarella
- Department of Pharmaceutical Sciences, University of Perugia, Via del Liceo 1, Perugia 06100, Italy
| | - Maria de Nazaré Correia Soeiro
- Laboratório de Biologia Celular, Instituto Oswaldo Cruz (FIOCRUZ), Fundação Oswaldo Cruz, Rio de Janeiro, Avenida Brasil 4365, Manguinhos, 21040-360 Rio de Janeiro, Brazil
| | - Louis Maes
- Laboratory of Microbiology, Parasitology and Hygiene (LMPH), University of Antwerp, Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Izet Karalic
- Laboratory for Medicinal Chemistry (Campus Heymans), Ghent University, Ottergemsesteenweg 460, B-9000 Gent, Belgium
| | - Guy Caljon
- Laboratory of Microbiology, Parasitology and Hygiene (LMPH), University of Antwerp, Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Serge Van Calenbergh
- Laboratory for Medicinal Chemistry (Campus Heymans), Ghent University, Ottergemsesteenweg 460, B-9000 Gent, Belgium
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Romero J, Velasco A, Pisani CF, Alviz I, Briceno D, Díaz JC, Della Rocca DG, Natale A, de Lourdes Higuchi M, Scanavacca M, Di Biase L. Advanced Therapies for Ventricular Arrhythmias in Patients With Chagasic Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:1225-1242. [PMID: 33663741 DOI: 10.1016/j.jacc.2020.12.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 11/24/2022]
Abstract
Chagas disease is caused by infection from the protozoan parasite Trypanosoma cruzi. Although it is endemic to Latin America, global migration has led to an increased incidence of Chagas in Europe, Asia, Australia, and North America. Following acute infection, up to 30% of patients will develop chronic Chagas disease, with most patients developing Chagasic cardiomyopathy. Chronic Chagas cardiomyopathy is highly arrhythmogenic, with estimated annual rates of appropriate implantable cardioverter-defibrillator therapies and electrical storm of 25% and 9.1%, respectively. Managing arrhythmias in patients with Chagasic cardiomyopathy is a major challenge for the clinical electrophysiologist, requiring intimate knowledge of cardiac anatomy, advanced training, and expertise. Endocardial-epicardial mapping and ablation strategy is needed to treat arrhythmias in this patient population, owing to the suboptimal long-term success rate of endocardial mapping and ablation alone. We also describe innovative approaches to improve acute and long-term clinical outcomes in patients with refractory ventricular arrhythmias following catheter ablation, such as bilateral cervicothoracic sympathectomy and bilateral renal denervation, among others.
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Affiliation(s)
- Jorge Romero
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Cristiano F Pisani
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Isabella Alviz
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - David Briceno
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Juan Carlos Díaz
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | | | - Andrea Natale
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA; Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, Texas, USA
| | - Maria de Lourdes Higuchi
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Mauricio Scanavacca
- Arrhythmia Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Luigi Di Biase
- Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine, New York, New York, USA; Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, Texas, USA.
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7
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Echeverría LE, Figueredo A, Rodriguez MJ, Salazar L, Pizarro C, Morillo CA, Rojas LZ, Gómez-Ochoa SA, Castillo VR. Survival after heart transplantation for Chagas cardiomyopathy using a conventional protocol: A 10-year experience in a single center. Transpl Infect Dis 2020; 23:e13549. [PMID: 33345420 DOI: 10.1111/tid.13549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Heart transplant (HT) remains the most frequently indicated therapy for patients with end-stage heart failure that improves prognosis in Chagas cardiomyopathy (CCM). However, the lack of benznidazole therapy and availability of RT-PCR follow-up in many centers is a major limitation to perform this life-saving intervention, as there are concerns related with the risk of reactivation. We aimed to describe the outcomes of a cohort of patients with CCM who underwent HT using a conventional protocol with mycophenolate mofetil, without benznidazole prophylaxis or RT-PCR follow-up. METHODS Retrospective cohort study. Between 2008 and 2018, 43 patients with CCM underwent HT. A descriptive analysis to characterize outcomes as rejection, infectious and neoplastic complications and a survival analysis was carried out. RESULTS Median of follow-up was 4.3 (IR 4.28) years. Survival at 1 month, 1 year, and 5 years was 95%, 85%, and 75%, respectively, infections being the main cause of death (60%). Reactivations occurred in only three patients (7.34%) and were not related to mortality. CONCLUSION This cohort showed a favorable survival and a low reactivation rate without an impact on mortality. Our results suggest that performing HT in patients with CCM following conventional guidelines and recommendations for other etiologies is a safe approach.
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Affiliation(s)
- Luis E Echeverría
- Heart Failure and Heart Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.,Advanced Heart Failure Group, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Antonio Figueredo
- Advanced Heart Failure Group, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.,Cardiovascular Surgery, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - María J Rodriguez
- Heart Failure and Heart Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Leonardo Salazar
- Advanced Heart Failure Group, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.,Extracorporeal Membrane Oxygenation (ECMO) and Mechanical Support Program, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Camilo Pizarro
- Advanced Heart Failure Group, Fundación Cardiovascular de Colombia, Floridablanca, Colombia.,Adult Intensive Care Unit, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Carlos A Morillo
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lyda Z Rojas
- Research Group and Development of Nursing Knowledge, Research Institute, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Sergio A Gómez-Ochoa
- Epidemiology and Research Unit, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Victor R Castillo
- Cardiovascular Surgery, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
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8
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Moreira MDC, Castilho FM, Braulio R, Andrade GFMDP, Melo JRDC. Heart Transplantation for Chagas Cardiomyopathy. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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9
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Moreira MDCV, Renan Cunha-Melo J. Chagas Disease Infection Reactivation after Heart Transplant. Trop Med Infect Dis 2020; 5:tropicalmed5030106. [PMID: 32610473 PMCID: PMC7558140 DOI: 10.3390/tropicalmed5030106] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 11/20/2022] Open
Abstract
Chagas disease, caused by a Trypanosona cruzi infection, is one of the main causes of heart failure in Latin America. It was originally a health problem endemic to South America, predominantly affecting residents of poor rural areas. With globalization and increasing migratory flows from these areas to large cities, the immigration of T. cruzi chronically-infected people to developed, non-endemic countries has occurred. This issue has emerged as an important consideration for heart transplant professionals. Currently, Chagas patients with end-stage heart failure may need a heart transplantation (HTx). This implies that in post-transplant immunosuppression therapy to avoid rejection in the recipient, there is the possibility of T. cruzi infection reactivation, increasing the morbidity and mortality rates. The management of heart transplant recipients due to Chagas disease requires awareness for early recognition and parasitic treatment of T. cruzi infection reactivation. This issue poses challenges for heart transplant professionals, especially regarding the differential diagnosis between rejection and reactivation episodes. The aim of this review is to discuss the complexity of the Chagas disease reactivation phenomenon in patients submitted to HTx for end-stage chagasic cardiomyopathy.
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Affiliation(s)
| | - José Renan Cunha-Melo
- Department of Surgery, School of Medicine, Federal University of Minas Gerais (UFMG), Av. Alfredo Balena 190, Belo Horizonte CEP 30130-110, MG, Brazil
- Correspondence:
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10
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Chagas cardiomyopathy and heart failure: From epidemiology to treatment. Rev Port Cardiol 2020; 39:279-289. [PMID: 32532535 DOI: 10.1016/j.repc.2019.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/10/2019] [Accepted: 12/01/2019] [Indexed: 12/28/2022] Open
Abstract
Chagas disease is among the neglected tropical diseases recognized by the World Health Organization that have received insufficient attention from governments and health agencies. Chagas disease is endemic in 21 Latin America regions. Due to globalization and increased migration, it has crossed borders and reached other regions including North America and Europe. The clinical presentation of the disease is highly variable, from general symptoms to severe cardiac involvement that can culminate in heart failure. Chagas heart disease is multifactorial, and can include dilated cardiomyopathy, thromboembolic phenomena, and arrhythmias that may lead to sudden death. Diagnosis is by methods such as enzyme-linked immunosorbent assay (ELISA) and the degree of cardiac involvement should be investigated with complementary exams including ECG, chest radiography and electrophysiological study. There have been insufficient studies on which to base specific treatment for heart failure due to Chagas disease. Treatment should therefore be derived from guidelines for heart failure that are not specific for this disease. Heart transplantation is a viable option with satisfactory success rates that has improved survival.
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11
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Santos É, Menezes Falcão L. Chagas cardiomyopathy and heart failure: From epidemiology to treatment. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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12
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Chagas disease: Historic perspective. Biochim Biophys Acta Mol Basis Dis 2020; 1866:165689. [DOI: 10.1016/j.bbadis.2020.165689] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 01/02/2020] [Accepted: 01/15/2020] [Indexed: 12/13/2022]
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13
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Chagas Disease: Chronic Chagas Cardiomyopathy. Curr Probl Cardiol 2019; 46:100507. [PMID: 31983471 DOI: 10.1016/j.cpcardiol.2019.100507] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 09/28/2019] [Indexed: 12/22/2022]
Abstract
Chagas disease (CD) is a tropical vector-borne infection caused by the protozoan parasite Trypanosoma cruzi (T. cruzi), also known as American Trypanosomiasis. It is considered endemic in all South and Central America and in this past decades its becoming a burden particularly in the United States and Europe due to human migration. The vast majority of patients during the acute phase are asymptomatic, while chronic symptomatic phase appears years later, with around 30% progressing toward detectable organ damage affecting mainly the cardiovascular and digestive systems. Chagas cardiomyopathy is the leading cause of nonischemic cardiomyopathy (NICM) in Latin America and affects around 30% of infected patients. The foremost characteristics are a diffuse myocarditis with focal fibrosis, mainly located in the apex and basal segments of the posterior and inferior wall, leading to a highly arrhythmogenic disease. Treatment can be etiologic during the parasitic infection, without and established efficacy during the advanced chronic symptomatic phase. Chronic Chagas cardiomyopathy treatment consists in guided medical therapy for non-ischemic cardiomyopathy, but more studies are imperative to improve clinical outcomes, some of them already in progress, and hopefully soon refine treatment and recommendations.
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14
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Martinez F, Perna E, Perrone SV, Liprandi AS. Chagas Disease and Heart Failure: An Expanding Issue Worldwide. Eur Cardiol 2019; 14:82-88. [PMID: 31360228 PMCID: PMC6659042 DOI: 10.15420/ecr.2018.30.2] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/01/2019] [Indexed: 01/28/2023] Open
Abstract
Chagas disease, originally a South American endemic health problem, is expanding worldwide because of people migration. Its main impact is on the cardiovascular system, producing myocardial damage that frequently results in heart failure. Pathogenic pathways are mainly related to inmunoinflamatory reactions in the myocardium and, less frequently, in the gastrointestinal tract. The heart usually shows fibrosis, producing dilatation and damage of the electrogenic cardiac system. These changes result in cardiomyopathy with heart failure and frequent cardiac arrhythmias and heart blocks. Diagnosis of the disease must include a lab test to detect the parasite or its immune reactions and the usual techniques to evaluate cardiac function. Therapeutic management of Chagas heart failure does not differ significantly from the most common treatment for dilated cardiomyopathy, with special focus on arrhythmias and several degrees of heart block. Heart transplantation is reserved for end-stage cases. Major international scientific organisations are delivering recommendations for prevention and early diagnosis. This article provides an analysis of epidemiology, prevention, treatment and the relationship between Chagas disease and heart failure.
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Affiliation(s)
- Felipe Martinez
- Cordoba National University, Instituto DAMIC Córdoba, Argentina.,Docencia, Asistencia Médica e Investigación Clínica (DAMIC) Medical Institute, Rusculleda Foundation for Research Córdoba Argentina
| | - Eduardo Perna
- Coronary Care Unit and Heart Failure Division, Juana Cabral Cardiovascular Institute Corrientes, Argentina
| | - Sergio V Perrone
- El Cruce Hospital Buenos Aires, Argentina.,Argentine Catholic University Buenos Aires, Argentina
| | - Alvaro Sosa Liprandi
- Cardiovascular Division, Sanatorio Güemes Hospital Buenos Aires, Argentina.,Postgraduate Medical School in Cardiology Universidad de Buenos Aires, Argentina
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15
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16
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Infections in Heart, Lung, and Heart-Lung Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7121494 DOI: 10.1007/978-1-4939-9034-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Half a century has passed since the first orthotopic heart transplant took place. Surgical innovations allowed for heart, lung, and heart-lung transplantation to save lives of patients with incurable chronic cardiopulmonary conditions. The complexity of the surgical interventions, chronic host health conditions, and antirejection immunosuppressive medications makes infectious complications common. Infections have remained one of the main barriers for successful transplantation and a source of significant morbidity and mortality. Recognition of infections and its management in this setting require outstanding clinical skills since transplant recipients may not exhibit classic signs or symptoms of disease, and laboratory work has some pitfalls. The prevention, identification, and management of infectious diseases complications in this population are a priority to undertake to improve the medical outcomes of transplantation. Herein, we reviewed the historical aspects, epidemiology, and prophylaxis of infections in heart, lung, and heart-lung transplantation. We also discuss the most prevalent organisms affecting the host and the organ systems involved.
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17
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18
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Gray EB, La Hoz RM, Green JS, Vikram HR, Benedict T, Rivera H, Montgomery SP. Reactivation of Chagas disease among heart transplant recipients in the United States, 2012-2016. Transpl Infect Dis 2018; 20:e12996. [PMID: 30204269 DOI: 10.1111/tid.12996] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heart transplantation has been shown to be a safe and effective intervention for progressive cardiomyopathy from chronic Chagas disease. However, in the presence of the immunosuppression required for heart transplantation, the likelihood of Chagas disease reactivation is significant. Reactivation may cause myocarditis resulting in allograft dysfunction and the rapid onset of congestive heart failure. Reactivation rates have been well documented in Latin America; however, there is a paucity of data regarding the risk in non-endemic countries. METHODS We present our experience with 31 patients with chronic Chagas disease who underwent orthotopic heart transplantation in the United States from 2012 to 2016. Patients were monitored following a standard schedule. RESULTS Of the 31 patients, 19 (61%) developed evidence of reactivation. Among the 19 patients, a majority (95%) were identified by laboratory monitoring using polymerase chain reaction testing. One patient was identified after the onset of clinical symptoms of reactivation. All subjects with evidence of reactivation were alive at follow-up (median: 60 weeks). CONCLUSIONS Transplant programs in the United States are encouraged to implement a monitoring program for heart transplant recipients with Chagas disease. Our experience using a preemptive approach of monitoring for Chagas disease reactivation was effective at identifying reactivation before symptoms developed.
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Affiliation(s)
- Elizabeth B Gray
- Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jaime S Green
- Division of Infectious Disease and International Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | | | - Theresa Benedict
- Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hilda Rivera
- Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan P Montgomery
- Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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19
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Nunes MCP, Beaton A, Acquatella H, Bern C, Bolger AF, Echeverría LE, Dutra WO, Gascon J, Morillo CA, Oliveira-Filho J, Ribeiro ALP, Marin-Neto JA. Chagas Cardiomyopathy: An Update of Current Clinical Knowledge and Management: A Scientific Statement From the American Heart Association. Circulation 2018; 138:e169-e209. [DOI: 10.1161/cir.0000000000000599] [Citation(s) in RCA: 201] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background:
Chagas disease, resulting from the protozoan
Trypanosoma cruzi
, is an important cause of heart failure, stroke, arrhythmia, and sudden death. Traditionally regarded as a tropical disease found only in Central America and South America, Chagas disease now affects at least 300 000 residents of the United States and is growing in prevalence in other traditionally nonendemic areas. Healthcare providers and health systems outside of Latin America need to be equipped to recognize, diagnose, and treat Chagas disease and to prevent further disease transmission.
Methods and Results:
The American Heart Association and the Inter-American Society of Cardiology commissioned this statement to increase global awareness among providers who may encounter patients with Chagas disease outside of traditionally endemic environments. In this document, we summarize the most updated information on diagnosis, screening, and treatment of
T cruzi
infection, focusing primarily on its cardiovascular aspects. This document also provides quick reference tables, highlighting salient considerations for a patient with suspected or confirmed Chagas disease.
Conclusions:
This statement provides a broad summary of current knowledge and practice in the diagnosis and management of Chagas cardiomyopathy. It is our intent that this document will serve to increase the recognition of Chagas cardiomyopathy in low-prevalence areas and to improve care for patients with Chagas heart disease around the world.
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20
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Fabiani S, Fortunato S, Bruschi F. Solid Organ Transplant and Parasitic Diseases: A Review of the Clinical Cases in the Last Two Decades. Pathogens 2018; 7:pathogens7030065. [PMID: 30065220 PMCID: PMC6160964 DOI: 10.3390/pathogens7030065] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to evaluate the occurrence of parasitic infections in solid organ transplant (SOT) recipients. We conducted a systematic review of literature records on post-transplant parasitic infections, published from 1996 to 2016 and available on PubMed database, focusing only on parasitic infections acquired after SOT. The methods and findings of the present review have been presented based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. From data published in the literature, the real burden of parasitic infections among SOT recipients cannot really be estimated. Nevertheless, publications on the matter are on the increase, probably due to more than one reason: (i) the increasing number of patients transplanted and then treated with immunosuppressive agents; (ii) the “population shift” resulting from immigration and travels to endemic areas, and (iii) the increased attention directed to diagnosis/notification/publication of cases. Considering parasitic infections as emerging and potentially serious in their evolution, additional strategies for the prevention, careful screening and follow-up, with a high level of awareness, identification, and pre-emptive therapy are needed in transplant recipients.
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Affiliation(s)
- Silvia Fabiani
- Infectious Disease Department, Azienda Ospedaliera Pisana, 56124 Pisa, Italy.
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
| | - Simona Fortunato
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
| | - Fabrizio Bruschi
- School of Infectious Diseases, Università di Pisa, 56124 Pisa, Italy.
- Department of Translational Research, N.T.M.S., Università di Pisa, 56124 Pisa, Italy.
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21
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Nogueira SS, Felizardo AA, Caldas IS, Gonçalves RV, Novaes RD. Challenges of immunosuppressive and antitrypanosomal drug therapy after heart transplantation in patients with chronic Chagas disease: A systematic review of clinical recommendations. Transplant Rev (Orlando) 2018; 32:157-167. [DOI: 10.1016/j.trre.2018.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 02/02/2023]
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22
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Meymandi S, Hernandez S, Park S, Sanchez DR, Forsyth C. Treatment of Chagas Disease in the United States. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018; 10:373-388. [PMID: 30220883 PMCID: PMC6132494 DOI: 10.1007/s40506-018-0170-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Chagas disease (CD) is endemic to much of Latin America, but also present in the United States (U.S.). Following a lengthy asymptomatic period, CD produces serious cardiac or gastrointestinal complications in 30-40% of people. Less than 1% of the estimated six million cases in the Americas, including 326,000-347,000 in the U.S., are diagnosed. Infected persons are typically unaware and the bulk of clinicians are unfamiliar with current treatment guidelines. This review provides U.S. and other clinicians with the latest knowledge of CD treatment. RECENT FINDINGS Chagas cardiomyopathy (CCM) causes severe fibrosis and autonomic damage in the myocardium. Eliminating the parasite through antitrypanosomal therapy with benznidazole, a nitroimidazole derivative or nifurtimox, a nitrofuran compound, potentially prevents heart failure and other sequelae of advanced CCM. Benznidazole, recently approved by the U.S. Food and Drug Administration (FDA) for children 2-12 years old, is the first-line therapy; optimal dosages are currently being studied. Antitrypanosomal therapy prevents congenital transmission; produces high cure rates for acute, congenital, and early chronic cases; and improves clinical outcomes in adult chronic indeterminate cases. However, this benefit was not observed in a large clinical trial that included patients with advanced CCM. SUMMARY Treatment with antitrypanosomal drugs can cure CD in acute, congenital, and early chronic cases and provides improved clinical outcomes for chronic indeterminate cases. This treatment should be offered as early as possible, before advanced CCM develops.
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Affiliation(s)
- Sheba Meymandi
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
| | - Salvador Hernandez
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
| | - Sandy Park
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
| | - Daniel R. Sanchez
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
| | - Colin Forsyth
- Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
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23
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Abstract
Chagas disease is an anthropozoonosis from the American continent that has spread from its original boundaries through migration. It is caused by the protozoan Trypanosoma cruzi, which was identified in the first decade of the 20th century. Once acute infection resolves, patients can develop chronic disease, which in up to 30-40% of cases is characterised by cardiomyopathy, arrhythmias, megaviscera, and, more rarely, polyneuropathy and stroke. Even after more than a century, many challenges remain unresolved, since epidemiological control and diagnostic, therapeutic, and prognostic methods must be improved. In particular, the efficacy and tolerability profile of therapeutic agents is far from ideal. Furthermore, the population affected is older and more complex (eg, immunosuppressed patients and patients with cancer). Nevertheless, in recent years, our knowledge of Chagas disease has expanded, and the international networking needed to change the course of this deadly disease during the 21st century has begun.
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Affiliation(s)
- José A Pérez-Molina
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investgación Sanitaria, Madrid, Spain.
| | - Israel Molina
- Infectious Diseases Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain; International Health Program of the Catalan Institute of Health, Barcelona, Spain
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Heart transplantation for Chagas cardiomyopathy. Rev Port Cardiol 2017; 36:871.e1-871.e4. [PMID: 29162358 DOI: 10.1016/j.repc.2016.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/01/2016] [Indexed: 11/22/2022] Open
Abstract
Chagas disease is an endemic disease in Latin America that is increasingly found in non-endemic areas all over the world due to the flow of migrants from Central and South America. We present the case of a Brazilian immigrant in Portugal who underwent orthotopic heart transplantation for end-stage Chagas cardiomyopathy. Immunosuppressive therapy included prednisone, mycophenolate mofetil and tacrolimus. Twelve months after the procedure she is asymptomatic, with good graft function, and with no evidence of complications such as graft rejection, opportunistic infections, neoplasms or reactivation of Trypanosoma cruzi infection. By reporting the first case in Portugal of heart transplantation for Chagas cardiomyopathy, we aim to increase awareness of Chagas disease as an emerging global problem and of Chagas cardiomyopathy as a serious complication for which heart transplantation is a valuable therapeutic option.
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25
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Heart transplantation for Chagas cardiomyopathy. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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26
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Bocchi EA, Bestetti RB, Scanavacca MI, Cunha Neto E, Issa VS. Chronic Chagas Heart Disease Management: From Etiology to Cardiomyopathy Treatment. J Am Coll Cardiol 2017; 70:1510-1524. [PMID: 28911515 DOI: 10.1016/j.jacc.2017.08.004] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 12/17/2022]
Abstract
Trypanosoma cruzi (T. cruzi) infection is endemic in Latin America and is becoming a worldwide health burden. It may lead to heterogeneous phenotypes. Early diagnosis of T. cruzi infection is crucial. Several biomarkers have been reported in Chagas heart disease (ChHD), but most are nonspecific for T. cruzi infection. Prognosis of ChHD patients is worse compared with other etiologies, with sudden cardiac death as an important mode of death. Most ChHD patients display diffuse myocarditis with fibrosis and hypertrophy. The remodeling process seems to be associated with etiopathogenic mechanisms and neurohormonal activation. Pharmacological treatment and antiarrhythmic therapy for ChHD is mostly based on results for other etiologies. Heart transplantation is an established, valuable therapeutic option in refractory ChHD. Implantable cardioverter-defibrillators are indicated for prevention of secondary sudden cardiac death. Specific etiological treatments should be revisited and reserved for select patients. Understanding and management of ChHD need improvement, including development of randomized trials.
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Affiliation(s)
- Edimar Alcides Bocchi
- Heart Institute (Incor) of São Paulo, University Medical School São Paulo, São Paulo, Brazil.
| | | | | | - Edecio Cunha Neto
- Heart Institute (Incor) of São Paulo, University Medical School São Paulo, São Paulo, Brazil
| | - Victor Sarli Issa
- Heart Institute (Incor) of São Paulo, University Medical School São Paulo, São Paulo, Brazil
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27
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Benatti RD, Oliveira GH, Bacal F. Heart Transplantation for Chagas Cardiomyopathy. J Heart Lung Transplant 2017; 36:597-603. [DOI: 10.1016/j.healun.2017.02.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/23/2016] [Accepted: 02/01/2017] [Indexed: 01/27/2023] Open
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28
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Lewis MD, Kelly JM. Putting Infection Dynamics at the Heart of Chagas Disease. Trends Parasitol 2016; 32:899-911. [PMID: 27612651 PMCID: PMC5086431 DOI: 10.1016/j.pt.2016.08.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/15/2016] [Accepted: 08/16/2016] [Indexed: 12/12/2022]
Abstract
In chronic Trypanosoma cruzi infections, parasite burden is controlled by effective, but nonsterilising immune responses. Infected cells are difficult to detect because they are scarce and focally distributed in multiple sites. However, advances in detection technologies have established a link between parasite persistence and the pathogenesis of Chagas heart disease. Long-term persistence likely involves episodic reinvasion as well as continuous infection, to an extent that varies between tissues. The primary reservoir sites in humans are not definitively known, but analysis of murine models has identified the gastrointestinal tract. Here, we highlight that quantitative, spatial, and temporal aspects of T. cruzi infection are central to a fuller understanding of the association between persistence, pathogenesis, and immunity, and for optimising treatment.
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Affiliation(s)
- Michael D Lewis
- Department of Pathogen Molecular Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892, USA.
| | - John M Kelly
- Department of Pathogen Molecular Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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29
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Klahr JI, Uribe AM, Roa N, González JM. Inmunidad celular en la patogénesis de la cardiopatía chagásica crónica. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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30
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Abstract
Physicians working in Europe and the United States should suspect Chagas heart failure in every patient coming from Latin America with chronic heart failure. Diagnosis should be confirmed by positive serology. Right bundle branch block and left anterior fascicular block on 12-lead electrocardiogram, enlarged cardiac silhouette with no pulmonary congestion on chest X-ray and left ventricular apical aneurysm on echocardiography are the distinctive features of this condition. The clinical course is poorer than that of non-Chagas heart failure; however, medical treatment is similar. Implantable cardioverter-defibrillators are useful in the primary and secondary prevention of sudden cardiac death. Cardiac resynchronisation therapy can be given to patients on optimal medical therapy and with lengthened QRS complex. Heart transplantation is the treatment of choice for patients with end-stage Chagas heart failure.
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31
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Bezerra CG, Adam EL, Baptista ML, Ciambelli GS, Kopel L, Bernoche C, Lopes LNGD, Macatrão-Costa MF, Falcão BDAA, Lage SG. Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry. Arq Bras Cardiol 2015; 106:26-32. [PMID: 26690691 PMCID: PMC4728592 DOI: 10.5935/abc.20150147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 10/14/2015] [Indexed: 11/24/2022] Open
Abstract
Background The use of aortic counterpulsation therapy in advanced heart failure is
controversial. Objectives To evaluate the hemodynamic and metabolic effects of intra-aortic
balloon pump (IABP) and its impact on 30-day mortality in patients
with heart failure. Methods Historical prospective, unicentric study to evaluate all patients
treated with IABP betwen August/2008 and July/2013, included in an
institutional registry named TBRIDGE (The Brazilian Registry of
Intra-aortic balloon pump in Decompensated heart failure - Global
Evaluation). We analyzed changes in oxygen central venous saturation
(ScvO2), arterial lactate, and use of vasoactive drugs
at 48 hours after IABP insertion. The 30-day mortality was estimated
by the Kaplan-Meier method and diferences in subgroups were evaluated
by the Log-rank test. Results A total of 223 patients (mean age 49 ± 14 years) were included.
Mean left ventricle ejection fraction was 24 ± 10%, and 30% of
patients had Chagas disease. Compared with pre-IABP insertion, we
observed an increase in ScvO2 (50.5% vs. 65.5%, p <
0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a
decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use
of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion.
Thirty-day survival was 69%, with lower mortality in Chagas disease
patients compared without the disease (p = 0.008). Conclusion After 48 hours of use, IABP promoted changes in the use of vasoactive
drugs, improved tissue perfusion. Chagas etiology was associated with
lower 30-day mortality. Aortic counterpulsation therapy is an
effective method of circulatory support for patients waiting for heart
transplantation.
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Affiliation(s)
| | - Eduardo Leal Adam
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Mariana Lins Baptista
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Liliane Kopel
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Claudia Bernoche
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Silvia Gelas Lage
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Mangini S, Alves BR, Silvestre OM, Pires PV, Pires LJT, Curiati MNC, Bacal F. Heart transplantation: review. EINSTEIN-SAO PAULO 2015; 13:310-8. [PMID: 26154552 PMCID: PMC4943829 DOI: 10.1590/s1679-45082015rw3154] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 02/08/2015] [Indexed: 12/20/2022] Open
Abstract
Heart transplantation is currently the definitive gold standard surgical approach in the treatment of refractory heart failure. However, the shortage of donors limits the achievement of a greater number of heart transplants, in which the use of mechanical circulatory support devices is increasing. With well-established indications and contraindications, as well as diagnosis and treatment of rejection through defined protocols of immunosuppression, the outcomes of heart transplantation are very favorable. Among early complications that can impact survival are primary graft failure, right ventricular dysfunction, rejection, and infections, whereas late complications include cardiac allograft vasculopathy and neoplasms. Despite the difficulties for heart transplantation, in particular, the shortage of donors and high mortality while on the waiting list, in Brazil, there is a great potential for both increasing effective donors and using circulatory assist devices, which can positively impact the number and outcomes of heart transplants.
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Affiliation(s)
| | | | - Odílson Marcos Silvestre
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Fernando Bacal
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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33
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Cardinalli-Neto A, Lorga-Filho AM, Silva EF, Lima RP, Palmegiani E, Bestetti RB. Clinical predictors of inducible sustained ventricular tachycardia during electrophysiologic study in patients with chronic Chagas' heart disease. IJC HEART & VASCULATURE 2015; 9:85-88. [PMID: 28785714 PMCID: PMC5497327 DOI: 10.1016/j.ijcha.2015.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 10/14/2015] [Accepted: 10/16/2015] [Indexed: 01/17/2023]
Affiliation(s)
- Augusto Cardinalli-Neto
- Department of Cardiology and Cardiovascular Surgery, Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Adalberto M Lorga-Filho
- Department of Cardiology and Cardiovascular Surgery, Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Elissandro F Silva
- Department of Cardiology and Cardiovascular Surgery, Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Renata P Lima
- Department of Cardiology and Cardiovascular Surgery, Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Eduardo Palmegiani
- Department of Cardiology and Cardiovascular Surgery, Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Reinaldo B Bestetti
- Post-Graduate Division of São José do Rio Preto Medical School, São José do Rio Preto, Brazil
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34
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Pierrotti LC, Kotton CN. Transplantation in the tropics: lessons on prevention and management of tropical infectious diseases. Curr Infect Dis Rep 2015; 17:492. [PMID: 26031964 DOI: 10.1007/s11908-015-0492-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Tropical infectious diseases (IDs) remain a rare complication in transplant recipients even in tropical settings, but this topic has become increasingly important during the last decade due to multiple factors. Interestingly, non-tropical countries report most of the experiences with tropical diseases. The reported experience from non-endemic regions, however, does not always reflect the experience of endemic areas. Most of the guidelines and recommendations in the literature may not be applicable in tropical settings due to logistical difficulties, cost, and lack of proven benefit. In addition, certain post-transplant prevention measures, as prophylaxis and reducing exposure risk, are not feasible. Nonetheless, risk assessment and post-transplant management of tropical IDs in tropical areas should not be neglected, and clinicians need to have a higher clinical awareness for tropical ID occurring in this population. Herein, we review the more significant tropical ID in transplant patients, focusing on relevant experience reported by tropical settings.
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Affiliation(s)
- Ligia C Pierrotti
- Infectious Diseases Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, 4° andar, São Paulo, 05403-900, SP, Brazil,
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35
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Roura M, Domingo A, Leyva-Moral JM, Pool R. Hispano-Americans in Europe: what do we know about their health status and determinants? A scoping review. BMC Public Health 2015; 15:472. [PMID: 25948239 PMCID: PMC4430018 DOI: 10.1186/s12889-015-1799-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 04/24/2015] [Indexed: 12/19/2022] Open
Abstract
Background Policy makers and health practitioners are in need of guidance to respond to the growing geographic mobility of Hispano-American migrants in Europe. Drawing from contributions from epidemiology, social sciences, demography, psychology, psychiatry and economy, this scoping review provides an up-to-date and comprehensive synthesis of studies addressing the health status and determinants of this population. We describe major research gaps and suggest specific avenues of further inquiry. Methods We identified systematically papers that addressed the concepts “health” and “Hispano Americans” indexed in five data bases from Jan 1990 to May 2014 with no language restrictions. We screened the 4,464 citations retrieved against exclusion criteria and classified 193 selected references in 12 thematic folders with the aid of the reference management software ENDNOTE X6. After reviewing the full text of all papers we extracted relevant data systematically into a table template to facilitate the synthesising process. Results Most studies focused on a particular disease, leaving unexplored the interlinkages between different health conditions and how these relate to legislative, health services, environmental, occupational, and other health determinants. We elucidated some consistent results but there were many heterogeneous findings and several popular beliefs were not fully supported by empirical evidence. Few studies adopted a trans-national perspective and many consisted of cross-sectional descriptions that considered “Hispano-Americans” as a homogeneous category, limiting our analysis. Our results are also constrained by the availability and varying quality of studies reviewed. Conclusions Burgeoning research has produced some consistent findings but there are huge gaps in knowledge. To prevent unhelpful generalisations we need a more holistic and nuanced understanding of how mobility, ethnicity, income, gender, legislative status, employment status, working conditions, neighbourhood characteristics and social status intersect with demographic variables and policy contexts to influence the health of the diverse Hispano-American populations present in Europe. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1799-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maria Roura
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB) Hospital Clínic, Universitat de Barcelona, Rosselló 132, 4th floor, 08036, Barcelona, Spain.
| | - Andreu Domingo
- Centre for Demographic Studies, Autonomous University of Barcelona, Carrer de Ca n'Altayó. Edifici E2, Bellaterra, Barcelona, 08193, Spain.
| | - Juan M Leyva-Moral
- Escola Superior d'Infemeria del Mar, University Pompeu Fabra, Doctor Aiguader, 80, Barcelona, Spain.
| | - Robert Pool
- Social Science and Global Health, Centre for Social Science and Global Health, University of Amsterdam, Postbus 15718, 1001, NE, Amsterdam, The Netherlands.
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Abstract
This review addresses relevant aspects of Chagas disease in the immunocompromised host. Chagas disease--one of the world's most neglected diseases-has become a global public health concern. Novel transmission modalities, such as organ transplantation, evidence of parasite persistence in chronically infected individuals--with the potential for reactivation under immunosuppression--and the prolonged survival of immunosuppressed patients call for an appraisal of the disease in this particular setting. The management and outcome of solid organ transplantation in the infected recipient with special focus on heart transplantation is addressed. The guidelines for management and the outcome of the recipients of organs from infected donors are discussed, and comments on haematopoietic stem cell transplantation are included. Finally, Chagas disease in other situations of impairment of the immune system, such as HIV/AIDS and autoimmune diseases, are considered. Immunosuppression has become an increasingly frequent condition that might modify the natural history of Trypanosoma cruzi infection. A number of strategies are available for Chagas disease management in the immunosuppressed patient. First, according to recent recommendations from the health authorities in Argentina, most infected patients would benefit from being treated at diagnosis. This has not been validated for patients with different immunosuppressive disorders. A different strategy would involve treating only patients with documented reactivation (either parasitaemia or clinical manifestations). These different approaches are discussed. To reach a diagnosis of parasitaemia, monitoring is essential, either with conventional methods or with molecular techniques that are not yet available in all centres. Collaborative studies are needed to improve the level of evidence, which will allow for better guidelines.
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Affiliation(s)
- R Lattes
- Transplant infectious Disease, Department of Transplantation, Instituto de Nefrología/Nephrology, Buenos Aires, Argentina
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37
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Bestetti RB, Restini CBA. Precordial chest pain in patients with chronic Chagas disease. Int J Cardiol 2014; 176:309-14. [PMID: 25127335 DOI: 10.1016/j.ijcard.2014.07.112] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 07/21/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022]
Abstract
Precordial chest pain affects about 15% to 33% of patients with chronic Chagas disease. In the absence of megaesophagus, it should be ascribed to chronic Chagas heart disease. Precordial chest pain is atypical because it can usually neither be associated to physical exercise nor be alleviated by nitroglycerin. However, in certain circumstances, precordial chest pain can masquerade as acute coronary syndrome. Although obstructive coronary artery disease can occasionally be found, microvascular angina seems to be the mechanism behind such phenomenon. Precordial chest pain not always has a benign clinical course; sometimes, it can herald a dismal prognosis. On the basis of cases previously reported, it seems that nitrates, betablockers and/or calcium channel blockers can be of value in the treatment of this condition.
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Affiliation(s)
- Reinaldo B Bestetti
- Medical Course, University of Ribeirão Preto, Brazil. Avenida Costábile Romano, 2201, Ribeirão Preto City 14096-900, Brazil.
| | - Carolina Baraldi A Restini
- Medical Course, University of Ribeirão Preto, Brazil. Avenida Costábile Romano, 2201, Ribeirão Preto City 14096-900, Brazil.
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38
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Chemello D, Goldraich L, Alvarez J, Beck-da-Silva L, Clausell N. Critical appraisal of costly therapy modalities for heart failure in a developing country. Curr Heart Fail Rep 2014; 10:421-6. [PMID: 24072512 DOI: 10.1007/s11897-013-0159-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Contemporaneous challenges in heart failure management include strategies to rationally use health economic resources and relative donor shortage to adequately offer electric devices (cardiac resynchronization therapy [CRT] and implantable cardioverter defibrillators [ICD]), ventricular assist devices (VADs) and heart transplant, respectively. These issues are particularly important in countries with middle-income rates and limited structured heart transplant centers, such as Brazil. Use of CRT and ICDs need to follow strict guidelines, further customized to public financial health conditions. Experience with VADs in is the early days in Brazil and will require extreme caution to allocate health public resources to develop VAD programs in highly selected centers. Chagas' disease is epidemiologically important in Brazil; outcomes of patients with Chagas' on electric devices are unclear while these patients fare better post-transplant than non-Chagas' patients. Thus, heart transplant remains an attractive option regarding both favorable outcomes and resource allocation for advanced heart failure patients in Brazil.
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Affiliation(s)
- Diego Chemello
- Hospital de Clinicas de Porto Alegre, Division of Cardiology, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, Brazil, 90035-903
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39
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Martinez-Perez A, Norman FF, Monge-Maillo B, Perez-Molina JA, Lopez-Velez R. An approach to the management of Trypanosoma cruzi infection (Chagas' disease) in immunocompromised patients. Expert Rev Anti Infect Ther 2014; 12:357-73. [PMID: 24484076 DOI: 10.1586/14787210.2014.880652] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The epidemiology of Chagas disease has changed in the last decades due to migration movements, population ageing and the emergence of new transmission routes. In endemic countries, health facilities and access to healthcare are improving and T. cruzi infected patients are also benefiting from medical advances. The HIV epidemic has spread to both endemic and non-endemic areas for T. cruzi, organ transplant rates have increased recently, especially in Latin America, and other medical conditions affecting the immune system are increasing their global burden. The natural course of Chagas disease is mainly determined by the host's cellular immune response. These conditions may therefore overlap with T. cruzi infection and alter the disease's natural history which may present with atypical clinical forms and a higher associated morbidity and mortality in immunocompromised patients. The present review aims to contribute to the management of immunosuppressed patients with T. cruzi infection.
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Affiliation(s)
- Angela Martinez-Perez
- Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramon y Cajal Hospital, Carretera Comenar 9.100 Km, 28034 Madrid, Spain
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40
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41
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Botoni FA, Ribeiro ALP, Marinho CC, Lima MMO, Nunes MDCP, Rocha MOC. Treatment of Chagas cardiomyopathy. BIOMED RESEARCH INTERNATIONAL 2013; 2013:849504. [PMID: 24350293 PMCID: PMC3857751 DOI: 10.1155/2013/849504] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 09/17/2013] [Accepted: 09/17/2013] [Indexed: 12/13/2022]
Abstract
Chagas' disease (ChD), caused by the protozoa Trypanosoma cruzi (T. cruzi), was discovered and described by the Brazilian physician Carlos Chagas in 1909. After a century of original description, trypanosomiasis still brings much misery to humanity and is classified as a neglected tropical disease prevalent in underdeveloped countries, particularly in South America. It is an increasing worldwide problem due to the number of cases in endemic areas and the migration of infected subjects to more developed regions, mainly North America and Europe. Despite its importance, chronic chagas cardiomyopathy (CCC) pathophysiology is yet poorly understood, and independently of its social, clinical, and epidemiological importance, the therapeutic approach of CCC is still transposed from the knowledge acquired from other cardiomyopathies. Therefore, the objective of this review is to describe the treatment of Chagas cardiomyopathy with emphasis on its peculiarities.
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Affiliation(s)
- Fernando A. Botoni
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, 30130 100 Belo Horizonte, MG, Brazil
- Hospital das Clínicas, Universidade Federal de Minas Gerais, 30130 100 Belo Horizonte, MG, Brazil
- Fundação Hospitalar do Estado de Minas Gerais, 30150 260 Belo Horizonte, MG, Brazil
| | - Antonio Luiz P. Ribeiro
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, 30130 100 Belo Horizonte, MG, Brazil
- Hospital das Clínicas, Universidade Federal de Minas Gerais, 30130 100 Belo Horizonte, MG, Brazil
| | | | - Marcia Maria Oliveira Lima
- Departamento de Fisioterapia, Universidade Federal do Vale do Mucuri e Jequitinhonha, 39100 000 Diamantina, MG, Brazil
| | - Maria do Carmo Pereira Nunes
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, 30130 100 Belo Horizonte, MG, Brazil
- Hospital das Clínicas, Universidade Federal de Minas Gerais, 30130 100 Belo Horizonte, MG, Brazil
| | - Manoel Otávio C. Rocha
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, 30130 100 Belo Horizonte, MG, Brazil
- Hospital das Clínicas, Universidade Federal de Minas Gerais, 30130 100 Belo Horizonte, MG, Brazil
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42
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Raviolo M, Solana M, Novoa M, Gualdesi M, Alba-Soto C, Briñón M. Synthesis, physicochemical properties of allopurinol derivatives and their biological activity against Trypanosoma cruzi. Eur J Med Chem 2013; 69:455-64. [DOI: 10.1016/j.ejmech.2013.08.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/28/2013] [Accepted: 08/31/2013] [Indexed: 10/26/2022]
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Bestetti RB, Couto LB, Cardinalli-Neto A. When a misperception favors a tragedy: Carlos Chagas and the Nobel Prize of 1921. Int J Cardiol 2013; 169:327-30. [PMID: 24063910 DOI: 10.1016/j.ijcard.2013.08.137] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 08/30/2013] [Indexed: 11/24/2022]
Abstract
Carlos Chagas, the discoverer of Chagas' disease was nominated to the Nobel Prize in 1921, but none did win the prize in that year. As a leader of a young scientist team, he discovered all aspects of the new disease from 1909 to 1920. It is still obscure why he did not win the Nobel Prize in 1921. Chagas was discarded by Gunnar Hedrèn on April 16, 1921. Hedrèn should have made a written report about the details of his evaluation to the Nobel Committee. However, such a document has not been found in the Nobel Committee Archives. No evidence of detractions made by Brazilian scientists on Chagas was found. Since Chagas nomination was consistent with the Nobel Committee requirements, as seen in the presentation letter by until now unknown Cypriano de Freitas, it become clear that Chagas did not win the Nobel Prize exclusively because the Nobel Committee did not perceive the importance of his discovery. Thus, it would be fair a posthumous Nobel Prize of 1921 to Carlos Chagas. A diploma of the Nobel Prize, as precedent with Dogmack in 1947, would recognize the merit of the scientist who made the most complete medical discovery of all times.
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Affiliation(s)
- Reinaldo B Bestetti
- Department of Medicine, Universidade de Ribeirão Preto, Ribeirão Preto City, Brazil.
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44
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Abstract
Parasitic diseases are rare infections after a solid organ transplant (SOT). Toxoplasmosis, Trypanosoma cruzi, and visceral leishmanias are the 3 main opportunistic protozoal infections that have the potential to be lethal if not diagnosed early and treated appropriately after SOT. Strongyloides stercoralis is the one helminthic disease that is life-threatening after transplant. This review addresses modes of transmission, methods of diagnosis, and treatment of the most serious parasitic infections in SOT. The role of targeted pretransplant screening of the donor and recipient for parasitic diseases is also discussed.
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Affiliation(s)
- Laura O'Bryan Coster
- Department of Infectious Diseases, Georgetown University Hospital, Washington, DC 20007, USA.
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45
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Schwartz BS, Mawhorter SD. Parasitic infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:280-303. [PMID: 23465021 DOI: 10.1111/ajt.12120] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- B S Schwartz
- Division of Infectious Diseases, University of California, San Francisco, San Francisco, CA, USA.
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46
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Bestetti RB, Rubio FG, Ferraz Filho JRL, Goes MJ, Neto DDS, Akio F, Villafanha DF. Trypanosoma cruzi infection reactivation manifested by encephalitis in a Chagas heart transplant recipient. Int J Cardiol 2013; 163:e7-8. [DOI: 10.1016/j.ijcard.2012.06.102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 06/24/2012] [Indexed: 10/28/2022]
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Perez-Mazliah DE, Alvarez MG, Cooley G, Lococo BE, Bertocchi G, Petti M, Albareda MC, Armenti AH, Tarleton RL, Laucella SA, Viotti R. Sequential combined treatment with allopurinol and benznidazole in the chronic phase of Trypanosoma cruzi infection: a pilot study. J Antimicrob Chemother 2012; 68:424-37. [PMID: 23104493 DOI: 10.1093/jac/dks390] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Even though the use of combined drugs has been proved to be effective in other chronic infections, assessment of combined treatment of antiparasitic drugs in human Chagas' disease has not been performed. Herein, a pilot study was conducted to evaluate the tolerance and side effects of a sequential combined treatment of two antiparasitic drugs, allopurinol and benznidazole, in the chronic phase of Trypanosoma cruzi infection. PATIENTS AND METHODS Changes in total and T. cruzi-specific T and B cells were monitored during a median follow-up of 36 months. Allopurinol was administered for 3 months (600 mg/day) followed by 30 days of benznidazole (5 mg/kg/day) in 11 T. cruzi-infected subjects. RESULTS The combined sequential treatment of allopurinol and benznidazole was well tolerated. The levels of T. cruzi-specific antibodies significantly decreased after sequential combined treatment, as determined by conventional serology and by a multiplex assay using recombinant proteins. The frequency of T. cruzi-specific interferon-γ-producing T cells significantly increased after allopurinol treatment and decreased to background levels following benznidazole administration in a substantial proportion of subjects evaluated. The levels of total naive (CD45RA + CCR7 + CD62L+) CD4 + and CD8 + T cells were restored after allopurinol administration and maintained after completion of the combined drug protocol, along with a decrease in T cell activation in total peripheral CD4 + and CD8 + T cells. CONCLUSIONS This pilot study shows that the combination of allopurinol and benznidazole induces significant modifications in T and B cell responses indicative of a reduction in parasite burden, and sustains the feasibility of administration of two antiparasitic drugs in the chronic phase of Chagas' disease.
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Affiliation(s)
- D E Perez-Mazliah
- Instituto Nacional de Parasitología Dr. Mario Fatala Chaben, Av. Paseo Colón 568, Buenos Aires (1063), Argentina
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Pérez-Mazliah D, Albareda MC, Alvarez MG, Lococo B, Bertocchi GL, Petti M, Viotti RJ, Laucella SA. Allopurinol reduces antigen-specific and polyclonal activation of human T cells. Front Immunol 2012; 3:295. [PMID: 23049532 PMCID: PMC3448060 DOI: 10.3389/fimmu.2012.00295] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 09/04/2012] [Indexed: 11/13/2022] Open
Abstract
Allopurinol is the most popular commercially available xanthine oxidase inhibitor and it is widely used for treatment of symptomatic hyperuricaemia, or gout. Although, several anti-inflammatory actions of allopurinol have been demonstrated in vivo and in vitro, there have been few studies on the action of allopurinol on T cells. In the current study, we have assessed the effect of allopurinol on antigen-specific and mitogen-driven activation and cytokine production in human T cells. Allopurinol markedly decreased the frequency of IFN-γ and IL-2-producing T cells, either after polyclonal or antigen-specific stimulation with Herpes Simplex virus 1, Influenza (Flu) virus, tetanus toxoid and Trypanosoma cruzi-derived antigens. Allopurinol attenuated CD69 upregulation after CD3 and CD28 engagement and significantly reduced the levels of spontaneous and mitogen-induced intracellular reactive oxygen species in T cells. The diminished T cell activation and cytokine production in the presence of allopurinol support a direct action of allopurinol on human T cells, offering a potential pharmacological tool for the management of cell-mediated inflammatory diseases.
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Affiliation(s)
- Damián Pérez-Mazliah
- Instituto Nacional de Parasitología "Dr. Mario Fatala Chaben" Ciudad Autónoma de Buenos Aires, Argentina
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Di Biase L, Santangeli P, Bai R, Tung R, David Burkhardt J, Shivkumar K, Natale A. The Emerging Role of Epicardial Ablation. Card Electrophysiol Clin 2012; 4:425-437. [PMID: 26939962 DOI: 10.1016/j.ccep.2012.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Sosa and colleagues first described a percutaneous approach (via the subxiphoid area) to access the pericardial space in 1996. Epicardial mapping and ablation is increasingly used for the treatment of supraventricular and ventricular arrhythmias and represents an adjunctive approach for challenging arrhythmias to improve procedural success rates. Epicardial ablation should be considered not only after the failure of an endocardial ablation but often as a first-line approach. Complications may occur during percutaneous access and epicardial ablation, and these might be reduced or avoided by improved operator skills and experience. New tools to access the epicardial space are being evaluated.
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Affiliation(s)
- Luigi Di Biase
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Biomedical Engineering, University of Texas, 3000 North I-35, Suite 720, Austin, TX 78705, USA; Department of Cardiology, University of Foggia, Foggia, Italy
| | - Pasquale Santangeli
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Cardiology, University of Foggia, Foggia, Italy
| | - Rong Bai
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA
| | - Roderick Tung
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Biomedical Engineering, University of Texas, 3000 North I-35, Suite 720, Austin, TX 78705, USA; EP Services, California Pacific Medical Center, San Francisco, CA, USA; Division of Cardiology, Stanford University, Palo Alto, CA, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
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