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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: 3] [Impact Index Per Article: 3.0] [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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Pinto‐Salinas M, Morón‐Castro J, Chavarri‐Velarde F, Soplopuco‐Palacios F, Palma‐Ortecho L, Lescano‐Alva M. Heart transplantation at the Peruvian National Heart Institute: One‐decade single‐center experience. J Card Surg 2022; 37:1550-1558. [DOI: 10.1111/jocs.16429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/22/2021] [Accepted: 01/13/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | - Julio Morón‐Castro
- Medical School Universidad Nacional Mayor de San Marcos Lima Peru
- Department of Cardiovascular Surgery Instituto Nacional Cardiovascular “Carlos Alberto Peschiera Carrillo” Lima Peru
| | - Fernando Chavarri‐Velarde
- Medical School Universidad Nacional Mayor de San Marcos Lima Peru
- Department of Cardiopediatrics Instituto Nacional Cardiovascular “Carlos Alberto Peschiera Carrillo” Lima Peru
| | - Franz Soplopuco‐Palacios
- Department of Cardiovascular Surgery Instituto Nacional Cardiovascular “Carlos Alberto Peschiera Carrillo” Lima Peru
| | - Luis Palma‐Ortecho
- Department of Cardiopediatrics Instituto Nacional Cardiovascular “Carlos Alberto Peschiera Carrillo” Lima Peru
| | - Miguel Lescano‐Alva
- Department of Clinical Cardiology Instituto Nacional Cardiovascular “Carlos Alberto Peschiera Carrillo” Lima Peru
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Torres RM, Correia D, Nunes MDCP, Dutra WO, Talvani A, Sousa AS, Mendes FDSNS, Scanavacca MI, Pisani C, Moreira MDCV, de Souza DDSM, de Oliveira Junior W, Martins SM, Dias JCP. Prognosis of chronic Chagas heart disease and other pending clinical challenges. Mem Inst Oswaldo Cruz 2022; 117:e210172. [PMID: 35674528 PMCID: PMC9172891 DOI: 10.1590/0074-02760210172] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/17/2021] [Indexed: 01/24/2023] Open
Abstract
In this chapter, the main prognostic markers of Chagas heart disease are addressed, with an emphasis on the most recent findings and questions, establishing the basis for a broad discussion of recommendations and new approaches to managing Chagas cardiopathy. The main biological and genetic markers and the contribution of the electrocardiogram, echocardiogram and cardiac magnetic resonance are presented. We also discuss the most recent therapeutic proposals for heart failure, thromboembolism and arrhythmias, as well as current experience in heart transplantation in patients suffering from severe Chagas cardiomyopathy. The clinical and epidemiological challenges introduced by acute Chagas disease due to oral contamination are discussed. In addition, we highlight the importance of ageing and comorbidities in influencing the outcome of chronic Chagas heart disease. Finally, we discuss the importance of public policies, the vital role of funding agencies, universities, the scientific community and health professionals, and the application of new technologies in finding solutions for better management of Chagas heart disease.
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5
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Bacal F, Murad CM, dos Santos Aragão CA, de Campos IW, da Costa Seguro LFB, Avila MS, Mangini S, Gaiotto FA, Strabelli TV, Marcondes-Braga FG. Transplantation for Chagas Heart Disease: a Comprehensive Review. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Avila MS, Belfort DDSP. Progress in Heart Transplantation in Brazil: is it Time to Build a National Database? Arq Bras Cardiol 2021; 116:754-755. [PMID: 33886723 PMCID: PMC8121400 DOI: 10.36660/abc.20210104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Mônica Samuel Avila
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas Instituto do Coração, São Paulo, SP - Brasil
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7
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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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8
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Radisic MV, Repetto SA. American trypanosomiasis (Chagas disease) in solid organ transplantation. Transpl Infect Dis 2020; 22:e13429. [DOI: 10.1111/tid.13429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Marcelo V. Radisic
- d. Institute. Instituto de Trasplante y Alta Complejidad (ITAC) Ciudad Autónoma de Buenos Aires Argentina
| | - Silvia A. Repetto
- Instituto de Investigaciones en Microbiologia y Parasitologia Medica (IMPaM) Facultad de Medicina Universidad de Buenos AiresConsejo Nacional de Investigaciones Cientificas y Tecnicas Ciudad Autónoma de Buenos Aires Argentina
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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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Bern C, Messenger LA, Whitman JD, Maguire JH. Chagas Disease in the United States: a Public Health Approach. Clin Microbiol Rev 2019; 33:e00023-19. [PMID: 31776135 PMCID: PMC6927308 DOI: 10.1128/cmr.00023-19] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Trypanosoma cruzi is the etiological agent of Chagas disease, usually transmitted by triatomine vectors. An estimated 20 to 30% of infected individuals develop potentially lethal cardiac or gastrointestinal disease. Sylvatic transmission cycles exist in the southern United States, involving 11 triatomine vector species and infected mammals such as rodents, opossums, and dogs. Nevertheless, imported chronic T. cruzi infections in migrants from Latin America vastly outnumber locally acquired human cases. Benznidazole is now FDA approved, and clinical and public health efforts are under way by researchers and health departments in a number of states. Making progress will require efforts to improve awareness among providers and patients, data on diagnostic test performance and expanded availability of confirmatory testing, and evidence-based strategies to improve access to appropriate management of Chagas disease in the United States.
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Affiliation(s)
- Caryn Bern
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | | | - Jeffrey D Whitman
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - James H Maguire
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Arshad A, Azeka E, Barbar S, Marcondes R, Siqueira A, Benvenuti L, Miura N, Jatene M, Filho VO. Long-Term Evaluation of Post-transplant Lymphoproliferative Disorders in Paediatric Heart Transplantation in Sao Paulo, Brazil. Pediatr Cardiol 2019; 40:1655-1662. [PMID: 31506731 DOI: 10.1007/s00246-019-02200-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/23/2019] [Indexed: 01/06/2023]
Abstract
We sought to better define the demographics and characteristics of post-transplant lymphoproliferative disorders (PTLD) in a cohort of paediatric OHT patients from a developing country. Data were collected from the Heart Institute, Sao Paulo, for all paediatric OHT recipients from October 1992 to October 2018. Group differences between the PTLD and non-PTLD cohorts were assessed by Fisher exact and Mann-Whitney U tests. Kaplan-Meier curves analysed the survival in each group. Data were reviewed for 202 paediatric OHT recipients. Overall 1-, 5- and 10-year survival for the entire cohort was 76.5%, 68.3% and 62.9%; 24 patients (11.9%) developed PTLD at a median 3.1 years (IQR 0.8-9.0) after OHT. Cases were evenly spread over the follow-up period, with PTLD diagnosed in 9.8% (n = 137) of patients who were alive at 3 years, 15.3% (n = 78) of patients who were alive at 5 years and 29.3% (n = 41) of patients who were alive at 10 years. The commonest form of PTLD was diffuse large B cell lymphoma (n = 9), and most patients received rituximab with immunosuppression and chemotherapy as treatment (n = 15). We identified no increased risk in mortality amongst the PTLD vs. non-PTLD cohorts in multivariate analysis (P = 0.365). PTLD after paediatric OHT had acceptable outcomes. However, risk factors for PTLD were not identified and warrant further investigation.
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Affiliation(s)
- Adam Arshad
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
- Heart Institute (InCor), University of São Paulo Medical School, Rua Araripina 95, São Paulo, Brazil.
| | - Estela Azeka
- Heart Institute (InCor), University of São Paulo Medical School, Rua Araripina 95, São Paulo, Brazil
| | - Samia Barbar
- Heart Institute (InCor), University of São Paulo Medical School, Rua Araripina 95, São Paulo, Brazil
| | - Raphael Marcondes
- Heart Institute (InCor), University of São Paulo Medical School, Rua Araripina 95, São Paulo, Brazil
| | - Adailson Siqueira
- Heart Institute (InCor), University of São Paulo Medical School, Rua Araripina 95, São Paulo, Brazil
| | - Luiz Benvenuti
- Heart Institute (InCor), University of São Paulo Medical School, Rua Araripina 95, São Paulo, Brazil
| | - Nana Miura
- Heart Institute (InCor), University of São Paulo Medical School, Rua Araripina 95, São Paulo, Brazil
| | - Marcelo Jatene
- Heart Institute (InCor), University of São Paulo Medical School, Rua Araripina 95, São Paulo, Brazil
| | - Vicente Odone Filho
- Pediatric Oncology, University of São Paulo Medical School, São Paulo, Brazil
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12
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Ayesta A, Urrútia G, Madrid E, Vernooij RWM, Vicent L, Martínez-Sellés M. Sex-mismatch influence on survival after heart transplantation: A systematic review and meta-analysis of observational studies. Clin Transplant 2019; 33:e13737. [PMID: 31630456 DOI: 10.1111/ctr.13737] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/03/2019] [Accepted: 10/08/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES Heart transplantation (HT) is the treatment for patients with end-stage heart disease. Despite contradictory reports, survival seems to be worse when donor/recipient sex is mismatched. This systematic review and meta-analysis aims to synthesize the evidence on the effect of donor/recipient sex mismatch after HT. METHODS We searched PubMed and EMBASE until November 2017. Comparative cohort and registry studies were included. Published articles were systematically selected and, when possible, pooled in a meta-analysis. The primary endpoint was one-year mortality. RESULTS After retrieving 556 articles, ten studies (76 175 patients) were included in the quantitative meta-analysis. Significant differences were found in one-year survival between sex-matched and mismatched recipients (odds ratio (OR) 1.30, 95% confidence interval (CI) 1.25-1.35, P < .001). In female recipients, we found that sex mismatch was not a risk factor for one-year mortality (OR = 0.93, 95% CI = 0.85-1.00, P = .06). However, in male recipients, we found that it was a risk factor for one-year mortality (OR = 1.38, 95% CI = 1.31-1.44, P < .001). CONCLUSIONS Sex mismatch increases one-year mortality after HT in male recipients. Its influence in long-term survival should be further explored with high-quality studies.
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Affiliation(s)
- Ana Ayesta
- Servicio de cardiología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Gerard Urrútia
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Centro Iberoamericano Cochrane, Barcelona, Spain
| | - Eva Madrid
- Centro Iberoamericano Cochrane, Barcelona, Spain.,Centro de Investigación Biomédica, Facultad de Medicina, Universidad de Valparaíso, Valparaíso, Chile.,Centro Interdisciplinar para Estudios de la Salud, Facultad de Medicina, Universidad de Valparaíso, Valparaíso, Chile
| | | | - Lourdes Vicent
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERCV, Madrid, Spain.,Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERCV, Madrid, Spain.,Universidad Complutense de Madrid, Madrid, Spain.,Universidad Europea de Madrid, Madrid, Spain
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13
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Ciolac EG, Castro RE, Marçal IR, Bacal F, Bocchi EA, Guimarães GV. Cardiac reinnervation affects cardiorespiratory adaptations to exercise training in individuals with heart transplantation. Eur J Prev Cardiol 2019; 27:1151-1161. [PMID: 31604403 DOI: 10.1177/2047487319880650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE The purpose of this study was to investigate the hemodynamic and cardiorespiratory adaptations to exercise in individuals with heart transplantation with evidence of cardiac reinnervation (cardiac reinnervation group) versus without evidence of cardiac reinnervation (no cardiac reinnervation group). METHODS Sedentary individuals with heart transplantation (age = 45.5 ± 2.2 years; time elapsed since surgery = 6.7 ± 0.7 years) were divided into the cardiac reinnervation (n = 16) and no cardiac reinnervation (n = 17) groups according to their heart rate response to cardiopulmonary exercise testing. The 24-hour ambulatory blood pressure, carotid-femoral pulse wave velocity, and cardiorespiratory fitness were assessed before and after 12 weeks of a thrice-weekly exercise program (five minutes of warm-up, 30 min of endurance exercise, one set of 10-15 reps in five resistance exercises, and five minutes of cool-down). RESULTS The cardiac reinnervation group had reduced (p < 0.01) 24-hour systolic/diastolic blood pressure (7/9 mm Hg), daytime systolic/diastolic blood pressure (9/10 mm Hg) and nighttime diastolic blood pressure (6 mm Hg) after training. The no cardiac reinnervation group reduced (p < 0.05) only 24-hour (5 mm Hg), daytime (5 mm Hg) and nighttime (6 mm Hg) diastolic blood pressure after training. Hourly analysis showed that the cardiac reinnervation group reduced systolic/diastolic blood pressure for 10/21 h, while the no cardiac reinnervation group reduced systolic/diastolic blood pressure for only 3/11 h. The cardiac reinnervation group also improved both maximal oxygen consumption (10.8%) and exercise tolerance (13.4%) after training, but the no cardiac reinnervation group improved only exercise tolerance (9.9%). Pulse wave velocity did not change in both groups. CONCLUSION There were greater improvements in ambulatory blood pressure and maximal oxygen consumption in the cardiac reinnervation than the no cardiac reinnervation group. These results suggest that cardiac reinnervation associates with hemodynamic and cardiorespiratory adaptations to exercise training in individuals with heart transplantation.
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Affiliation(s)
- Emmanuel G Ciolac
- School of Sciences, Physical Education Department, Exercise and Chronic Disease Research Laboratory, São Paulo State University - UNESP, Brazil
| | - Rafael E Castro
- School of Medicine, Heart Institute, University of São Paulo - USP, Brazil
| | - Isabela R Marçal
- School of Sciences, Physical Education Department, Exercise and Chronic Disease Research Laboratory, São Paulo State University - UNESP, Brazil
| | - Fernando Bacal
- School of Medicine, Heart Institute, University of São Paulo - USP, Brazil
| | - Edimar A Bocchi
- School of Medicine, Heart Institute, University of São Paulo - USP, Brazil
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14
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The spectrum of myocarditis: from pathology to the clinics. Virchows Arch 2019; 475:279-301. [DOI: 10.1007/s00428-019-02615-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/15/2019] [Accepted: 06/20/2019] [Indexed: 12/14/2022]
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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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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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Bocchi EA, Rassi S, Guimarães GV. Safety profile and efficacy of ivabradine in heart failure due to Chagas heart disease: a post hoc analysis of the SHIFT trial. ESC Heart Fail 2018; 5:249-256. [PMID: 29266804 PMCID: PMC5933959 DOI: 10.1002/ehf2.12240] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 09/12/2017] [Accepted: 11/14/2017] [Indexed: 12/11/2022] Open
Abstract
AIMS The SHIFT trial showed that ivabradine reduced heart rate (HR) and the risk of cardiovascular outcomes. Concerns remain over the efficacy and safety of ivabradine on heart failure (HF) due to Chagas disease (ChD). We therefore conducted a post hoc analysis of the SHIFT trial to investigate the effect of ivabradine in these patients. METHODS AND RESULTS SHIFT was a randomized, double-blind, placebo-controlled trial in symptomatic systolic stable HF, HR ≥ 70 b.p.m., and in sinus rhythm. The ChD HF subgroup included 38 patients, 20 on ivabradine, and 18 on placebo. The ChD HF subgroup showed high prevalence of bundle branch right block and, compared with the overall SHIFT population, lower systolic blood pressure; higher use of diuretics, cardiac glycosides, and antialdosterone agents; and lower use of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker or target daily dose of beta-blocker. ChD HF presented a poor prognosis (all-cause mortality at 2 years was ~60%). The mean twice-daily dose of ivabradine was 6.26 ± 1.15 mg and placebo 6.43 ± 1.55 mg. Ivabradine reduced HR from 77.9 ± 3.8 to 62.3 ± 10.1 b.p.m. (P = 0.005) and improved functional class (P = 0.02). A trend towards reduction in all-cause death was observed in ivabradine arm vs. placebo (P = 0.07). Ivabradine was not associated with serious bradycardia, atrioventricular block, hypotension, or syncope. CONCLUSIONS ChD HF is an advanced form of HF with poor prognosis. Ivabradine was effective in reducing HR in these patients and improving functional class. Although our results are based on a very limited sample and should be interpreted with caution, they suggest that ivabradine may have a favourable benefit-risk profile in ChD HF patients.
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Affiliation(s)
- Edimar Alcides Bocchi
- Heart Institute (InCor)São Paulo University Medical School (HC‐FUMSP)Rua Dr Melo Alves 690, 4o andar, Bairro Cerqueira CesarSão PauloSão PauloCEP 014170‐010Brazil
| | - Salvador Rassi
- Medical SchoolFederal University of GoiásGoiâniaGoiásBrazil
| | - Guilherme Veiga Guimarães
- Heart Institute (InCor)São Paulo University Medical School (HC‐FUMSP)Rua Dr Melo Alves 690, 4o andar, Bairro Cerqueira CesarSão PauloSão PauloCEP 014170‐010Brazil
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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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Kransdorf EP, Fishbein MC, Czer LSC, Patel JK, Velleca A, Tazelaar HD, Roy RR, Steidley DE, Kobashigawa JA, Luthringer DJ. Pathology of Chronic Chagas Cardiomyopathy in the United States: A Detailed Review of 13 Cardiectomy Cases. Am J Clin Pathol 2016; 146:191-8. [PMID: 27425387 DOI: 10.1093/ajcp/aqw098] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The pathologic features of chronic Chagas cardiomyopathy may not be widely appreciated in the United States. We sought to describe the gross, microscopic, immunohistochemical, and molecular pathology features useful to diagnose chronic Chagas cardiomyopathy. METHODS The features from a case series of cardiectomy specimens of patients undergoing heart transplantation (12 patients) or mechanical circulatory support device implantation (one patient) for chronic Chagas cardiomyopathy at three institutions in the United States are reported and analyzed. RESULTS Gross findings included enlarged and dilated ventricles (100% of cases), mural thrombi (54%), epicardial plaques (42%), and left ventricular aneurysm (36%). Microscopic evaluation revealed myocarditis (100% of cases) characterized by mononuclear cell infiltration, fibrosis (100%), nonnecrotizing granulomas (62%), and giant cells (38%). Two specimens (15%) showed rare intracellular amastigotes. Immunohistochemical assays for Trypanosoma cruzi organisms were negative in all cardiectomy specimens, whereas tissue polymerase chain reaction was positive in six (54%) of 11 cases. CONCLUSIONS The gross and microscopic features of chronic Chagas cardiomyopathy in the United States appear similar to those reported in endemic countries. Importantly, tissue polymerase chain reaction may be useful to confirm the diagnosis.
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Affiliation(s)
| | - Mike C Fishbein
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA
| | | | | | | | - Henry D Tazelaar
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ
| | - R Raina Roy
- Department of Cardiology, Maricopa Integrated Health System, Phoenix, AZ
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CASTRO RAFAELERTNER, GUIMARÃES GUILHERMEVEIGA, DA SILVA JOSÉMESSIASRODRIGUES, BOCCHI EDIMARALCIDES, CIOLAC EMMANUELGOMES. Postexercise Hypotension after Heart Transplant. Med Sci Sports Exerc 2016; 48:804-10. [DOI: 10.1249/mss.0000000000000846] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ciolac EG, Castro RE, Greve JMD, Bacal F, Bocchi EA, Guimarães GV. Prescribing and Regulating Exercise with RPE after Heart Transplant: A Pilot Study. Med Sci Sports Exerc 2016; 47:1321-7. [PMID: 25343537 DOI: 10.1249/mss.0000000000000553] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The objective of this study is to analyze the use of the 6-20 RPE scale for prescribing and self-regulating heated water-based exercise (HEx) and land-based exercise (LEx) in heart transplant recipients. METHODS Fifteen (five females) clinically stable heart transplant recipients (time since surgery = 4.0 ± 2.5 yr) age 46.7 ± 11.8 yr underwent a symptom-limited maximal graded exercise test on a treadmill to determine their HR at anaerobic threshold (HRAT), respiratory compensation point (HRRCP), and maximal effort (HRmax). After a week, patients were randomized to perform 30 min of both HEx (walking inside the pool) and LEx (treadmill walking) sessions at a pace between 11 and 13 on the 6-20 RPE scale and had their HR measured every 4 min. The interval between sessions was 48-72 h. RESULTS No significant differences between sessions were found in the average HR during HEx and LEx. Patients showed a delay in HR increase during both interventions, with the stabilization beginning after 8 min of exercise. Exercise HR was maintained between the HRAT and HRRCP (in the aerobic exercise training zone) for the most part of both HEx (72% of HR measurements) and LEx (66% of HR measurements). Only a few HR measurements stayed below HRAT (HEx = 9%, LEx = 13%) or above HRRCP (HEx = 19%, LEx = 21%) during both exercise sessions. CONCLUSION Exercise HR was maintained in the aerobic exercise training zone (between HRAT and HRRCP) for the most part of both sessions, suggesting that the 6-20 RPE scale may be an efficient tool for prescribing and self-regulating HEx and LEx in heart transplant recipients.
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Affiliation(s)
- Emmanuel Gomes Ciolac
- 1Exercise and Chronic Disease Research Laboratory, Physical Education Department, School of Sciences, São Paulo State University - UNESP, Bauru, BRAZIL; 2Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRAZIL; 3Institute of Orthopedics and Traumatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRAZIL
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Abstract
PURPOSE OF REVIEW The diagnosis and management of acute and chronic infections with the microorganism Trypanosoma cruzi, which causes Chagas disease, is important in solid organ transplantation in both endemic and nonendemic countries. In this review, we examine recently published data on the topic of Chagas disease in solid organ transplantation, with an emphasis on data relevant to heart transplantation. RECENT FINDINGS Most people with chronic T. cruzi infection have the intermediate form of disease, but approximately 2% of infected persons will progress to Chagas cardiomyopathy per year. The risk of T. cruzi transmission with liver or kidney transplantation appears to be substantially less than that with heart transplantation. For patients with Chagas cardiomyopathy undergoing heart transplant, a structured clinical and laboratory monitoring protocol is necessary to monitor for T. cruzi reactivation. Recent data indicate that laboratory monitoring of peripheral blood with polymerase chain reaction testing can identify reactivation prior to the occurrence of symptoms and allograft injury. SUMMARY Transplant clinicians should exercise vigilance in surveillance for Chagas disease in both organ donors and recipients. Although Chagas disease may seem uncommon, it is pervasive in endemic and several nonendemic countries, including the United States and Spain.
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Bocchi EA, Tanigawa RY, Brandão SMG, Cruz F, Issa V, Ayub-Ferreira S, Chizzola P, Souza G, Fiorelli AI, Bacal F, Pomerantzeff PMA, Honorato R, Lourenço-Filho D, Guimarães G, Benvenuti LA. Immunohistochemical quantification of inflammatory cells in endomyocardial biopsy fragments after heart transplantation: a new potential method to improve the diagnosis of rejection after heart transplantation. Transplant Proc 2015; 46:1489-96. [PMID: 24935318 DOI: 10.1016/j.transproceed.2013.12.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/09/2013] [Accepted: 12/16/2013] [Indexed: 11/30/2022]
Abstract
Inconsistencies in cardiac rejection grading systems corroborate the concept that the evaluation of inflammatory intensity and myocyte damage seems to be subjective. We studied in 36 patients the potential role of the immunohistochemical (IHC) counting of inflammatory cells in endomyocardial biopsy (EMB) as an objective tool, testing the hypothesis of correlation between the International Society for Heart and Lung Transplantation 2004 rejection and IHC counting of inflammatory cells. We observed a progressive increment in CD68+ cells/mm(2) (P = .000) and CD3+ cells/mm(2) (P = .000) with higher rejection grade. A strong correlation between the grade of cellular rejection and both CD68+ cells/mm(2) and CD3+ cells/mm(2) was obtained (P = .000). One patient with CD3+ and CD68+ cells/mm(2) above the upper limit of the 95% confidence interval for cells/mm(2) found in rejection grade 1R evolved to rejection grade 2R without treatment. In patients with 2R that did not respond to treatment the values of CD68+ or CD3+ cells were higher than the overall median values for rejection grade 2R. For diagnosis of rejection needing treatment, the CD68+ and CD3+ cells/mm(2) areas under the receiver operating characteristic curves were 0.956 and 0.934, respectively. IHC counting of mononuclear inflammatory infiltrate in EMB seems to have additive potential role in evaluation of EMB for the diagnosis and prognosis of rejection episodes.
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Affiliation(s)
- E A Bocchi
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil.
| | - R Y Tanigawa
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - S M G Brandão
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - F Cruz
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - V Issa
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - S Ayub-Ferreira
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - P Chizzola
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - G Souza
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - A I Fiorelli
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - F Bacal
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - P M A Pomerantzeff
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - R Honorato
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - D Lourenço-Filho
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - G Guimarães
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
| | - L A Benvenuti
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, Brazil
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Pascoalino LN, Ciolac EG, Tavares AC, Castro RE, Ayub-Ferreira SM, Bacal F, Issa VS, Bocchi EA, Guimarães GV. Exercise training improves ambulatory blood pressure but not arterial stiffness in heart transplant recipients. J Heart Lung Transplant 2014; 34:693-700. [PMID: 25662857 DOI: 10.1016/j.healun.2014.11.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 10/30/2014] [Accepted: 11/04/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Hypertension is the most prevalent comorbidity after heart transplantation (HT). Exercise training (ET) is widely recommended as a key non-pharmacologic intervention for the prevention and management of hypertension, but its effects on ambulatory blood pressure (ABP) and some mechanisms involved in the pathophysiology of hypertension have not been studied in this population. The primary purpose of this study was to investigate the effects of ET on ABP and arterial stiffness of HT recipients. METHODS 40 HT patients, randomized to ET (n = 31) or a control group (n = 9) underwent a maximal graded exercise test, 24-hour ABP monitoring, and carotid-femoral pulse wave velocity (PWV) assessment before the intervention and at a 12-week follow-up assessment. The ET program was performed thrice-weekly and consisted primarily of endurance exercise (40 minutes) at ~70% of maximum oxygen uptake (Vo2MAX). RESULTS The ET group had reduced 24-hour (4.0 ± 1.4 mm Hg, p < 0.01) and daytime (4.8 ± 1.6 mm Hg, p < 0.01) systolic ABP, and 24-hour (7.0 ± 1.4 mm Hg, p < 0.001) daytime (7.5 ± 1.6 mm Hg, p < 0.001) and nighttime (5.9 ± 1.5 mm Hg, p < 0.001) diastolic ABP after the intervention. The ET group also had improved Vo2MAX (9.7% ± 2.6%, p < 0.001) after the intervention. However, PWV did not change after ET. No variable was changed in the control group after the intervention. CONCLUSIONS The 12-week ET program was effective for reducing ABP but not PWV in heart transplant recipients. This result suggests that endurance ET may be a tool to counteract hypertension in this high-risk population.
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Affiliation(s)
- Lucas Nóbilo Pascoalino
- Heart Institute, School of Medicine, University of São Paulo - USP, São Paulo, São Paulo, Brazil
| | - Emmanuel Gomes Ciolac
- Exercise and Chronic Disease Research Laboratory, Physical Education Department, School of Sciences, São Paulo State University - UNESP, Bauru, São Paulo, Brazil.
| | - Aline Cristina Tavares
- Heart Institute, School of Medicine, University of São Paulo - USP, São Paulo, São Paulo, Brazil; Syrian-Lebanese Hospital, São Paulo, São Paulo, Brazil
| | - Rafael Ertner Castro
- Heart Institute, School of Medicine, University of São Paulo - USP, São Paulo, São Paulo, Brazil
| | | | - Fernando Bacal
- Heart Institute, School of Medicine, University of São Paulo - USP, São Paulo, São Paulo, Brazil
| | - Victor Sarli Issa
- Heart Institute, School of Medicine, University of São Paulo - USP, São Paulo, São Paulo, Brazil
| | - Edimar Alcides Bocchi
- Heart Institute, School of Medicine, University of São Paulo - USP, São Paulo, São Paulo, Brazil
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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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Kim HJ, Jung SH, Kim JJ, Kim JB, Choo SJ, Yun TJ, Chung CH, Lee JW. Early postoperative complications after heart transplantation in adult recipients: asan medical center experience. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:426-32. [PMID: 24368968 PMCID: PMC3868689 DOI: 10.5090/kjtcs.2013.46.6.426] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 06/30/2013] [Accepted: 08/05/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart transplantation has become a widely accepted surgical option for end-stage heart failure in Korea since its first success in 1992. We reviewed early postoperative complications and mortality in 239 patients who underwent heart transplantation using bicaval technique in Asan Medical Center. METHODS Between January 1999 and December 2011, a total of 247 patients aged over 17 received heart transplantation using bicaval technique in Asan Medical Center. After excluding four patients with concomitant kidney transplantation and four with heart-lung transplantation, 239 patients were enrolled in this study. We evaluated their early postoperative complications and mortality. Postoperative complications included primary graft failure, cerebrovascular accident, mediastinal bleeding, renal failure, low cardiac output syndrome requiring intra-aortic balloon pump or extracorporeal membrane oxygenation insertion, pericardial effusion, and inguinal lymphocele. Follow-up was 100% complete with a mean follow-up duration of 58.4±43.6 months. RESULTS Early death occurred in three patients (1.3%). The most common complications were pericardial effusion (61.5%) followed by arrhythmia (41.8%) and mediastinal bleeding (8.4%). Among the patients complicated with pericardial effusion, only 13 (5.4%) required window operation. The incidence of other significant complications was less than 5%: stroke (1.3%), low cardiac output syndrome (2.5%), renal failure requiring renal replacement (3.8%), sternal wound infection (2.0%), and inguinal lymphocele (4.6%). Most of complications did not result in the extended length of hospital stay except mediastinal bleeding (p=0.034). CONCLUSION Heart transplantation is a widely accepted option of surgical treatment for end-stage heart failure with good early outcomes and relatively low catastrophic complications.
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Affiliation(s)
- Ho Jin Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Sung-Ho Jung
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Joong Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Joon Bum Kim
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Suk Jung Choo
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Tae-Jin Yun
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Cheol Hyun Chung
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Won Lee
- Division of Cardiology, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
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Kransdorf EP, Czer LSC, Luthringer DJ, Patel JK, Montgomery SP, Velleca A, Mirocha J, Zakowski PC, Zabner R, Gaultier CR, Qvarnstrom Y, Benedict T, Steurer F, Bosserman E, Paddock CD, Rafiei M, Kobashigawa JA. Heart transplantation for Chagas cardiomyopathy in the United States. Am J Transplant 2013; 13:3262-8. [PMID: 24165397 PMCID: PMC10183729 DOI: 10.1111/ajt.12507] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/12/2013] [Accepted: 09/12/2013] [Indexed: 01/25/2023]
Abstract
Since an initial case in 2006, we noted multiple patients undergoing heart transplantation (HTx) for Chagas cardiomyopathy (CC) at our transplant program. The clinical characteristics, laboratory results and outcomes of patients with CC undergoing HTx in the United States have not been reported previously. In 2010, we implemented a systematic screening and management program for patients undergoing HTx for CC. Before HTx, all patients with idiopathic dilated cardiomyopathy who were born in a Chagas disease endemic country were screened for Trypanosoma cruzi (TC) infection with serology. After HTx, monitoring for TC reactivation was performed using clinical visits, echocardiography, endomyocardial biopsy and serial whole blood polymerase chain reaction (PCR) testing. Between June 2006 and January 2012, 11 patients underwent HTx for CC. One patient was empirically treated due to the presence of TC amastigotes in explanted cardiac tissue. Two patients experienced allograft dysfunction due to TC reactivation and three patients experienced subclinical reactivation (positive PCR results), which were treated. Chagas disease is a common cause of dilated cardiomyopathy in patients from endemic countries undergoing HTx at a transplant program in the United States. Reactivation is common after transplantation and can cause adverse outcomes.
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Bocchi EA, Arias A, Verdejo H, Diez M, Gómez E, Castro P. The Reality of Heart Failure in Latin America. J Am Coll Cardiol 2013; 62:949-58. [DOI: 10.1016/j.jacc.2013.06.013] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 06/07/2013] [Accepted: 06/13/2013] [Indexed: 11/26/2022]
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Silva EAD, Carvalho DV. Transplante cardíaco: complicações apresentadas por pacientes durante a internação. ESCOLA ANNA NERY 2012. [DOI: 10.1590/s1414-81452012000400005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Com o avanço da ciência, a insuficiência cardíaca tem como possibilidade de intervenção o transplante cardíaco. Este trabalho teve como objetivos traçar o perfil demográfico dos pacientes submetidos ao transplante cardíaco e identificar as complicações apresentadas durante a internação. Trata-se de um estudo descritivo, quantitativo, realizado com 44 prontuários de pacientes submetidos a transplante de junho/2006 a julho/2009 em um Hospital Universitário de Belo Horizonte, Minas Gerais, Brasil. O projeto atendeu às recomendações da Resolução 196/96. Pelos resultados, a maioria dos pacientes era do sexo masculino, casada, escolaridade de nível fundamental e idade média de 45,2 anos. A miocardiopatia chagásica foi a principal causa de insuficiência cardíaca. As complicações predominantes foram alteração da glicemia, insuficiência renal e infecções. A taxa de mortalidade na internação foi de 20,4%. Além das complicações biológicas só foram registradas ansiedade e depressão. São necessárias pesquisas sobre o tema nos âmbitos psicossociais e espirituais, contribuindo para o desenvolvimento científico.
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Pettit SJ, Jhund PS, Hawkins NM, Gardner RS, Haj-Yahia S, McMurray JJ, Petrie MC. How Small Is Too Small? A Systematic Review of Center Volume and Outcome After Cardiac Transplantation. Circ Cardiovasc Qual Outcomes 2012; 5:783-90. [DOI: 10.1161/circoutcomes.112.966630] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen J. Pettit
- From the Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (S.J.P., R.S.G., S.H.-Y., M.C.P.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom (P.S.J., J.J.V.M.); Institute of Cardiovascular Medicine & Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (N.M.H.)
| | - Pardeep S. Jhund
- From the Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (S.J.P., R.S.G., S.H.-Y., M.C.P.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom (P.S.J., J.J.V.M.); Institute of Cardiovascular Medicine & Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (N.M.H.)
| | - Nathaniel M. Hawkins
- From the Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (S.J.P., R.S.G., S.H.-Y., M.C.P.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom (P.S.J., J.J.V.M.); Institute of Cardiovascular Medicine & Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (N.M.H.)
| | - Roy S. Gardner
- From the Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (S.J.P., R.S.G., S.H.-Y., M.C.P.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom (P.S.J., J.J.V.M.); Institute of Cardiovascular Medicine & Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (N.M.H.)
| | - Saleem Haj-Yahia
- From the Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (S.J.P., R.S.G., S.H.-Y., M.C.P.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom (P.S.J., J.J.V.M.); Institute of Cardiovascular Medicine & Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (N.M.H.)
| | - John J.V. McMurray
- From the Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (S.J.P., R.S.G., S.H.-Y., M.C.P.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom (P.S.J., J.J.V.M.); Institute of Cardiovascular Medicine & Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (N.M.H.)
| | - Mark C. Petrie
- From the Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (S.J.P., R.S.G., S.H.-Y., M.C.P.); Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom (P.S.J., J.J.V.M.); Institute of Cardiovascular Medicine & Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (N.M.H.)
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Bern C, Kjos S, Yabsley MJ, Montgomery SP. Trypanosoma cruzi and Chagas' Disease in the United States. Clin Microbiol Rev 2011; 24:655-81. [PMID: 21976603 PMCID: PMC3194829 DOI: 10.1128/cmr.00005-11] [Citation(s) in RCA: 456] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Chagas' disease is caused by the protozoan parasite Trypanosoma cruzi and causes potentially life-threatening disease of the heart and gastrointestinal tract. The southern half of the United States contains enzootic cycles of T. cruzi, involving 11 recognized triatomine vector species. The greatest vector diversity and density occur in the western United States, where woodrats are the most common reservoir; other rodents, raccoons, skunks, and coyotes are also infected with T. cruzi. In the eastern United States, the prevalence of T. cruzi is highest in raccoons, opossums, armadillos, and skunks. A total of 7 autochthonous vector-borne human infections have been reported in Texas, California, Tennessee, and Louisiana; many others are thought to go unrecognized. Nevertheless, most T. cruzi-infected individuals in the United States are immigrants from areas of endemicity in Latin America. Seven transfusion-associated and 6 organ donor-derived T. cruzi infections have been documented in the United States and Canada. As improved control of vector- and blood-borne T. cruzi transmission decreases the burden in countries where the disease is historically endemic and imported Chagas' disease is increasingly recognized outside Latin America, the United States can play an important role in addressing the altered epidemiology of Chagas' disease in the 21st century.
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Affiliation(s)
- Caryn Bern
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Infections in heart transplant recipients in Brazil: The challenge of Chagas' disease. J Heart Lung Transplant 2010; 29:286-90. [DOI: 10.1016/j.healun.2009.08.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 07/31/2009] [Accepted: 08/02/2009] [Indexed: 11/20/2022] Open
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Incidence and outcomes of infections in cardiac allograft recipients: A Brazilian perspective. Am J Infect Control 2010; 38:162-3. [PMID: 20176285 DOI: 10.1016/j.ajic.2009.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 05/23/2009] [Accepted: 05/26/2009] [Indexed: 11/23/2022]
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Abstract
A hundred years from its description, Chagas cardiomyopathy remains a challenging disease. Although successful vector-control strategies have decreased the incidence of Chagas disease in several Latin American countries, both migration to urban areas and immigration have spread the disease worldwide; and now, blood transfusion, organ transplantation, and vertical transmission are a concern. The pathogenesis of Chagas cardiomyopathy involves complex host-parasite interactions, where low-grade but incessant systemic infection and triggered autoimmune reaction are the main mechanisms for its development, with the contribution of autonomic damage and microvascular disturbances. Chagas cardiomyopathy is the most important clinical presentation of Chagas disease and comprises a wide range of manifestations, including heart failure, arrhythmias, heart blocks, sudden death, thromboembolism, and stroke. Recently, simple clinical prognostic scores have been developed to identify high-risk patients and help with management. The treatment of Chagas cardiomyopathy focuses mostly on managing heart failure, arrhythmias, and thromboembolism. The role of specific antiparasitic therapy in the chronic form is not yet defined, and a randomized trial is now under way to address this crucial point. In this article, we review the main clinical aspects of Chagas cardiomyopathy and underscore some upcoming challenges for the appropriate control, diagnosis, and management of this complex disease.
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Affiliation(s)
- Andréia Biolo
- Division of Cardiology, Hospital de Clínicas de Porto Alegre and Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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Britto CC. Usefulness of PCR-based assays to assess drug efficacy in Chagas disease chemotherapy: value and limitations. Mem Inst Oswaldo Cruz 2009; 104 Suppl 1:122-35. [DOI: 10.1590/s0074-02762009000900018] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Accepted: 06/01/2009] [Indexed: 11/21/2022] Open
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Bestetti RB, Theodoropoulos TA. A Systematic Review of Studies on Heart Transplantation for Patients With End-Stage Chagas’ Heart Disease. J Card Fail 2009; 15:249-55. [DOI: 10.1016/j.cardfail.2008.10.023] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 09/19/2008] [Accepted: 10/17/2008] [Indexed: 11/24/2022]
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A 23 years of uneventful evolution in a heart-transplanted patient with chagasic cardiomyopathy on a two-drug immunosuppressive protocol. Transplantation 2009; 87:454-5. [PMID: 19202456 DOI: 10.1097/tp.0b013e31819790c5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Blum JA, Zellweger MJ, Burri C, Hatz C. Cardiac involvement in African and American trypanosomiasis. THE LANCET. INFECTIOUS DISEASES 2008; 8:631-41. [PMID: 18922485 DOI: 10.1016/s1473-3099(08)70230-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
American trypanosomiasis (Chagas disease) and human African trypanosomiasis (HAT; sleeping sickness) are both caused by single-celled flagellates that are transmitted by arthropods. Cardiac problems are the main cause of morbidity in chronic Chagas disease, but neurological problems dominate in HAT. Physicians need to be aware of Chagas disease and HAT in patients living in or returning from endemic regions, even if they left those regions long ago. Chagas heart disease has to be taken into account in the differential diagnosis of cardiomyopathy, primarily in patients with pathological electrocardiographic (ECG) findings, such as right bundle branch block or left anterior hemiblock, with segmental wall motion abnormalities or aneurysms on echocardiography, and in young patients with stroke in the absence of arterial hypertension. In HAT patients, cardiac involvement as seen by ECG alterations, such as repolarisation changes and low voltage, is frequent. HAT cardiopathy in general is benign and does not cause relevant congestive heart failure and subsides with treatment. We review the differences between the American and African trypanosomiasis with the main focus on the heart.
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Rationale and design of a randomized placebo-controlled trial assessing the effects of etiologic treatment in Chagas' cardiomyopathy: the BENznidazole Evaluation For Interrupting Trypanosomiasis (BENEFIT). Am Heart J 2008; 156:37-43. [PMID: 18585495 DOI: 10.1016/j.ahj.2008.04.001] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 04/01/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Benznidazole is effective for treating acute and chronic (recently acquired) Trypanosoma cruzi infection (Chagas' disease). Recent data indicate that parasite persistence plays a pivotal role in the pathogenesis of chronic Chagas' cardiomyopathy. However, the efficacy of trypanocidal therapy in preventing clinical complications in patients with preexisting cardiac disease is unknown. STUDY DESIGN BENEFIT is a multicenter, randomized, double-blind, placebo-controlled clinical trial of 3,000 patients with Chagas' cardiomyopathy in Latin America. Patients are randomized to receive benznidazole (5 mg/kg per day) or matched placebo, for 60 days. The primary outcome is the composite of death; resuscitated cardiac arrest; sustained ventricular tachycardia; insertion of pacemaker or cardiac defibrillator; cardiac transplantation; and development of new heart failure, stroke, or systemic or pulmonary thromboembolic events. The average follow-up time will be 5 years, and the trial has a 90% power to detect a 25% relative risk reduction. The BENEFIT program also comprises a substudy evaluating the effects of benznidazole on parasite clearance and an echo substudy exploring the impact of etiologic treatment on left ventricular function. Recruitment started in November 2004, and >1,000 patients have been enrolled in 35 centers from Argentina, Brazil, and Colombia to date. CONCLUSION This is the largest trial yet conducted in Chagas' disease. BENEFIT will clarify the role of trypanocidal therapy in preventing cardiac disease progression and death.
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Campos SV, Strabelli TMV, Amato Neto V, Silva CP, Bacal F, Bocchi EA, Stolf NAG. Risk Factors for Chagas' Disease Reactivation After Heart Transplantation. J Heart Lung Transplant 2008; 27:597-602. [DOI: 10.1016/j.healun.2008.02.017] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 01/06/2008] [Accepted: 02/17/2008] [Indexed: 11/26/2022] Open
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Marchiori PE, Alexandre PL, Britto N, Patzina RA, Fiorelli AA, Lucato LT, Rosemberg S, Pereira SLA, Stolf NG, Scaff M. Late Reactivation of Chagas’ Disease Presenting in a Recipient as an Expansive Mass Lesion in the Brain after Heart Transplantation of Chagasic Myocardiopathy. J Heart Lung Transplant 2007; 26:1091-6. [DOI: 10.1016/j.healun.2007.07.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 07/18/2007] [Accepted: 07/23/2007] [Indexed: 11/25/2022] Open
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Aranguiz-Santander E, Merello L, Pedemonte O, Torres H, Vera A, Alburquerque J. Heart Transplantation in Chile: Preliminary Report From the Gustavo Fricke Hospital in Vina del Mar. Transplant Proc 2007; 39:619-21. [PMID: 17445559 DOI: 10.1016/j.transproceed.2006.12.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to analyze our results as the national reference center of the public health network in Chile. PATIENTS AND METHODS Retrospective analysis of all transplantations performed between 1998 and 2005 was done and actuarial survival estimates were calculated according to Kaplan-Meier. RESULTS Heart transplantations were performed in 25 patients of mean age 43 +/- 11.2 years. Eight patients (32%) were transplanted from a national priority list; all patients were under intensive care support with inotropic therapy, 4 were mechanically ventilated, and 1 required an intra-aortic counter pulsation balloon. The average time on the waiting list was 145 days in nonurgent cases and 9.4 days in urgent ones. Perioperative mortality occurred in 1 patient (4%) due to primary graft failure; 2 patients died due to infectious complications during the first year of follow-up; and 1 died due to a non-cytomegalovirus (CMV) infection at 51 months after transplantation. Two patients developed acute rejection with full recovery. The most common morbidities in the current series were hypertension (71%); hyperlipidemia (71%); renal dysfunction (24%); diabetes (10%); and vasculopathy (10%). Actuarial survival rates were 87.2% and 74.7% at 12 and 86 months, respectively. At 7 years follow-up, 20 patients were in New York Heart Association (NYHA) Class I and one Class II. CONCLUSION Our heart transplantation program showed comparable results in the short and midterm follow-up when compared with other international reports, confirming that heart transplantation is an excellent therapeutic option for patients with end-stage heart failure.
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Affiliation(s)
- E Aranguiz-Santander
- Department of Cardiovascular Surgery, Gustavo Fricke Hospital, Vina del Mar, and the University of Valparaíso, Valparaíso, Chile.
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Abstract
BACKGROUND Chagas disease remains a significant public health issue and a major cause of morbidity and mortality in Latin America. Despite nearly 1 century of research, the pathogenesis of chronic Chagas cardiomyopathy is incompletely understood, the most intriguing challenge of which is the complex host-parasite interaction. METHODS AND RESULTS A systematic review of the literature found in MEDLINE, EMBASE, BIREME, LILACS, and SCIELO was performed to search for relevant references on pathogenesis and pathophysiology of Chagas disease. Evidence from studies in animal models and in anima nobile points to 4 main pathogenetic mechanisms to explain the development of chronic Chagas heart disease: autonomic nervous system derangements, microvascular disturbances, parasite-dependent myocardial aggression, and immune-mediated myocardial injury. Despite its prominent peculiarities, the role of autonomic derangements and microcirculatory disturbances is probably ancillary among causes of chronic myocardial damage. The pathogenesis of chronic Chagas heart disease is dependent on a low-grade but incessant systemic infection with documented immune-adverse reaction. Parasite persistence and immunological mechanisms are inextricably related in the myocardial aggression in the chronic phase of Chagas heart disease. CONCLUSIONS Most clinical studies have been performed in very small number of patients. Future research should explore the clinical potential implications and therapeutic opportunities of these 2 fundamental underlying pathogenetic mechanisms.
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Affiliation(s)
- Jose Antonio Marin-Neto
- Cardiology Division, Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, São Paulo, Brazil.
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Bocchi EA, Ahualli L, Amuchastegui M, Boullon F, Cerutti B, Colque R, Fernandez D, Fiorelli A, Olaya P, Vulcado N, Perrone SV. Recommendations for Use of Everolimus After Heart Transplantation: Results From a Latin-American Consensus Meeting. Transplant Proc 2006; 38:937-42. [PMID: 16647515 DOI: 10.1016/j.transproceed.2006.02.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Despite improvements during the last decades, heart transplantation remains associated with several medical complications, which limit clinical outcomes: acute rejection with hemodynamic compromise, cytomegalovirus (CMV) infections, allograft vasculopathy, chronic renal failure, and neoplasias. Everolimus, a proliferation signal inhibitor, represents a new option for adjunctive immunosuppressive therapy. Everolimus displays better efficacy in de novo heart transplant patients than azathioprine for prophylaxis of biopsy-proven acute rejection episodes of at least ISHLT grade 3A (P < .001), of allograft vasculopathy (P < .01), and of CMV infections (P < .01). These findings suggest that everolimus potentially play an important role as part of immunosuppressive therapy in heart transplant recipients. Heart transplant investigators from Latin America produced recommendations for everolimus use in daily practice based on available data and their own experience.
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Affiliation(s)
- E A Bocchi
- Institutions of the participants of the Consensus Meeting: Heart Institute, Heart Failure and Heart Transplantation Unit, São Paulo, Brazil.
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Drigo SA, Cunha-Neto E, Ianni B, Cardoso MRA, Braga PE, Faé KC, Nunes VL, Buck P, Mady C, Kalil J, Goldberg AC. TNF gene polymorphisms are associated with reduced survival in severe Chagas' disease cardiomyopathy patients. Microbes Infect 2005; 8:598-603. [PMID: 16427798 DOI: 10.1016/j.micinf.2005.08.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Revised: 07/29/2005] [Accepted: 08/19/2005] [Indexed: 11/22/2022]
Abstract
Chronic Chagas' disease cardiomyopathy (CCC) is the most important clinical outcome of infection by the parasite Trypanosoma cruzi, affecting 18 million individuals in Latin America. One-third of CCC patients develop heart failure due to end-stage dilated cardiomyopathy, and their survival is reduced by 50% compared to patients with other cardiomyopathies. Genetic susceptibility may play a role in the differential survival of severe CCC patients. Given the role of TNF-alpha in the progression of heart failure, and the increased TNF-alpha plasma and heart tissue levels observed in these patients, we chose TNF as a candidate gene for increased mortality in severe CCC patients. We typed the TNFa microsatellite and the -308 TNF promoter polymorphism and then analyzed the survival curves of 42 patients with severe ventricular dysfunction (left ventricular ejection fraction<or=40%) according to the presence of the TNF2 promoter allele or the TNFa2 microsatellite allele, both previously associated with high TNF-alpha production. Multivariate regression analysis (Cox proportional hazards model) revealed the TNF genotype and age of onset of severe CCC as independent predictors of mortality in severe CCC. We showed that patients positive for TNF2 or TNFa2 alleles display a significantly shorter survival time compared to those carrying other alleles; the median survival times were 2.9 and 8 months, respectively (HR(adj)=2.28, p=0.020). We have identified for the first time a genetic factor related to reduced survival in severe Chagas' disease cardiomyopathy. The association of TNF genotype with earlier death in CCC should be taken into account when planning therapeutic intervention.
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Affiliation(s)
- Sandra A Drigo
- Heart Institute (InCor), School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar 44, bloco 2, 9 andar, CEP: 05403-001 São Paulo, Brazil
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Benvenuti LA, Roggério A, Sambiase NV, Fiorelli A, Higuchi MDL. Polymerase chain reaction in endomyocardial biopsies for monitoring reactivation of Chagas' disease in heart transplantation. Cardiovasc Pathol 2005; 14:265-8. [PMID: 16168900 DOI: 10.1016/j.carpath.2005.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Revised: 05/09/2005] [Accepted: 06/02/2005] [Indexed: 11/25/2022] Open
Abstract
Polymerase chain reaction (PCR) has been used to detect microbiological agent recurrence after heart transplantation of viral-induced cardiomyopathies. We report a case of reactivation of Chagas' disease after heart transplantation in which parasites could be detected in the endomyocardial biopsy using hematoxylin-eosin-stained sections, immunohistochemistry, and PCR for Trypanosoma cruzi DNA. Interestingly, PCR results remained positive in the endomyocardial biopsy 53 days after the beginning of successful treatment, pointing to the possibility of chronic persistence of parasites in the myocardium after the reactivation of Chagas' disease.
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Affiliation(s)
- Luiz Alberto Benvenuti
- Laboratory of Pathology, Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar 44, 05403-000 São Paulo, Brazil.
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Bacal F, Silva CP, Bocchi EA, Pires PV, Moreira LFP, Issa VS, Moreira SA, das Dores Cruz F, Strabelli T, Stolf NAG, Ramires JAF. Mychophenolate mofetil increased chagas disease reactivation in heart transplanted patients: comparison between two different protocols. Am J Transplant 2005; 5:2017-21. [PMID: 15996254 DOI: 10.1111/j.1600-6143.2005.00975.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Heart transplantation (HT) remains the treatment of choice for advanced chagasic cardiomyopathy. New immunosuppression protocols have provided better control of rejection (RJ) and cardiac allograft vasculopathy. However, their influence on infection and Chagas disease reactivation (CDR) is not well established. The aim of this study was to compare the CDR rate in patients under two different immunosuppression protocols. We studied 39 chagasic patients who had undergone orthotopic HT between April, 1987 and June, 2004. They were divided into two groups, one taking azathioprine (group 1=24 patients) and the other taking mycophenolate mofetil (group 2=15 patients), in the standard doses (2 mg/kg/day and 2 g/day, respectively), beside prednisone and cyclosporine, in equivalent doses. The number of CDR and RJ episodes were analyzed in the first and second years after HT. CDR rates were 8%+/-5% at 1 year and 12%+/-6% at 2 years of follow-up in group 1. Otherwise, patients in group 2 presented CDR rates of 75%+/-10% and 81%+/-9% at the same periods, respectively (p<0.0001, hazard ratio=6.06). When comparing RJ rates in the first year after HT, both groups had similar behavior under both immunosuppression protocols (p=0.88). These data show that current prescribed doses of mycophenolate mofetil increase the early risk of CDR without changing RJ incidence in this period.
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Affiliation(s)
- Fernando Bacal
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
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