Long-term follow-up of patients with Chagas cardiomyopathy living in a non-endemic area: moving towards identification of early markers of disease progression

Background

The number of patients with Chagas disease residing in Europe has increased significantly due to migration flows. Globally, Chagas cardiomyopathy has worse prognosis than other types of dilated cardiomyopathies and about 30% of patients develop cardiac involvement after a variable latency period (10–30 years). However, there is lack of data regarding the evolution of patients with Chagas disease living in a non-endemic area and potential early predictors of disease progression.

OBJETIVE

To describe the natural course of Chagas disease, the incidence rate of transformation into cardiac form and to assess if early predictors of myocardial involvement translate into a worse long-term prognosis in our non-endemic cohort.

Methods

Clinical and echocardiographic follow-up was performed in 202 individuals from endemic areas of Chagas disease. At baseline, electrocardiogram, BNP and a comprehensive echocardiography including diastolic function and longitudinal myocardial strain were performed. Four different groups were defined: healthy controls (N=77); Chagas indeterminate form (positive serology, normal ECG and left ventricle (LV) dimensions and LV ejection fraction (>50%) and no segmental abnormalities, N=92); Chagas patients with abnormal ECG but normal LV dimensions and motility (N=15); and Chagas patients with LV diameter>55 mm or LV ejection fraction<50% or segmental abnormalities (N=18). The primary clinical outcome included advanced atrioventricular block, sustained ventricular tachycardia, heart failure, heart transplant, death or progression of cardiac disease defined as LV systolic dysfunction or new segmental abnormalities. Kaplan Meier with Long rank test and Cox regression analysis was used.

Results

Mean age was 37±9 and 34% were male. Median follow-up was 69 months (range 1 to 147). The primary endpoint occurred in a total of 17 (8.4%) individuals: 5 (5.4%) in the Indeterminate group; 3 (20%) in the abnormal ECG group; and 9 (50%) in the group with abnormal LV dimension or motility, with no events among controls (long-rank test<0.01, Figure 2). Six patients evolved from the indeterminate phase to cardiac involvement (2 with isolated ECG changes and 4 with abnormal echocardiography without previous changes in ECG (Figure 1). On echocardiography, there were no differences regarding changes in LV dimensions or LV ejection fraction between Chagas patients with normal baseline echo and controls, but a significantly reduction of Em was observed (−1.6±3.0 vs. 0.2±1.0) in the former. Excluding patients with abnormal echo at baseline, BNP (HR=1.03, p=0.001), Em (HR=0.78, p=0.05) and left atrial diameter (1.23, p=0.01) were predictors of the combined event.

Conclusions

Conversion from the indeterminate to Chagas cardiomyopathy in our cohort was approximately 1.1%/year, but it may happen directly with contractility disturbances. BNP and comprehensive echocardiography may help to early detect disease progression.

Figure 1. Distribution of patients and KM curves

Funding Acknowledgement

Type of funding source: None

P1810May early myocardial involvement detection in chagas disease have a prognosis impact?

Background

Brain natriuretic peptide (BNP) and novel echocardiographic techniques such as speckle-tracking and a comprehensive evaluation of diastolic function can detect early myocardial involvement in patients with Chagas disease. However, there is lack of longitudinal studies that can confirm whether this early myocardial involvement translates into a worse prognosis.

Purpose

To assess if early myocardial involvement detected by BNP or a comprehensive echocardiographic evaluation was associated with future events in Chagas disease.

Methods

182 consecutive individuals from endemic areas who underwent T. cruzi screening where prospectively included from 2007 to 2014. ECG, BNP and a comprehensive echocardiography including diastolic function and longitudinal myocardial strain were performed. Four different groups were defined: healthy controls (N=77); Chagas indeterminate form (positive serology, normal ECG and left ventricle (LV) diameter (<55 mm), LV ejection fraction (>50%) and no segmental abnormalities, N=88); Chagas patients with abnormal ECG but normal LV dimensions and motility (N=7); and Chagas patients with LV diameter>55 mm or LV ejection fraction<50% or segmental abnormalities (N=13). The primary outcome included advanced atrioventricular block, sustained ventricular tachycardia, heart failure, heart transplant or death. Kaplan Meier with Long rank test and Cox regression analysis was used.

Results

Mean age was 37±9 and 34% were male. Median follow-up was 63 months (range 1 to 137). The primary endpoint occurred in a total of 11 (10%) individuals: 2 (2.4%) in the Indeterminate group; 3 (43%) in the abnormal ECG group; and 6 (46%) in the group with abnormal LV dimension or motility, with no events among controls (long-rank test<0.01, Figure). In the global population, age, BNP, diastolic dysfunction parameters and longitudinal strain at the inferior and lateral walls were significant predictors. In the cohort of Chagas patients with normal standard echocardiography (N=92), ECG abnormalities (HR=49, p=0.001), Em (HR=0.68, p=0.03), deceleration time (HR=0.01, p=0.01), left atrial diameter (HR=1.24, p<0.01) and longitudinal strain at the midventricular lateral wall (HR=0.75, p=0.028) remained significantly associated with outcome.

Cumulative survival without events

Conclusions

Outcome was significantly more frequent in Chagas patients with abnormalities in ECG or standard echocardiography. In early forms of the disease, myocardial involvement detected by BNP or a comprehensive echocardiography was associated with prognosis, and may help to individualize treatment and follow-up.

C-63 The Role of Neuropsychological Assessment in Congenital Diaphragmatic Hernia

Objective

This case study examined the neurodevelopmental profile associated with congenital diaphragmatic hernia (CDH). CDH is primarily linked to chromosomal abnormality and results in pulmonary hypoplasia and significant respiratory difficulties. CDH occurs in 1 in 2,500 live births in the United States. More severe cases require extracorporeal membrane oxygenation (ECMO) and surgical hernia repair. Survivors are at risk of pulmonary hypertension, gastrointestinal disorders, structural brain abnormalities, and neurodevelopmental disorders. Past studies suggested early ECMO and surgical repair are associated with greater subsequent impairment.

Method

A 16-year-old male with a history of CDH presented for neuropsychological evaluation. History is remarkable for ECMO, surgical repair, pulmonary hypertension, and gastrostomy tube.

Results

Assessment revealed significant neurodevelopmental deficits impacting multiple domains including cognitive reasoning, visual construction, verbal memory, and executive functioning. Decoding and underlying phonemic awareness were preserved, while reading comprehension and applied math were significantly impaired, suggesting significant weaknesses in higher-order language. Social intent was strong despite weak social cognition. Elevated symptoms of anxiety and depression were evident.

Conclusions

CDH carries significant morbidity secondary to compromised respiratory functions and long-term pulmonary hypertension. Neurodevelopmental deficits are strongly associated with CDH and merit early detection, intervention, and follow-up. This case study illustrates the global neurodevelopmental difficulties in CDH requiring ECMO and surgical repair. This study illustrates escalating difficulties navigating academic and social demands as the need for higher order language and social cognition increase through adolescence. Serial neuropsychological assessments may be useful in facilitating and adapting interventions, assessing progress, detecting behavioral health symptoms, and contributing to optimal outcomes in CDH.

Regulation of Saccharomyces cerevisiae catalase gene expression by copper

Treatment of Saccharomyces cerevisiae cells with copper induces the activity of Cu/Zn superoxide dismutase (SOD) and catalase. To understand the level at which Cu regulates catalase, the expression of the S. cerevisiae CTA1 (encoding the peroxisomal catalase A) and CTT1 (encoding the cytosolic catalase T) genes was monitored as a function of Cu treatment. Copper was found to specifically induce transcription of CTT1, but not CTA1, mRNA. Moreover, genetic and biochemical studies demonstrate that this induction is independent of the ACE1 Cu trans-activator controlling the expression of yeast Cu/Zn SOD and metallothionein genes. Copper regulation of CTT1 thus appears to represent a novel metal regulatory pathway in S. cerevisiae cells.

Cloned yeast and mammalian transcription factor TFIID gene products support basal but not activated metallothionein gene transcription

Transcription factor IID (TFIID), the "TATA binding factor," is thought to play a key role in the regulation of eukaryotic transcriptional initiation. We have studied the role of TFIID in the transcription of the yeast metallothionein gene, which is regulated by the copper-dependent activator protein ACE1. Both basal and induced transcription of the metallothionein gene require TFIID and a functional TATA binding site. Crude human and mouse TFIID fractions, prepared from mammalian cells, respond to stimulation by ACE1. In contrast, human and yeast TFIID proteins expressed from the cloned genes do not respond to ACE1, except in the presence of wheat germ or yeast total cell extracts. These results indicate that the cloned TFIID gene products lack a component(s) or modification(s) that is required for regulated as compared to basal transcription.

Sites of topoisomerase I action on X. laevis ribosomal chromatin: transcriptionally active rDNA has an approximately 200 bp repeating structure

The sites at which topoisomerase I interacts with the transcriptionally active ribosomal chromatin of Xenopus oocytes were mapped by treating oocyte nuclei first with camptothecin to stabilize topoisomerase I-rDNA reaction intermediates, and then with SDS to resolve these adducts as protein-linked nicks in the DNA. Strikingly, the topoisomerase I sites are concentrated in the region encoding the 18S, 5.8S, and 28S rRNAs, where they are spaced with a periodicity of approximately 200 nucleotides. Plasmid rDNA that has assembled into a nucleoprotein structure in an oocyte nuclear extract yields this same restricted pattern of sites, while rDNA that is not in a chromatin structure exhibits a continuum of topoisomerase I cleavages. Thus, the approximately 200 bp spacing of sites of topoisomerase I interaction evidently reflects rDNA chromatin structure. These results indicate that the active rRNA genes are organized into nucleosome-like arrays, with topoisomerase I located in the linker regions.

Recurrence of neuroblastoma following prolonged remission

A 6-year-old girl with unresectable and metastatic neuroblastoma had a complete remission with irradiation to the primary tumor and systemic administration of cyclophosphamide. The patient was disease-free for 16 years but had an explosive recurrence of tumor six weeks after a hysterectomy. Although no clear cause-and-effect relationship exists between the surgery and the recurrence, this case illustrates that a recurrence is possible after a long disease-free interval. Diagnostic and therapeutic procedures in such patients should be undertaken with caution.