Myocardial involvement in Chagas disease: Insights from cardiac magnetic resonance
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1 Myocardial involvement in Chagas disease: Insights from cardiac magnetic resonance Ander Regueiro a,b, Ana García-Álvarez a,b,c, Marta Sitges a,b, José Tomás Ortiz-Pérez a, Maria Teresa De Caralt a, María Jesús Pinazo a, Elizabeth Posada a, Magda Heras a,b, Joaquim Gascón a, Ginés Sanz a,c. a Hospital Clínic, Barcelona, b HERACLES Cardiovascular Network, Barcelona. c CNIC Instituto de Salud Carlos III, Madrid. Spain ESC 2011, Paris
2 Disclosures None This work was partially supported by a grant from the Fondo de Investigaciones Sanitarias (FIS), Instituto de Salud Carlos III, Madrid, Spain [PI ]
3 Background Chagas disease is a major cause of morbidity and mortality in Latin America 1. Emerging health problem in non endemic countries as a result of growing population's movements 2. Chronic Chagas cardiomyopathy is the most serious and frequent manifestation and the main cause of mortality among these patients 3. 1 Dias J, et al. Mem Inst Oswaldo Cruz 2002;97: Gascón J, et al. Rev Esp Cardiol 2007;60(9). 3 Prata A. et al. Lancet Infect Dis 2001;1:
4 Diagnosis of CCC Positive serology for Trypanosoma cruzi. Chest X-ray. ECG. Echocardiogram. Late diagnosis in advanced stages. Fibrosis is the main pathologic characteristic.
5 Cardiac magnetic resonance Non-invasive modality to assess tissue characteristics. Myocardial fibrosis using contrast delayed enhancement. Ischemic Non-Ischemic
6 CMR in Chagas disease Rochitte CE, et al. J Am Coll Cardiol 2005;46:1553-8
7 Objective CMR characteristics in patients with different forms of Chagas disease living in a non-endemic area.
8 Study population Inclusion criteria Microbiologic confirmation ELISA using T. cruzi lysate. ELISA with recombinant antigens. Immunofluorescence. Exclusion criteria History of cardiac disease 2 cardiovascular traditional risk factors for CAD Alcohol consumption (> 8 g per day in women and 16 g per day in men)
9 Patient classification Group 1 Indeterminate form of Chagas disease Group 2 Chronic Chagas cardiomyopathy diagnosed by ECG abnormalities and normal 2D echocardiography Group 3 Chronic Chagas cardiomyopathy with abnormal 2D echocardiogram
10 Cardiac magnetic resonance 1.5-T scanner. Regional and global LV functions with SSFP sequence. T1-weighted inversion-recovery fast gradientecho pulse sequence after IV administration of gadodiamine-dtpa (0.2 mmol/kg).
11 Cardiac magnetic resonance Manual planimetry of endocardial and epicardial borders at end-systolic and end-diastolic frames. Manual planimetry of contrast-enhanced images (signal intensity >2 SD normal nulled myocardium). Location of DE according to the 17-segment model. Pattern: Transmural, endocardial, epicardial and mid-myocardium scar.
12 Patient characteristics
13 CMR characteristics
14 Abnormal ventricular motion
15 Delayed-enhancement distribution
16 Delayed enhancement pattern Heterogeneous DE pattern. 22.3% epicardial DE. Apical and inferobasal segments. Two possible mechanisms Persistent myocardial inflammation. Ischemia due to micro-vascular disturbances.
17 Clinical, ECG and CMR characteristics according to the presence of DE
18 Conclusions Pattern of DE in Chagas disease resembles that of both ischemic and non ischemic cardiomyopathies. Special predilection for the apical and inferobasal segments of the left ventricle. Such findings plus a epidemiological history should favor CCC in the differential diagnosis of patients with heart failure.
19 Clinical implications Early detection of myocardial involvement. Relationship between echocardiographic parameters and biomarkers. Heterogeneous pattern should be taken into account in the differential diagnosis of cardiomyopathy in non-endemic areas. Epidemiological history is crucial. Arrhythmogenic substrate.
20
21 Prevalence of delayed enhancement 23.9% vs. 68.6% in other studies. More advanced cardiac involvement in patients recruited from Chagas disease endemic areas. Free of possible reinfections which could explain early and more severe progression of cardiomyopathy in other cohorts.
22 Rochitte CE, et al. J Am Coll Cardiol 2005;46:1553-8
23 Rochitte CE, et al. J Am Coll Cardiol 2005;46:1553-8
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