Myocardial involvement in Chagas disease: Insights from cardiac magnetic resonance

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Abstract

Background

Chagas' disease is becoming a public health problem in Europe because of migratory movements. Cardiac magnetic resonance (CMR) has emerged as a non-invasive tool to assess cardiac tissue characteristics. There is scarce data available on CMR in patients with Chagas' disease.

Objective

To describe CMR findings in patients with Chagas' disease living in a non-endemic area focusing on differentiation from other cardiomyopathies and relation with clinical status.

Methods and results

Sixty-seven Chagas' disease patients divided into 3 groups—group 1 (indeterminate form: positive serology without ECG or 2D-echocardiographic abnormalities; N = 27), group 2 (ECG abnormalities of Chagas' disease but normal 2D-echocardiography; N = 19), and group 3 (regional wall motion abnormalities, LV end-diastolic diameter > 55 mm or LV ejection fraction < 50% on echocardiography; N = 21)—were studied. The presence of wall motion abnormalities and delayed enhancement (DE) by CMR was more frequent in the inferolateral and apical segments. DE distribution in the myocardial wall was heterogeneous (subendocardial 26.8%, midwall 14.0%, subepicardial 22.6%, and transmural 36.0% of total segments with DE) and related to larger cardiac chambers and worse systolic function.

Conclusion

Pattern of DE in Chagas' disease may mimic that of both ischemic and nonischemic cardiomyopathies, with especial predilection for the apical and inferolateral segments of the left ventricle. These findings support that myocardial involvement in chronic Chagas' cardiomyopathy (CCC) may be due to both microvascular disturbances and chronic myocarditis and may favor CCC in the differential diagnosis of patients with compatible epidemiological history and heart failure of uncertain etiology.

Section snippets

Background

Chagas' disease represents a major cause of morbidity and mortality in Latin America [1] and an emerging health problem in countries where the disease is not endemic as a result of growing population's movements [2], [3], [4]. Chronic Chagas' cardiomyopathy (CCC) is the most serious and frequent manifestation of Chagas' disease and the main cause of mortality among these patients [5] and is associated to a poorer survival compared with other forms of cardiomyopathies [6]. Currently, the

Study population

Consecutive Chagas' disease patients evaluated at our Institution who underwent CMR from July 2007 to March 2010 were included. All patients received T. cruzi serological tests. Diagnosis of Chagas' disease was established on microbiologic confirmation by any combinations of at least two positive commercial serological tests using different antigens [14]: ELISA using T. cruzi lysate (Ortho-Clinical Diagnostics ®, Johnson & Johnson), ELISA with recombinant antigens (BioELISA Chagas®, Biokit) and

Patient characteristics

A total of 67 consecutive patients were included, 27 patients in Group 1, 19 patients in Group 2 and 21 patients in Group 3. All patients were originally from Latin America, the highest proportion was from Bolivia (N = 57, 85.1%) and the remaining subjects were from Brazil (N = 2, 3.0%), Venezuela (N = 1, 1.5%), Colombia (N = 2, 3.0%), Paraguay (N = 2, 3.0%) and Ecuador (N = 1, 1.5%). All of them were residents in Spain at the time of inclusion in the study. Patient characteristics are shown in Table 1.

Discussion

The aim of our study was to characterize the CMR pattern in a wide spectrum of Chagas' disease patients living in non-endemic areas. The most significant findings are the following: first, DE indicating myocardial scar or fibrosis was present in an important percentage of patients (more than 50% of patients with echocardiographic abnormalities) and was associated with other markers of LV involvement; second, DE was predominantly found in the apex and infero-lateral wall of the LV and had a very

Funding

This work was partially supported by a grant from the Fondo de Investigaciones Sanitarias (FIS), Instituto de Salud Carlos III, Madrid, Spain [PI 070773] and from Department d'Universitats, Recerca y Societat de la Informació de la Generalitat de Catalunya, Spain [2009SGR385].

Acknowledgements

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

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    1

    The first two authors equally contributed to this work.

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