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Chagas Disease and the Kissing Bug: An Invisible Giant

2019; Elsevier BV; Volume: 33; Issue: 8 Linguagem: Inglês

10.1053/j.jvca.2019.01.014

1532-8422

Andre F. Gosling, Cláudio Léo Gelape,

Trypanosoma species research and implications

“Triatoma Infestans is how I am formally called,But I have many nicknames all over Brazil,Bicudo, Barbeiro, or Chupão,I am the famous bug. (...)(...) Places that I like to make my homeCracks in cob walls or unfinished furnitureIn every place that I arrive, I find my cozy spotAnd my offspring are raised.”1Queiroz P.O. Barbeiro de Chagas. Projeto Ciência na Estrada Educação e Cidadania. Fundação Oswaldo Cruz, 2009Google Scholar THESE VERSES written by Brazilian poet Pádua de Queiroz illustrate the burden of Chagas disease. The disease was described more than 100 years ago by Carlos Chagas, in Brazil, and remains a major social and public health problem in Latin America.2WHOFirst WHO report on neglected tropical diseases: Working to overcome the global impact of neglected tropical diseases. World Health Organization, Geneva2010Google Scholar The World Health Organization considers Chagas a neglected tropical disease and claims that “it affects populations with low visibility and little political voice.”3Chagas C. Nova trypanosomíase humana. Estudo sobre a morfologia e o ciclo evolutivo do Schizotripanum cruzi n. gen. Sp, ajente etiolójico de nova entidade mórbida do homem.Mem Inst Oswaldo Cruz. 1909; 1: 159-218Crossref Google Scholar Chagas disease results from infection with a hemoflagellate protozoan parasite named Trypanosoma cruzi. Besides affecting the gastrointestinal tract, resulting in megaesophagus and megacolon, Chagas most frequently affects the heart (incidence of approximately 24%).4Sabino E.C. Ribeiro A.L. Salemi V.M. et al.Ten-year incidence of Chagas cardiomyopathy among asymptomatic Trypanosoma cruzi-seropositive former blood donors.Circulation. 2013; 127: 1105Crossref PubMed Scopus (109) Google Scholar Chronic Chagas cardiomyopathy is a late manifestation, with up to a 30-year latency, and represents the most common cause of nonischemic cardiomyopathy in Latin America.5Andrade J.P. Marin Neto J.A. Paola A.A. et al.I Latin American guidelines for the diagnosis and treatment of Chagas’ heart disease: Executive summary.Arq Bras Cardiol. 2011; 96: 434-442Crossref PubMed Scopus (130) Google Scholar, 6Schofield C.J. Dias J.C. A cost-benefit analysis of Chagas disease control.Mem Inst Oswaldo Cruz. 1991; 86: 285Crossref PubMed Scopus (63) Google Scholar Four different pathophysiological mechanisms have been proposed to explain the cardiac manifestations of Chagas, including cardiac dysautonomia, microvascular disturbances, parasite-dependent myocardial damage, and immune-mediated myocardial injury. Those processes may result in cardiac arrhythmias, heart failure, aneurysms, and sudden death (60% of all deaths).7Bestetti RB Muccillo G. Clinical course of Chagas’ heart disease: A comparison with dilated cardiomyopathy.Int J Cardiol. 1997; 60: 187-193Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar It can be challenging to diagnose and treat the disease, especially in nonendemic areas. Despite being considered a nonendemic area, the burden of Chagas in the United States is significant, and it is estimated that 300,000 infected immigrants reside in the United States, with 30,000 to 45,000 cases of Chagas cardiomyopathy. Most of those immigrants are originally from South America.8Bern C. Montgomery S.P. An estimate of the burden of Chagas disease in the United States.Clin Infect Dis. 2009; 49: e52-e54Crossref PubMed Scopus (444) Google Scholar Babb et al. report a case of Chagas in a patient who had previously immigrated to the United States and presented with chest pain and symptoms of heart failure.9Babb D.E. Vera-Arroyo A. Rodriguez-Blanco Y. et al.An unusual suspect in a case of left ventricular aneurysm.J Cardiothorac Vasc Anesth. 2019; 33: 2344-2348Abstract Full Text Full Text PDF Scopus (1) Google Scholar The patient was found to have a large left apical aneurysm, which was surgically managed. Left ventricular apical aneurysms represent the most common echocardiographic abnormality and are seen in over 50% of Chagas patients with cardiac involvement.10Bittencourt A.L. Congenital Chagas disease.Am J Dis Child. 1976; 130: 97-103PubMed Google Scholar A few centers in Brazil have published their experience in performing surgery to treat ventricular aneurysms and heart failure in patients with Chagas, but the outcome of these patients when compared to a similar group of patients who are medically managed is unknown.11Wanderley Neto J. Torres L.D.F. Elias D.O. et al.Aneurisma chagásico do ventrículo esquerdo: Aspecto cirúrgico em 29 casos.Rev Bras Cir Cardiovasc. 1992; 7: 180-185Crossref Google Scholar, 12Batista R.J. Partial left ventriculectomy—the Batista procedure.Eur J Cardiothorac Surg. 1999; 15: S12-S19Crossref PubMed Google Scholar With the absence of convincing evidence, management decisions for those patients should be made by a multidisciplinary team, involving cardiac surgery and subspecialties of cardiology such as electrophysiology and heart failure. Overall, in Brazil it is uncommon for patients with chagasic ventricular aneurysms to be referred for resections. The main concerns regarding chagasic aneurysms are their arrhythmogenic nature and association with thromboembolic events. Ventricular arrhythmias are frequent and range from premature ventricular contractions to life-threatening rhythms such as sustained ventricular tachycardia and ventricular fibrillation.13Rassi Júnior A. Rassi A.G. Rassi S.G. et al.Arritmias ventriculares na doença de Chagas. Particularidades diagnósticas, prognósticas e terapêuticas.Arq Bras Cardiol. 1995; 65: 377-387PubMed Google Scholar Patients usually present with palpitations, syncope, or sudden death.14Rassi Júnior A. Rassi S.G. Rassi A. Morte súbita na Doença de Chagas.Arq Bras Cardiol. 2001; 76: 75-85PubMed Google Scholar Amiodarone is considered the safest antiarrhythmic used for ventricular arrhythmias, which are not necessarily linked to aneurysms.15Chiale P.A. Halpern M.S. Nau G.J. et al.Efficacy of amiodarone during long-term treatment of malignant ventricular arrhythmias in patients with chronic chagasic myocarditis.Am Heart J. 1984; 107: 656-665Crossref PubMed Scopus (39) Google Scholar These patients should also be evaluated for possible ablation or placement of an implantable cardioverter-defibrillator. Surgical management is rarely employed. Although there is no evidence to support this practice, aneurysmal resection could be considered in cases of arrhythmias that are refractory to medical therapy. Thromboembolic events are also an important problem in Chagas (incidence from 0.56 to 3%) and are associated with mural thrombosis and apical aneurysms.16Lopes E.R. Marquez J.O. Costa Neto B. et al.Associação entre acidentes vasculares encefálicos e doença de Chagas.Rev Soc Bras Med Trop. 1991; 24: 101-104Crossref PubMed Google Scholar The decision regarding anticoagulation in Chagas patients arose from a prospective study with 1,043 subjects.17Sousa A.S. Xavier S.S. Freitas G.R. et al.Prevention strategies of cardioembolic ischemic stroke in Chagas’ disease.Arq Bras Cardiol. 2008; 91: 306-310Crossref PubMed Scopus (60) Google Scholar The authors designed a score to predict the risk of cerebrovascular accidents, which includes left ventricular systolic dysfunction (2 points), presence of apical aneurysm (1 point), abnormal repolarization on electrocardiogram (1 point), and age over 48 years (1 point). Warfarin is indicated in scores equal to or above 4. Surgical resection of left ventricular aneurysms is not recommended as prophylaxis against thromboembolic events.17Sousa A.S. Xavier S.S. Freitas G.R. et al.Prevention strategies of cardioembolic ischemic stroke in Chagas’ disease.Arq Bras Cardiol. 2008; 91: 306-310Crossref PubMed Scopus (60) Google Scholar Chagas once was considered a potential contraindication for transplantation because of the theoretical risk of recurrence with immunosuppression. However, early South American experience in the 1980s established the feasibility of heart transplantation in those patients. Currently, Chagas cardiomyopathy is the third most important indication for cardiac transplantation in Brazil.18Andrade J.P. Marin-Neto J.A. Paola A.A. et al.Sociedade Brasileira de Cardiologia. I Diretriz Latino Americana para o Diagnostico e Tratamento da Cardiopatia Chagasica.Arquivos Brasileiros de Cardiologia. 2011; 97: 1-48PubMed Google Scholar, 19Benatti RD Oliveira GH Bacal F et al.Heart Transplantation for Chagas Cardiomyopathy.J Heart Lung Transplant. 2017; 36: 597-603Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Bocchi et al. have reported better outcomes in transplanted patients with Chagas compared to other heart transplant patients.20Bocchi E.A. Fiorelli A. The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi.Ann Thorac Surg. 2001; 71: 1833-1838Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Criteria for heart transplant in Chagas disease are the same as for other causes of heart failure. When considering those patients for a ventricular assist device some challenges arise, such as the well-known risk of developing right ventricular failure, and it is unclear whether patients with Chagas would be at higher risk for developing this complication.21Moreira L.F. Galantier J. Benício A. et al.Left ventricular circulatory support as bridge to heart transplantation in Chagas’ disease cardiomyopathy.Artificial Organs. 2007; 31: 253-258Crossref PubMed Scopus (25) Google Scholar Although Chagas disease and its related cardiomyopathy recently have attracted more attention in developed nations, there is still paucity of published research.22Aquatella H. Acsh F.M. Barbosa M.M. et al.Recommendations for multimodality cardiac imaging in patients with Chagas disease: A report from the American Society of Echocardiography in Collaboration With the InterAmerican Association of Echocardiography (ECOSIAC) and the Cardiovascular Imaging Department of the Brazilian Society of Cardiology (DIC-SBC).J Am Soc Echocardiogr. 2018; 31: 3-25PubMed Google Scholar, 23Bern C. Chagas’ disease.N Engl J Med. 2015; 5: 456-466Crossref Scopus (481) Google Scholar, 24Pereira M.C. Beaton A. Acquatella H. et al.Chagas cardiomyopathy: An update of current clinical knowledge and management.Circulation. 2018; 138: e169-e209PubMed Google Scholar Many questions remain unanswered regarding treatment of chagasic left ventricular aneurysms. Aneurysm size is variable, ranging from small “hollow punch” lesions to large aneurysms (as seen in the case reported by Babb et al.), hardly distinguishable from those seen with myocardial infarction.9Babb D.E. Vera-Arroyo A. Rodriguez-Blanco Y. et al.An unusual suspect in a case of left ventricular aneurysm.J Cardiothorac Vasc Anesth. 2019; 33: 2344-2348Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 25Acquatella H. Echocardiography in Chagas heart disease.Circulation. 2007; 115: 1124-1131Crossref PubMed Scopus (160) Google Scholar, 26Viotti R.J. Vigliano C. Laucella S. et al.Value of echocardiography for diagnosis and prognosis of chronic Chagas disease cardiomyopathy without heart failure.Heart. 2004; 90: 655-660Crossref PubMed Scopus (110) Google Scholar In some circumstances (refractory arrhythmias, systolic dysfunction with ventricular dyskinesia, intra-ventricular thrombus formation), it is possible that patients with large aneurysms could benefit from surgical resection. There is a need for evidence. Chagas still remains, as the poetry says, a “tragedy that rings no bells, patients who do not pay, a disease that does not sell.”27Galeano E. Chagas, una tragedia silenciosa - Médicos Sin Fronteras. Editorial Losada, 2005Google Scholar An Unusual Suspect in a Case of Left Ventricular AneurysmJournal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 8PreviewTrue left ventricular aneurysms are most frequently seen after acute transmural myocardial infarction. These aneurysms are distinct from apical left ventricular pseudoaneurysms, which can also be seen in ischemia, and have a different treatment course. A major dilemma for clinicians is using echocardiographic information to make this distinction. Coronary angiography aids in this distinction; however, in the case of normal coronaries alternate etiologies must be considered. The differential for a patient with a left ventricular aneurysm and normal coronaries or no prior cardiac surgery is broad and includes traumatic, infectious and infiltrative causes. Full-Text PDF