[CRT-FORUM] 62E Desfibrilators in Chronic chagasic cardiomyopathy. Dr. Perez Riera

[CRT-INFO]

CRT-D FOR CHRONIC CHAGASIC CARDIOMYOPATHY

Dear colleague Dr. Bruno P Valdigem Fellow in invasive electrophysiology
from UNIFESP/EPM-São Paulo Brazil: we think that your question is very
important for us the Latin Americans ( and also in others countries see
later) because Chagas' disease or American trypanosomiasis, is a potentially
lethal parasitic zoonosis prevalent and endemic only in Latin America. The
entity constitutes and important public health problem in most of the Latin
American countries. Endemic in Latin America from the north of Mexico to the
South of Argentina and Chile. The number of people infected with Chagas'
disease worldwide is estimated to be about 16 - 18 million in 18 countries
of Latin America1.
It has 90,000,000 exposed.
There is 120,000 new cases diagnosed in Latin America.
Mortality: Killing 45.000 to 50.000 people/year.
The main cause of mortality is cardiac cardiomyopathy:
1) Approximately 60% SCD. It is a rare complication, that may be the
first manifestation of Chagas' disease. It’s causes are: VF, bradyarrhtymia,
thromboembolism and rarely aneurism rupture

2) Approximately 30% CHF
3) Approximately 15% Cerebral or pulmonary embolism
4) Others (Approximately 5%) severe acute myocarditis,
meningoencephalitis in newborn, volvulus of he dilated sigmoid megacolon (1)

Brazil prevalence: 1.3% global prevalence rate. 17 thousand deaths/year in
Brazil, from which 5 thousand by heart disease. In Sao Paulo Capital City,
it is estimated in 300,000 infected patients. In the state of Sao Paulo
there is 500.
It is estimated that 20-30% of individuals infected with T. cruzi will
develop symptomatic heart disease at some point during their lives.
Approximately 60% of patients display the indeterminate form and only 10%
severe heart disease.
It is estimated that approximately 25% of individuals infected with T. cruzi
will develop symptomatic heart disease at some point during their lives.
The beetles that transmit Chagas live in cracks in the walls and roofs of
mud and straw housing, which are common in rural areas and poor urban slums
in Latin America. Population movements from rural to urban areas in the
1970s and 80s brought Chagas into cities, and it became an urban infection
transmitted through blood transfusions. Blood banks reported T. cruzi
infection rates ranging from 1.7% in Sao Paulo, Brazil, to 53% in Santa
Cruz, Bolivia, where Chagas infection rates far exceeded those of HIV and
hepatitis. Chagas is most common among the poorest and most vulnerable
populations. Often unaware of how the disease is caught or what their
chances of being cured are, those infected by T. cruzi are unlikely to be in
a position to fight for their right to be treated. Treatment of the disease
has been systematically sidelined by national and regional health
authorities.
The process of urbanization in Latin America and migratory population
movements from endemic countries have led to the disease being diagnosed in
non-endemic areas2.
Spain: In Barcelona's immigrant population from Latin America with risk
factors for American Trypanosomiasis were screened for Chagas disease by
immunofluorescence assay and 34% had a positive tests3.
USA: Immigrants from México and Central and South America is estimated in
100.00 -675.000 are infected. In the summer of 2006, Patricia Dorn, Ph.D.
from Loyola University New Orleans discovered the first human case of
insect-transmitted Chagas parasite in Louisiana and the sixth ever in the
U.S. Previously there had only been five reported cases of insect
transmission of the Chagas parasite to humans in the United States4. Three
of these cases occurred in Texas infants, two in 1955 and the other in 1983.
The fourth case occurred in a 56-year-old California woman in 1982. The
fifth case occurred in rural Tennessee in 1998 in an 18-month-old child. The
bug was found in the child's crib, and the infection was detected by PCR and
treated during the acute stage. Another case of an infant in Texas is
currently under investigation.
There are several reasons that likely explain why so few people become
infected in the U.S. The most important is that people don't tend to live in
houses that provide good habitat for the bugs and that the bugs can get into
at night. The other is that apparently the behavior of the bugs found in the
U.S. means that they transmit the parasite only poorly. Rather than
defecating and depositing the parasite on the skin during the blood meal (as
happens in Mexico and Central and S. America), the bugs in U.S. take the
blood meal, leave the host and defecate elsewhere about 30 min. later.
The blood just began to be screened for the Chagas parasite in the U.S. in
2007. Already there are significant numbers of infected blood units
identified.
Switzerland: Several cases have been recently diagnosed in Switzerland,
where systematic screening of groups at risk should be implemented.
Considering the variable transmission patterns, screening strategies should
be adapted to the different groups at risk. As the vast majority of persons
at risk belong to marginalized communities with limited access to care,
systematic screening and treatment of infected individuals represent a major
challenge in order to interrupt the congenital transmission and improve the
long-term prognosis5.
The specific differential characteristics of chronic chagasic
cardiomyopathy, lack of knowledge of the disease among many healthcare
workers, and the fact that arrhythmia or sudden death is frequently the
first manifestation of disease
Chronic Chagas disease patients required pacemaker implant at a younger age
in contrast with patients with other cardiac pathologies. The clinical
recognition of Chagas disease associated with cardiomyopathy is low despite
the epidemiological data.

Your Question: Is there any evidence-based data on Defibrilators or CRT-D
for Chronic Chagasic cardiomyopathy?
Answer: Several studies have shown that HF may benefit from CRT. Studies
have demonstrated a beneficial effect of RV bifocal pacing, using two leads
at different positions, in similar patient populations. In Chagas disease 30
patients who developed severe DCM (NYHA class II or IV) + AF + AV block.
Patients underwent endocardial dual-chamber pacemaker implantation with two
RV leads-one placed near the RVOT and the other in the apex6.
Patients were examined by:
1) Evolutionary NYHA class determination before and 3, 6, 12, 18, 24,
and 36 Months after CRT.
2) ECHO
3) Holter monitoring
4) EPS.
Compared to the baseline, the LVEF increased in the first month of CRT, the
LV end diastolic diameter decreased, all patients were downgraded to NYHA
class I or II, and the incidence of VT decreased. However, these could not
be maintained and worsened after 6 months CRT. There was a mortality rate of
43.3% during the first year, and only 23.3% of patients remained alive after
3 years. They underwent an EPS, which revealed complexes VT justifying ICD
in 6 out of 7 patients. The favorable effects of RV bifocal pacing could not
be maintained beyond the first 6 months, likely due to the VT. Therefore,
CRT combined with ICD from the outset may be recommended for this patient
group.

References
1) Moreira M da C, Heringer-Walther S, Wessel N, Moreira Ventura T,
Wang Y, Schultheiss HP, Walther T Prognostic value of natriuretic peptides
in Chagas' disease: a 3-year follow-up investigation. Cardiology. 2008;
110:217-225.

2) Dubner S, Schapachnik E, Riera AR, Valero E. Chagas disease:
state-of-the-art of diagnosis and management.Cardiol J. 2008;15(6):493-504.

3) Manzardo C, Treviño B, Gómez i Prat J, Cabezos J, Monguí E, Clavería
I, Luis Del Val J, Zabaleta E, Zarzuela F, Navarro R. Communicable diseases
in the immigrant population attended to in a tropical medicine unit:
epidemiological aspects and public health issues. Travel Med Infect Dis.
2008; 64-11.

4) Herwaldt BL, Grijalva MJ, Newsome AL, McGhee CR, Powell MR, Nemec
DG, et al. Use of polymerase chain reaction to diagnose the fifth reported
US case of autochthonous transmission of Trypansoma cruzi, in Tennessee,
1998. J Infect Dis 2000;181:395–399.

5) Jackson Y, Chappuis F, Loutan L.Chagas disease in Switzerland:
managing an emerging infection and interrupting its transmissionRev Med
Suisse. 2008; 4:1212-4, 1216-1217.

6) da Silva Menezes A. Outcome of right ventricular bifocal pacing in
patients with permanent atrial fibrillation and severe dilated
cardiomiopathy due to Chagas disease: three years of follow-up. J Interv
Card Electrophysiol. 2004 Dec; 11: 193-198.

All the best for all
Sérgio Dubner, MD PhD FACC& Edgardo Schapachnik, MD& Andrés Ricardo Pérez
Riera MD

> Greetings to everyone. Is there any evidence-based data on 
> Defibrilators or CRT-D for Chronic Chagasic cardiomyopathy? Apart from 
> bifocal RV stimulation, throughly detailed by colleagues.
> Thank you
> Bruno P Valdigem
> Fellow in invasive electrophysiology
> UNIFESP/EPM-SP
>


-- 
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee