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Heart transplantation in 107 cases of Chagas' disease
A I Fiorelli1, R H B Santos, J L Oliveira
1Heart Institute of Sao Paulo University Medical School, Sao Paulo, Brazil. fiorelliai@uol.com.br
Insights
Cardiac transplantation for Chagas' disease presents unique challenges, including disease reactivation and increased cancer risk. Despite these risks, it remains the only effective treatment for end-stage disease.
Area of Science:
- Cardiology
- Infectious Diseases
- Transplantation Medicine
Background:
- Chagas' disease is a significant parasitic infection endemic to South America.
- Cardiac involvement is a common and severe manifestation of Chagas' disease.
Purpose of the Study:
- To review the outcomes of cardiac transplantation in patients with Chagas' disease.
- To analyze the specific challenges including disease reactivation, immunosuppression protocols, and mortality rates.
Main Methods:
- A retrospective review of 107 heart transplantations performed for Chagas' disease over 25 years (1985-2010).
- Analysis of patient demographics, functional status, and pre-transplant support.
- Evaluation of post-transplant complications, focusing on Chagas' disease reactivation and mortality causes.
Main Results:
- Hospital mortality was 17.7%, primarily due to infection and graft dysfunction.
- Late mortality was 25.2%, with rejection, infection, and cancers (lymphoma, sarcoma) being major contributors.
- Chagas' disease reactivation was diagnosed in 71.8% of cases via myocardial parasite identification.
Conclusions:
- Cardiac transplantation in Chagas' disease patients faces distinct challenges, notably disease reactivation and a higher incidence of malignancies.
- Immunosuppression, particularly steroid use, is linked to increased risks of cancer and Chagas' disease reactivation.
- Despite complications, transplantation offers a life-altering treatment for end-stage Chagas' disease, with early diagnosis and treatment (e.g., benzonidazole) potentially reversing histological changes.
Introduction:
Chagas' disease is endemic in South America.
Objective:
This research reviewed the experience with cardiac transplantation in Chagas' disease, emphasizing reactivation, immunosuppression, and mortality.
Methods:
Over 25 years from March 1985 to March 2010, 107/409 (26.2%) patients with Chagas' disease underwent heart transplantation, patients including 74 (71.1%) men and 72 (67.2%), in functional class IV with 33 (30.8%) on vasopressors and 17 (10.7%) on mechanical circulatory support.
Results:
The diagnosis of disease reactivation was performed by identifying the parasite in the myocardium (n = 23; 71.8%) in the subcutaneous tissue (n = 8; 25.0%), in blood (n = 11; 34.3%), or in central nervous tissue (n = 1; 3.1%). Hospital mortality was 17.7% (n = 19) due to infection (n = 6; 31.5%), graft dysfunction (n = 6; 31.5%), rejection (n = 4; 21.1%), or sudden death (n = 2; 10.5%). Late mortality was 27 (25.2%) cases, which were distributed as: rejection (n = 6; 22.2%), infection (n = 6; 22.2%), (n = lymphoma 4; 14.8%), sarcoma (n = 2; 7.4%), for constrictive pericarditis (n = 2; 7.4%) reactivation of Chagas' disease in the central nervous system (n = 1; 7.1%).
Conclusions:
Transplantation in Chagas' disease has peculiar problems that differ from other etiologies due to the possibility of disease reactivation and the increased possibility of emergence of cancers. However, transplantation is the only treatment able to modify the natural progression of the disease in its terminal phase. Early diagnosis and rapid introduction of benzonidazole reverses the histological patterns. Immunosuppression, especially steroids, predisposes to the development of cancer and disease reactivation.
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