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Heart transplantation in Chagas' disease. 10 years after the initial experience
V B de Carvalho1, E F Sousa, J H Vila
1Universidade de Säo Paulo, Brazil.
Insights
Heart transplantation (HT) offers a promising treatment for end-stage chronic Chagas' heart disease (CCHD). This study found low rates of Trypanosoma cruzi reactivation and reduced allograft rejection, suggesting HT is a viable option for CCHD patients.
Area of Science:
- Cardiology
- Infectious Diseases
- Transplantation Immunology
Background:
- Heart transplantation (HT) for chronic Chagas' heart disease (CCHD) is controversial due to risks of Trypanosoma cruzi reactivation and allograft rejection.
- Active myocarditis in CCHD may increase rejection incidence and severity.
Purpose of the Study:
- To prospectively evaluate the long-term outcomes of heart transplantation in patients with end-stage chronic Chagas' heart disease.
- To assess the safety and efficacy of HT regarding T. cruzi reactivation and allograft rejection in CCHD patients.
Main Methods:
- Prospective follow-up of 10 CCHD patients undergoing HT.
- Immunosuppression with cyclosporine A and azathioprine, with T. cruzi reactivation prophylaxis using benzonidazole.
- Monitoring included blood tests, myocardial biopsies, serological tests, and rejection surveillance.
Main Results:
- At a mean follow-up of 34 months, 70% of patients were alive in NYHA class I.
- Rejection episodes were significantly less frequent (1.6 vs. 5.7) and less severe in CCHD patients compared to controls (P=.0001).
- Three instances of T. cruzi parasitemia were successfully treated with benzonidazole; no recurrence in the allograft was observed.
Conclusions:
- Heart transplantation plays a significant role in managing CCHD.
- Low frequency of T. cruzi reactivation and absence of disease recurrence in the allograft were observed.
- The decreased incidence and severity of rejection warrant further investigation.
Background:
Heart transplantation (HT) as a therapeutic option for end-stage chronic Chagas' heart disease (CCHD) is controversial. Reactivation of Trypanosoma cruzi infection and recurrence of the disease in the allograft are likely to occur. Furthermore, active myocarditis has been reported to predispose patients to an increased incidence and severity of rejection.
Methods And Results:
We prospectively investigated the long-term follow-up of 10 patients with CCHD who underwent HT. Immunosuppression was based on cyclosporine A and azathioprine. T cruzi reactivation was prevented with benzonidazole. Besides allograft rejection surveillance, T cruzi infection was monitored through blood tests, myocardial biopsies, and serological tests. Over a mean follow-up period of 34 +/- 38 months (range, 73 to 124 months), 7 patients are alive and in NYHA functional class I. Life expectancy was 78% for the second year and 65% for 10 years. Rejection was less frequent in chagasic than in age- and sex-matched control patients (mean +/- SD, 1.60 +/- 1.26 versus 5.70 +/- 1.89 episodes per patient, respectively; P = .0001); decreased severity of rejection was also observed (P = .006). T cruzi parasitemias detected on three occasions were successfully treated with benzonidazole. There were no signs of recurrence of the disease in the allograft.
Conclusions:
These results suggest an important role of HT in the treatment of CCHD. There was a low frequency of T cruzi infection reactivation and no signs of recurrence of the disease in the allograft. The surprisingly decreased rejection incidence and severity require further studies for elucidation.