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Background: We assessed the effects of exercise-based training programs (EBTP) in patients with chronic Chagas cardiomyopathy (CCC) through a systematic review and meta-analysis. Methods: We conducted a search in Pubmed/Medline, Embase, Scopus, Web of Science, Cochrane Library, Virtual Health Library, and SciELO until January 2023. Randomized controlled trials (RCTs) and non-randomized intervention studies (NRIS) investigating the effects of EBTP in CCC patients were included. The primary outcomes were all-cause mortality, cardiovascular mortality, and health-related quality of life (HRQoL), and the secondary outcomes were exercise capacity by peak VO2, heart failure-related hospital admissions (HFRHA), and left ventricular ejection fraction (LVEF). Results: The search strategy yielded 3617 studies. After removing duplicates and screening, eight studies (3 RCTs and 5 NRIS) involving 222 patients were included. Seven studies were conducted in Brazil. The age range was from 30 to 71 years, and 47.1% were male. Data on mortality, HRQoL, LVEF, and HFRHA were scarcely reported. The meta-analysis pooling four studies showed that the peak VO2 was significantly higher (mean difference 4.45, 95% confidence interval 3.50 to 5.39 mL/kg/min, I2 = 0%) in the EBTP group compared to the control group. Conclusion: The evidence available was limited and heterogeneous. While EBTP has shown to improve HRQoL and exercise capacity, there is no conclusive information about the other proposed outcomes. These positive effects present an opportunity to provide treatment to CCC patients in low- and middle-income countries. Further studies are needed to ascertain the effects of EBTP on hard outcomes in this population.Registration number: CRD42022334060.
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Background: To assess the diagnostic accuracy of the Mayo Clinic echocardiographic criteria for differentiating between constrictive pericarditis and restrictive cardiomyopathy. Methods: We searched electronic databases for the date range from their inception to July 1, 2022. The index tests were the Mayo Clinic echocardiographic criteria. We performed a bivariate random-effects model to estimate the pooled sensitivity and specificity, each with 95% confidence interval (CI). The area under the curve of the summary receiver operator characteristic curves, with 95% CI, was also calculated. Results: We included 17 case-control studies involving 889 patients. The pooled sensitivity and specificity (95% CI), respectively, were as follows: ventricular septal shift, 82% (60%-94%) and 78% (65%-87%); respiratory variation in mitral inflow ≥ 14.6%, 71% (51%-85%) and 82% (66%-91%); septal e' velocity ≥ 8 cm/s, 83% (80%-87%) and 90% (83%-95%); septal e' velocity/lateral e' velocity ≥ 0.88, 74% (64%-82%) and 81% (70%-88%); and hepatic vein ratio in expiration ≥ 0.79, 73% (65%-81%) and 71% (19%-96%). The area under the curve of the summary receiver operator characteristic curves varied from 0.75 to 0.85, with overlapping CIs across index tests. Conclusions: Our meta-analysis suggests that all echocardiographic parameters from the Mayo Clinic criteria have good diagnostic accuracy for differentiating between constrictive pericarditis and restrictive cardiomyopathy.
Contexte: Évaluation de l'exactitude diagnostique des critères échocardiographiques de la clinique Mayo visant à faire la distinction entre une péricardite constrictive et une cardiomyopathie restrictive. Méthodologie: Nous avons effectué une recherche dans des bases de données électroniques pour la période s'étendant de leur date de création au 1er juillet 2022. Les tests de concordance portaient sur les critères échocardiographiques de la clinique Mayo. Nous avons réalisé un modèle à effets aléatoires et à deux variables afin d'estimer la sensibilité et la spécificité en fonction des données regroupées, chacune avec un intervalle de confiance (IC) à 95 %. L'aire sous la courbe des courbes caractéristiques sommaires de la performance du test, avec un IC à 95 %, a également été calculée. Résultats: Nous avons inclus 17 études cas-témoins comptant 889 patients. Selon les données groupées, la sensibilité et la spécificité (IC à 95 %), respectivement, étaient les suivantes : déplacement du septum interventriculaire, 82 % (60 à 94 %) et 78 % (65 à 87 %); variation respiratoire lors du remplissage mitral ≥ 14,6 %, 71 % (51 à 85 %) et 82 % (66 à 91 %); vitesse eʹ mesurée en septal ≥ 8 cm/s, 83 % (80 à 87 %) et 90 % (83 à 95 %); rapport vitesse eʹ mesurée en septal/vitesse eʹ mesurée en latéral ≥ 0,88, 74 % (64 à 82 %) et 81 % (70 à 88 %); et rapport veineux hépatique lors de l'expiration ≥ 0,79, 73 % (65 à 81 %) et 71 % (19 à 96 %). L'aire sous la courbe des courbes caractéristiques sommaires de la performance du test variait de 0,75 à 0,85, avec des IC se chevauchant dans les tests de concordance. Conclusions: Notre méta-analyse laisse entendre que tous les paramètres échocardiographiques de la clinique Mayo ont une bonne exactitude diagnostique pour faire la distinction entre la péricardite constrictive et la cardiomyopathie restrictive.
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A 35-year-old female presented to our emergency department with clinical signs of acute heart failure. Clinical workup identified severe right heart (RH) dilation and dysfunction with a crossing membrane structure in the right atrium. Right heart catheterization confirmed high output heart failure (HOHF), pulmonary hypertension (PH), and left-to-right blood shunting followed by the documentation of multiple liver and pulmonary arteriovenous malformations (AVMs). Hereditary Hemorrhagic Telangiectasia (HHT) diagnosis was made according to clinical criteria and was established as the cause of HOHF because of chronic volume overload from systemic to pulmonary shunts. With this illustrative case, we aim to discuss the broad spectrum of clinical manifestations of HHT and the unusual phenotype of HOHF secondary to HHT. This case also highlights the broad diagnosis of atrial echocardiographic abnormalities and cardiac structural distortion secondary to high output that can be misleading at imaging evaluation.
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Global Longitudinal Strain (GLS) is a useful tool to follow-up heart transplant (HT) recipients. Important inter-vendor variability of GLS measurements has been reported in healthy subjects and different conditions, but there is still limited evidence among HT patients. We assessed the reliability and validity of GLS using two vendors (General Electric and Philips) in a group of consecutive and stable adult HT recipients. Patients underwent two concurrent GLS analyses during their echocardiographic follow-up. We evaluated GLS inter-vendor reliability using Bland-Altman's limits of agreement (LOA) plots, computing its coverage probability (CP) and the intraclass correlation coefficient (ICC). Validity was assessed though receiver operating characteristics (ROC) curves, predictive values, sensitivity and specificity of GLS for each vendor to detect a normal left ventricle function. 78 pairs of GLS studies in 53 stable HT patients were analyzed. We observed a modest inter-vendor reliability with a broad LOA (less than 50% of values falling out our CP of 2% and an ICC of 0.49). ROC analyses (areas under the curve of 0.824 Vs. 0.631, p < 0.05) and diagnosis test indices (Sensitivity of 0.73 Vs. 0.64; and Specificity of 0.79 Vs. 0.50) favored GE over Philips. Inter-vendor variability for GLS analysis exceeded clinically acceptable limits in HT recipients. GLS from GE software seemed to show higher validity as compared to Philips'. The present study provides evidence to consider caution for the interpretation of GLS for clinical management in the follow-up of HT patients, especially when GLS is measured by different vendors.
Subject(s)
Heart Transplantation , Ventricular Function, Left , Adult , Colombia , Heart Transplantation/adverse effects , Heart Ventricles , Humans , Predictive Value of Tests , Reproducibility of Results , Tertiary Care CentersABSTRACT
Background: Chagas cardiomyopathy (CC) increases cardiovascular mortality associated with congestive heart failure (CHF), ventricular arrhythmias (VA), and sudden cardiac death (SCD). Different imaging techniques have been tested to assess disease progression and cardiac risk in individuals with Chagas disease (ChD). In this systematic review, we evaluated the accuracy in detecting cardiac complications in CC patients using cardiac magnetic resonance (CMR) and speckle tracking echocardiography (STE). Methods: A search was done on PubMed, Cochrane, and Embase for studies in humans over 18 years of age with ChD. Demographic data, research methodology, imaging parameters, and cardiac outcomes were extracted, and study quality was assessed, resulting in a narrative description. Results: Twelve studies with 1124 patients were analyzed. One study discovered a contractility pattern by STE. Four studies assessed the identification of Early Cardiac Impairment (ECI) and VA risk, respectively, while three studies evaluated the risk of SCD. Global Longitudinal Strain (GLS) identified patients with ECI (-18.5 ± 3.4% non-fibrosis vs -14.0 ± 5.8% fibrosis, p = 0.006 and -18 ± 2% non-fibrosis vs -15 ± 2% fibrosis, p = 0.004). The amount of fibrosis > 11.78% or in two or more contiguous transmural segments were markers for VA risk. GLS and the amount of fibrosis were found to be predictors of SCD. Conclusions: STE may be considered a screening technique for identifying the subclinical status of CHF. CMR using Late Gadolinium Enhancement (LGE) is considered a relevant parameter for stratifying patients with ChD who are at risk of SCD. Fibrosis and GLS can be used as markers to categorize patients at risk for arrhythmias.
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Chronic manifestations of Chagas disease present as disabling and life-threatening conditions affecting mainly the cardiovascular and gastrointestinal systems. Although meaningful research has outlined the different molecular mechanisms underlying Trypanosoma cruzi's infection and the host-parasite interactions that follow, prompt diagnosis and treatment remain a challenge, particularly in developing countries and also in those where the disease is considered non-endemic. This review intends to present an up-to-date review of the parasite's life cycle, genetic diversity, virulence factors, and infective mechanisms, as well as the epidemiology, clinical presentation, diagnosis, and treatment options of the main chronic complications of Chagas disease.
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Despite nearly a century of research and accounting for the highest disease burden of any parasitic disease in the Western Hemisphere, Chagas disease (CD) is still a challenging diagnosis, primarily due to its poor recognition outside of Latin America. Although initially considered endemic to Central and South America, globalization, urbanization, and increased migration have spread the disease worldwide in the last few years, making it a significant public health threat. The international medical community's apparent lack of interest in this disease that was previously thought to be geographically restricted has delayed research on the complex host-parasite relationship that determines myocardial involvement and its differential behavior from other forms of cardiomyopathy, particularly regarding treatment strategies. Multiple cellular and molecular mechanisms that contribute to degenerative, inflammatory, and fibrotic myocardial responses have been identified and warrant further research to expand the therapeutic arsenal and impact the high burden attributed to CD. Altogether, cardiac dysautonomia, microvascular disturbances, parasite-mediated myocardial damage, and chronic immune-mediated injury are responsible for the disease's clinical manifestations, ranging from asymptomatic disease to severe cardiac and gastrointestinal involvement. It is crucial for healthcare workers to better understand CD transmission and disease dynamics, including its behavior on both its acute and chronic phases, to make adequate and evidence-based decisions regarding the disease. This review aims to summarize the most recent information on the epidemiology, pathogenesis, clinical presentation, diagnosis, screening, and treatment of CD, emphasizing on Chagasic cardiomyopathy's (Ch-CMP) clinical presentation and pathobiological mechanisms leading to sudden cardiac death.
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The persistence of inflammatory processes in the myocardium in varying degrees of chronic Chagas heart disease has been poorly investigated. We hypothesized that edema could occur in patients with chronic chagasic cardiomyopathy and corresponds to the persistence of inflammatory processes in the myocardium. Eighty-two Chagas disease (CD) seropositive patients (64.6% females; age = 58.9 ± 9.9) without ischemic heart disease or conditions that cause myocardial fibrosis and dilation were considered. Late gadolinium enhancement (LGE) and T2-weighted magnetic resonance imaging of edema were obtained and represented using a 17-segment model. Patients were divided into three clinical groups according to the left ventricular (LV) ejection fraction (EF) as G1 (EF > 60%; n=37), G2 (35% > EF < 60%; n=33), and G3 (EF < 35%; n=12). Comparisons were performed by the Fisher or ANOVA tests. Bonferroni post hoc, Spearman correlation, and multiple correspondence analyses were also performed. Edema was observed in 8 (9.8%) patients; 2 (5.4%) of G1, 4 (12.1%) of G2, and 2 (16.7%) of G3. It was observed at the basal inferolateral segment in 7 (87.5%) cases. LGE was observed in 48 (58.5%) patients; 16 (43.2%) of G1, 21 (63.6%) of G2, and 11 (91.7%) of G3 (p < 0.05). It was observed in the basal inferior/inferolateral/anterolateral segments in 35 (72.9%) patients and in the apical anterior/inferior/lateral and apex segments in 21 (43.7%), with midwall (85.4%; n=41), subendocardial (56.3%; n=27), subepicardial (54.2%; n=26), transmural (31.2%; n=15), and RV (1.2%; n=1) distribution. Subendocardial lesions were observed only in patients with LVEF < 35%. There was no involvement of the mid-inferolateral/anterolateral segments with an LVEF > 35% (p < 0.05). Deteriorations of the LV and RV systolic functions were positively correlated (r s =0.69; p < 0.05) without evidence of LGE in the RV. Edema can be found in patients with chagasic cardiomyopathy in the chronic stage. In later stages of cardiac dilation with low LVEF, the LGE pattern involves subendocardium and mid locations. Deteriorations of RV and LV are positively correlated without evidence of fibrosis in the RV.
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Resumen Introducción: el ultrasonido cardiaco enfocado ha sido propuesto como una aproximación útil para mejorar la toma de decisiones clínicas, permitiendo identificar rápidamente signos ultrasonográficos de una lista específica de diagnósticos potenciales. Objetivo: evaluar un programa de entrenamiento para médicos sin experiencia en ecocardiografía a fin de realizar ultrasonido cardiaco enfocado por medio de un dispositivo portátil (ecoscopio). Materiales y métodos: se compararon los resultados obtenidos mediante ecoscopia realizada por los médicos que recibieron el entrenamiento, con los obtenidos mediante ecocardiografía convencional realizada por cardiólogos expertos. Métodos: un total de 5 médicos no cardiólogos incluyendo un estudiante de Medicina de último año, 2 residentes de Medicina Interna y 2 Intensivistas participaron en un curso de entrenamiento de cuatro semanas, dirigido por un Cardiólogo experto de nivel III así: Primera semana: teoría y bases de ecocardiografía (3 horas diarias) Segunda semana: teoría de la adquisición de imágenes. Hallazgos normales y anormales (50 estudios). Tercera semana: manejo del ecoscopio (50 estudios). Cuarta semana: recolección de datos. Se incluyeron pacientes programados para ecocardiografía convencional en el Laboratorio de métodos no invasivos. A cada paciente se le realizaron dos exámenes. El primero consistió en una ecoscopia hecha por médico que recibió el entrenamiento y el segundo consistió en un ecocardiograma realizado por un cardiólogo experto. Los parámetros ecocardiográficos evaluados fueron: fracción de eyección del ventrículo izquierdo, disfunción ventricular derecha, crecimiento auricular izquierdo, hipertensión pulmonar, enfermedad valvular cardiaca y derrame pericárdico. Por medio de análisis de concordancia (índice Kappa) se compararon los resultados encontrados en ecoscopia versus ecocardiografía. Resultados: de 221 estudios se obtuvo concordancia moderada en fracción de eyección del ventrículo izquierdo (к =0,541, p<0,000), función ventricular derecha (к =0,403, p<0,001), dilatación de la aurícula izquierda (к =0,413, p<0,001), valvulopatía mitral (к =0,466, p<0,001) y tricuspídea (к =0,437, p<0,001). La valvulopatía aórtica mostró un acuerdo débil. El derrame pericárdico y la hipertensión pulmonar tuvieron concordancia pobre y débil, respectivamente. Conclusiones: con un tiempo limitado de formación, los participantes sin experiencia previa en técnicas de ultrasonido y utilizando ecoscopia, alcanzaron un acuerdo moderado en la mayoría de las mediciones cuando se comparó con ecocardiografía convencional practicada por ecocardiografistas expertos. Es necesario un estudio con mayor número de participantes que determine el tiempo de formación ideal para obtener resultados comparables con ecocardiografía.
Abstract Introduction: Focused cardiac ultrasound has been proposed as a useful approach for improving clinical decision making, as well as to be able to rapidly identify the ultrasound signs of a specific list of potential diagnoses. Objective: To evaluate a training program for physicians with no experience in cardiac ultrasound with the aim performing focused cardiac ultrasound using a portable device (echoscopy). Materials and methods: The results obtained from echoscopy performed by the physicians that received training were compared with those obtained with conventional cardiac ultrasound carried out by expert cardiologists. A total of 5 non-cardiologist doctors, including 1 medical student, 2 Internal Medicine residents, and 2 from Intensive Medicine, took part in a four-week training course given by a Level III Cardiology specialist. The course included: First week: Theory and basis of cardiac ultrasound (3 hours daily) Second week: Theory of acquiring images. Normal and abnormal findings (50 studies). Third week: handling of the echoscope (50 studies). Fourth week: Data collection. The study included patients scheduled for conventional cardiac ultrasound in the Non-Invasive Methods Laboratory. Two examinations were carried out on each patient. The first consisted of an echoscopy performed by a doctor that had received the training, and the second consisted of a cardiac ultrasound carried out by an expert cardiologist. The ultrasound parameters evaluated were: left ventricular ejection fraction, right ventricular dysfunction, left atrial enlargement, pulmonary hypertension, cardiac valve disease, and pericardial effusion. The results found in echoscopy versus cardiac ultrasound were compared using concordance analysis (Kappa Index). Results: The following results were obtained on the 221 studies performed: moderate agreement in left ventricular ejection fraction (к =0.541, P<.000), right ventricular function (к =0.403, P<.001), left atrial enlargement (к =0.413, P<.001), mitral valve and tricuspid valve disease (к =0.437, P<.001 and (к =0.466, P<.001, respectively). There was weak agreement with aortic valve disease. Pericardiac effusion and the presence of pulmonary hypertension had a poor and week agreement, respectively. Conclusions: With a limited training period, the participants with no previous experience in ultrasound techniques and using echoscopy achieved a moderate agreement in the majority of measurements when compared with conventional cardiac ultrasound performed by experts in the technique. A study with a larger number of participants is required in order to determine the ideal training period to obtain results comparable with cardiac ultrasound.