Cardiac device-related infective endocarditis need for lead extraction whatever the device according to the ESC EORP EURO-ENDO registry.

Aims: Cardiac device-related infective endocarditis (CDRIE) is a severe complication of cardiac device (CD) implantation and is usually treated by antibiotic therapy and percutaneous device extraction. Few studies report the management and prognosis of CDRIE in real life. In particular, the rate of device extraction in clinical practice and the management of patients with left heart infective endocarditis (LHIE) and an apparently non-infected CD (LHIE+CDRIE-) are not well described. Methods and results: We sought to study in EURO-ENDO, the characteristics, prognosis, and management of 483 patients with a CD included in the European Society of Cardiology EurObservational Research Programme EURO-ENDO registry. Three populations were compared: 280 isolated CDRIE (66.7 ± 14.3 years), 157 patients with LHIE and an apparently non-infected CD (LHIE+CDRIE-) (71.1 ± 13.6), and 46 patients with both LHIE and CDRIE (LHIE+CDRIE+) (70.2 ± 10.1). Echocardiography was not always transoesophageal echography (TOE); it was transthoracic echography (TTE) for isolated CDRIE in 88.4% (TOE = 67.6%), for LHIE+CDRIE- TTE = 93.0% (TOE = 58.6%), and for CDRIE+LHIE+ TTE = 87.0% (TOE = 63.0%). Nuclear imaging was performed in 135 patients (positive for 75.6%). In-hospital mortality was lower in isolated CDRIE 13.2% vs. 22.3% and 30.4% for LHIE+CDRIE- and LHIE+CDRIE+ (P = 0004). Device extraction was performed in 62.1% patients with isolated CDRIE, 10.2% of LHIE+CDRIE- patients, and 45.7% of CDRIE+LHIE+ patients. Device extraction was associated with a better prognosis [hazard ratio 0.59 (0.40-0.87), P = 0.0068] even in the LHIE+CDRIE- group (P = 0.047). Conclusion: Prognosis of endocarditis in patients with a CD remains poor, particularly in the presence of an associated LHIE. Although recommended by guidelines, device extraction is not always performed. Device removal was associated with better prognosis, even in the LHIE+CDRIE- group.

Guideline of the Brazilian Society of Cardiology on Diagnosis and Treatment of Patients with Chagas Disease Cardiomyopathy / Diretriz da Sociedade Brasileira de Cardiologia sobre Diagnóstico e Tratamento de Pacientes com Cardiomiopatia da Doença de Chagas

This guideline aimed to update the concepts and formulate the standards of conduct and scientific evidence that support them, regarding the diagnosis and treatment of the Cardiomyopathy of Chagas disease, with special emphasis on the rationality base that supported it.  Chagas disease in the 21st century maintains an epidemiological pattern of endemicity in 21 Latin American countries. Researchers and managers from endemic and non-endemic countries point to the need to adopt comprehensive public health policies to effectively control the interhuman transmission of T. cruzi infection, and to obtain an optimized level of care for already infected individuals, focusing on diagnostic and therapeutic opportunistic opportunities.   Pathogenic and pathophysiological mechanisms of the Cardiomyopathy of Chagas disease were revisited after in-depth updating and the notion that necrosis and fibrosis are stimulated by tissue parasitic persistence and adverse immune reaction, as fundamental mechanisms, assisted by autonomic and microvascular disorders, was well established. Some of them have recently formed potential targets of therapies.  The natural history of the acute and chronic phases was reviewed, with enhancement for oral transmission, indeterminate form and chronic syndromes. Recent meta-analyses of observational studies have estimated the risk of evolution from acute and indeterminate forms and mortality after chronic cardiomyopathy. Therapeutic approaches applicable to individuals with Indeterminate form of Chagas disease were specifically addressed. All methods to detect structural and/or functional alterations with various cardiac imaging techniques were also reviewed, with recommendations for use in various clinical scenarios. Mortality risk stratification based on the Rassi score, with recent studies of its application, was complemented by methods that detect myocardial fibrosis.  The current methodology for etiological diagnosis and the consequent implications of trypanonomic treatment deserved a comprehensive and in-depth approach. Also the treatment of patients at risk or with heart failure, arrhythmias and thromboembolic events, based on pharmacological and complementary resources, received special attention. Additional chapters supported the conducts applicable to several special contexts, including t. cruzi/HIV co-infection, risk during surgeries, in pregnant women, in the reactivation of infection after heart transplantation, and others.     Finally, two chapters of great social significance, addressing the structuring of specialized services to care for individuals with the Cardiomyopathy of Chagas disease, and reviewing the concepts of severe heart disease and its medical-labor implications completed this guideline.

Esta diretriz teve como objetivo principal atualizar os conceitos e formular as normas de conduta e evidências científicas que as suportam, quanto ao diagnóstico e tratamento da CDC, com especial ênfase na base de racionalidade que a embasou. A DC no século XXI mantém padrão epidemiológico de endemicidade em 21 países da América Latina. Investigadores e gestores de países endêmicos e não endêmicos indigitam a necessidade de se adotarem políticas abrangentes, de saúde pública, para controle eficaz da transmissão inter-humanos da infecção pelo T. cruzi, e obter-se nível otimizado de atendimento aos indivíduos já infectados, com foco em oportunização diagnóstica e terapêutica. Mecanismos patogênicos e fisiopatológicos da CDC foram revisitados após atualização aprofundada e ficou bem consolidada a noção de que necrose e fibrose sejam estimuladas pela persistência parasitária tissular e reação imune adversa, como mecanismos fundamentais, coadjuvados por distúrbios autonômicos e microvasculares. Alguns deles recentemente constituíram alvos potenciais de terapêuticas. A história natural das fases aguda e crônica foi revista, com realce para a transmissão oral, a forma indeterminada e as síndromes crônicas. Metanálises recentes de estudos observacionais estimaram o risco de evolução a partir das formas aguda e indeterminada e de mortalidade após instalação da cardiomiopatia crônica. Condutas terapêuticas aplicáveis aos indivíduos com a FIDC foram abordadas especificamente. Todos os métodos para detectar alterações estruturais e/ou funcionais com variadas técnicas de imageamento cardíaco também foram revisados, com recomendações de uso nos vários cenários clínicos. Estratificação de risco de mortalidade fundamentada no escore de Rassi, com estudos recentes de sua aplicação, foi complementada por métodos que detectam fibrose miocárdica. A metodologia atual para diagnóstico etiológico e as consequentes implicações do tratamento tripanossomicida mereceram enfoque abrangente e aprofundado. Também o tratamento de pacientes em risco ou com insuficiência cardíaca, arritmias e eventos tromboembólicos, baseado em recursos farmacológicos e complementares, recebeu especial atenção. Capítulos suplementares subsidiaram as condutas aplicáveis a diversos contextos especiais, entre eles o da co-infecção por T. cruzi/HIV, risco durante cirurgias, em grávidas, na reativação da infecção após transplante cardíacos, e outros.    Por fim, dois capítulos de grande significado social, abordando a estruturação de serviços especializados para atendimento aos indivíduos com a CDC, e revisando os conceitos de cardiopatia grave e suas implicações médico-trabalhistas completaram esta diretriz. 

Predictors of mortality in patients with dilated cardiomyopathy: relevance of chagas disease as an etiological factor.

INTRODUCTION AND OBJECTIVES: Previous studies on the influence of Chagas disease on mortality in patients with heart failure were limited by the heterogeneity of the patient populations. Few data are available on the association between the underlying cause of dilated cardiomyopathy and long-term prognosis. The aims of this study were to identify risk factors for mortality in patients with dilated cardiomyopathy that was either secondary to Chagas disease or idiopathic and to determine the prognostic value of identifying Chagas disease as the underlying etiology of dilated cardiomyopathy. METHODS: We investigated outcomes in 287 patients with heart failure secondary to dilated cardiomyopathy. Patients were divided into two groups according to the underlying etiology: Chagas cardiomyopathy (224 patients) and idiopathic dilated cardiomyopathy (63 patients). The study end-points were death and heart transplantation. RESULTS: Over a median follow-up period of 39.5 months, 104 patients died and 9 underwent heart transplantation. Under multivariate Cox proportional hazards analysis, New York Heart Association functional class, left ventricular ejection fraction, right ventricular function and left atrial volume remained predictors of an adverse outcome. Chagas etiology was also independently associated with a poor prognosis (hazard ratio=2.48; 95% confidence interval, 1.28-4.78; P=.007) compared with idiopathic disease, after adjustment for other well-established predictive parameters in heart failure. CONCLUSIONS: The identification of Chagas etiology in patients with dilated cardiomyopathy was of prognostic significance. Chagas cardiomyopathy was associated with poorer survival compared with idiopathic disease, irrespective of other clinical and echocardiographic parameters related to a poor prognosis in heart failure.

Factores predictivos de la mortalidad en pacientes con miocardiopatía dilatada: importancia de la enfermedad de Chagas como etiología / Predictors of mortality in patients with dilated cardiomyopathy: relevance of Chagas disease as an etiological factor

Introducción y objetivos. Los estudios previos en los que se ha abordado la influencia de la enfermedad de Chagas en la mortalidad de pacientes con insuficiencia cardiaca han tenido la limitación de la heterogeneidad de la población estudiada. Existen pocos datos sobre la asociación entre la causa subyacente de la miocardiopatía dilatada y el pronóstico a largo plazo. El objetivo de este estudio es identificar los factores de riesgo de mortalidad en pacientes con miocardiopatía dilatada secundaria a enfermedad de Chagas o idiopática, y determinar el valor pronóstico de la identificación de la enfermedad de Chagas como etiología subyacente de la miocardiopatía dilatada. Métodos. Hemos evaluado la evolución de 287 pacientes con insuficiencia cardiaca secundaria a miocardiopatía dilatada. Se agrupó a los pacientes en dos categorías según la causa subyacente: miocardiopatía de Chagas (224 pacientes) y miocardiopatía dilatada idiopática (63 pacientes). Las variables de valoración fueron la muerte y el trasplante cardiaco. Resultados. A lo largo de una mediana de seguimiento de 39,5 meses, fallecieron 104 pacientes y se practicó un trasplante cardiaco a 9. En un análisis de riesgos proporcionales de Cox multivariable, la clase funcional de la NYHA, la fracción de eyección ventricular izquierda, la función ventricular derecha y el volumen auricular izquierdo se mantuvieron como factores predictivos de una evolución adversa. La etiología de Chagas se asoció de manera independiente a un mal pronóstico (razón de riesgos = 2,48; intervalo de confianza del 95%, 1,28-4,78; p = 0,007) en comparación con la idiopática, tras introducir un ajuste respecto a otros parámetros predictivos bien establecidos en la insuficiencia cardiaca. Conclusiones. La identificación de la etiología de Chagas en pacientes con miocardiopatía dilatada tiene importancia pronóstica. La miocardiopatía de Chagas se asoció a una supervivencia peor que la de la idiopática, con independencia de los demás factores clínicos y ecocardiográficos de mal pronóstico en la insuficiencia cardiaca (AU)

Introduction and objectives. Previous studies on the influence of Chagas disease on mortality in patients with heart failure were limited by the heterogeneity of the patient populations. Few data are available on the association between the underlying cause of dilated cardiomyopathy and long-term prognosis. The aims of this study were to identify risk factors for mortality in patients with dilated cardiomyopathy that was either secondary to Chagas disease or idiopathic and to determine the prognostic value of identifying Chagas disease as the underlying etiology of dilated cardiomyopathy. Methods. We investigated outcomes in 287 patients with heart failure secondary to dilated cardiomyopathy. Patients were divided into two groups according to the underlying etiology: Chagas cardiomyopathy (224 patients) and idiopathic dilated cardiomyopathy (63 patients). The study end-points were death and heart transplantation. Results. Over a median follow-up period of 39.5 months, 104 patients died and 9 underwent heart transplantation. Under multivariate Cox proportional hazards analysis, New York Heart Association functional class, left ventricular ejection fraction, right ventricular function and left atrial volume remained predictors of an adverse outcome. Chagas etiology was also independently associated with a poor prognosis (hazard ratio=2.48; 95% confidence interval, 1.28-4.78; P=.007) compared with idiopathic disease, after adjustment for other well-established predictive parameters in heart failure. Conclusions. The identification of Chagas etiology in patients with dilated cardiomyopathy was of prognostic significance. Chagas cardiomyopathy was associated with poorer survival compared with idiopathic disease, irrespective of other clinical and echocardiographic parameters related to a poor prognosis in heart failure (AU)