Heart transplantation in Chagas' disease. 10 years after the initial experience.

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.

[Relationship of average level and variability of blood pressure with the geometry of the left ventricle in systemic hypertension]. / Relação do nível médio e variabilidade da pressão arterial com a geometria do ventrículo esquerdo na hipertensão arterial sistêmica.

PURPOSE: To study the relation between the average level and variability of blood pressure (VBP) obtained by ambulatory monitoring (AMBP) and the geometric pattern (GP) of the left ventricle (LV) obtained by echocardiography (ECHO) in patients with hypertension (Hy) METHODS: AMBP and ECHO were performed in 37 patients with Hy, divided into three groups: group A--11 women using antihypertensive therapy (AH); group B--15 men using AH and group C--7 male and 4 female without AH. The GP of LV was obtained by ECHO based on mass index (MI) and relative thickness of the wall (RTW). Mean systolic (MSBP) and diastolic (MDBP) were analyzed during daytime (DT) and nighttime (NT) periods. VBP was defined by mean standard deviation (SD) of mean pressures considered. RESULTS: In G-A, there was a significant association between the MI and both VBP and MSBP (r = 0.65 and p < 0.005, r = 0.61, and p < 0.005, respectively), and MSBP and VBP during the DP (r = 0.64 and p < 0.005, r = 0.75, and p < 0.005). In G-B, there was a relation between the LVRTW (r = 0.55 and p < 0.005), and MSBP during the DP (r = 0.65 and p < 0.005). In G-C, there was a significant association (p < 0.005) between the MI and the MDBP in the DP and with the MSBP in the NP (r valueS ranged from 0.51 to 0.66). There was also a significant relation (p < 0.005) between the LVRTW and the SD of all variables in both DP and NP (r ranged from 0.47 to 0.78 and mean diastolic in the wakeful period (r = 0.42 to 0.78) and MDBP in the DP (r = 0.42 and p < 0.05). CONCLUSION: Both the increase in VBP and the mean BP are involved in the changes of LVGP in Hy.

[Angioplasty in native coronary circulation in patients treated with myocardial revascularization]. / Angioplastia na circulação coronária nativa em pacientes submetidos a cirurgia de revascularização miocárdica.

PURPOSE: To evaluate the clinical results after angioplasty in the native coronary vessels in patients who had undergone previous coronary artery surgery. METHODS: From June 1987 to July 1990, 69 patients with previous coronary artery surgery underwent coronary angioplasty in the native arteries. Age ranged from 31 to 82 (mean = 57.5) years, fifty eight were males. Angina was present in all patients. The patients were classified in three groups according to the following criteria: group I--incomplete revascularization following bypass surgery (28 patients); group II--progression of the disease in ungrafted vessels (24 patients) and group III--progression of the disease in grafted vessels (17 patients). RESULTS: Primary success was achieved in 94% (65/69). Ninety-five percent in group I, 92% in group II and 94% in group III. Complications occurred in 4%; emergency surgery or deaths were not observed in this study. Forty patients (61%) repeated coronary arteriography an average follow-up of 4 months and restenosis was detected in 10 (25%); 8 of them were redilated. Survival rates was 95% and 75% of them were free of coronary events after an average follow-up of 13 months. CONCLUSION: Coronary angioplasty in these patients is a safe and effective interventional procedure in the treatment of coronary artery disease in native coronary vessels.

[Chronic active hepatitis and possible relationship with immunosuppressive therapy]. / Hepatite crônica ativa e possível relação com terapia imunossupressora.

A 54-year-old man with Chagas cardiomyopathy that was submitted to a heart transplantation and five months later presented a progressive increase in liver enzymes. Diagnosis of chronic active hepatitis was confirmed by histopathologic studies. A transitory interruption of treatment with azathioprine and the posterior re-introduction of small doses, as well as the use of lesser amounts of cyclosporin-A improved the clinical and laboratory pictures. Despite several investigations the pathogenesis of hepatitis remained undetermined, although some type of drug injury was presumed to be involved. The eventual role of viruses as the primary inciting event could not be completely ruled out.