Association of left ventricular abnormalities with incident cerebrovascular events and sources of thromboembolism in patients with chronic Chagas cardiomyopathy

Abstract

Background Although Chagas cardiomyopathy is related to thromboembolic stroke, data on risk factors for cerebrovascular events in Chagas disease is limited. Thus, we assessed the relationship between left ventricular (LV) impairment and cerebrovascular events and sources of thromboembolism in patients with Chagas cardiomyopathy. Methods This retrospective cohort included patients with chronic Chagas cardiomyopathy who underwent cardiovascular magnetic resonance (CMR). CMR was performed with a 1.5 T scanner to provide LV volumes, mass, ejection fraction (LVEF), and myocardial fibrosis. The primary outcome was a composite of incident ischemic cerebrovascular events (stroke or transient ischemic attack—TIA) and potential thromboembolic sources (atrial fibrillation (AF), atrial flutter, or intracavitary thrombus) during the follow-up. Results A total of 113 patients were included. Median age was 56 years (IQR: 45–67), and 58 (51%) were women. The median LVEF was 53% (IQR: 41–62). LV aneurysms and LV fibrosis were present in 38 (34%) and 76 (67%) individuals, respectively. The median follow-up time was 6.9 years, with 29 events: 11 cerebrovascular events, 16 had AF or atrial flutter, and two had LV apical thrombosis. In the multivariable model, only lower LVEF remained significantly associated with the outcomes (HR: 0.96, 95% CI: 0.93–0.99). Patients with reduced LVEF lower than 40% had a much higher risk of cerebrovascular events and thromboembolic sources (HR: 3.16 95% CI: 1.38–7.25) than those with normal LVEF. The combined incidence rate of the combined events in chronic Chagas cardiomyopathy patients with reduced LVEF was 13.9 new cases per 100 persons-year. Conclusions LV systolic dysfunction is an independent predictor of adverse cerebrovascular events and potential sources of thromboembolism in patients with chronic Chagas cardiomyopathy.

Emerging Trends in Left Ventricular Thrombus: A Comprehensive Review of Non-Ischemic and Ischemic Cardiopathies, Including Eosinophilic Myocarditis, Chagas Cardiomyopathy, Amyloidosis, and Innovative Anticoagulant Approaches

“…The main manifestations of chronic Chagas cardiomyopathy are heart failure, arrhythmia, and sudden cardiac death [42,45]. Chagas cardiomyopathy has also been independently associated with the risk of developing a stroke, with a significant cardioembolic risk secondary to the atrial fibrillation or LVT occurrence [42,45,46]. A recent study by Moreira HT et al, involving 330 patients with Chagas cardiomyopathy, found a prevalence of ischemic cerebrovascular events (ICE) of 20%, with 67 patients experiencing an ICE [46].…”

“…Chagas cardiomyopathy has also been independently associated with the risk of developing a stroke, with a significant cardioembolic risk secondary to the atrial fibrillation or LVT occurrence [42,45,46]. A recent study by Moreira HT et al, involving 330 patients with Chagas cardiomyopathy, found a prevalence of ischemic cerebrovascular events (ICE) of 20%, with 67 patients experiencing an ICE [46]. Most patients were classified in New York Heart Association classes I or II (75%) with an average left ventricular ejection fraction of 39 ± 14% [46].…”

“…A recent study by Moreira HT et al, involving 330 patients with Chagas cardiomyopathy, found a prevalence of ischemic cerebrovascular events (ICE) of 20%, with 67 patients experiencing an ICE [46]. Most patients were classified in New York Heart Association classes I or II (75%) with an average left ventricular ejection fraction of 39 ± 14% [46]. Left ventricular mural thrombi were found in 48 patients (15%), and 128 patients (39%) had apical aneurysms.…”

Use of Three-Dimensional Echocardiography in the Analysis of Ventricular Function in Chagas Disease

“…The most characteristic segmental changes occur in the inferior, inferolateral, and apical segments of the left ventricle (LV). 4,6,[15][16][17] These segments are not always adequately assessed on two-dimensional (2D) studies, due to image shortening (which can exclude the apical segments from analysis) or to not including segments in the quantification of global function of Simpson's biplane method (which does not encompass the inferolateral segments). 6 Assessment of left ventricular ejection fraction (LVEF) is one of the main parameters for classification and staging of patients with Chagas disease; therefore, it is recommended to use methods that show high accuracy and reproducibility for estimating LVEF.…”

“…Cardiac involvement represents the most feared manifestation, characterized by complications with high morbidity and mortality, such as heart failure, arrhythmias, and stroke. 1,2,4 In this scenario, echocardiography is the most commonly used complementary exam for assessment and follow-up of patients with Chagas disease, making it possible to analyze cardiac structure and function, detect intracavitary DOI: https://doi.org/10.36660/abcimg.20230093i thrombi, and assess secondary valve involvement. 1,5 In recent years, new techniques, such as three-dimensional (3D) echocardiography and the assessment of myocardial strain using the speckle-tracking method have shown to be promising in the assessment of cardiac mechanics in various clinical scenarios.…”