Case report: diagnosis of chronic Chagas cardiomyopathy using a multimodality imaging approach

Shannon Li; Estefania Oliveros Soles; Parikshit S. Sharma; Anupama Rao

doi:10.1093/ehjcr/ytac487

December 27, 2022European Heart Journal - Case ReportsOpen Access

Case report: diagnosis of chronic Chagas cardiomyopathy using a multimodality imaging approach

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Why the study?

Chagas heart disease affects approximately 300 000 people in the USA but remains an under-recognized potential aetiology of dilated cardiomyopathy.

Key Points

To describe the utility of multimodality cardiac imaging in diagnosing and managing chronic Chagas cardiomyopathy in a non-endemic setting.
Clinical assessment of a 54-year-old man from Mexico presenting with chest pain, syncope, and hemodynamically unstable ventricular tachycardia.
Diagnostic evaluation using coronary angiography, transthoracic echocardiography, cardiac magnetic resonance imaging, and Trypanosoma cruzi serologic testing.
Transthoracic echocardiography demonstrated a left ventricular ejection fraction of 35–40%, apical akinesis, and an apical septal aneurysm with non-obstructive coronary arteries.
Cardiac magnetic resonance confirmed an apical aneurysm, transmural late gadolinium enhancement across the apex, and an apical thrombus, with positive T. cruzi serology confirmed by the CDC.
Catheter ablation for ventricular tachycardia and guideline-directed medical therapy successfully prevented further syncopal episodes and arrhythmias.

Structured PICO

P

Population

1 54-year-old man originally from Mexico presenting with chest pain, recurrent syncopal episodes, and hemodynamically unstable ventricular tachycardia.

I

Intervention

Multimodality imaging (echocardiography and cardiac magnetic resonance) leading to diagnosis, followed by VT ablation and guideline-directed medical therapy (anticoagulation, beta-blocker, ACE inhibitor).

O

Outcome

Diagnosis of Chagas heart disease and prevention of recurrent syncope or ventricular tachycardia.

Multimodality imaging, including echocardiography and CMR, plays a crucial role in identifying under-recognized Chagas cardiomyopathy in patients presenting with heart failure and ventricular arrhythmias.

Implication

Alerts clinicians to under-recognized Chagas cardiomyopathy in US immigrants; extends multimodality imaging for diagnosis and management.

Abstract

Background In the USA, ∼300 000 people are affected by Chagas heart disease, a growing, but commonly overlooked, public health issue. Chagas as a potential aetiology of dilated cardiomyopathy remains under-recognized. We present a case where multimodality imaging was essential in the diagnosis and management of Chagas heart disease. Case summary A 54-year-old man, originally from Mexico, presented to the emergency department with chest pain and recurrent syncopal episodes, found to be in haemodynamically unstable ventricular tachycardia (VT) requiring urgent cardioversion. Urgent coronary angiography revealed no obstructive disease. A transthoracic echocardiogram revealed moderately reduced left ventricular systolic function (left ventricular ejection fraction 35–40%) with apical akinesis and an aneurysm of the apical septum. Cardiac magnetic resonance (CMR) confirmed a prominent apical aneurysm with dyskinesis of the apical septum, with the evidence of transmural myocardial late gadolinium enhancement of the entire left ventricular apex and a small apical thrombus. Serologic testing was positive for Trypanosoma cruzi IgG antibody, which was confirmed on repeat testing at the Centers for Disease Control and Prevention. Patient underwent VT ablation and was discharged on guideline-directed medical therapy including a regimen of anticoagulation, beta-blocker, and angiotensin-converting enzyme inhibitor therapies. He has had no subsequent syncope or VT. Discussion Chagas heart disease remains under-recognized and under-diagnosed despite the growing burden of T. cruzi infection in the USA. Suspicion for Chagas heart disease should be considered in patients presenting with heart failure symptoms and ventricular arrhythmias with the right corresponding history and imaging findings on echocardiogram and CMR.