Case Session

SCMR 22nd Annual Scientific Sessions

7 - Diagnosis of Chronic Chagas Cardiomyopathy: A Multimodality Imaging Approach

Presenter(s)

• 

  Estefania Oliveros, MD

  Cardiology fellow
  Rush University Medical Center

Author Only(s)

• 

  Hena Patel, MD

  Cardiology Fellow
  Rush University Medical Center
• AV

  Aviral Vij, MD

  Cardiology Fellow
  John Stroger Cook County Hospital
• RT

  Richard Trohman, MD, MBA

  Professor and Senior Attending Physician
  Rush University Medical Center
• PS

  Parikshit Sharma, MD

  Attending
  Rush University Medical Center
• AR

  Anupama Rao, MD

  Attending
  Rush University Medical Center

Description of Clinical Presentation: A 54-year-old man, originally from Mexico, presented to the emergency department after experiencing chest pain and recurrent syncopal episodes. On arrival, he was found to be in hemodynamically unstable wide complext tachycardia requiring urgent cardioversion with restoration of sinus rhythm.

Diagnostic Techniques and Their Most Important Findings:

He underwent urgent coronary angiography which revealed no obstructive disease.  A transthoracic echo revealed moderately reduced left ventricular systolic function (ejection fraction 35-40%) with apical akinesis and an aneurysm of the apical septum. Cardiac MRI (CMR) confirmed a prominent apical aneurysm with dyskinesis of the apical septum. There was transmural myocardial late gadolinium enhancement of the entire left ventricular apex, extending into the mid anterolateral wall, indicating extensive fibrosis. Additionally, a small apical thrombus was visualized. Given the CMR findings and normal coronaries, further history was obtained.  The patient reported emigrating from Mexico to the United States 20 years ago, but recalled living in a small mud hut in Mexico that was swarming with “chinches,” small nocturnal bugs that routinely bit the sleeping inhabitants. The history and clinical findings raised a strong suspicion for Chagas heart disease. Specific serologic testing was positive for Trypanosoma cruzii IgG antibody. Repeat testing at the Centers for Disease Control and Prevention(CDC) testing was also positive, confirming the diagnosis of Chagas cardiomyopathy.

Given his recurrent syncope and clinical VT, the patient subsequently underwent an electrophysiology study which confirmed an apical septal VT origin corresponding to the region of fibrosis seen on CMR. He underwent VT mapping and ablation via an epicardial and endocardial approach. A large area of low voltage corresponding with the apical aneurysm was noted on mapping. The VT was easily induced and upon studying was deemed to be likely intra-septal and micro-reentrant and was successfully ablated on the septal edge of the scar and healthy LV myocardium. He then underwent loading with oral Sotalol and a defibrillator was placed for secondary prevention of sudden cardiac death. The patient was discharged on guideline directed medical therapy including a regimen of anticoagulation, beta-blocker and ACE-inhibitor therapies.  He has had no subsequent syncope or VT.

Learning Points from this Case: This case highlights the critical role of an interdisciplinary approach to the successful diagnosis and treatment of Chagas heart disease.