CVM Grand Rounds 4-15-26

Name: CVM Grand Rounds 4-15-26
Uploaded: 2026-04-20T13:34:13.7Z
Duration: 1 h 6 min 34 s

April 20, 2026

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00:12Yes.
02:50Yeah.
03:31Okay. Good afternoon.
03:33Welcome to,
03:35Yale University cardiology,
03:37grand rounds,
03:39the most important cardiology meeting
03:41in the state of Connecticut.
03:43Some,
03:44announcements. So this is the
03:45code, the CME code, so
03:47you can claim your your
03:49CME.
03:52This is our,
03:54cardiology grant runs from, next
03:56week.
03:57And also on the twenty
03:59ninth, we'll have a faculty,
04:01research meeting. And
04:02then in May, we have,
04:05we'll have a case conference
04:06by our advanced heart failure
04:08group and one of our
04:09stellar fellows,
04:11doctor Michael Fury. So looking
04:12forward to that.
04:16Disclosures.
04:21So,
04:22today is a real honor
04:23for me to be here.
04:25Doctor Eric Velasquez, chief of
04:27cardiovascular medicine at Yale School
04:29of Medicine,
04:30Francine LaRusso, senior vice president
04:32of heart and vascular,
04:33doctor Thomas Balcizak, chief clinical
04:35officer of Yale New Haven
04:37Health System,
04:38doctor Robert Robrock, associate dean
04:40for global health education
04:42at Yale West Global Medicine,
04:44friends and colleagues.
04:46Good afternoon, and thank you
04:48for all being here.
04:50Today, we commemorate the International
04:52Day of Chagas disease.
04:55Although
04:56car doctor Carlos Chagas discovers
04:58discovered this disease more than
05:00a century ago and we
05:02know that it disproportionately
05:04affects the most vulnerable,
05:06underserved and isolated communities in
05:08Latin America, we still do
05:10not have a complete understanding
05:12of its pathophysiology.
05:14We continue to lack optimal
05:15diagnostic methods and we don't
05:17yet have a truly effective
05:19treatment.
05:20Chagas disease continues to claim
05:22the lives of thousands of
05:23patients in the prime of
05:25their lives with devastating consequences
05:28for their families and communities.
05:31Through CEDAY, the Chagas disease
05:32alliance at Yale, scientists and
05:34healthcare professionals from Latin America
05:37and Yale have joined forces.
05:39Together, we collaborate as colleagues
05:42and advance research efforts to
05:44better understand and combat this
05:46disease.
05:48It is now my great
05:50honor to introduce doctor Rachel
05:52Marcus.
05:53Doctor Marcus graduated from Stanford
05:56Medical School in nineteen ninety
05:57four and completed her internship
06:00and residency at Brigham and
06:02Women's Hospital in Boston
06:04before returning to Stanford for
06:05a fellowship in cardiovascular medicine.
06:08Driven by a long standing
06:10commitment to serving underserved communities
06:13both in the United States
06:14and abroad, she founded LaSocha,
06:17a non profit organization dedicated
06:19to fight against Chagga disease,
06:21where she also helped develop
06:23its medical program.
06:26She has also supported research
06:27in chagal disease in collaboration
06:29with John Hopkins University
06:31in addition to her work
06:32as a staff cardiologist at
06:33the National Institutes of Health.
06:36Please join me in welcoming
06:38doctor Marcus. It is a
06:40true honor to have her
06:41with us today at cardio
06:43at the Yale Cardiology Ground
06:44Rounds at Yale University. Thank
06:46you.
06:54So thank you so much.
06:55I am the one who's
06:56honored to be here with
06:58you all. It's just so
06:59thrilling to,
07:00have Yale University
07:02being with the the pinnacle
07:04of academic and and cardiology
07:06excellence thinking about Chagas disease.
07:08So it's a real thrill
07:09for me to be here.
07:11I'm gonna give you sort
07:12of a boots on the
07:13ground in the trenches view
07:14of the kind of work
07:15that we do with Chagas
07:16disease in the United States.
07:18And part of the reason
07:19that I have LaSoche in
07:21red here is to remind
07:22me to remind you that
07:23I am the medical director
07:25of the Latin American Society
07:26of Chagas.
07:28And our mission really is
07:29dedicated to raising awareness of
07:31Chagas disease.
07:32So generally, actually, when I'm
07:33talking to audiences, they know
07:35nothing about Chagas disease.
07:37And this is a little
07:38trickier for me today because
07:39there are a lot of
07:39people in this audience who
07:40actually know more about Chagas
07:42disease than I do. So
07:43I'm trying to hit the
07:43sweet spot to be able
07:44to teach people about Chagas
07:46disease, but not more people
07:47who know so much about
07:48it. But the other thing
07:50is that I really do
07:51focus on Chagas disease in
07:52the Latin American immigrant population
07:54in the United States.
07:55The other reason that I
07:57have read up there is
07:58because I'm a fellow of
07:59the American Society of ECHO,
08:02and oops. I went the
08:03wrong way.
08:06Here we go. So I
08:08had too much time on
08:09my hands, and I told
08:11AI some people have been
08:11telling me I need to
08:12learn a little bit more
08:13about AI, so I decided
08:14to get AI to make
08:15a picture of me as
08:17grumpy echo lab lady with
08:19a hammer.
08:20And the reason why I'm
08:21grumpy grumpy echo lab lady
08:22with a hammer in this
08:23particular picture is because
08:25I do,
08:26spend a lot of time
08:27thinking about echo, a lot
08:28of time looking at echo,
08:30scrutinizing
08:30echoes to look for some
08:32of the subtle findings related
08:33to Chagas disease, and we
08:35miss them a lot in
08:36the United States. So up
08:37on the echo screen, there
08:39is actually a beautiful echocardiogram
08:41that was done in Brazil
08:42by Carmina Nunez, and I
08:44happened to be there while
08:45she was doing it. So
08:46I took a picture to
08:47show what a perfectly image
08:48apex of a patient with
08:50Shaka's disease should look like.
08:51But I'm unhappy because I
08:52don't see that very often.
08:54The other reason
08:55the reason that I have
08:56the hammer is because
08:58when you're a hammer, everything
08:59looks like a nail. And
09:00I have to remind myself
09:01that I think about Chagas
09:02if you could give me
09:03an extra hour in my
09:04day, I would think about
09:05Chagas disease twenty five hours,
09:07seven days a week. But
09:08not everybody's like that. So
09:09I have to remember that
09:10that not everybody looks at
09:11every echo as if it
09:12might have Chagas disease. But
09:14those are those are my
09:15disclosures for this talk.
09:17Okay. Moving on. So the
09:19story begins, Chagas disease in
09:20the United States. This is
09:22a mummy from the south
09:23of Texas. You probably recognize
09:25this picture,
09:26probably from about a thousand
09:27years ago that was found.
09:28And I'm sorry to do
09:29this to you during lunch,
09:30but the arrows are pointing
09:31towards the incredible
09:33amount of impacted fecal material
09:35in this mummy's colon. This
09:37mummy had mega megacolon
09:39and was then found actually
09:41by PCR testing to have
09:42evidence of trypanosoma cruzi infection.
09:44So we know that in
09:45Texas, in southern Texas near
09:47the Mexico border, we have
09:48at least established Chagas disease
09:50in the United States as
09:51far back as a thousand
09:52years ago. I wanna fast
09:54forward a lot
09:56to two thousand seven and
09:57to give a huge shout
09:58out to this cardiologist. Her
09:59name is Sheba Meymandi.
10:01And she was working in
10:02the Olive View Medical Center
10:03as a heart failure cardiologist
10:04and realized that a lot
10:06of the people who were
10:07seeing her there, who were
10:08Spanish speakers, were at risk
10:09for Chagas disease. And so
10:10she started testing them, and
10:12she started understanding the disease
10:14was really, in the United
10:15States. She started publicizing this,
10:17and she developed the OliveU
10:19Center of Excellence for Chagas
10:21disease, which really is the
10:22only center of its kind
10:23in the United States. And
10:25all of us who think
10:26a lot about Chagas disease
10:27in the US owe her
10:28an incredible,
10:29debt of gratitude for the
10:31work that she's done and
10:32continues to do.
10:34Okay. So this is though
10:35it it's certainly true that
10:36about thirteen years ago, I
10:37decided to focus very incredibly
10:39myopically on Chagas disease, and
10:41this is my thirteen years
10:42of Lesocha.
10:43We started,
10:45with the talk in the
10:46community. This was in December
10:47of twenty twelve, and then
10:48we started doing
10:50screening programs at the Bolivian
10:52mobile consulate program. So the
10:53Bolivian consulate,
10:55has,
10:56the ability to go out
10:57into the community on weekends
10:58so that people can come
10:59get their their, their passports
11:01processed and things like that.
11:02And we basically developed a
11:03convenient sample of people who
11:05were interested in getting tested
11:06for Chagas disease. And what
11:07we found very quickly was
11:09that we had a tremendous
11:10amount of Chagas disease in
11:11that population. So the we
11:12actually presented a a poster
11:14at ASTMNH
11:15later that year showing twenty
11:17five percent seroprevalence rate in
11:18the people that we saw.
11:20Crazy. Right?
11:21So then we,
11:23started doing more testing in
11:25the community with Johns Hopkins,
11:27as as, was alluded to.
11:30And we then with that
11:32John Johns Hopkins research project,
11:34which I'll tell you a
11:35little bit more about later,
11:36we inherited the patients that
11:37were identified through that seroprevalence
11:39study. And this is our
11:40our beginning of of our
11:41LaSoche continuity of care clinic.
11:43And here you can see
11:44some of my, my my,
11:46my labor here. This is
11:48my son, Saul, doing an
11:49EKG
11:50on this patient.
11:51And what I should say
11:53is that we've,
11:54really benefited incredibly from very,
11:56very generous benefactors, one of
11:58whom lent us this EKG
11:59machine.
12:00Here we are doing educational
12:02activities in the community. This
12:04is at a program for
12:05Central American immigrants to get
12:06their citizenship. And so we
12:07went into the community to
12:08teach them about Chagas disease.
12:10This is particularly important,
12:13in at least in our
12:14neck of the woods for
12:15all immigrants from places other
12:16than Bolivia. Bolivians are incredibly
12:18knowledgeable about Chagas disease, and
12:20if you offer Chagas disease
12:21testing, they will come because
12:22they all know someone who's
12:23been impacted by the disease.
12:25But in Central America and
12:26in Mexico, the disease is
12:27much less well known, so
12:28people are much less likely
12:29to get the testing. And
12:30so educational activities are really
12:32important.
12:34This was a real milestone
12:35for us, around the pandemic.
12:37We actually were finally able
12:39to get buy in from
12:40a large scale safety net
12:42prenatal testing clinic in Northern
12:44Virginia, and we started testing
12:45with them at twenty eight
12:46weeks of pregnancy. To date,
12:47we've tested about five thousand
12:49women, and we found thirty
12:50one who have Chagas disease.
12:52While we haven't yet identified
12:54a baby with neonatal Chagas
12:55disease, we found a fifteen
12:56year old son of one
12:57of the moms, and one
12:58of the moms was sixteen
12:59when she got pregnant. And
13:01so we've been able to
13:01identify two children with Chagas
13:03disease.
13:05And that just feels like
13:06a huge win for us.
13:08We also have roped in
13:09Georgetown medical students to go
13:11with us out to screening
13:12fairs in the community, which
13:13we do a lot of,
13:14particularly in the summer months.
13:15We get donated in BIOS
13:17rapid test kits, which we
13:18use, and then we offer
13:19free confirmatory testing. All of
13:21our services are free.
13:22We've also partnered with some
13:24other organizations that do incredible
13:25work with Chagas disease. I
13:26was the team echocardiographer
13:28for Project Pacer International, which
13:30runs missions to Bolivia to
13:31put in pacemakers and defibrillators
13:33in individuals who can't afford
13:34them, which is many Bolivians.
13:38This just this year, we
13:39actually have now signed a
13:41formal agreement with the council
13:42of Bolivia that we have
13:44a formal relationship
13:45regarding Chagas disease testing and
13:47Chagas disease activities with the
13:48Bolivian immigrant community.
13:50I've been incredibly fortunate to
13:52be able to meet some
13:53of the luminaries in the
13:54world of Chagas. You might
13:55recognize Luis Echeverria and Carlos
13:56Murillo in this in this
13:57in this picture, and I've
13:58just filled really gratified that
14:00they they, they let me
14:02be in the picture with
14:02them.
14:04And also along the way,
14:05some other there are other
14:07folks doing this work in
14:07the United States, and this
14:09is the US Chagas disease
14:10clinicians network, which has now,
14:13not quite monthly, but maybe
14:14quarterly meetings to do educational
14:16activities about Chagas disease. So
14:17we're really thrilled to see
14:18that there are people who
14:19are gathering interest
14:21here today. And then Bernardo,
14:23has included me in c
14:24day, which is just wonderful.
14:26And now most recently, I'm
14:28at NIH and I'm starting
14:29a Chagas cardiomyopathy
14:31project there, and I'm hoping
14:32to get referrals from from
14:33for peoples, to help me
14:35with my studies.
14:37And finally, we were part
14:38of the first annual US
14:39Chagas disease meeting, that occurred
14:41at Tulane right around the
14:42ACC,
14:43which was really a a
14:44wonderful a wonderful sort of
14:46coalescence of some of the
14:47people. Unfortunately,
14:49we didn't have everybody, but,
14:51but we're hoping that in
14:51the years to come, we
14:52can actually gather steam. So
14:54this is what I've been
14:55doing with Chagas disease.
14:57Okay.
14:58This is a patient of
14:59mine who I met when
15:00he, had an LVAD place
15:02for Chaga's cardiomyopathy,
15:03and I thought it's important
15:04to sort of return us
15:05to the world of the
15:06patients now because that's why
15:07we're here.
15:08And I will hopefully
15:11get this to play.
15:58So just to stop and
16:00and talk a little bit
16:00about Carlos, he was an
16:02amazing went through his LVAD,
16:04went through his heart transplant.
16:05I went to the hospital
16:07to meet with him after
16:08he had his transplant, tried
16:09to get his family to
16:10do testing because as we
16:11are aware, family members of
16:13an individual with Chagas disease
16:14are considerably higher risk for
16:15that. They did not want
16:17it,
16:18in spite of multiple efforts.
16:20And, unfortunately, very recently, his
16:22brother was admitted to the
16:23hospital with stage d heart
16:24failure with Chagas cardiomyopathy.
16:26The other thing that is
16:28true of some of these
16:29patients is that it's very
16:30difficult for them to take
16:31time off from work. And,
16:32unfortunately, Carlos was one of
16:33those individuals, and he was,
16:35probably unable to get his
16:37medications,
16:38and, unfortunately, died probably from
16:40rejection.
16:41So this is the world
16:42in which these immigrants live.
16:43If they're lucky enough to
16:44be able to get transplants,
16:45they still are are really,
16:47having a hard time getting
16:48the care that they need.
16:50So now to go back
16:51up to sort of a
16:52fifty thousand foot view, one
16:54of the things I do
16:55like to do is to
16:55raise awareness of Chagas disease.
16:57And this is from the
16:58RAISE study, which is recently
16:59published data. And I did
17:00wanna point your, point your
17:02attention to a couple of
17:03things here. First of all,
17:04the number of cases were
17:05estimated in nineteen ninety to
17:07be twelve thou twelve million
17:08six hundred thousand. And usually
17:10now, most of us when
17:11we're giving talks will cite
17:12a number of about five,
17:13seven, six million people still
17:15with Chagas disease.
17:16All of a sudden, Tom
17:17Ribeiro, who from from Brazil,
17:20has actually incredibly
17:22uptitrated this number looking now
17:24at ten million people. So
17:26all of the the sort
17:26of,
17:27pry we were having in
17:28the reduced number of cases,
17:30we have to step that
17:31back a tiny bit. Nevertheless,
17:32there has been a decrease
17:34in in patients over the
17:35course of the years, probably
17:36due to incredible efforts like
17:37the Southern Cone initiative.
17:39But we are seeing when
17:40you look over here is
17:41that the aging of the
17:42patients is actually the the
17:43patients are moving to an
17:44older age range,
17:46which means something about the
17:47patients that we need to
17:48be thinking about looking for
17:48Chagas disease in and expecting
17:50it. But also these are
17:51patients who are now gathering
17:52comorbidities.
17:53And so these are now
17:54patients who have diabetes. They
17:55now have, they have hypertension,
17:57and so we're now having
17:58to treat them for multiple,
18:00chronic medical conditions.
18:02I did wanna point out
18:03there we're still having about
18:04eight million eight hundred eight
18:06thousand, goodness me, deaths per
18:08year.
18:09And I did wanna add
18:10here,
18:12if I can, a map
18:13of the United States and
18:14talk about the figures that
18:15we usually quote in the
18:16United States. So there have
18:17been estimates now over the
18:18course of the past two
18:20decades, really, of of about
18:21three hundred thousand cases of
18:22Chagas disease in the United
18:24States.
18:25Using this data,
18:26and using
18:27some of the new migratory
18:29pattern data, some researchers from
18:31Johns Hopkins who were were
18:32doing a a DALY analysis
18:36of Chagas disease have actually
18:36significantly ratcheted up the number
18:36of estimated cases. So now
18:38we're thinking about four hundred
18:39and twenty seven. That's a
18:40very precise number, but but
18:41higher than what we usually
18:42were thinking of with about
18:44eighty two thousand having Chagas
18:46cardiomyopathy.
18:47So that's the backdrop of
18:48what we think we're dealing
18:49with,
18:50you know, plus or minus
18:52ten thousand. I don't know.
18:54In any event, so how
18:55does this make me feel
18:56like this? So we're trying
18:58hard. We're trying to do
18:59what we can do. But
19:00all of a sudden, now
19:00we've gone from six million
19:02cases to ten million cases.
19:03We've gone from three hundred
19:04thousand cases in the United
19:05States to four hundred and
19:06seventy thousand cases in the
19:07United States. From fifty
19:09seven,
19:10thousand
19:11Chagas cardiomyopathy to eighty thousand.
19:13So our our work is
19:14even getting harder for us
19:16as we get more and
19:17more data,
19:18in any event.
19:20Okay. So and we really
19:22do need to still work
19:23on raising awareness of Chagas
19:24disease. So I I I've
19:26highlighted here, something that I
19:28think, Bernardo, you put up
19:29on on one of your
19:29slides, which is work from
19:30Erica Ryack, who was here
19:32getting a degree in public
19:33health,
19:34who was looking at Chagas
19:35disease screening awareness practices and
19:37perceived barriers among health care
19:38providers in Connecticut.
19:40And these are just some
19:41of many studies that have
19:42shown that there's a real
19:43lack of awareness of Chagas
19:44disease in the in the
19:45provider community. And one of
19:47the problems that I have
19:48with some of these data,
19:49these data that look at
19:50people sending out surveys and
19:51asking people to complete them
19:53is I think there's selection
19:54bias. I think if somebody
19:55sent me something about Chagas
19:57disease, I would fill it
19:58in. If somebody sent something
19:59about Chagas disease to somebody
20:00who doesn't know anything about
20:01Chagas disease, maybe they would
20:03delete that email. So I
20:04think that while we do
20:06see that there is some
20:06awareness of Chagas disease, it's
20:08not that nobody knows about
20:09it. I am a little
20:10bit worried that it's the
20:11people that didn't reply to
20:12these surveys that we really
20:14have to worry about.
20:16And so this is I'm
20:17sorry. I should have put
20:18that up there first. Okay.
20:19So now to dial back,
20:20just to make sure everybody
20:21in the room actually knows
20:22what Chagas disease is.
20:24Chagas disease is an infection
20:26with this beautiful hemoflagellate
20:28parasite. It's a zoonosis, so
20:29it can affect any mammalian
20:31species.
20:32And it likes to lodge
20:34itself in smooth muscle linings
20:36of the heart and of
20:36the GI tract and and
20:38of the central nervous system,
20:40and it can lead to
20:41a chronic lymphocytic,
20:42in some cases, fairly indolent
20:44myocarditis, which is really why
20:46we think about it in
20:47the in the cardiology community.
20:50Who is likely to get
20:51it? So in general,
20:53for vector borne disease, it's
20:54somebody who's lived in a
20:55house that has a wall
20:56that looks like this.
20:58You can see it's plastered
20:59and somebody's pulled a piece
21:00of the plaster off of
21:01the wall, and you can
21:01see these bugs sitting here,
21:03ready to go ahead and
21:04bite.
21:05In general, we think and
21:07and this is really interesting
21:08to hear what doctor Hamer
21:09was talking about earlier today,
21:11that you really need to
21:12have repetitive and sustained exposure
21:14to these bugs in order
21:16to contract a case. And
21:17there's been some statistical modeling
21:18that has said you need
21:19somewhere between nine hundred and
21:21a couple of thousand,
21:23in interactions with one of
21:25these bugs because the the
21:26mechanism of transmission is not
21:26really all that effective. And
21:26that matters when we think
21:26about shock transmission
21:28is not really all that
21:29effective. And that matters when
21:30we think about Chagas disease,
21:32in the United States.
21:33So this is what the
21:34bug looks like. And there
21:36are a variety of different
21:38kinds of bugs and people
21:39from a variety of different
21:41countries call it a different
21:42name. And the one that's
21:43particularly difficult for me is
21:45Chinche, which is what it's
21:46called in Central America because
21:47the problem is that people
21:49in the United States
21:50call bedbugs Chinche. And so
21:52if you ask people if
21:52they know their Chinche, they're
21:53gonna say yes, and then
21:54they're gonna think it's this
21:55the the bedbug. Why does
21:56it matter? Well, because if
21:58somebody recognizes the bug, they
21:59really are at higher risk
22:00for having the disease, which
22:01I'm not saying that you
22:03shouldn't test somebody who doesn't
22:04recognize the bug, but we
22:05do know that having some
22:06familiarity with the bug is
22:08really a problem.
22:09And what you do see
22:10from this map is that
22:11we have disease that ranges
22:12from Argentina
22:14all the way up to
22:15that we used to say
22:16the lower half of the
22:17United States, but now I'm
22:18feeling like we should say
22:19the the the upper the
22:21lower two thirds of the
22:22United States. It seems to
22:23be going up, and who
22:24knows what's gonna happen with
22:25climate change?
22:26So,
22:27this is a a recent
22:29published piece, and, doctor Hamer,
22:30you see, is the is
22:31the final final author on
22:32this, Shagas disease and endemic
22:34disease in the United States.
22:35Some of you might have
22:36seen lay press coverage of
22:37this, so I did feel
22:38like I needed to cover
22:38it today. This was a
22:40perspective,
22:41piece talking about the state
22:42of the evidence that we
22:43have about,
22:44autochthonous or domestically acquired disease
22:46in the US.
22:48I think this is actually
22:49a fantastic
22:51question to be asking and
22:52one that should absolutely be
22:54addressed. We know that we
22:55have bug here. We know
22:57that the bug has parasite,
22:58and we know that there
22:59are bug human interactions, and
23:00we know that there are
23:01cases.
23:02How much? We need to
23:03find out. Because just because
23:05I think about Latin American
23:06immigrants with Chagas disease, there
23:08is not a single person
23:09with Chagas disease in the
23:09United States who should not
23:11receive the appropriate care for
23:12what they have, and we
23:13need to find them.
23:14So just to sort of
23:15drive that home, here is
23:17that map. It to me,
23:18it does look like it's
23:19the lower two thirds. I
23:19don't know, Sarah, if you'll
23:20give me permission to describe
23:21it that way now.
23:22And these are a variety
23:24of the eleven,
23:25triatomine species that we have.
23:27And I put arrows towards
23:28a gyrstaccharide
23:29and sangosuga because those are
23:30some of the ones that
23:31are most likely to be
23:32infected with parasite and the
23:33ones that we have a
23:34lot of sense are actually
23:36interacting with humans.
23:38We'll talk a little bit
23:39more about this later if
23:40we have time. In any
23:40event so we'll go back
23:41now to phases of disease.
23:42So we start off with
23:43T. Cruzi infection.
23:45We are talking a lot
23:46about vector mediated disease, but
23:47there are other ways to
23:48get the illness including through
23:49transfusion,
23:50probably congenital disease now, with
23:52maternal fetal transmission is really
23:54important in thinking about this,
23:57and,
23:58orally transmitted disease. Although, I
23:59don't know how much we'll
24:00we'll see that in the
24:01United States, with some a
24:03few caveats.
24:04So generally, people go into
24:05the acute stage of the
24:06disease. And if you are
24:08lucky enough to find it,
24:09which very few of my
24:10patients are because in general,
24:12they were infected when they
24:13were living in a rural
24:14environment. They didn't have a
24:15lot money, and the the
24:17symptoms are very, very nonspecific.
24:18They didn't get medical care
24:19for that infection, and so
24:21they then they did not
24:22get treatment for it. So
24:23they were not able to
24:24avail themselves of this cure
24:25after treatment.
24:27So in general, they all
24:28pass into the chronic phase.
24:30Unfortunately, not many people get
24:31so sick that they die,
24:32although people with orally transmitted
24:34disease seem to have a
24:35more fulminant case.
24:37So what I I like
24:38about this, though, is that
24:40it does mention chronic phase,
24:41that five to ten percent
24:42of people will go very
24:43quickly into the determinant form.
24:45And that recognizes that if
24:46you look at children who
24:47have Chagas
24:48disease, that if you look
24:49at the series, including those
24:51when they were treated with
24:51benzodiazepine,
24:53that the kids actually can
24:54leave childhood with EKG abnormalities.
24:57So it's likely that some
24:58of these kids are getting
24:59so sick that they develop
25:00EKG abnormalities.
25:01And then if you don't,
25:02if you you you you
25:03go directly into this indeterminate
25:05form where you don't have
25:06EKG abnormalities,
25:08about
25:08two percent per year will
25:10then pass into the cardiac
25:11phase, twenty to forty percent.
25:13So overall, we end up
25:14with about seventy percent of
25:15people staying in the indeterminate
25:16form permanently,
25:18and we end up with
25:18about thirty percent of people
25:20having some sort of end
25:21organ manifestation, which can include
25:22cardiac disease, why we're here
25:24today, digestive disease, which is
25:25less common,
25:27and cardiodigestive
25:28disease, which is less common
25:29even still.
25:31Okay. So we'll talk a
25:32little bit more about the
25:33acute phase here. The symptoms
25:34are pretty nonspecific. Malaise, adenopathy,
25:36it's frequently not remembered as
25:38an adult. That's most of
25:39my patients do not recall
25:40having
25:41their time with Chagas disease.
25:44And the one thing that
25:45I really should say, reiterate
25:47is that paracetemia is present,
25:48and treatment with antiparasitic medications
25:50is effective for cure. You
25:51see Romagna's sign here. For
25:53some of you, this may
25:53be what you remember from
25:54medical school about Chagas disease.
25:56This, this, unlucky young lady
25:58probably got some infected fecal
25:59material on her eye, and
26:00she has a painless palpebral
26:02edematous reaction to that, which
26:04can last up to a
26:05month.
26:06Okay.
26:08We've actually talked about this
26:09a little bit except for
26:10the other acute presentation that
26:11I really should have mentioned,
26:12which is really important here
26:13is reactivation disease.
26:15That's something that you can
26:16see frequently in the post
26:17transplant setting, particularly with our
26:19cardiac patients.
26:21And it can't if you
26:22are not doing surveillance well
26:23enough for it, you might
26:24actually, end up with an
26:26acute, very important presentation.
26:28We'll move on. So these
26:29are the kinds that you
26:30might actually see in the
26:31United States.
26:32Again, we don't know about
26:34oral. Okay.
26:35So the indeterminate phase, talk
26:37a little bit more about
26:38that. How do we actually
26:39diagnose it? Well, that's diagnosed
26:40based on serology, and we'll
26:42talk about that in a
26:42minute. We do say that
26:43the end of significant manifestations
26:45for about seventy percent of
26:46people, two percent per year
26:47progress. What I wanna remind
26:48a roomful of cardiologists is
26:49that aging itself also causes
26:52development of EKG abnormalities.
26:54I've done a kind of
26:54back of the envelope calculation
26:56from the studies that actually
26:57included people with Chagas disease
26:58and people who did not
26:59have Chagas disease, and it
27:00seems like the excess risk
27:02is probably about it's probably
27:04about a hundred percent higher,
27:05but it goes from one
27:06percent to two percent. So
27:07any human being, as we
27:09know from Framingham, as we
27:10know from any sort of
27:11the big database studies that
27:12look at folks with with
27:13just being human and getting
27:15older, you get more EKG
27:16abnormalities. Nevertheless, there's an excess
27:18risk with Chagas. So let's
27:20talk about serology for a
27:21minute.
27:22So this is tricky. This
27:23poor lady is having to
27:25deal with calls about Chagas
27:26disease serologic testing. And why?
27:27It's because of this big
27:28plot plot on the on
27:29the,
27:31on the left. So this
27:32came out of a very
27:33recent extremely well written v
27:35review about Chagas disease. I
27:37think that was public published
27:38in Lancet, and it's showing
27:39this the array of Chagas
27:41disease test that we have
27:42in the United States. And
27:43where you see some chicken
27:45scratches from me with red
27:46and black is where they
27:47didn't actually get it quite
27:49right. So that's a problem.
27:50Right? The people who wrote
27:51the paper are truly experts,
27:53but sometimes the landscape just,
27:55just changes like that. And
27:57the labs don't reach out
27:58to you and tell you
27:59that they've stopped doing what
28:00they said they were doing
28:01before. You have to figure
28:02it out. So what we
28:03what I can tell you
28:04though is that the good
28:06news recently is that the
28:07commercial labs in the United
28:09States now tend to be
28:10offering two tests for Chagas
28:11disease. So that's fantastic. So
28:13it means if you order
28:14through Labcorp, you are gonna
28:15get a wiener ELISA and
28:17a hemogen ELISA at the
28:18same time. And if you're
28:19lucky, they both are positive
28:20and then you've actually confirmed
28:21your patient because you have
28:22two different ELISAs for Chagas
28:24disease.
28:25If you go to Quest
28:26instead, the first test you
28:27get is Wiener. And if
28:28you test positive on that,
28:30you reflex then to INBIOS.
28:32If you get two of
28:32those positive, you're golden. You
28:34now actually have a diagnosis
28:35of Chagas disease. The trickier
28:37thing is when you have
28:38one that's positive and ones
28:39that's negative. What do you
28:40do with that? You have
28:41not confirmed the diagnosis of
28:42Chagas disease. So then you
28:43need to actually go looking
28:44somewhere else. Typically, that has
28:46been the CDC.
28:48They do very high quality
28:49testing, but I'm not sure
28:50if any of you have
28:51familiarity with getting blood there.
28:53It is a production, and
28:55it's one of the main
28:56reasons that it's hard for
28:57me to get people to
28:59convict to be convinced to
29:00actually start testing
29:02because the process of getting
29:03the blood there is extremely
29:04complicated,
29:05and it varies state by
29:07state, and it varies county
29:08by county. So, unfortunately, it
29:10just gets very, very complex.
29:13So and and then finally,
29:16no. I think that's actually
29:17what I wanted to say
29:18about that. In any event,
29:18you can see why this
29:19poor lady looks so frazzled
29:21because this is really a
29:21huge issue.
29:23So the final thing that
29:24I really wanted to say
29:25about it
29:26is that it's incredibly
29:28expensive. So if you're lucky
29:30and you have a patient
29:30too that has insurance, you're
29:32fine. You can order your
29:33test and the patient will
29:34be covered. If you're unlucky
29:36and you work in a
29:37federally qualified health center, which
29:38is where a lot of
29:39these patients are seen,
29:41those centers simply cannot afford
29:43to pay a hundred dollars
29:44for Chagas disease testing. They
29:46just can't do it. So
29:47when Lesocha
29:48tries to go and support
29:49Chagas disease testing and we
29:51say, we will help you,
29:52neighborhood health center, where you
29:54see seven thousand immigrants at
29:55a minimum a year who
29:56need this testing, we then
29:58have to write a grant
29:59for seven hundred thousand dollars
30:01to support the testing. And
30:02if I were a grantor,
30:04I'm not sure I would
30:04wanna give me seven hundred
30:06thousand dollars to support testing
30:07and sure enough, they didn't
30:09because it's a huge amount
30:10of money to spend on
30:11testing. The irony being that
30:13if you order this testing
30:14and Medicaid reimburses you, Medicaid's
30:16gonna give you about, I
30:17don't know, maybe twenty bucks.
30:19So there's a real disconnect,
30:20and we really have to
30:22work on that because right
30:23now, it's one one of
30:24many huge barriers we have
30:26to instituting
30:27testing at the appropriate level,
30:29which is really in the
30:30primary care setting.
30:31So I'll get out my
30:32soapbox, and we'll keep on
30:33going. So now we'll turn
30:35back to chronic disease. And
30:36so what is chronic Chagas
30:38disease or Chagas cardiomyopathy?
30:40That's at a minimum defined
30:41as positive serology,
30:43confirmed testing,
30:44and an abnormal EKG. So
30:46why do I put an
30:47asterisk there? Well, because an
30:48EKG is a snapshot of
30:50one moment in time. And
30:51what I can tell you
30:52is sometimes I'll have a
30:53patient will come in, and
30:54they'll have a heart rate
30:55of fifty two or fifty
30:56four. And then I put
30:57them on the bed, and
30:58I start doing their echo,
30:59and all of a sudden
31:00their heart rate's forty five.
31:01And they're not sleeping. It's
31:02not sleep apnea. They didn't
31:03start to snore.
31:05And I'm thinking that's not
31:06okay. A heart rate of
31:07forty five is too low.
31:08So I've identified somebody where
31:10that initial snapshot EKG is
31:12actually probably not an overall
31:13accurate,
31:16arbiter of how their cardiovascular
31:18system is is going. Same
31:20thing happens with intermittent ectopy.
31:21Somebody lies down all of
31:22a sudden they're having PVCs
31:24all over the place. That's
31:25not a normal heart. We
31:26see rate related bundle branch
31:27blocks. So we always have
31:28to have remember that the
31:30EKG is pretty darn good
31:31at telling us who has
31:32Chagas cardiomyopathy, but it's not
31:34perfect, which is why we
31:35also want to do an
31:36echocardiogram to see whether or
31:37not we can find any
31:38subclinical findings or even some
31:40clinical findings that we might
31:41be missing.
31:43And some folks will even
31:44say MRI, but in resource
31:45poor environments, that's pretty tricky.
31:47In any event, people tend
31:49to present about fifteen to
31:50thirty years after the time
31:51of likely infection, and we
31:52heard a lot this morning,
31:54and I will reiterate that
31:55we just do not know
31:56really yet who it is
31:57who's gonna progress to develop
31:59significant cardiovascular disease. We have
32:01lots of hypotheses. We have
32:02some beautiful work that was
32:03done recently in Argentina looking
32:05at SNPs. We have proteomics.
32:06We have metabolomics.
32:08We have biomarkers. All those
32:09kinds of things. But as
32:10of yet, we don't have
32:11the holy grail, which is
32:12gonna tell us which patients
32:13are gonna stay in an
32:13interminate phase, and we do
32:15not need to worry about
32:15you, and which patients are
32:17going to progress, and we
32:18really do need to worry
32:19about you.
32:20Okay. So this is a
32:21busy, busy, busy, busy slide
32:23about cardiac pathophysiology.
32:25I really just wanna hammer
32:26that there are probably
32:28mechanisms, all of which cause
32:29myocardial scar and fibrosis.
32:31So there's parasite persistence.
32:33There's immune and inflammatory,
32:35mediated injury and dysregulation.
32:37There's microvascular abnormalities, which is
32:39important because we do think
32:40watershed ischemia plays a role
32:41in some of the pathophysiology
32:43and autonomic derangements.
32:45And we have even more
32:46sophisticated analyses of some of
32:48these biomarkers,
32:49and interferons and interleukins. And
32:51I'm gonna leave that for
32:52people, to talk. You can
32:53ask a question about it,
32:54but, but people far more
32:56expert than I can answer
32:57some of those questions for
32:58you.
32:59So this slide, though, if
33:01I had to show you
33:01one slide to tell you
33:02all of the bad things
33:03that chagas cardiomyopathy
33:04can do, it would be
33:05this one. So we're gonna
33:06start with some gross pathology
33:08specimens.
33:09I'm gonna tell a story
33:10about this guy. I don't
33:10know if it happens to
33:11be true, but I'm imagining
33:12this is a patient who
33:13came into heart failure clinic,
33:15with significant congestive heart failure,
33:17also had a stroke, and
33:19also had some ventricular tachyarrhythmias.
33:21Why? Well, this is a
33:22big baggy heart. You can
33:23see it's really, really big.
33:24You can see there's an
33:25arrow pointing towards this red
33:26blob at the apex. That's
33:28an that's an apical thrombus.
33:29And you can see this
33:30white line here, which is
33:31apical scarring and fibrosis. So
33:33this patient really
33:34hit for the cycle. He's
33:35got every bad thing that
33:36chagas can do to you.
33:37Heart failure,
33:39stroke, and arrhythmia.
33:40This is also probably a
33:41patient who's showing up in
33:43your cardiology office, and you're
33:44going to do diagnostic testing
33:46for Chagas disease because it's
33:47a symptomatic patient.
33:49Unlike the story that I
33:50tell about this patient
33:52who actually was probably fine
33:54until the day that he
33:55had a massive right middle
33:57cerebral artery stroke
33:58and now is totally incapacitated.
34:00Why do I say that?
34:01Because, otherwise, this heart looks
34:02really pretty healthy. Right? There's
34:03maybe even some LVH here,
34:05but it's fundamentally healthy myocardial
34:07muscle with this focal apical
34:09aneurysm that we might miss
34:10if we don't do our
34:11echo very carefully. And this
34:13is a patient where the
34:13only way we're gonna know
34:15that this is what this
34:16patient has is if we've
34:17done screening for Chagas disease
34:19just because of where they're
34:20from. And then we find
34:21out they have Chagas disease,
34:22and then we they we
34:23do their cardiac evaluation, and
34:24then we find this. And
34:25then we know that we
34:26need to worry about the
34:27risk for thrombotic disease.
34:29Same for this patient here.
34:30I'm imagining this is a
34:31patient who was out running
34:32around on the soccer field
34:34and all of a sudden
34:34had sudden cardiac death. This
34:36is a patient who has
34:37pretty normal looking distal inferolateral
34:40wall, but scarring here in
34:41the basal inferolateral wall. That's
34:42what that arrow was showing.
34:44Thought to be due to
34:44watershed ischemia.
34:46This is intensely arrhythmogenic.
34:48So this might be a
34:48patient, again, who the only
34:50way we know that they
34:51have this potentially life altering
34:53problem with their heart is
34:54if we've screened them for
34:56Chagas disease, and then we
34:57do the appropriate cardiac testing
34:59downstream to be able to
35:00restratify them for the bad
35:01complications of Chagas.
35:03Finally, with this, I wanted
35:04just to remind myself to
35:05remind you that Chagas causes
35:06bradyarrhythmias
35:07in addition to tachyarrhythmias.
35:09You can see this is
35:09intensified process of the His
35:11Purkinje system.
35:12And I also want to
35:14hammer on you with my
35:15hammer that Chagas disease is
35:17bizarrely
35:18like sarcoid cardiomyopathy.
35:19So if you're seeing a
35:20patient who has these kinds
35:21of manifestations and you're thinking
35:23about sarcoid, but they happen
35:24to be speaking to you
35:25in Spanish, you really need
35:27to be thinking about Chagas
35:28disease.
35:29At the some of the
35:30overlaps are really, really scary
35:32and intriguing.
35:34Okay. So now what we're
35:35gonna do is we're gonna
35:36run through a real case
35:37presentation. This was me playing
35:38around with AI. This is
35:40not actually the patient, but,
35:41a a case that we
35:42did actually see, and I
35:44think it's really illustrative
35:45as to how the,
35:47the care in the United
35:48States is not designed to
35:50really offer optimal care to
35:52these patients.
35:53Even in a hospital where
35:54I had already spent probably
35:56five years
35:57telling every single fellow about
35:59Chagas disease, talking until I
36:01was blue in the face
36:02to every single Echolab attending.
36:03So I would consider people
36:04to actually know about Chagas
36:06disease. Maybe I just did
36:07a really bad job, but
36:08I don't think we did
36:09a great job with this
36:10patient. So fifty six year
36:11old man from El Salvador,
36:13no past medical history, no
36:14meds, and no insurance. He
36:16presented to the hospital with
36:17sudden onset of left sided
36:18weakness and third speech. He
36:20was quite hypertensive.
36:22Baseline labs otherwise looked okay,
36:24and his MRI showed an
36:25acute right frontal stroke from
36:26an occluded right MCA, which
36:28is a classic place for
36:29a cardio embolic disease from
36:31Chagas disease. He also was
36:32noted to have had prior
36:34old left cerebellar and cerebral,
36:36strokes noted. So here's his
36:37EKG.
36:39So anybody who is familiar
36:41with Chagas disease knows that
36:42this is Chagas disease. Right?
36:44So he's got a right
36:45bundle branch block. I don't
36:46know if there's any EPs
36:48in the audience who wanna
36:49weigh on whether or not
36:51this is the left anterior
36:52fascicular block or whether or
36:53not we just call it
36:55a bizarre axis, but it's
36:56clearly a very, very pathological
36:58EKG that is very suggestive
36:59of Chagas disease. So let's
37:01talk a little bit about
37:02the EKG with Chagas disease,
37:04just to sort of make
37:04sure that everybody's on the
37:05same we have a level
37:06playing field here. We know
37:07that Chagas disease does like
37:08to attack the conduction system,
37:10and this is a meta
37:11analysis of about forty nine
37:12studies with thirty two thousand
37:14patients in it. And these
37:15are the EKG findings that
37:16sort of jumped out as
37:17being highly associated with Chagas.
37:19I do like to show
37:20this, but then I always
37:21have to say, just because
37:22your EKG abnormality isn't on
37:24this list does not mean
37:24that the patient doesn't have
37:25Chagas cardiomyopathy.
37:26There's some other notable things
37:28that aren't on this list
37:29that just weren't as highly
37:30associated.
37:31And I do also wanna
37:32say that indeterminate Chagas disease
37:34really means that you have
37:34a normal EKG.
37:36And so things that aren't
37:37normal, you probably need to
37:38think about them even if
37:39we're not even if they're
37:40not on this list.
37:41Moving along, though, this is
37:42a different way of cutting
37:43into the same problem. These
37:44are two datasets from places
37:46that looked at folks who
37:47actually had heart failure. The
37:48top is from Brazil. The
37:49bottom is from the Paradigm
37:50atmosphere heart failure dataset. And
37:52what you see is a
37:53bizarre,
37:54predilection of the folks with
37:56Chagas to have right bundle
37:57branch block or bifascicular block.
37:58So fifty percent of those
37:59Chagas patients had bifascicular block.
38:01So that means to me,
38:02Spanish speaker, bad heart, bifascicular
38:05block, my pretest probability for
38:07Chagas disease is is just
38:08through the roof. And interestingly,
38:10the other non ischemic, right
38:11bundle branch block is just
38:12not that common except for
38:14sarcoids. So just keep that
38:15in your mind.
38:16The but is what is
38:17also true is that as
38:18we were saying,
38:20the Chagas disease patients can't
38:21present with left bundle. So
38:22just because you don't have
38:23a right bundle if you
38:24do have a left bundle,
38:25it doesn't mean it's not
38:26Chagas disease. Same basic pattern
38:27here in this lower slide,
38:29with slightly different numbers. Okay.
38:31So this was his chest
38:32X-ray.
38:33I you know, I it's
38:34been so long since I
38:35thought about chest X rays.
38:36I'm always trying to figure
38:37out which are the anterior
38:38ribs, which are the posterior
38:39ribs. Is it a good
38:40inflation? I think we can
38:41all agree that this patient
38:42has a dilated heart,
38:44and that will become relevant
38:45in a moment.
38:46And this is his echo.
38:47And here's grumpy echo lab
38:49lady again. This was just
38:51it was bad. We did
38:52a bad job with these
38:53echoes, and I will show
38:54you why. I'm really embarrassed
38:55that doctor McNamara is here,
38:56and I'm showing him these
38:57terrible echoes that we did.
38:59If I can get them
39:00to play, which would be
39:02very important.
39:03Let's see.
39:04Okay. Here's the first one.
39:06So, you know, it's a
39:07parasternal long axis view. I
39:08will tell you that now
39:09that I am I'm,
39:11grumpy shot, echo lab lady
39:13with my with my hammer
39:14and my nail, I'm always
39:15looking at the basal inferolateral
39:16wall, and I didn't feel
39:17so good about the basal
39:18inferolateral wall mostly that we
39:20didn't see it. Here's the
39:21next image. This is just
39:22a terrible foreshortened apical four
39:24chamber view. I didn't it's
39:25been our right right? It's
39:26terrible. It's such a bad
39:27echo. And then here, we're,
39:29like, following the strongest guidelines.
39:31Right? We're supposed to be
39:31using three d. Well, you
39:32can't take a bad two
39:33d image and get a
39:34good three d image out
39:35of it. Right? It just
39:36it won't work. And forget
39:37about strain. Like, it would
39:39be wonderful to do strain,
39:40but not on these images.
39:41Okay. So at this point,
39:43very interestingly, I had given
39:45an in service to the
39:46neurology service. So I got
39:47a call from the neurology
39:48PA who said to me,
39:49we have a patient who
39:50has a stroke, and he's
39:51from El Salvador. Do you
39:52think he could have Chagas
39:53disease?
39:54Good for you. So I
39:56call I call the lab,
39:57and I'm like,
39:58I don't think we really
39:59clarified what was going on
40:00with the apex. Would you
40:01mind bringing the patient back
40:02down for contrast, which we
40:04have. Right?
40:05So and they should have
40:06given him anyway. Chagas
40:08Chagas or no. This patient
40:09definitely needed contrast. So here
40:10are the contrast images, and
40:12I'm even still embarrassed about
40:13these. So but I think
40:15what you can see is
40:16that the Apex doesn't look
40:17a hundred percent normal. It
40:18wasn't a beautiful contrast injection.
40:20This is probably a little
40:21bit of a trabeculation there.
40:22And then they went off
40:23faxes.
40:25And from one beat to
40:26the next, the guy breathes
40:27in, breathes out. But you're
40:29I'm still not feeling great
40:30about the ep Apex. I
40:31am feeling a little bit
40:32less good about his LV
40:33function.
40:34So
40:35the guy the the the
40:37director of the echo lab,
40:38who knows so much echo,
40:39it's ridiculous, writes in his
40:41note, there is an echo
40:43density at the apex, which
40:44we think might be trabeculation
40:46because, overall, his dejection fraction
40:47is so good. It would
40:48seem very unlikely that he
40:49would have a thrombus at
40:50his apex.
40:51At which point, I felt
40:52like clearly I must be
40:53doing a terrible job because
40:55this patient so obviously in
40:57my mind had Chagas disease,
40:58and, of course, they could
40:59have an apical thrombus.
41:01So at that point, I
41:02said, I'm giving up. The
41:03patient needs an MRI, which
41:05is what we did next.
41:06So I wanna illustrate this
41:08point again, though, because I
41:09can't all of you who
41:10are going out into the
41:11world and doing echoes, this
41:12is another patient that we
41:14identified through the prenatal testing
41:15program who had a lot
41:16of PVCs on on her
41:18baseline ECG.
41:20And this is her her
41:21apical two chamber view where
41:22I think we can agree
41:23we don't see the apex
41:24well, but we don't see
41:26a very, very focal area
41:27of her apex.
41:28So we brought her back
41:29in for contrast, and this
41:31is what she has. So
41:32contrast,
41:33game changer. Right? Like, we're
41:35able to see that apex
41:36beautifully. We'd be able to
41:37see whether or not this
41:38patient had apical thrombus,
41:40also a game changer in
41:41terms of management.
41:42So if there's, like, really
41:43one point, if you forget
41:45everything else that I say,
41:46we should be giving contrast
41:48to our patients with Chagas
41:49disease where we're thinking about
41:50Chagas disease. We should we
41:52know a with a hypertrophic
41:53cardiomyopathy, we have to worry
41:55about those apical aneurysms that
41:56we're not gonna see if
41:57we don't give contrast
41:58or if our sonographers don't
42:00do a scrupulous job of
42:01off axis imaging for the
42:02apex. Chagas disease is exactly
42:04the same way.
42:06Okay. So what can echo
42:07tell us? Well, Mina has
42:09already done a fantastic job
42:10of explaining that, but I'll
42:11review it again. The first
42:12thing that echo does is
42:14it really you know, it
42:14allows us to assess ventricular
42:16function, and that will actually
42:17allow us to stage the
42:18patient. So we do have
42:19this staging form,
42:20indeterminate form. A is positive
42:22serology, normally, KG, no structural
42:24heart disease.
42:25B one, as defined by
42:27the Brazilian,
42:28guidelines, is an EF of
42:30of over fifty five percent,
42:31but structural cardiomyopathy,
42:33meaning basically normal LV function
42:35but an abnormal EKG or
42:36an abnormal subtle abnormal echo
42:38findings. B two is LV
42:39dysfunction with no heart failure.
42:41C is LV dysfunction and
42:42heart failure. And d is
42:43bad, you know, your your
42:45your, advanced heart failure therapy,
42:47people. So that's really important
42:49because we do know that
42:50when we look at mortality
42:51and Chagas disease that it
42:52is really very highly tied
42:54to ejection
42:55correction. But we also know
42:56that that can't tell us
42:58everything. Right? Like, we're missing
42:59something here because this is
43:00a guy. He didn't die
43:02from Chagas disease, but he
43:03had a big stroke from
43:05Chagas disease, and that has
43:06to matter. So our staging
43:08system has let us down
43:09a little bit because
43:10is he really b one?
43:12B one sounds kinda mild,
43:13but he can't be b
43:14one because he just had
43:15this huge stroke. So somehow,
43:17EF can't be
43:19the be all and end
43:20all. And you see that
43:21actually here in the ejection
43:22fraction part where you see
43:24that, oh, that EF is
43:26really closely tied to overall
43:28mortality, really tied to cardiovascular
43:30mortality, really tied to heart
43:31failure. But when you get
43:32to sudden death and stroke,
43:34not so much anymore.
43:35So we have to think
43:36beyond EF even if it
43:38is in and and and
43:40functional class really important in
43:41terms of determining risk.
43:43So the other thing is
43:44we really wanna focus on
43:45this indeterminate form a. What
43:47do we know about echoes
43:48in patients who are indeterminate
43:49phase that might help us
43:50figure out whether or not
43:51they're gonna progress?
43:53And we do know that
43:54there are a lot of
43:55tools in our toolbox to
43:56look at this. There's diastology.
43:58There's left atrial size. It
43:59could left atrial reservoir strain,
44:01RV size and function,
44:03global longitudinal strain, which as
44:05I've just pointed out to
44:06you, like, for me, sometimes
44:07that's aspirational. The echo images
44:09just have to be good
44:10to be able to get
44:11good strain. This is an
44:12echo I did myself, then
44:13I was very proud of
44:14my ability to get good
44:15strain images. But I noticed
44:17that I had this very
44:18significant problem here in the
44:19poster posterior wall, basal infoposterior,
44:22which is where we know
44:23that the strongest problems start.
44:25But I redid it three
44:26times because I was not
44:27gonna let bad data have
44:28me actually end up giving
44:30ascribing to this patient a
44:31problem with their inferior posterior
44:32wall. So on the basis
44:34of this, I wanted this
44:35patient to get an MRI.
44:36And, unfortunately, bringing it back
44:37to the world of Shagas
44:38in the United States,
44:39after his first visit with
44:41me, he had an ankle
44:42monitor put on by ice,
44:43and he cannot go into
44:44the into the magnet. So
44:45these are some of the
44:46barriers to care that we
44:47face, in the United States.
44:49In any event, we also
44:50know that mechanical dispersion can
44:52be helpful in terms of
44:53risk of arrhythmia, associated valvular
44:55disease, and PA pressure, which
44:56is, of course, it's bad.
44:57Elevated PA pressure is bad
44:58no matter what your cardiomyopathy
45:00is. Okay. So what are
45:02our additional tools in our
45:04Shagas toolkit to try and
45:05help us to figure out
45:06what's going on with these
45:07patients and what we need
45:08to worry about with them?
45:09Well, we've we've talked a
45:10lot about RASI score, and
45:11that's really important because if
45:12you go to up to
45:13date, the Chagas cardiomyopathy
45:14section, it's RASI score figures
45:17prominently. And if you go
45:18to the American Heart Association,
45:20Chagas,
45:21recommendations,
45:22it is recommended that everybody
45:24get a Rossi score. And
45:25it is really important because
45:26it does tell us who
45:27is going to die. But
45:29like we've been talking about,
45:30maybe that's not sufficient. Maybe
45:32we need to worry about
45:33other things for these patients.
45:35So for our patient, he
45:36had cardiomegaly. That's why I
45:37put that chest X-ray up.
45:38Although, from my mind, we
45:40see that on the echo,
45:41and everybody should have an
45:42echo. So we could do
45:43the echo and save the
45:44X-ray.
45:45He has wall motion abnormalities.
45:46He's male, and he had
45:47low voltage on his EKG.
45:49And that gives him eight
45:50points, which is moderate risk.
45:52And as we said, moderate
45:53risk for what? It's moderate
45:54risk for death. We'd what
45:56about stroke? What about,
45:58VT?
45:58And as Minna pointed out
46:00earlier in her in her
46:01talk, we haven't yet seen
46:02what his rhythm monitoring has
46:04shown, but nothing has come
46:05up yet. So how else
46:06could we look at him?
46:07Well, there's also the benefit
46:08echo substudy, which was a
46:10really clever way, I think,
46:11of looking at this and
46:12really a hat tip to
46:13how important scar is in
46:14these patients. So looking at
46:16wall motion score index indices,
46:19they stratified
46:20the patients who were in
46:20the benefit trial into three
46:22groups, a wall motion score
46:23index less than one, one
46:25to one point five, and
46:26above one point five. And
46:27you can see that it
46:27does a really nice job
46:28of telling you who's gonna
46:29die, and it also does
46:31a really nice job of
46:32telling you who's gonna get
46:33VT.
46:34So the higher the score
46:36the the more scar, the
46:37more likely you are to
46:38have VT. Not a surprise.
46:39So our patient has a
46:40wall motion score index of
46:41one point four. That puts
46:43him at the cusp between
46:44the three point one percent
46:45VT at five years follow-up
46:47and seven percent VT at
46:48five years follow-up. That's an
46:49awful lot of VT, and
46:50we'll keep that in mind
46:51for later in the presentation.
46:53And finally, what about his
46:54risk of of thromboembolic event?
46:56So this is a really
46:57tricky one because this is
46:58the only tool that we
46:59have, and it actually got
47:00taken out of the Brazilian
47:02guidelines.
47:03So now what do we
47:04do? I think a lot
47:06of us, you know, the
47:06people that I talk to
47:07who who do more Shagas
47:09work than I do still
47:10rely on this in a
47:11way because we don't really
47:12have any other way to
47:13risk stratify people for stroke.
47:14And we're trying to think
47:15about who needs primary prevention
47:18because, of course, if somebody
47:19has secondary prevention, you know
47:20you're gonna be anticoagulating. But
47:21who needs primary prevention? Is
47:23it that young woman who
47:24who has normal LV function
47:25and just has an apical
47:26aneurysm?
47:27So we know that systolic
47:29dysfunction matters. And try as
47:31I might, I can't find
47:32an EF cutoff for what
47:33systolic dysfunction means for this
47:34particular trial. Minna, if you
47:36happen to know, please share
47:37because I can't find it.
47:39Apical aneurysm,
47:41primary,
47:42AV repolarization
47:43abnormalities. I also can't find
47:45a definition for that in
47:46age greater than forty eight.
47:47So I use this. I
47:48use this, and then we
47:49go into the realm of
47:50shared decision making, which is
47:52complicated because I'm trying to
47:53share decision making with you,
47:54and you can see how
47:55complicated a disease is. Try
47:57that with somebody
47:58who, is trying to talk
47:59to you through an interpreter
48:01and has low health care
48:01literacy. It's really, really complicated.
48:04But I have last case
48:05bias, and I remember my
48:06patients who have had horrible
48:07catastrophic strokes. And so I'm
48:09likely to put my thumb
48:10a little bit on the
48:11scale in terms of anticoagulation
48:12of of of apical aneurysms.
48:14But we don't know, and
48:15this is a huge, huge
48:16barrier to to effective care
48:18for these folks. Okay. And
48:19our patient had a four
48:21to five point, which is
48:22a greater than four percent
48:23risk. And that matters because
48:25in this study, they also
48:26took a group of people
48:27and they put them on
48:27anticoagulation.
48:28They saw what their bleeding
48:29rate was. And with a
48:30point score of four or
48:31five,
48:32the the risk benefit from
48:34from the anticoagulation
48:36seemed to significantly enough exceed
48:38the the bleeding risk that
48:39that was the recommendation was
48:41to think about anticoagulation in
48:42the population. Okay.
48:44So
48:44he did get the MRI.
48:45We're gonna go back to
48:46the patient. And I put
48:47two asterisks there to explain
48:48why,
48:50two things. It used to
48:51be back in the day
48:52where you'd only get one
48:53Shagas test, right off the
48:54bat, and then you'd have
48:55to get commercial you'd have
48:57to get CDC confirmatory testing,
48:58which would take a couple
48:59of weeks to come back.
49:00At which point, your patient
49:01has been discharged from the
49:02hospital, and you may or
49:03may not ever see them
49:04again. So I will tell
49:05you that I would frequently
49:06ask for MRIs before the
49:08patient had been confirmed because
49:09I wanted that information. I
49:10wanted to know about what
49:12their heart was like so
49:13that I could counsel them
49:13appropriately before they left. The
49:15second thing is,
49:18is
49:19that
49:20I don't actually remember what
49:21the second thing is, so
49:22we'll move along. In any
49:23event, what it showed was
49:24regional thinning and transmural LGE
49:26of that apical aneurysm with
49:28subepipicardial
49:29LGE extending to adjacent regions
49:31of the apical septum and
49:32RB apex. The majority of
49:33LV has near transmural LGE
49:35with scattered sparing of the
49:37endocardium, patchy foci in the
49:38basal septum. So really
49:40tons of scar everywhere.
49:42And I think you can
49:43see here, if I can
49:44get this to play.
49:48Maybe I can't.
49:51You can see that aneurysm
49:53out of the apex,
49:54which I do not think
49:55we saw in all its
49:56glory no matter how many
49:57times we did echo imaging
49:58and no matter how no
50:00matter how much contrast we
50:01gave. So sometimes MRI is
50:02just the way that you
50:03have to go. Okay. So
50:04what did we learn from
50:05this? His EF was forty
50:06one percent, worse, I think,
50:07than what had been stated
50:08on the echo, which was
50:09fifty. And he has tons
50:11of scar. Twenty one point
50:13five percent of his LV
50:14is scar, twenty nine point
50:15eight grams of scar. Why
50:16do I mention that? Let's
50:18talk a little bit about,
50:21I can get to the
50:21what can MRI tell us
50:23about folks with Chagas disease?
50:24So this is from a
50:24meta analysis. There are lovely
50:26studies that have looked at
50:27m r MRI and Chagas.
50:29We know that people in
50:30the indeterminate phase will actually
50:32have gadolinium uptake probably, in
50:34the meta analysis about twenty,
50:35twenty five percent.
50:37What what does it mean?
50:38I don't know. I don't
50:39like it. We shouldn't have
50:40gadolinium in your heart.
50:42The extent in the indeterminate
50:44phase has been looked at.
50:45Myocardial fibrosis in VT, we
50:47know they are strongly correlated.
50:48The amount of myocardial fibrosis
50:50in VT is also strongly
50:51correlated. Myocardial fibrosis is strongly
50:53associated with mortality
50:55and MACE.
50:56And this is from a
50:57very recently published study looking
50:58at a cohort of, I
50:59think, about a hundred and
51:00twenty, hundred and fifty patients
51:02in Colombia,
51:03looking at the patterns of
51:04abnormalities on MRI and what
51:06you see is what we
51:06would expect, which is it's
51:07the apex and the basal
51:09inferolateral wall.
51:11In terms of trying to
51:11help figure out how to
51:13restratify our patient,
51:15these are some of the
51:15markers that have come up
51:16as being portending really bad
51:18outcomes, some of which is
51:19death, but some of which
51:20is also ventricular arrhythmia. Greater
51:22than twelve point three grams
51:23of scar, two consecutive transmural
51:25segments, greater than six involved
51:26segments.
51:27Percent of scar is a
51:28little tricky. I haven't actually
51:29seen a published one for
51:30Shagas disease, but we all
51:31know that that works on
51:32hypertrophic cardiomyopathy.
51:34Our patient has yes basically
51:36to all of them. So
51:37this is somebody that we
51:38think has a high likelihood
51:39of having an arrhythmic complication
51:40of Chagas disease.
51:42Okay. Moving on. His subsequent
51:44course, he was discharged from
51:45the hospital on warfarin and
51:46atorvastatin
51:47with probable Chagas cardiomyopathy.
51:49So So they wouldn't even
51:50go so far as to
51:51say he had Chagas cardiomyopathy.
51:52It was probable Chagas cardiomyopathy.
51:54And I see that a
51:54lot. People are very reluctant
51:56to actually finally say the
51:57patient has Chagas disease.
51:58He then and he gets
51:59a a BIOTRONIC ILR because
52:01they're not satisfied that we've
52:02identified the source of embolus.
52:04They still wanna make sure
52:04that he doesn't have atrial
52:05fibrillation.
52:06Fine. I mean, he may
52:07have atrial fibrillation, but folks
52:09with Chagas disease do, but
52:10I feel like we've kind
52:11of asked and answered that
52:12question.
52:13He's then unfortunately lost a
52:14follow-up for three years, which
52:15is also not uncommon.
52:17This he doesn't have insurance.
52:19I try to call the
52:20place where he goes for
52:21follow-up, which is not in
52:22our hospital system. I call
52:23and I call and I
52:24call. Nobody answers me because
52:26they don't wanna hear what
52:26I have to say or
52:27for whatever reason. And then
52:28finally, he gets a new
52:29insurance platform and can come
52:31back to the hospital, and
52:31they look at what they
52:32find on his ILR, and
52:33he's having five second pauses
52:35at night, profound bradyarrhythmia, and
52:36some non sustained BT. At
52:38which point, we all agree
52:39he should get a primary
52:40prevention defibrillator because we have
52:43access to that in the
52:44United States.
52:46He then no shows three
52:47quarters of his next visits
52:49because he doesn't wanna miss
52:50work.
52:51Again, an issue that we
52:52face in the United States,
52:54including
52:55the day that he's supposed
52:56to get his EP procedure
52:57for his pacemaker.
52:59So what should we be
53:00doing with this patient? This
53:01is the idealized patient pathway.
53:03So we're gonna skip down
53:04to the bottom where we
53:05get to tertiary care center
53:07just because,
53:08they're they're I think we
53:09have to, just for the
53:10sake of time, move along.
53:11And the first thing is
53:12to be evaluated by a
53:13physician familiar with Chagas disease.
53:16So
53:17it's a real problem that
53:18we have. Right? Look, we
53:19don't have a lot of
53:19physicians in the United States
53:21who are familiar with Chagas
53:22disease, and that's why I
53:23spend all this time talking
53:24to people. But people, sometimes,
53:26they're busy or they don't,
53:27you know, they don't remember
53:28that there are things that
53:29they might not know about
53:30this disease process or they
53:31lump it into other other
53:32cardiomyopathies.
53:34And so the patient then
53:35doesn't quite get the care
53:36that they need.
53:38Then we need to assist
53:39their we're gonna assess their
53:40risk for arrhythmia and indication
53:41for amiodarone, but you have
53:43to have some background in
53:43Chagas to actually be able
53:45to apply that well and
53:46then put people on GDMT.
53:48So
53:49the first question that I
53:50get though if somebody calls
53:52me about it, which happens
53:53quite a bit, is should
53:54I give antiparasitic therapy to
53:55my patient with Chagas cardiomyopathy?
53:57No. That's the question that
53:58they ask. They don't ask
53:59any follow-up questions about how
54:01do I risk stratify them
54:02for arrhythmia, how do I
54:03risk stratify them for stroke,
54:05what to do with their
54:06family. They don't ask the
54:07questions that I wish they
54:08were asking. I mean, this
54:09is a good question to
54:09ask, and we actually seem
54:11to have an answer to
54:12it, which is from a
54:12randomized trial of vincidazole versus
54:14placebo published in the New
54:15England Journal in twenty fifteen.
54:17The mean age of patients
54:18in this trial was fifty
54:20five, which is a little
54:21older than some of the
54:22young people that we see
54:23with Chagas disease, and we
54:24have to keep that in
54:25mind. But at five and
54:26seven years of follow-up, there
54:27was no benefit in terms
54:28of hard cardiac endpoints, for
54:30patients,
54:31who had CHAGUS receiving benzodiazepine
54:33versus placebo.
54:34It's important to note that
54:35most of the patients in
54:36the trial were class one
54:38or class two in terms
54:39of the heart failure scale,
54:40and they tended to have
54:41basically preserved LV function. So
54:43this was not, as is
54:44published widely in the literature,
54:45a a trial of advanced
54:47heart failure. This was a
54:48a trial of people who
54:49had kind of early to
54:51early to maybe early mid
54:53chagas cardiomyopathy.
54:55And they did a subgroups
54:56analysis and didn't really find
54:57any subgroups that would benefit
54:58with the exception of the
54:59folks who were taking amiodarone,
55:01who seem to benefit more.
55:02And then there may be
55:03a trend towards treatment benefit
55:04in Brazil, which is why
55:05I think the Brazil Brazilian
55:07cardiologist seem to be more
55:08bullish about, antiparasitic treatment. Where
55:11do I stand if I
55:11have a patient who has
55:12mild cardiomyopathy
55:14who I think is two
55:14standard deviations below the mean
55:16in terms of age, I
55:17will offer them treatment
55:18with shared decision making, because
55:20I we don't really know
55:21is is my answer. Okay.
55:23Otherwise, we're gonna be looking
55:24at guideline directed medical therapy.
55:27Until very, very recently, there
55:29were very if if there
55:30were randomized trials, they were
55:32tiny in Chagas disease. So
55:34we really did not have
55:34robust evidence.
55:36So we were basically applying
55:38GDMT
55:38based on what we do
55:40for other cardiomyopathies.
55:42In the past year, we
55:43actually have some studies that
55:45were done specifically in Chagas
55:46patients.
55:47The first was I I
55:48I don't know why they
55:49put the timeline this way.
55:50I think that Parachute actually
55:51came out before ANSWER, but
55:53both of these studies looked
55:54at secubitrol valsartan in in
55:56folks with fairly significant Chagas
55:58cardiomyopathy. And answer heart failure
56:00was an EF of thirty.
56:01Average in Parachute, it was
56:03an EF of about thirty
56:04two. Answer, you can see
56:05it's much smaller with one
56:06hundred and ninety patients. Parachute
56:08four sixty to four sixty.
56:09And they were randomized to
56:11succubitril, a valsartan versus enalapril,
56:13it was ten milligrams.
56:14And what ANSWER was looking
56:16at was change in EF
56:17and BNP,
56:18and what parachute was looking
56:20at was a sort of
56:21a a MACE mortality
56:23endpoint,
56:24and then also at BNP.
56:26And what both of them
56:27found was that succubital vosartan
56:29does a very good job
56:29in reducing BNP relative to
56:31enalapril ten, but that there
56:33was no otherwise clinically significant
56:36meaningful endpoint there.
56:38But what it does show
56:39us is that we can
56:40do these studies
56:41in the world where where
56:43where a lot of folks
56:44with chagas live. And we
56:45can see that it it
56:46reduces BNP, you know, and
56:48whether or not it it
56:49has the same impact as
56:50enalapril mortality, that wasn't something
56:52that we were really able
56:53to test,
56:54but that we should be
56:55giving these patients, GDMT.
56:57So those are two exciting
56:59new additions to the the
57:00pantheon.
57:02And so then I wanted
57:03to switch, switch gears to
57:04the rhythm monitoring, which I
57:05think was really important in
57:07this patient. And I would
57:07say that, basically, anyone who's
57:09an abnormal EKG, anyone who
57:10has symptoms should be getting,
57:12should be getting rhythm monitoring.
57:14This patient definitely needed. It
57:16also really tipped us over
57:17in terms of his Rossi
57:18score, but it also tipped
57:19us over in terms of
57:20his risk for, for lethal
57:22arrhythmia.
57:23We know that non sustained
57:23VT is a poor prognostic
57:25sign.
57:26And then just to talk
57:27in the abstract about who
57:28needs a defibrillator, and this
57:29is really, I think, a
57:30tricky question to answer. You
57:32know, we we we tend
57:33we're here, so we're so
57:34focused on EF.
57:35And what we know is
57:37that these folks, because of
57:38their scarifying cardiomyopathy,
57:40because they're very much like
57:41sarcoid, they are more likely
57:42to have sudden cardiac death
57:43at EFs that we wouldn't
57:44worry about in most of
57:45the patients who come into
57:46our office. So that's where
57:48the chaga specialist comes in,
57:49and it's not we heard
57:50earlier today from an from
57:52a from an, electrophysiologist
57:54who said it's not in
57:54the guidelines.
57:56But if somebody comes in
57:57and they have non sustained
57:58VT and they have scar
58:00and their EF is a
58:01little bit low, we should
58:02probably give that patient, a
58:03defibrillator.
58:04If your EP doesn't wanna
58:05do that, maybe you get
58:06them to do programmed electrical
58:08stimulation, see if you can
58:09induce VT. They are very
58:10inducible,
58:11but I really worry about
58:12these folks. So what kinds
58:14of things could we look
58:15at to try and help
58:16guide our decision making? So
58:17we know that Chagas patients
58:18are at risk for VTs
58:19at higher EFs. That's why
58:20the ESC guidelines include a
58:22two way indication for, primary
58:24prevention of an EF less
58:25than forty.
58:27And we know we've already
58:28really talked about all of
58:29these things here, so I
58:30won't belabor them. We also
58:31have a study that came
58:32out fairly recently called the
58:34Chagosik trial, which tried to
58:35answer this question. Unfortunately, this
58:37the one big problem with
58:39this trial was that it
58:41happened during COVID and enrollment
58:42was really poor. So they
58:43were hoping to get nine
58:44hundred patients. They ended up
58:45only getting three hundred. That
58:47is a huge
58:48difference in power. I'm not
58:49a statistician,
58:50but that right away makes
58:52me very concerned that we
58:53can't really rely on these
58:54study results.
58:55The other thing that I
58:56think is really important is
58:57these folks were pretty sick.
58:58They had EFs of, average
58:59of about thirty seven percent.
59:01What they did was they
59:02randomized folks to amiodarone versus
59:04defibrillator, and what they found
59:05is at the end of
59:06six years of follow-up, there
59:07was no benefit in terms
59:08of mortality in the patients
59:10who got the defibrillators.
59:11Well, there's a couple of
59:12things that I think are
59:13kind of interesting about this
59:14even though I just told
59:14you we shouldn't pay much
59:15attention to this trial because
59:16it was underpowered.
59:17One is that if you
59:18stop the trial at three
59:19years, I put a little
59:20black line there, you can
59:21see those curves look like
59:22they're pretty far apart. Nobody
59:23did this analysis,
59:25just me with the line
59:26that I drew on there.
59:27But the fact is, I
59:28think we have a very
59:29sick group of patients in
59:30this trial, and they're gonna
59:32die from pump failure. So
59:33you can put a defibrillator
59:34in, and they might do
59:35better for a little while.
59:36But then that pump failure
59:37is gonna catch up with
59:38them, and they're gonna die.
59:39What if we'd done this
59:40in a trial where the
59:41average EF was forty five
59:43and not thirty
59:44five?
59:45And then the other thing
59:47so and and then the
59:48the final thing is that
59:49I should say because Carlos
59:50Maria told me to say
59:51this is that defibrillator did
59:53what it was supposed to
59:54do. It reduced sudden death
59:56magnificently. And what it also
59:57did was it reduced hospitalizations
59:59probably because people who are
01:00:00getting shocked
01:00:01over and over again,
01:00:03or people who are having
01:00:04a lot of VTs, particularly
01:00:06a lot of VTs and
01:00:07not getting shocked, are gonna
01:00:08end up in the hospital
01:00:09with heart failure if they
01:00:09live to tell tell the
01:00:10tale. So
01:00:11I'm not sure what to
01:00:13make of this trial. I
01:00:14think that as the trial
01:00:15is sad, further studies are
01:00:17warranted to confirm the evidence
01:00:18generated by this trial. Why
01:00:19do I bring it up?
01:00:20Because people bring it up
01:00:21with me. Somebody says, oh,
01:00:22defibrillators don't work in Chagas
01:00:24disease.
01:00:24Please don't let this trial
01:00:26be the answer to the
01:00:27question. I I don't think
01:00:28it deserves that.
01:00:29Okay. So as if on
01:00:31cue, our patient presents five
01:00:32years later without his defibrillator
01:00:34because he's not gone to
01:00:36his follow-up meetings
01:00:37with this.
01:00:38And this is
01:00:40ventricular tachycardia, which I think
01:00:42we also learned earlier today
01:00:43from doctor, Abendano,
01:00:45is coming from the inferolateral
01:00:47wall and is likely epicardial.
01:00:49It matches every single criteria
01:00:50that he has. So
01:00:52no surprise. We knew this
01:00:53was gonna happen from benefit.
01:00:55We knew this was gonna
01:00:56happen from his from his,
01:00:57from his loop tracing. Okay.
01:00:59And here's his repeat echo.
01:01:02You can see now that
01:01:03rather than having a very
01:01:04mild basal inferolateral
01:01:07problem, he now has a
01:01:07basal inferolateral aneurysm.
01:01:10And because he was lost
01:01:11to follow-up and stopped taking
01:01:12his anticoagulation,
01:01:13we now see beautifully the
01:01:15apical thrombus that he has.
01:01:18Okay.
01:01:19I did wanna shout out
01:01:20actually to other alternate imaging,
01:01:21not even MRI. This is
01:01:23actually a CT abdomen that
01:01:24he had during the same
01:01:25hospital stay because he presented
01:01:27with abdominal pain. And what
01:01:29you can see
01:01:32is that if you look
01:01:33carefully,
01:01:34the thrombus is there.
01:01:36And this is another really
01:01:37great, I think, example of
01:01:39that, another patient where I
01:01:40felt like we hadn't seen
01:01:41the apex very well. And
01:01:42this is a patient who
01:01:43also had a CT of
01:01:44the abdomen and pelvis. It
01:01:45turns out it beautifully images
01:01:46the bottom of the heart,
01:01:47and you can see an
01:01:48apical aneurysm that we hadn't
01:01:49seen and a beautiful thrombus
01:01:51there. So remember, go into
01:01:52the chart. You can find
01:01:53alternate cardiac imaging that can
01:01:54be helpful.
01:01:55I need to move along.
01:01:56So he gets worse. He
01:01:57gets a Saint Jude by
01:01:58VICD place, start on amiodarone,
01:02:00GDMT. He starts getting shocked.
01:02:02They add myxiletine.
01:02:03He gets more shocks. And
01:02:04then in spite of his
01:02:05suspected epicardial VT, they write
01:02:08it in the chart, he
01:02:09gets an endocardial ablation,
01:02:10which, no surprise, does not
01:02:12work because what he needed
01:02:14was an epicardial endocardial procedure.
01:02:16So this is where, like,
01:02:18phone your friend, the Chagas
01:02:19the the cardiologist is familiar
01:02:21with Chagas disease because they
01:02:22would have said to this
01:02:23EP, please don't do this
01:02:25procedure. Send this patient to
01:02:26somebody who can do epicardial
01:02:28and endocardial procedures
01:02:29and get this guy up
01:02:30under control with his VTs.
01:02:32So we should talk really
01:02:33briefly about refractory VTs.
01:02:36Basically, it's really common in
01:02:38this disease. People get lots
01:02:39of shocks. They have more
01:02:40scar because of it. There
01:02:42are some things we can
01:02:43do aside from epicardial procedures.
01:02:44We can also do sympathetic
01:02:46ganglionectomy and renal denervation. And
01:02:48this on the this, really
01:02:49graphic right here shows the
01:02:51algorithm of what you should
01:02:52do with somebody who has
01:02:53VT recurrent VTs and VT
01:02:55storm from Chagas. Why does
01:02:57it matter? We've seen people
01:02:58get transplanted because of VT
01:02:59who did not go through
01:03:00this algorithm.
01:03:02You might not be able
01:03:02to stave off transplant. Heart
01:03:04pump failure is in their
01:03:05future, but the fact is
01:03:06maybe you can push it
01:03:07down the line a little
01:03:08bit, and why wouldn't you
01:03:09wanna do that? So we
01:03:10have these tools in our
01:03:11toolkit.
01:03:12Prognosis is bad. I think
01:03:13I'm running out of time.
01:03:14This is a patient who
01:03:15got his LVAD on the
01:03:16same day that he got
01:03:17his,
01:03:19the same day he got
01:03:19his, diagnosis of Chagas disease.
01:03:22We know that you can
01:03:23transplant. Transplant is great. People
01:03:25reactivate. That's a problem. But
01:03:27in the United States, we
01:03:28do surveillance for it, and
01:03:29we find it, and we
01:03:29treat it, and people do
01:03:30well. The real problem is
01:03:32accessibility.
01:03:33Most of my patients would
01:03:34not be eligible because of
01:03:35the nature of their status
01:03:37in the United States. So
01:03:38it's not a tool in
01:03:39our toolkit for most people.
01:03:41Why do we care? We
01:03:41have Chagas disease all over
01:03:43the United States. This is
01:03:44a map of prevalence,
01:03:46in Latin,
01:03:47American born immigrants
01:03:48across the US. The blue
01:03:50hearts are places in the
01:03:51United States that are doing
01:03:52Chagas disease work on a
01:03:53clinical basis, so I wanted
01:03:54to make sure to give
01:03:55them a shout out. We've
01:03:56got a big huge heart
01:03:57in Texas because there's so
01:03:58many people there thinking about
01:03:59it.
01:04:00We have some prevalence studies.
01:04:01The top one here, is
01:04:03the study we were involved
01:04:04with. We have a four
01:04:04percent seroprevalence rate in the
01:04:05Washington DC metropolitan area. It's
01:04:10prevalence,
01:04:11highest risk, immigrant community in
01:04:13the United States.
01:04:14But, otherwise, we estimate that
01:04:16there's probably about a one
01:04:17to one point five percent
01:04:18risk in Latin American born
01:04:19immigrants in the US. So
01:04:20anywhere they're living, they should
01:04:21be tested.
01:04:22And we know that if
01:04:23you go into the cardiology
01:04:24clinics, you're gonna find even
01:04:25more Chagas disease. And I'll
01:04:26point really to the bottom
01:04:27study that we did at
01:04:28MedStar Washington Hospital Center where,
01:04:31I was in the ECHO
01:04:32lab. I looked at people
01:04:33that ECHO's ordered for things
01:04:34that might smell a little
01:04:35bit like chagas cardiomyopathy.
01:04:37So
01:04:38chest pain, palpitations,
01:04:40VT, AFib, stroke, heart failure.
01:04:43And of the ninety seven
01:04:44people that we we tested
01:04:45and included, sixteen percent of
01:04:47them had chagas. And if
01:04:48they had EFs less than
01:04:49fifty, it was twenty five
01:04:50percent of them who have
01:04:51gone on to transplant and
01:04:52to die, unfortunately.
01:04:54I'm not gonna talk about
01:04:55autochthonous cases. Those are my
01:04:57dogs who don't have Chagas.
01:04:58I will finish with barriers
01:04:59to care, though. This is
01:05:00incredibly important.
01:05:02So this is from one
01:05:03of the most beautiful screening
01:05:04programs in the country. It's
01:05:06at East Boston Health Center.
01:05:07They see a lot of
01:05:09of Central American immigrants, and
01:05:10they do a beautiful job.
01:05:11They have embedded Chagas disease
01:05:13testing into primary care, which
01:05:15is the way it should
01:05:15be done. And even there,
01:05:17where they understand this disease
01:05:19and everyone has insurance because
01:05:21it's Massachusetts and there's universal
01:05:23health care,
01:05:24when you look at a
01:05:25hundred idealized patients, these are
01:05:27the lost of follow-up that
01:05:29you see along the way.
01:05:30So all Chagas is a
01:05:31hundred, referred is ninety four,
01:05:33seventy four is evaluated, thirty
01:05:35eight is treatment initiated, and
01:05:36only one is completed.
01:05:38And this is basically a
01:05:40table of all of the
01:05:41barriers to care. I wish
01:05:42I had the time to
01:05:43go through all of them,
01:05:44but it's worth looking them
01:05:45because all of them are
01:05:46true. And as people working
01:05:48on Chagas disease in the
01:05:49United States, it's our obligation
01:05:50to try to understand them
01:05:51and to mitigate them as
01:05:52best as we can.
01:05:54So in some, sorry I
01:05:55ran over, it's a complicated
01:05:57disease about which practitioners in
01:05:58the US are woefully unaware.
01:06:00It's made even more complicated
01:06:01by the fact that it's
01:06:02a neglected tropical disease. We
01:06:03need better risk stratification tools.
01:06:05We really need guidelines because
01:06:06then when people say what
01:06:07do the guidelines say, we
01:06:08can tell them. And collaborative
01:06:10efforts, like what Bernardo is
01:06:12trying to do, are key
01:06:12to this. And if we
01:06:14don't screen, we won't find
01:06:15subclinical disease and find our
01:06:16patients before they get sick,
01:06:18and we won't be able
01:06:18to provide the patients with
01:06:19the care that they need.
01:06:20Thank you so much. I
01:06:21really appreciate your attention.