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Ann Thorac Surg 1995;60:1408-1409
© 1995 The Society of Thoracic Surgeons
Surgical Division-Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
This article by Blanche and associates on heart transplantation in Chagas' cardiomyopathy is important because a report of The Pan American Health Organization [1] estimates that 12 million persons are infected by Trypanosoma cruzi and 35 million are at risk of infection, and because this subject is quite controversial. It is accepted that cardiomyopathy or digestive ``megas syndrome'' will develop in half of the infected population [2].
In 1987 my colleagues and I reported heart transplantation in this indication [3]. Our experience at the Heart Institute, University of São Paulo, now is 21 patients, and recently we presented at the Heart-Lung Transplantation Society Meeting the Brazilian experience with 58 cases [4]. The indication may be considered controversial due to the coexistence of other organ involvement in Chagas' disease as well as the possibility of reactivation of the parasite infection. Digestive involvement, the most frequent associated pathology, can be detected in the pretransplantation evaluation. On the other hand, reactivation represents a complication the prevention of which is not yet established. The immunosuppression protocol varied in the Brazilian series of 58 patients. Double immunosuppression was used in 34.5%, triple in 55.2%, and triple plus antithymocyte globulin in 10.3%; it had no relation with reactivation. In this same series, there were 41 episodes of reactivation in 19 patients (32.8%). This complication occurred in patients with pretransplantation and in those with an initial period of treatment with benzonidazole, the most potent trypanocidal drug. There were 3 cases of lymphoproliferative disorder, 2 of Kaposi's sarcoma, and 2 of carcinomas. Despite these additional complications in the actuarial curve there was a 70% one-year and 58% five-year survival.
In relation to this article by Blanche and associates, the main controversial point is the indefinite use of nifurtimox after transplantation. In our experience [4] the episodes of reactivation occurred more frequently within the first year, but a few patients presented reactivation from the second to the sixth year, and the second patient reported in the present article has only a 12-month follow-up and is at risk for the complication. On the other hand, in rabbits an incidence of 32% of lymphomas in animals treated with nifurtimox and 41% in those treated with benzonidazole has been reported [5]. Although this effect was not observed in humans with both drugs, it must be considered as we use immunosuppression in the patients who receive transplants. Diminishing the dose of cyclosporine and not using antithymocyte globulin prophylactically, we are not observing reactivation any more and we also are not using any antiparasite drug postoperatively [6].
In regard to the use of cardiomyoplasty as an alternative to transplantation, my colleagues and I made an analysis of the South American experience of 112 patients with this procedure. The survival was 86.1% and 49.8% after 1 and 5 years for dilated cardiomyopathy and 40% and 9.5% in the same period for Chagas' cardiomyopathy [7]. We therefore agree with Blanche and associates that heart transplantation is a valid and attractive treatment option for end-stage Chagas' disease cardiomyopathy.
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