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Chagas cardiomyopathy (CC) has a worse prognosis than other forms of cardiomyopathy and up to 10% of patients may progress to end-stage heart failure. In this article, we have performed a comprehensive literature review of heart transplantation (HT) for CC, including results after HT, management of immunosuppression, and Chagas disease (CD) reactivation. CD used to be considered a contraindication to HT due to the risks of disease reactivation with immunosuppression. Nonetheless, multiple reports have consistently demonstrated the feasibility and safety of HT for refractory CC. CD reactivation must be routinely screened in the first-year post-transplant, and in recent years, polymerase chain reactions (PCR)-based techniques have been used more often. HT is now considered the best treatment for end-stage Chagas heart disease. In addition, studies of immunosuppressive medications have shown that these patients require a lesser degree of immunosuppression, mainly to balance reactivation risks.

Introduction The novel coronavirus infection emerged in Wuhan, China, in the end of 2019 and is now a pandemic. The relation between COVID-19 and thrombotic events is well established, even for patients under prophylactic anticoagulation. Although venous and arterial thromboembolic events have been described, usually stroke and acute myocardial infarction (AMI),, there are few reports of arterial thrombosis in unusual sites. Almost all reports of thrombotic events are of intensive care unit (ICU) patients, and the incidence of thromboembolism in [...]

Introdução: A Covid-19 é uma doença infecciosa altamente contagiosa, com manifes-tações e evolução ainda a esclarecer por completo. No sistema cardiovascular, a interação com o vírus provoca danos de maneira direta e indireta. O objetivo desta revisão é avaliar os aspectos fisiopatológicos e clínicos da miocardite por SARS-CoV-2. Metodologia: Nesta revisão, a busca eletrônica foi conduzida nas seguintes bases de dados: Pubmed, Scielo, Medline e ClinicalTrials.gov. Os descritores usados (heart failure, heart diseases, myocarditis, Covid-19, coronavírus, SARS-CoV-2) estavam inseridos nos Descritores em Ciências da Saúde (DeCS). Revisão: O acometimento miocárdico pelo vírus SARS-CoV-2 parece acontecer por dois mecanismos diferentes: ação direta ou por induzir elevação de citocinas inflamatórias. A miocardite viral pode ser dividida em fase aguda, subaguda e crônica. A aguda caracteriza-se pela presença de viremia, a subaguda, caracterizada por infiltrado de linfócitos T, segue invadindo o miocárdio, e atingindo o pico em 7 a 14 dias depois da inoculação viral e a fase crônica caracteriza-se pela deposição intensa de colágeno no interstício miocárdico com fibrose miocárdica. O diagnóstico da miocardite é feito através da suspeita clínica, juntamente com métodos diagnósticos não invasivos, porém a confirmação diagnóstica só é possível com a análise histológica obtida pela biópsia endomiocárdica, que é indicada para os casos refratários ou que evoluem com choque cardiogênico. O tratamento específico da miocardite pode envolver terapêutica imunossupressora e antiviral. A infecção por SARS-CoV-2 pode também cursar com miocardite, e há dados anatomopatológicos que sugerem tal associação e relatos de caso que descrevem inclusive quadros de miocardite fulminante relacionada à Covid-19. Os mecanismos fisiopatológicos da miocardite por SARS-CoV-2 não são completamente compreendidos e estudos prospectivos são necessários para a melhor compreensão desta associação. Conclusão: Os dados atuais sugerem que a Covid-19 é patologia com potencial de gravidade, que pode levar à lesão miocárdica com vários espectros clínicos, incluindo miocardite

BACKGROUND Data on the prevention of fractures after heart transplant (HTx) are controversial in the literature. Understanding the effects of HTx on bone may guide appropriate treatments in this high-risk population. METHODS Seventy adult HTx patients were followed for 12 months. Clinical and laboratory parameters, bone mineral density, microarchitecture, and vertebral fractures were assessed at baseline (after intensive care unit discharge) and at 6 and 12 months. Patients received recommendations regarding calcium intake and vitamin D supplementation after HTx. RESULTS At baseline, 27% of patients had osteoporosis, associated with the length of hospitalization before HTx (P = 0.001). Bone mineral density decreased in the first 6 months, with partial recovery later. Bone microarchitecture deteriorated, mainly in the trabecular bone in the first 6 months and cortical bone in the subsequent 6 months. At baseline, 92.9% of patients had vitamin D levels

Epipericardial fat necrosis is an uncommon clinical condition of unknown etiology. It typically presents as acute pleuritic chest pain and should be differentiated from acute pulmonary embolism and acute coronary syndrome. This condition is diagnosed by characteristic chest computed tomography findings of an ovoid mediastinal fatty lesion with intrinsic and surrounding soft-tissue stranding. Treatment of epipericardial fat necrosis includes the administration of anti-inflammatory agents, and symptoms usually resolve within a few days after treatment initiation. This disease entity has rarely been reported since it was first described in 1957. Most current knowledge of epipericardial fat necrosis is based on case reports that describe this condition in previously healthy individuals. We present the case of a 39-year-old woman with a history of heart transplant, who presented with chest pain secondary to epipericardial fat necrosis. Serial computed tomography revealed lesion resolution after appropriate treatment.

As the current COVID-19 pandemic progresses, more symptoms and signals related to how the disease manifests in the human body arise in the literature. Skin lesions and coagulopathies may be confounding factors on routine care and patient management. We analyzed the metabolic and lipidic profile of the skin from COVID-19 patients using imprints in silica plates as a non-invasive alternative, in order to better understand the biochemical disturbances caused by SARS-CoV-2 in the skin. One hundred and one patients (64 COVID-19 positive patients and 37 control patients) were enrolled in this cross-sectional study from April 2020 to June 2020 during the first wave of COVID-19 in São Paulo, Brazil. Fourteen biomarkers were identified related to COVID-19 infection (7 increased and 7 decreased in COVID-19 patients). Remarkably, oleamide has shown promising performance, providing 79.0% of sensitivity on a receiver operating characteristic curve model. Species related to coagulation and immune system maintenance such as phosphatidylserines were decreased in COVID-19 patients; on the other hand, cytokine storm and immunomodulation may be affected by molecules increased in the COVID-19 group, particularly primary fatty acid amides and N-acylethanolamines, which are part of the endocannabinoid system. Our results show that skin imprints may be a useful, noninvasive strategy for COVID-19 screening, by electing a pool of biomarkers with diagnostic potential.

BACKGROUND: Heart transplant (HT) recipients may be at higher risk of acquiring SARS-CoV-2 infection and developing critical illness. The aim of this study is to describe characteristics and outcomes of HT recipients infected by SARS-COV-2, from a high-volume transplant center. METHODS: We have described data of all adult HT recipients with confirmed COVID-19 by RT-PCR in nasopharyngeal samples from April 5th,2020 to January 5th, 2021. Outcomes and follow-up were recorded until February 5th, 2021. RESULTS: Forty patients were included. Twenty-four patients (60%) were men; the median age was 53 (40-60) years old; median HT time was 34 months and median follow-up time 162 days. The majority needed hospitalization (83%). Immunosuppressive therapy was reduced/withdrawn in the majority of patients, except from steroids, which were maintained. Seventeen patients (42.5%) were classified as having severe disease according to the ordinal scale developed by the WHO Committee. They tended to have lower absolute lymphocyte count (p

COVID-19 is still placing a heavy health and financial burden worldwide. Impairment in patient screening and risk management plays a fundamental role on how governments and authorities are directing resources, planning reopening, as well as sanitary countermeasures, especially in regions where poverty is a major component in the equation. An efficient diagnostic method must be highly accurate, while having a cost-effective profile. We combined a machine learning-based algorithm with mass spectrometry to create an expeditious platform that discriminate COVID-19 in plasma samples within minutes, while also providing tools for risk assessment, to assist healthcare professionals in patient management and decision-making. A cross-sectional study enrolled 815 patients (442 COVID-19, 350 controls and 23 COVID-19 suspicious) from three Brazilian epicenters from April to July 2020. We were able to elect and identify 19 molecules related to the disease's pathophysiology and several discriminating features to patient's health-related outcomes. The method applied for COVID-19 diagnosis showed specificity >96% and sensitivity >83%, and specificity >80% and sensitivity >85% during risk assessment, both from blinded data. Our method introduced a new approach for COVID-19 screening, providing the indirect detection of infection through metabolites and contextualizing the findings with the disease's pathophysiology. The pairwise analysis of biomarkers brought robustness to the model developed using machine learning algorithms, transforming this screening approach in a tool with great potential for real-world application.

O Departamento de Insuficiencia Cardiaca (DEIC), da Sociedade Brasileira de Cardiologia, completou 20 anos de existencia em 2020 e representa um robusto legado nas areas de atividades cientificas e associativismo da cardiologia brasileira. Sua construcao representou um marco importante no enfrentamento da insuficiencia cardiaca (IC), uma complexa sindrome clinica progressiva e frequentemente fatal. A IC deve ser abordada de forma multidisciplinar, apoiada na ciencia translacional e nas boas praticas (diretrizes e protocolos clinicos), envolvendo pacientes, familias, cuidadores, gestores e toda [...]

Heart transplantation is the standard of therapy for patients with end-stage heart disease. Since the first human-to-human heart transplantation, performed in 1967, advances in organ donation, surgical techniques, organ preservation, perioperative care, immunologic risk assessment, immunosuppression agents, monitoring of graft function and surveillance of long-term complications have drastically increased recipient survival. However, there are yet many challenges in the modern era of heart transplantation in which immunosuppression may play a key role in further advances in the field. A fine-tuning of immune modulation to prevent graft rejection while avoiding side effects from over immunosuppression has been the vital goal of basic and clinical research. Individualization of drug choices and strategies, taking into account the recipient's clinical characteristics, underlying heart failure diagnosis, immunologic risk and comorbidities seem to be the ideal approaches to improve post-transplant morbidity and survival while preventing both rejection and complications of immunosuppression. : The aim of the present review is to provide a practical, comprehensive overview of contemporary immunosuppression in heart transplantation. Clinical evidence for immunosuppressive drugs is reviewed and practical approaches are provided. Cardiac allograft rejection classification and up-to-date management are summarized. Expanding therapies, such as photophoresis, are outlined. Drug-to-drug interactions of immunosuppressive agents focused on cardiovascular medications are summarized. Special situations involving heart transplantation such as sarcoidosis, Chagas diseases and pediatric immunosuppression are also reviewed. The evolution of phamacogenomics to individualize immunosuppressive therapy is described. Finally, future perspectives in the field of immunosuppression in heart transplantation are highlighted.

Purpose Cognitive impairment and mood deviation often occurs in patients with heart failure. Frailty and sarcopenia have been widely studied in patients with heart disease, but cognitive frailty has been little explored. High complexity of patients referred for heart transplantation connected with socioeconomic characteristics in a developing country underlines the importance to investigate cognitive and mood conditions in this population. The purpose of the study is to evaluate the prevalence of cognitive impairment and depression symptoms in patients with heart failure in waiting list for heart transplantation. Methods Cognition was assessed with the Montreal Cognitive Assessment (MoCA) and Wechsler Abbreviated Scale of Intelligence (WASI). Tables 1 and 2 show the domains evaluated by these tests and the established frailty criteria. Depression symptoms was assessed with Beck Depression Inventory (BDI). Patients included in waiting-list from Nov/2018 to May/2020 in our institution had its cognitive assessment in four weeks. Results 57 patients were evaluated; 77% were male; 49.9 was the average age; Chagas disease was the main etiology (38%), followed by dilated cardiomyopathy (28%) and ischemic cardiomyopathy (8%). 8.5 was the average of school years; 55% belong to social class “E” according to monthly family income and 28% reported history of mental health treatment or psychotropic use. Considering scales described above, 35% had mild symptons for depression; 89% denoted frailty on the brief cognitive screening test (MoCA) and 80% in the global intelligence scale (WASI), with emphasis on lower scores on non-verbal tasks over verbal tasks. Conclusion In our cohort, the prevalence of cognitive frailty in patients in heart transplant waiting list was alarming. Socioeconomic conditions seem to be a crucial issue in worse performance of candidates reflecting specific features and challenges regarding heart transplantation in a developing country.

Background: Evidence regarding biomarkers for risk prediction in patients with infective endocarditis (IE) is limited. We aimed to investigate the value of a panel of biomarkers for the prediction of in-hospital mortality in patients with IE. Methods: Between 2016 and 2018, consecutive IE patients admitted to the emergency department were prospectively included. Blood concentrations of nine biomarkers were measured at admission (D0) and on the seventh day (D7) of antibiotic therapy: C-reactive protein (CRP), sensitive troponin I (s-cTnI), procalcitonin, B-type natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL6), tumor necrosis factor α (TNF-α), proadrenomedullin, alpha-1-acid glycoprotein, and galectin 3. The primary endpoint was in-hospital mortality. Results: Among 97 patients, 56% underwent cardiac surgery, and in-hospital mortality was 27%. At admission, six biomarkers were independent predictors of in-hospital mortality: s-cTnI (OR 3.4; 95%CI 1.8–6.4; P

Introduction Antibody-mediated rejection (AMR) is an important cause of allograft dysfunction. It usually occurs after the first month of heart transplant (HT), but an early presentation is possible. We present an unusual case of a female HT recipient who had early AMR with no evidence of pre-sensitization to the donor. Case Report A woman, 45 years old, idiopathic dilated cardiomyopathy, two kids, with previous negative panel reactive antibody (PRA) was submitted to HT with success. The prospective crossmatch was negative and she did not receive blood cells during the surgery. The donor was a woman, 47 years old, who had a hemorrhagic stroke. After the procedure, she needed low doses of vasoactive drugs, received immunosuppression therapy according to institutional protocol and maintained normal ventricular function. On the 5th day, she developed biventricular graft dysfunction (left ventricular ejection fraction of 40%) requiring inotropes. The PRA revealed a donor specific antibody (DSA) not previously detected and the result of endomyocardial biopsy (EMB) confirmed acute AMR (pAMR2). Patient was successfully treated with methylprednisolone, plasmapheresis, immunoglobulin and rituximab. Biventricular function recovered; no DSA was detected and new EMB showed no rejection findings. Summary AMR results from recipient antibodies against donor-HLA antigens, causing complement activation, inflammation and injury to the allograft endothelium. In general, it occurs in the first two months after HT due to a rise in DSA by the contact with donor-HLA antigens. Early AMR, that occurs in the first week, is related to pre-sensitization to donor HLA antigens and associated with graft dysfunction. In this case report, no previous antibody had been detected. Two possibilities could explain such findings: the presence of non-HLA antibodies or the presence of memory B cells with levels of DSA too low to be detected on PRA. This case highlights the importance of monitoring antibodies in HT recipients with early allograft dysfunction even with previous negative PRA.

Introduction The relation between coronavirus 2019 disease (COVID-19) and thrombotic events is well established, and both arterial and venous thrombotic events are described. Although arterial events occur in about 3.6 to 10.5% of critically ill patients, they are usually stroke or acute myocardial infarction. Arterial thrombosis of other sites is rare. Case Report We report a case of a 28-year-old male heart transplant recipient admitted into emergency department presenting right flank pain associated with fever, chills, nausea and vomiting for three days. Apart from diabetes mellitus and dyslipidemia, he had no other comorbidity and he was on regular immunosuppression. Physical exam revealed right costovertebral angle tenderness. Blood tests showed C-reactive protein of 317mg/dL, lactate dehydrogenase of 1827U/L, D-dimer of 4126ng/mL, ferritin of 651ng/mL and leukocytosis of 16100/mm³. An abdominal and thoracic computed tomography scan (CT scan) revealed sparse luminal peripheral thrombi in the descending thoracic aorta. One of the thrombi extended to right renal artery ostium and caused subocclusion of the proximal segment of this artery. Right kidney presented multiple renal infarcts. Also ground-glass opacities were found in 25% of pulmonary parenchyma. COVID-19 was suspected and nasopharynx real-time fluorescence polymerase chain reaction result for SARS-CoV-2 was positive. Coagulopathy tests were performed because of atypical presentation and lupus anticoagulant (LAC) was positive. Hydration, antibiotics and anticoagulation with enoxaparin were prescribed. The patient recovered and became asymptomatic. Warfarin was prescribed and patient was discharged after 15 days of hospitalization. Summary This case report illustrates the heterogeneity of clinical presentation of COVID-19 and reinforces the existence of a prothrombotic state, even in the outpatient setting. Moreover, it adds information to the recent reports regarding the presence of antiphospholipid antibodies in COVID-19, although their importance in the pathophysiology of thromboembolic events in this setting is still not clear. The implication of these findings in transplant recipients is even less established, and this case report highlights the need for further research.

Purpose Heart transplant(HT) recipients with SARS-CoV-2 infection may be at high risk of developing critical illness. The aim was to describe the characteristics and clinical outcomes of HT recipients with coronavirus-19 disease(COVID-19). Methods We prospectively included all adult HT recipients who received the diagnosis of COVID-19 in our institution. Inclusion criteria were one or more clinical symptoms of SARS-CoV-2 infection in the previous seven days and positive SARS-CoV-2 RT-PCR in nasopharyngeal samples. The enrollment was carried out from April to June, 2020. Demographic features, clinical characteristics, modes of transmission, laboratory data and other known prognosis markers at admission and through follow up were recorded. Patients were categorized according to the ordinal scale developed by WHO Committee. Outcomes and follow up were recorded until Aug/2020. Results Twenty-one HT recipients were included, most of them were men (57%); with median age of 48 years old and median HT time of 12 mo. The majority needed hospitalization. Immunosuppressive therapy was reduced or withdrawn in the majority of patients, except from steroids. Ten patients were classified as having severe disease according to WHO Committee scale. Lymphopenia was an independent predictor of severe disease and absolute lymphocyte count

Introduction The disease caused by the coronavirus 2019 (COVID-19) is mainly characterized by symptoms related to the upper respiratory tract associated with fever and constitutional symptoms, progressing in the most severe cases to pneumonia and severe acute respiratory syndrome (SARS). However, due to the increasing number of cases, atypical presentations have been found. Among them, thromboembolic manifestations stand out, since the virus itself seems to predispose to changes in the coagulation system. Case Report A 62-year-old male patient who underwent cardiac transplantation 6 months ago, secondary to chagasic cardiomyopathy, had pain and edema in his left foot for 1 week. Upon admission, he was eupneic, afebrile, heart rate of 96bpm, blood pressure of 120 × 70mmhg, with edema and erythema on his left foot. Chagas reactivation, cellulite or deep vein thrombosis were the diagnostic hypotheses suggested. Soft tissue ultrasound and venous doppler of the left lower limb were compatible with deep venous thrombosis and superficial thrombophlebitis. Skin lesion biopsy confirmed Chagas reactivation. Antibiotic therapy with cefazolin, full anticoagulation with enoxaparin and treatment with benzonidazole were introduced. In the second day of hospitalization, patient presented myalgia and dry cough, in addition to an increased C-reactive protein and multiple ground-glass opacities on computed tomography of the chest, suggestive of COVID-19. This finding was corroborated by a positive result of RT-PCR for SARS-COV2. The patient evolved with SARS, requiring progressive use of vasoactive drugs, mechanical ventilation and pronation. Summary It is currently known that COVID-19 increases the risk of thromboembolic events, especially in hospitalized patients, reaching an incidence of 25%, even in the presence of effective prophylaxis. Several mechanisms have been proposed for this association, but not with robust evidence. Despite these increased cases, there are no reports in the literature of initial presentation with a thromboembolic event in a heart transplant patient, emphasizing the importance of clinical suspicion and appropriate investigation.

Heart transplantation is the gold standard treatment for advanced heart failure. Left ventricular assist devices (LVADs), despite being a good option for these patients, are not quite available in developing countries. Time spent in heart transplant waiting list has increased lately even in regions where the number of transplants has also risen showing that a new strategy should be sought. Transplant process organization combined with multidisciplinary work are linked to better outcomes while improvement in donor’s care and in pre-transplant evaluation might be opportunities to change the long waiting list scenario. For the first time in Brazil, a survey with the most expressive heart transplant centers has been made, which allows an overview of treatment of advanced heart failure in a developing country. We also described a model of heart transplant team, which has proved to be a success when compared to the largest heart transplant centers in Latin America.

Purpose: Introduction Pre-transplant irreversible pulmonary hypertension (PH) is a contraindication to heart transplantation (HTx) due to the high risk of post-transplant right ventricular (RV) dysfunction. When ventricular assist devices (VAD) are not available, HTx may be considered in selected patients PH. Objective To evaluate the incidence of right ventricular dysfunction in patients with reversible PH compared to patients with no PH submitted to HT. Methods We performed a retrospective analysis of all HTx performed from Jan-13 to Oct-17 at Heart Institute using RedCap database. PH was defined according to the presence of at least one of the following criteria at baseline: pulmonary systolic artery pressure (PSAP) > 50mmHg or pulmonary vascular resistance (PVR) >5uW or transpulmonary gradient (TPG) >15. Patients with PVR below 5uW at baseline or after the reversibility test were submitted to HTx. Early RV and LV dysfunctions and 30-day mortality were evaluated in patients with and without PH. Diastolic pulmonary gradient (DPG) was also evaluated in this cohort. Results 200 patients were submitted to HTx, 126(63%) were male, 127(63.5%) self-declared white, and with average age of 46.3±12.2 years-old. Of these patients, 180 had underwent to pre-transplant right heart catheterization. Considering criteria described above, 87(48.3%) patients had PH and were compared to patients with no PH (n=93,51.7%). Moderate/severe RV dysfunction was present in 16(18.8%) patients in PH group and 10(11.1%) patients in no HP group (p=0.152). There was also no difference in LV dysfunction (p=0.621) or 30-day mortality (p=0.534) between groups. All RV catheterization measures were higher in PH group (p Conclusion In our cohort, the incidence of RV as well as LV dysfunction and 30-day mortality were similar in patients with and without PH. In a population where VAD is not available, HTx could be an alternative to patients with PH, especially if DPG is low. Larger prospective studies should be performed to test the role of DPG in patient evaluation to HTx.

Purpose Endomyocardial biopsy (EMB) remains the gold standard for the diagnosis of graft rejection after heart transplantation (HT). The exact time point at which the first EMB could be safely performed varies between centers and the majority performs the first EMB within 7 days after HT. Our purpose was to evaluate the frequency of acute rejection after HT at the first EMB performed later than usual protocols. Methods Retrospective study that evaluated first EMB results in patients after HT from January 2013 to December 2017 at Heart Institute. Acute rejection was defined as the grade ≥2R according to the International Society for Heart and Lung Transplantation. Demographic data and immunosuppressive drugs at the time of EMB were collected. Continuous variables were expressed as media ± standard deviation. Results We analyzed 168 patients who performed the first EMB. The majority was male (61.9%) and the mean age was 48.1±12.8 years. No patients received induction immunosuppressive therapy. The mean time for the first EMB was 13.9 + 6.7 days. Forty-six (27.4%) episodes of cell-mediated acute rejection (> 2R) and 7 (4.2%) episodes of antibody-mediated acute rejection were identified. The time for the first EMB in the group that had rejection was 11.59±3.7 days and in the group without rejection was 14.7±7.4 days (p= 0.01). 30-day mortality was 3 (2.5%) in no rejection group and in 0 in rejection group whitout statistical difference (p: 0.283). Conclusion Our analysis reveals that despite late (after 10 days) first EMB, the frequency of acute rejection is similar to previous reported even without an induction immunosuppressive therapy. In addition, the presence of acute rejection in the first biopsy did not increase mortality in the first 30 days. The study suggests that this approach is safe and should be further evaluated in order to adopt a less invasive protocol.

BackgroundChagas cardiomyopathy (ChC) prevalence is decreasing in Brazil and medical therapies for heart failure (HF) have improved in the last decade. Whether these changes modified the prognosis of ChC relative to non-Chagas cardiomyopathies (NChC) remains unknown. This study evaluated the temporal trends in population attributable risk (PAR) of ChC for 2-year mortality among patients with HF enrolled at years 2002–2004 (era 1) and 2012–2014 (era 2) in a Brazilian university hospital.MethodsWe prospectively studied 362 (15% with ChC) and 582 (18% with ChC) HF patients with ejection fraction ≤50% in eras 1 and 2, respectively and estimated the PAR of ChC for 2-year mortality.ResultsThere were 145 deaths (29 in ChC) in era 1 and 85 deaths (26 in ChC) in era 2. In multivariable Cox-regression analysis adjusted for age, sex, ejection fraction, heart rate, body mass index, hypertension, diabetes mellitus, systolic blood pressure and ischaemic/valvar aetiology, ChC was associated with higher risk of death in era 1 (HR (95% CI)=1.92 (1.00 to 3.71), p=0.05) and era 2 (HR (95% CI)=3.51 (1.94 to 6.36), pConclusionAlthough the absolute death rates decreased over time in the ChC and NChC groups, the PAR of ChC for mortality increased among patients with HF, driven by increases in the HR associated with ChC. Our results highlight the need for additional efforts aiming to prevent and treat ChC.

Background Clinical and experimental conflicting data have questioned the relationship between infectious agents, inflammation and dilated cardiomyopathy (DCM). Objectives The aim of this study was to determine the frequency of infectious agents and inflammation in endomyocardial biopsy (EMB) specimens from patients with idiopathic DCM, explanted hearts from different etiologies, including Chagas' disease, compared to donated hearts. Methods From 2008 to 2011, myocardial samples from 29 heart donors and 55 patients with DCMs from different etiologies were studied (32 idiopathic, 9 chagasic, 6 ischemic and 8 other specific etiologies). Inflammation was investigated by immunohistochemistry and infectious agents by immunohistochemistry, molecular biology, in situ hybridization and electron microscopy. Results There were no differences regarding the presence of macrophages, expression of HLA class II and ICAM-I in donors and DCM. Inflammation in Chagas' disease was predominant. By immunohistochemistry, in donors, there was a higher expression of antigens of enterovirus and Borrelia , hepatitis B and C in DCMs. By molecular biology, in all groups, the positivity was elevated to microorganisms, including co-infections, with a higher positivity to adenovirus and HHV6 in donors towards DCMs. This study was the first to demonstrate the presence of virus in the heart tissue of chagasic DCM. Conclusions The presence of inflammation and infectious agents is frequent in donated hearts, in the myocardium of patients with idiopathic DCM, myocardial dysfunction related to cardiovascular diseases, and primary and secondary cardiomyopathies, including Chagas' disease. The role of co-infection in Chagas' heart disease physiopathology deserves to be investigated in future studies.