CME Information: 1.50 credits; ABIM MOC Points: 1.50
Expiration Date: January 31, 2019
You must be logged in and own this product in order to post comments.
Very complete and informative article.
“Recommendations for Multimodality Cardiac Imaging in Patients with
CME Information: 1.50 credits
date: January 2018 Valid through: January 2019
Introduction/Statement of Need:
Chagas disease (ChD) is a significant public health problem in most Latin American countries. Observed mainly in rural areas, in recent decades it has spread to cities and
to nonendemic countries, mostly as a result of migration of infected people. Increasing numbers of cases are now being identified in the United States, Spain, and other countries, which makes its diagnosis and management of increasing interest worldwide. There are two clinical phases of T.cruzi infection: acute ChD, seen early after acquiring the infection, and chronic ChD, lasting for decades. About 70% to 80% of individuals with chronic T. cruzi infection remain asymptomatic (indeterminate form), while 20% to 30% develop cardiac and/or gastrointestinal disease. Patients with chronic Chagas heart disease (ChHD) are staged according to the severity of myocardial damage and symptoms of congestive heart failure. The purpose of this document is to provide recommendations for the use of cardiac ultrasound and other imaging modalities in the diagnosis, classification, and risk assessment of myocardial damage from early to advanced forms of ChHD.
This activity is designed for all cardiac sonographers and cardiovascular physicians with a primary interest and knowledge base in the field of echocardiography; in
addition, residents, researchers, clinicians, intensivists, and other medical professionals.
At the end of this activity the reader will better be able to:
2. Recognize the potential role of multiple cardiac imaging modalities in the management of patients with ChD and Chagas Heart Disease (ChHD)
3. Define the overall goals of imaging in the symptomatic stages of ChHD
4. Characterize the clinical phases – acute ChD, (indeterminate), and chronic ChD – of T. cruzi infection
5. Recognize the special features of EKG and each other imaging modality in relation to ChD
The American Society of Echocardiography is accredited by the Accreditation
Council for Continuing Medical Education to provide continuing medical
education for physicians.
The American Society of Echocardiography designates this enduring material for
a maximum of 1.50 AMA
PRA Category 1 CreditsTM. Physicians should claim only
the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.50 MOC point in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
ARDMS, CCI and Sonography Canada recognize ASE’s certificates and have agreed to honor the credit hours toward their registry requirements for sonographers.
The American Society of Echocardiography is committed to ensuring that its educational mission and all sponsored educational programs are not influenced by the special interests of
any corporation or individual, and its mandate is to retain only those authors whose financial interests can be effectively resolved to maintain the goals and
educational integrity of the activity. While a monetary or professional affiliation with a corporation does not necessarily influence an author’s presentation, the Essential Areas and policies of the ACCME require that any relationships that could possibly conflict with the educational value of the activity be resolved prior to publication and disclosed to the audience. Disclosures of faculty and commercial support relationships, if any, have been indicated.
Harry Acquatella, MD, FASE, Federico M. Asch, MD, FASE, Marcia M. Barbosa, MD, PhD, FASE, Marcio Barros, MD, PhD, Caryn Bern, MD, MPH, Joao L. Cavalcante, MD, FASE, Luis
Eduardo Echeverria Correa, MD, Joao Lima, MD, Rachel Marcus, MD, Jose Antonio Marin-Neto, MD, PhD, Ricardo Migliore, MD, PhD, Jose Milei, MD, PhD, Carlos A. Morillo, MD, Maria Nunes, MD, PhD, Marcelo Luiz Campos Vieira, MD, PhD, Rodolfo Viotti, MD
According to ACCME policy, ASE implemented mechanisms to resolve all conflicts of interest prior to the planning and implementation of this activity.
authors reported no actual or potential conflicts of interest in relation to this document:
Acquatella, MD, FASE, Federico M. Asch, MD, FASE, Marcia M. Barbosa, MD, PhD, FASE, Marcio Barros, MD, PhD, Joao L. Cavalcante, MD, FASE, Jose Antonio
Marin-Neto, MD, PhD, Ricardo Migliore, MD, PhD, Jose Milei, MD, PhD, Maria Nunes, MD, PhD, Marcelo Luiz Campos Vieira, MD, PhD, Rodolfo Viotti, MD
The following authors reported relationships with one or more commercial interests:
Caryn Bern, MD, MPH: Chemogroup (Consultant, Advisor); Luis Eduardo Echeverria Correa, MD: Roche (Research Grant Support (Including PI)); Joao Lima, MD:
Toshiba Medical Systems (Research Grant Support (Including PI)); Rachel Marcus, MD: Bayer (Consultant, Advisor);Carlos A. Morillo, MD,: Canadian Institute for
Health Research: (Research Grant Support (Including PI)); TDR-WHO (BENEFIT trial): (Research Grant Support (Including PI)); Merck Shape & Dohme (STOP-CHAGAS trial): (Research Grant Support (Including PI)); Bayer: (Research Grant Support (Including PI)), (Speaker / Speaker’s Bureau); BMS/Pfizer: (Research Grant Support (Including PI));
Boehringer Ingelheim (Speaker / Speaker’s Bureau); Boston Scientific (Consultant, Advisor)
The following 2017-2018 ASE Board of Directors, Guidelines and Standards Committee and a representative for the Society for Cardiovascular Magnetic Resonance reviewed this document and reported
no actual or potential conflicts of interest in relation to this document:
Reviewers included Bonita Anderson, MApplSC, DMU, AMS, ACS, AFASA, FASE, Federico Asch, MD, FASE, Stephen Little, MD, FASE, Azin Alizadehasl, MD, FASE, Kim Baker, BS, RDCS, RVT, FASE, Scott Choyce, RDCS, RVT, RDMS, FASE, Frederick Cobey, MD, FASE, Benjamin W. Eidem, MD, FASE, Mark Friedberg, MD, FASE, Edward Gill, MD, FASE, Neal Gerstein, MD, FASE, Yvonne Gilliland, MD, FACC, FASE, Robi
Goswami, MD, FASE, Lanqi Hua, RDCS, (AE/PE/FE), FASE, Renuka Jain, MD, FASE, Pei-Ni Jone, MD, FASE, James Kirkpatrick, MD, FASE, Allan L. Klein, MD, FASE, Stephen H. Little, MD, FASE, Elizabeth McIlwain, MPH, RCS, FASE, Maryellen H. Orsinelli, RN, RDCS, FASE, Alan Pearlman, MD, FASE, Andy Pellett, PhD, RCS, RDCS, FASE, Dermot Phelan, MD, PhD, FACC, FASE, Michael Picard, MD, FASE, Sue D. Phillip, RCS, FASE, Sorin Pislaru, MD, PhD, FASE, Juan Carlos Plana, MD, FASE, Charlene Porcelli, RDCS, RDMS, FASE, Geoffrey Rose, MD, FASE, David Rubenson, MD, FASE, Liza Sanchez, RCS, FASE, Fadi Shamoun, MD, FASE, Elaine Shea, ACS, RCS, RCCS, FASE, Madhav Swaminathan, MD, FASE, James D. Thomas, MD, FASE, David Wiener, MD, FASE
The following board and guidelines and standards committee members reported relationships with one or more commercial interests:
Alicia Armour, BS, MA, RDCS, FASE – Philips Healthcare (Speakers Bureau), Jao Cavalcante, MD, FASE – Medtronic Inc. (Grants or Research Support), Keith Collins, MDS, RDCS, FASE – IBM (Stockholdership), Sabe De, MD, FASE – Bayer (Speakers Bureau); Astra Zeneca (Speakers Bureau), Craig Fleishman, MD, FASE – W.L. Gore Echo Core Lab (Scientific Advisory Committee), John Gorcsan III, MD, FASE -
Medtronic (Research Grant Support, Including PI); Hitachi Aloka (Research Grant Support, including PI); GE (Research Grant Support, Including PI), Steve Heitner, MD, FASE – Bracco Diagnostics (Scientific Advisory Committee); Alnylam Pharmaceuticals (Scientific Advisory Committee); Amgen Pharmaceuticals (Scientific Advisory Committee); Takeda Pharmaceuticals (Scientific Advisory Committee); MyoKardia (Scientific Advisory Committee), Jonathan Lindner, MD, FASE – GE Healthcare (Research Grant Support, Including PI), Rick Meece, ACS, RDCS, RCS, RCIS, FASE – Philips Healthcare (Speakers Bureau); Abbott Medical (Speakers Bureau); Edwards Lifesciences (Speakers Bureau), William Perez, MD, FASE – Alibaba Holdings (Stockowernership); Myriad Genetics (Stockownership), American Energy Industries (Stockownership), Vera H. Rigolin, MD, FASE – Pfizer (Stockownership), Raymond Stainback, MD, FASE – GE (Stockownership), Douglas Shook, MD, FASE – Edwards Life Sciences (Research Grant Support, Including PI); Liva-Nova (Education); Boston Scientific (Education); Edwards Lifesciences (Consultant/Advisor)
The following ACCME reviewers, ASE Staff and CME editors reported no actual or potential conflicts of interest in relation to this document:
Pricilla Peters, BA, RDCS, Andra Duncan, MD, FASE, Tia Gordon, RDCS, FASE, Mary Lawson, and Christina LaFuria
The following ACCME reviewers, ASE Staff and CME editors reported relationships with one or more commercial interests:
Method of Participation: Online Only
Estimated Time to
Complete this Activity: 1.50
Receiving CME Credit:
To receive online CME credit for this activity, read the full activity then complete the posttest and evaluation. A score of 70% or higher is required for
successful completion. You will be able to print your CME certificate immediately following successful completion of the posttest and evaluation.
You will need a compatible browser like Mozilla FireFox, Google Chrome or safari to view the content. Internet Explorer may not work.
This report is made available by ASE as a courtesy reference source for members. This report contains recommendations only and should not be used as the sole basis to make medical practice
decisions or for disciplinary action against any employee. The statements and recommendations contained in this report are primarily based on the opinions of experts, rather than on scientifically verified data. ASE makes no express or implied warranties regarding the completeness or accuracy of the information in this report, including the warranty of merchantability or fitness for a
particular purpose. In no event shall ASE be liable to you, your patients, or any other third parties for any decision made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of medical advice by ASE or create any physician patient relationship between ASE and your patients or anyone else.
Copyright American Society of Echocardiography. Questions? Contact us at email@example.com
1. Lewinsohn, R. Carlos Chagas and the discovery of Chagas' disease (American trypanosomiasis). J R Soc Med. 1981;74:451–455.
2. Chagas disease in Latin America: an epidemiological update based on 2010 estimates. Wkly Epidemiol Rec. 2015;90:33–43.
3. Ribeiro, A.L., Marcolino, M.S., Prineas, R.J., Lima-Costa, M.F. Electrocardiographic abnormalities in elderly Chagas disease patients: 10-year follow-up of the Bambui Cohort Study of Aging. J Am Heart Assoc. 2014;3:e000632.
4. Andrade, J.P., Marin-Neto, J.A., Paola, A.A., Vilas-Boas, F., Oliveira, G.M., Bacal, F. et al, I Latin American guidelines for the diagnosis and treatment of Chagas cardiomyopathy Arq Bras Cardiol. 2011;97:1–48.
5. Bern, C., Montgomery, S.P., Herwaldt, B.L., Rassi, A., Marin-Neto, J.A., Dantas, R.O. et al, Evaluation and treatment of Chagas disease in the United States: a systematic review. JAMA. 2007;298:2171–2181.
6. Rassi, A., Marin-Neto, J.A. Chagas disease. Lancet. 2010;375:1388–1402.
7. Bern, C., Kjos, S., Yabsley, M.J., Montgomery, S.P. Trypanosoma cruzi and Chagas' disease in the United States. Clin Microbiol Rev. 2011;24:655–681.
8. Shikanai-Yasuda, M.A., Carvalho, N.B. Oral transmission of Chagas disease. Clin Infect Dis. 2012;54:845–852.
9. Bern, C., Montgomery, S.P. An estimate of the burden of Chagas disease in the United States. Clin Infect Dis. 2009;49:e52–e54.
10. Gascon, J., Bern, C., Pinazo, M.J. Chagas disease in Spain, the United States and other non-endemic countries. Acta Trop. 2010;115:22–27.
11. Schofield, C.J., Galvão, C. Classification, evolution, and species groups within the Triatominae. Acta Trop. 2009;110:88–100.
12. Samuels, A.M., Clark, E.H., Galdos-Cardenas, G., Wiegand, R.E., Ferrufino, L., Menacho, S. et al, Epidemiology of and impact of insecticide spraying on Chagas disease in communities in the Bolivian Chaco. PLoS Negl Trop Dis. 2013;7:e2358.
13. Fernandez, A.B., Nunes, M.C., Clark, E.H., Samuels, A., Menacho, S., Gomez, J. et al, Electrocardiographic and echocardiographic abnormalities in Chagas disease: findings in residents of rural Bolivian communities hyperendemic for Chagas disease. Glob Heart. 2015;10:159–166.
14. Rassi, A., Marcondes de Rezende, J. American trypanosomiasis (Chagas disease). Infect Dis Clin North Am. 2012;26:275–291.
15. Hashimoto, K., Schofield, C.J. Elimination of Rhodnius prolixus in Central America. Parasit Vectors. 2012;5:45.
16. Schofield, C.J., Jannin, J., Salvatella, R. The future of Chagas disease control. Trends Parasitol. 2006;22:583–588.
17. Tenney, T.D., Curtis-Robles, R., Snowden, K.F., Hamer, S.A. Shelter dogs as sentinels for Trypanosoma cruzi transmission across Texas. Emerg Infect Dis. 2014;20:1323–1326.
18. Cantey, P.T., Stramer, S.L., Townsend, R.L., Kamel, H., Ofafa, K., Todd, C.W. et al, The United States Trypanosoma cruzi Infection Study: evidence for vector-borne transmission of the parasite that causes Chagas disease among United States blood donors. Transfusion. 2012;52:1922–1930.
19. Garcia, M.N., Aguilar, D., Gorchakov, R., Rossmann, S.N., Montgomery, S.P., Rivera, H. et al, Evidence of autochthonous Chagas disease in southeastern Texas. Am J Trop Med Hyg. 2015;92:325–330.
20. Edwards, M.S., Rench, M.A., Todd, C.W., Czaicki, N., Steurer, F.J., Bern, C. et al, Perinatal screening for Chagas disease in southern Texas. J Pediatric Infect Dis Soc. 2015;4:67–70.
21. Garcia, M.N., Murray, K.O., Hotez, P.J., Rossmann, S.N., Gorchakov, R., Ontiveros, A. et al, Development of Chagas cardiac manifestations among Texas blood donors. Am J Cardiol. 2015;115:113–117.
22. Kapelusznik, L., Varela, D., Montgomery, S.P., Shah, A.N., Steurer, F.J., Rubinstein, D. et al, Chagas disease in Latin American immigrants with dilated cardiomyopathy in New York City. Clin Infect Dis. 2013;57:e7.
23. Stimpert, K.K., Montgomery, S.P. Physician awareness of Chagas disease, USA. Emerg Infect Dis. 2010;16:871–872.
24. Verani, J.R., Montgomery, S.P., Schulkin, J., Anderson, B., Jones, J.L. Survey of obstetrician-gynecologists in the United States about Chagas disease. Am J Trop Med Hyg. 2010;83:891–895.
25. Tarleton, R.L., Zhang, L. Chagas disease etiology: autoimmunity or parasite persistence. Parasitol Today. 1999;15:94–99.
26. Rassi, A. Jr., Rassi, A., Marin-Neto, J.A. Chagas heart disease: pathophysiologic mechanisms, prognostic factors and risk stratification. Mem Inst Oswaldo Cruz. 2009;104:152–158.
27. Rossi, M.A. The pattern of myocardial fibrosis in chronic Chagas' heart disease. Int J Cardiol. 1991;30:335–340.
28. Marin-Neto, J.A., Cunha-Neto, E., Maciel, B.C., Simões, M.V. Pathogenesis of chronic Chagas heart disease. Circulation. 2007;115:1109–1123.
29. de Oliveira, L.F., Romano, M.M., de Carvalho, E.E., Cabeza, J.M., Salgado, H.C., Fazan Júnior, R. et al, Histopathological correlates of global and segmental left ventricular systolic dysfunction in experimental chronic Chagas cardiomyopathy. J Am Heart Assoc. 2016;5:e002786.
30. Rossi, M.A. Microvascular changes as a cause of chronic cardiomyopathy in Chagas' disease. Am Heart J. 1990;120:233–236.
31. Simões, M.V., Pintya, A.O., Bromberg-Marin, G., Sarabanda, A.V., Antloga, C.M., Pazin-Filho, A. et al, Relation of regional sympathetic denervation and myocardial perfusion disturbance to wall motion impairment in Chagas' cardiomyopathy. Am J Cardiol. 2000;86:975–981.
32. Garzon, S.A., Lorga, A.M., Nicolau, J.C. Electrocardiography in Chagas' heart disease. Sao Paulo Med J. 1995;113:802–813.
33. Marques, J., Mendoza, I., Noya, B., Acquatella, H., Palacios, I., Marques-Mejias, M. ECG manifestations of the biggest outbreak of Chagas disease due to oral infection in Latin-America. Arq Bras Cardiol. 2013;101:249–254.
34. Porto, C.C. The electrocardiogram in the prognosis and evolution of Chagas' disease Arq Bras Cardiol. 1964;17:313–346.
35. Sabino, E.C., Ribeiro, A.L., Salemi, V.M., Di Lorenzo Oliveira, C., Antunes, A.P., Menezes, M.M. et al, Ten-year incidence of Chagas cardiomyopathy among asymptomatic Trypanosoma cruzi-seropositive former blood donors. Circulation. 2013;127:1105–1115.
36. Cardoso, R., Garcia, D., Fernandes, G., He, L.I., Lichtenberger, P., Viles-Gonzalez, J. et al, The prevalence of atrial fibrillation and conduction abnormalities in Chagas' disease: a meta-analysis. J Cardiovasc Electrophysiol. 2016;27:161–169.
37. Nunes, M.C., Dones, W., Morillo, C.A., Encina, J.J., Ribeiro, A.L., Council OCDOTISOC. Chagas disease: an overview of clinical and epidemiological aspects. J Am Coll Cardiol. 2013;62:767–776.
38. Baranchuk, A., Femenia, F., López-Diez, J.C., Muratore, C., Valentino, M., Retyk, E. et al, Fragmented surface ECG was a poor predictor of appropriate therapies in patients with Chagas' cardiomyopathy and ICD implantation (Fragmented ECG in Chagas' Cardiomyopathy Study). Ann Noninvasive Electrocardiol. 2014;19:43–49.
39. Rassi, A., Little, W.C., Xavier, S.S., Rassi, S.G., Rassi, A.G., Rassi, G.G. et al, Development and validation of a risk score for predicting death in Chagas' heart disease. N Engl J Med. 2006;355:799–808.
40. Salles, G., Xavier, S., Sousa, A., Hasslocher-Moreno, A., Cardoso, C. Prognostic value of QT interval parameters for mortality risk stratification in Chagas' disease: results of a long-term follow-up study. Circulation. 2003;108:305–312.
41. Marcolino, M.S., Palhares, D.M., Ferreira, L.R., Ribeiro, A.L. Electrocardiogram and Chagas disease: a large population database of primary care patients. Glob Heart. 2015;10:167–172.
42. Echeverría, L.E., Rojas, L.Z., Calvo, L.S., Roa, Z.M., Rueda-Ochoa, O.L., Morillo, C.A. et al, Profiles of cardiovascular biomarkers according to severity stages of Chagas cardiomyopathy. Int J Cardiol. 2017;227:577–582.
43. Gascón, J., Albajar, P., Cañas, E., Flores, M., Gómez i Prat, J., Herrera, R.N. et al, Diagnosis, management and treatment of chronic Chagas' heart disease in areas where Trypanosoma cruzi infection is not endemic Rev Esp Cardiol. 2007;60:285–293.
44. Ribeiro, A.L., Lombardi, F., Sousa, M.R., Lins Barros, M.V., Porta, A., Costa Val Barros, V. et al, Power-law behavior of heart rate variability in Chagas' disease. Am J Cardiol. 2002;89:414–418.
45. Lang, R.M., Badano, L.P., Mor-Avi, V., Afilalo, J., Armstrong, A., Ernande, L. et al, Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28:1–39.e14.
46. Acquatella, H., Schiller, N.B., Puigbó, J.J., Giordano, H., Suárez, J.A., Casal, H. et al, M-mode and two-dimensional echocardiography in chronic Chagas' heart disease. A clinical and pathologic study. Circulation. 1980;62:787–799.
47. Acquatella, H. Echocardiography in Chagas heart disease. Circulation. 2007;115:1124–1131.
48. Viotti, R.J., Vigliano, C., Laucella, S., Lococo, B., Petti, M., Bertocchi, G. et al, Value of echocardiography for diagnosis and prognosis of chronic Chagas disease cardiomyopathy without heart failure. Heart. 2004;90:655–660.
49. Hundley, W.G., Kizilbash, A.M., Afridi, I., Franco, F., Peshock, R.M., Grayburn, P.A. Effect of contrast enhancement on transthoracic echocardiographic assessment of left ventricular regional wall motion. Am J Cardiol. 1999;84:1365–1368 (A8).
50. Mulvagh, S.L., Rakowski, H., Vannan, M.A., Abdelmoneim, S.S., Becher, H., Bierig, S.M. et al, American Society of Echocardiography consensus statement on the clinical applications of ultrasonic contrast agents in echocardiography. J Am Soc Echocardiogr. 2008;21:1179–1201.
51. Thanigaraj, S., Schechtman, K.B., Pérez, J.E. Improved echocardiographic delineation of left ventricular thrombus with the use of intravenous second-generation contrast image enhancement. J Am Soc Echocardiogr. 1999;12:1022–1026.
52. Lancellotti, P., Tribouilloy, C., Hagendorff, A., Popescu, B.A., Edvardsen, T., Pierard, L.A. et al, Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2013;14:611–644.
53. Zoghbi, W.A., Adams, D., Bonow, R.O., Enriquez-Sarano, M., Foster, E., Grayburn, P.A. et al, Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017;30:303–371.
54. Lang, R.M., Badano, L.P., Tsang, W., Adams, D.H., Agricola, E., Buck, T. et al, EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr. 2012;25:3–46.
55. Tsang, W., Salgo, I.S., Medvedofsky, D., Takeuchi, M., Prater, D., Weinert, L. et al, Transthoracic 3D echocardiographic left heart chamber quantification using an automated adaptive analytics algorithm. JACC Cardiovasc Imaging. 2016;9:769–782.
56. Vieira, M.L., Nomura, C.H., Tranchesi, B., de Oliveira, W.A., Naccarato, G., Serpa, B.S. et al, Real-time three-dimensional echocardiographic left ventricular systolic assessment: side-by-side comparison with 64-slice multi-detector cardiac computed tomography. Eur J Echocardiogr. 2010;11:257–263.
57. Endo, Y., Maddukuri, P.V., Vieira, M.L., Pandian, N.G., Patel, A.R. Quantification of right ventricular volumes and function by real time three-dimensional echocardiographic longitudinal axial plane method: validation in the clinical setting. Echocardiography. 2006;23:853–859.
58. Maddukuri, P.V., Vieira, M.L., DeCastro, S., Maron, M.S., Kuvin, J.T., Patel, A.R. et al, What is the best approach for the assessment of left atrial size? Comparison of various unidimensional and two-dimensional parameters with three-dimensional echocardiographically determined left atrial volume. J Am Soc Echocardiogr. 2006;19:1026–1032.
59. Geyer, H., Caracciolo, G., Abe, H., Wilansky, S., Carerj, S., Gentile, F. et al, Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications. J Am Soc Echocardiogr. 2010;23:351–369.
60. Voigt, J.U., Pedrizzetti, G., Lysyansky, P., Marwick, T.H., Houle, H., Baumann, R. et al, Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging. 2015;16:1–11.
61. Barbosa, M.M., Costa Rocha, M.O., Vidigal, D.F., Bicalho Carneiro, R.C., Araújo, R.D., Palma, M.C. et al, Early detection of left ventricular contractility abnormalities by two-dimensional speckle tracking strain in Chagas' disease. Echocardiography. 2014;31:623–630.
62. García-Álvarez, A., Sitges, M., Regueiro, A., Poyatos, S., Jesus Pinazo, M., Posada, E. et al, Myocardial deformation analysis in Chagas heart disease with the use of speckle tracking echocardiography. J Card Fail. 2011;17:1028–1034.
63. Silva, C.E., Ferreira, L.D., Peixoto, L.B., Monaco, C.G., Gil, M.A., Ortiz, J. et al, Evaluation of segmentary contractility in Chagas' disease by using the integral of the myocardial velocity gradient (myocardial strain) obtained through tissue Doppler echocardiography Arq Bras Cardiol. 2005;84:285–291.
64. Gomes, V.A., Alves, G.F., Hadlich, M., Azevedo, C.F., Pereira, I.M., Santos, C.R. et al, Analysis of regional left ventricular strain in patients with Chagas disease and normal left ventricular systolic function. J Am Soc Echocardiogr. 2016;29:679–688.
65. Nascimento, C.A., Gomes, V.A., Silva, S.K., Santos, C.R., Chambela, M.C., Madeira, F.S. et al, Left atrial and left ventricular diastolic function in chronic Chagas disease. J Am Soc Echocardiogr. 2013;26:1424–1433.
66. Barros, M.V., Leren, I.S., Edvardsen, T., Haugaa, K.H., Carmo, A.A., Lage, T.A. et al, Mechanical dispersion assessed by strain echocardiography is associated with malignant arrhythmias in Chagas cardiomyopathy. J Am Soc Echocardiogr. 2016;29:368–374.
67. Rochitte, C.E., Nacif, M.S., de Oliveira Júnior, A.C., Siqueira-Batista, R., Marchiori, E., Uellendahl, M. et al, Cardiac magnetic resonance in Chagas' disease. Artif Organs. 2007;31:259–267.
68. Torreão, J.A., Ianni, B.M., Mady, C., Naia, E., Rassi, C.H., Nomura, C. et al, Myocardial tissue characterization in Chagas' heart disease by cardiovascular magnetic resonance. J Cardiovasc Magn Reson. 2015;17:97.
69. Mewton, N., Liu, C.Y., Croisille, P., Bluemke, D., Lima, J.A. Assessment of myocardial fibrosis with cardiovascular magnetic resonance. J Am Coll Cardiol. 2011;57:891–903.
70. Lee-Felker, S.A., Thomas, M., Felker, E.R., Traina, M., Salih, M., Hernandez, S. et al, Value of cardiac MRI for evaluation of chronic Chagas disease cardiomyopathy. Clin Radiol. 2016;71:618.e1–618.e7.
71. Mello, R.P., Szarf, G., Schvartzman, P.R., Nakano, E.M., Espinosa, M.M., Szejnfeld, D. et al, Delayed enhancement cardiac magnetic resonance imaging can identify the risk for ventricular tachycardia in chronic Chagas' heart disease. Arq Bras Cardiol. 2012;98:421–430.
72. Rochitte, C.E., Oliveira, P.F., Andrade, J.M., Ianni, B.M., Parga, J.R., Avila, L.F. et al, Myocardial delayed enhancement by magnetic resonance imaging in patients with Chagas' disease: a marker of disease severity. J Am Coll Cardiol. 2005;46:1553–1558.
73. Weinsaft, J.W., Kim, H.W., Crowley, A.L., Klem, I., Shenoy, C., Van Assche, L. et al, LV thrombus detection by routine echocardiography: insights into performance characteristics using delayed enhancement CMR. JACC Cardiovasc Imaging. 2011;4:702–712.
74. Weinsaft, J.W., Kim, J., Medicherla, C.B., Ma, C.L., Codella, N.C., Kukar, N. et al, Echocardiographic algorithm for post-myocardial infarction LV thrombus: a gatekeeper for thrombus evaluation by delayed enhancement CMR. JACC Cardiovasc Imaging. 2016;9:505–515.
75. Arbab-Zadeh, A., Miller, J.M., Rochitte, C.E., Dewey, M., Niinuma, H., Gottlieb, I. et al, Diagnostic accuracy of computed tomography coronary angiography according to pre-test probability of coronary artery disease and severity of coronary arterial calcification. The CORE-64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography) international multicenter study. J Am Coll Cardiol. 2012;59:379–387.
76. Arreaza, N., Puigbó, J.J., Acquatella, H., Casal, H., Giordano, H., Valecillos, R. et al, Radionuclide evaluation of left-ventricular function in chronic Chagas' cardiomyopathy. J Nucl Med. 1983;24:563–567.
77. Bellido, C.A., Guibourg, H.C., Chwojnik, A., Marrero, H.G., Argento, R., Arce, L.C. Radioisotopic evaluation of left ventricular function in patients with Chagas disease Rev Clin Esp. 1984;172:279–281.
78. Kuschnir, E., Sgammini, H., Castro, R., Evequoz, C., Ledesma, R., Brunetto, J. Evaluation of cardiac function by radioisotopic angiography, in patients with chronic Chagas cardiopathy Arq Bras Cardiol. 1985;45:249–256.
79. Abuhid, I.M., Pedroso, E.R., Rezende, N.A. Scintigraphy for the detection of myocardial damage in the indeterminate form of Chagas disease. Arq Bras Cardiol. 2010;95:30–34.
80. Peix, A., García, R., Sánchez, J., Cabrera, L.O., Padrón, K., Vedia, O. et al, Myocardial perfusion imaging and cardiac involvement in the indeterminate phase of Chagas disease. Arq Bras Cardiol. 2013;100:114–117.
81. Hiss, F.C., Lascala, T.F., Maciel, B.C., Marin-Neto, J.A., Simões, M.V. Changes in myocardial perfusion correlate with deterioration of left ventricular systolic function in chronic Chagas' cardiomyopathy. JACC Cardiovasc Imaging. 2009;2:164–172.
82. Landesmann, M.C., da Fonseca, L.M., de B Pereira, B., do Nascimento, E.M., Rosado-de-Castro, P.H., de Souza, S.A. et al, Iodine-123 metaiodobenzylguanidine cardiac imaging as a method to detect early sympathetic neuronal dysfunction in Chagasic patients with normal or borderline electrocardiogram and preserved ventricular function. Clin Nucl Med. 2011;36:757–761.
83. Gadioli, L.P., Miranda, C.H., Pintya, A.O., de Figueiredo, A.B., Schmidt, A., Maciel, B.C. et al, The severity of ventricular arrhythmia correlates with the extent of myocardial sympathetic denervation, but not with myocardial fibrosis extent in chronic Chagas cardiomyopathy: Chagas disease, denervation and arrhythmia. J Nucl Cardiol. 2017; (In press).
84. Miranda, C.H., Figueiredo, A.B., Maciel, B.C., Marin-Neto, J.A., Simões, M.V. Sustained ventricular tachycardia is associated with regional myocardial sympathetic denervation assessed with 123I-metaiodobenzylguanidine in chronic Chagas cardiomyopathy. J Nucl Med. 2011;52:504–510.
85. Pazin-Filho, A., Romano, M.M., Gomes Furtado, R., de Almeida Filho, O.C., Schmidt, A., Marin-Neto, J.A. et al, Left ventricular global performance and diastolic function in indeterminate and cardiac forms of Chagas' disease. J Am Soc Echocardiogr. 2007;20:1338–1343.
86. Ribeiro, A.L., Nunes, M.P., Teixeira, M.M., Rocha, M.O. Diagnosis and management of Chagas disease and cardiomyopathy. Nat Rev Cardiol. 2012;9:576–589.
87. Nunes, M.C., Barbosa, M.M., Ribeiro, A.L., Colosimo, E.A., Rocha, M.O. Left atrial volume provides independent prognostic value in patients with Chagas cardiomyopathy. J Am Soc Echocardiogr. 2009;22:82–88.
88. Milei, J., Fernández Alonso, G., Vanzulli, S., Storino, R., Matturri, L., Rossi, L. Myocardial inflammatory infiltrate in human chronic Chagasic cardiomyopathy: Immunohistochemical findings. Cardiovasc Pathol. 1996;5:209–219.
89. Barros, M.L., Ribeiro, A., Nunes, M.C., Rocha, M.O. Association between left ventricular wall motion abnormalities and ventricular arrhythmia in the indeterminate form of Chagas disease Rev Soc Bras Med Trop. 2011;44:213–216.
90. Pazin-Filho, A., Romano, M.M., Almeida-Filho, O.C., Furuta, M.S., Viviani, L.F., Schmidt, A. et al, Minor segmental wall motion abnormalities detected in patients with Chagas' disease have adverse prognostic implications. Braz J Med Biol Res. 2006;39:483–487.
91. Oliveira, J.S., Mello De Oliveira, J.A., Frederigue, U., Lima Filho, E.C. Apical aneurysm of Chagas's heart disease. Br Heart J. 1981;46:432–437.
92. Carod-Artal, F.J., Gascon, J. Chagas disease and stroke. Lancet Neurol. 2010;9:533–542.
93. Nunes, M.C., Kreuser, L.J., Ribeiro, A.L., Sousa, G.R., Costa, H.S., Botoni, F.A. et al, Prevalence and risk factors of embolic cerebrovascular events associated with Chagas heart disease. Glob Heart. 2015;10:151–157.
94. Nunes, M.C., Barbosa, M.M., Rocha, M.O. Peculiar aspects of cardiogenic embolism in patients with Chagas' cardiomyopathy: a transthoracic and transesophageal echocardiographic study. J Am Soc Echocardiogr. 2005;18:761–767.
95. Arteaga-Fernández, E., Barretto, A.C., Ianni, B.M., Mady, C., Lopes, E.A., Vianna, C.B. et al, Cardiac thrombosis and embolism in patients having died of chronic Chagas cardiopathy Arq Bras Cardiol. 1989;52:189–192.
96. Samuel, J., Oliveira, M., Correa De Araujo, R.R., Navarro, M.A., Muccillo, G. Cardiac thrombosis and thromboembolism in chronic Chagas' heart disease. Am J Cardiol. 1983;52:147–151.
97. Picard, M.H., Popp, R.L., Weyman, A.E. Assessment of left ventricular function by echocardiography: a technique in evolution. J Am Soc Echocardiogr. 2008;21:14–21.
98. Pereira Nunes, M.C., Barbosa, M.M., Ribeiro, A.L., Amorim Fenelon, L.M., Rocha, M.O. Predictors of mortality in patients with dilated cardiomyopathy: relevance of Chagas disease as an etiological factor. Rev Esp Cardiol. 2010;63:788–797.
99. Mancuso, F.J., Almeida, D.R., Moisés, V.A., Oliveira, W.A., Mello, E.S., Poyares, D. et al, Left atrial dysfunction in Chagas cardiomyopathy is more severe than in idiopathic dilated cardiomyopathy: a study with real-time three-dimensional echocardiography. J Am Soc Echocardiogr. 2011;24:526–532.
100. Rassi, A., Rassi, S.G. Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation. 2007;115:1101–1108.
101. Nunes, M.C., Carmo, A.A., Rocha, M.O., Ribeiro, A.L. Mortality prediction in Chagas heart disease. Expert Rev Cardiovasc Ther. 2012;10:1173–1184.
102. Nunes, M.P., Colosimo, E.A., Reis, R.C., Barbosa, M.M., da Silva, J.L., Barbosa, F. et al, Different prognostic impact of the tissue Doppler-derived E/e′ ratio on mortality in Chagas cardiomyopathy patients with heart failure. J Heart Lung Transplant. 2012;31:634–641.
103. Caeiro, T., Amuchastegui, L.M., Moreyra, E., Gibson, D.G. Abnormal left ventricular diastolic function in chronic Chagas' disease: an echocardiographic study. Int J Cardiol. 1985;9:417–424.
104. Combellas, I., Puigbo, J.J., Acquatella, H., Tortoledo, F., Gomez, J.R. Echocardiographic features of impaired left ventricular diastolic function in Chagas's heart disease. Br Heart J. 1985;53:298–309.
105. Nagueh, S.F., Smiseth, O.A., Appleton, C.P., Byrd, B.F., Dokainish, H., Edvardsen, T. et al, Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277–314.
106. Migliore, R.A., Guerrero, F.T., Armenti, A., Fernández, C., Adaniya, M.E., Iannariello, J. et al, Diastolic function in Chagas diseaseMedicina (B Aires). 1990;50:537–542.
107. Barros, M.V., Rocha, M.O., Ribeiro, A.L., Machado, F.S. Doppler tissue imaging to evaluate early myocardium damage in patients with undetermined form of Chagas' disease and normal echocardiogram. Echocardiography. 2001;18:131–136.
108. Barros, M.V., Machado, F.S., Ribeiro, A.L., Rocha, M.O. Diastolic function in Chagas' disease: an echo and tissue Doppler imaging study. Eur J Echocardiogr. 2004;5:182–188.
109. Migliore, R.A., Adaniya, M.E., Tamagusuku, H., Lapuente, A. Assessment of diastolic function in Chagas disease with pulsed Doppler tissue imagingMedicina (B Aires). 2003;63:692–696.
110. Garcia-Alvarez, A., Sitges, M., Pinazo, M.J., Regueiro-Cueva, A., Posada, E., Poyatos, S. et al, Chagas cardiomyopathy: the potential of diastolic dysfunction and brain natriuretic peptide in the early identification of cardiac damage. PLoS Negl Trop Dis. 2010;:4.
111. Leong, D.P., Grover, S., Molaee, P., Chakrabarty, A., Shirazi, M., Cheng, Y.H. et al, Nonvolumetric echocardiographic indices of right ventricular systolic function: validation with cardiovascular magnetic resonance and relationship with functional capacity. Echocardiography. 2012;29:455–463.
112. Rudski, L.G., Lai, W.W., Afilalo, J., Hua, L., Handschumacher, M.D., Chandrasekaran, K. et al, Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685–713.
113. Moreira, H.T., Volpe, G.J., Marin-Neto, J.A., Nwabuo, C.C., Ambale-Venkatesh, B., Gali, L.G. et al, Right ventricular systolic dysfunction in Chagas disease defined by speckle-tracking echocardiography: a comparative study with cardiac magnetic resonance imaging. J Am Soc Echocardiogr. 2017;30:493–502.
114. Mady, C., de Moraes, A.V., Galiano, N., Décourt, L.V. Hemodynamic study of the indeterminate form of Chagas' disease Arq Bras Cardiol. 1982;38:271–275.
115. Marin-Neto, J.A., Bromberg-Marin, G., Pazin-Filho, A., Simões, M.V., Maciel, B.C. Cardiac autonomic impairment and early myocardial damage involving the right ventricle are independent phenomena in Chagas' disease. Int J Cardiol. 1998;65:261–269.
116. Nunes, M.C., Rocha, M.O., Ribeiro, A.L., Colosimo, E.A., Rezende, R.A., Carmo, G.A. et al, Right ventricular dysfunction is an independent predictor of survival in patients with dilated chronic Chagas' cardiomyopathy. Int J Cardiol. 2008;127:372–379.
117. Barros, M.V., Machado, F.S., Ribeiro, A.L. Da Costa Rocha MO. Detection of early right ventricular dysfunction in Chagas' disease using Doppler tissue imaging. J Am Soc Echocardiogr. 2002;15:1197–1201.
118. Furtado, R.G., Frota, D.C., Silva, J.B., Romano, M.M., Almeida Filho, O.C., Schmidt, A. et al, Right ventricular Doppler echocardiographic study of indeterminate form of Chagas disease. Arq Bras Cardiol. 2015;104:209–217.
119. Moreira, H.T., Volpe, G.J., Marin-Neto, J.A., Ambale-Venkatesh, B., Nwabuo, C.C., Trad, H.S. et al, Evaluation of right ventricular systolic function in Chagas disease using cardiac magnetic resonance imaging. Circ Cardiovasc Imaging. 2017;:10.
120. Parada, H., Carrasco, H.A., Añez, N., Fuenmayor, C., Inglessis, I. Cardiac involvement is a constant finding in acute Chagas' disease: a clinical, parasitological and histopathological study. Int J Cardiol. 1997;60:49–54.
121. Alarcón de Noya, B., Díaz-Bello, Z., Colmenares, C., Ruiz-Guevara, R., Mauriello, L., Zavala-Jaspe, R. et al, Large urban outbreak of orally acquired acute Chagas disease at a school in Caracas, Venezuela. J Infect Dis. 2010;201:1308–1315.
122. Guimarães, F.N., da Silva, N.N., Clausell, D.T., de Mello, A.L., Rapone, T., Snell, T. et al, Epidemic out-brake of Chaga's disease in Teutonia (Estrela-Rio Grande do Sul) probably due to gastrointestinal infectionHospital (Rio J). 1968;73:1767–1804.
123. Sartori, A.M., Shikanai-Yasuda, M.A., Amato Neto, V., Lopes, M.H. Follow-up of 18 patients with human immunodeficiency virus infection and chronic Chagas' disease, with reactivation of Chagas' disease causing cardiac disease in three patients. Clin Infect Dis. 1998;26:177–179.
124. Bastos, C.J., Aras, R., Mota, G., Reis, F., Dias, J.P., de Jesus, R.S. et al, Clinical outcomes of thirteen patients with acute Chagas disease acquired through oral transmission from two urban outbreaks in northeastern Brazil. PLoS Negl Trop Dis. 2010;4:e711.
125. Carme, B., Aune, I., Nguyen, G., Aznar, C., Beaudet, B. Four cases of acute Chagasic myocarditis in French Guiana. Am J Trop Med Hyg. 2001;64:162–163.
126. Pinto, A.Y., Valente, S.A., Valente, V.C. Emerging acute Chagas disease in Amazonian Brazil: case reports with serious cardiac involvement. Braz J Infect Dis. 2004;8:454–460.
127. Ribeiro, A.L., Rocha, M.O. Indeterminate form of Chagas disease: considerations about diagnosis and prognosis Rev Soc Bras Med Trop. 1998;31:301–314.
128. Teixeira, A.R., Hecht, M.M., Guimaro, M.C., Sousa, A.O., Nitz, N. Pathogenesis of Chagas' disease: parasite persistence and autoimmunity. Clin Microbiol Rev. 2011;24:592–630.
129. Dias, J.C. The indeterminate form of human chronic Chagas' disease: a clinical epidemiological review. Rev Soc Bras Med Trop. 1989;22:147–156.
130. Carrasco Guerra, H.A., Palacios-Prü, E., Dagert de Scorza, C., Molina, C., Inglessis, G., Mendoza, R.V. Clinical, histochemical, and ultrastructural correlation in septal endomyocardial biopsies from chronic Chagasic patients: detection of early myocardial damage. Am Heart J. 1987;113:716–724.
131. Maciel, B.C., de Almeida Filho, O.C., Schmidt, A., Marin-Neto, J.A. Ventricular function in Chagas' heart disease. Sao Paulo Med J. 1995;113:814–820.
132. Ortiz, J., Barretto, A.C., Matsumoto, A.Y., Mônaco, C.A., Ianni, B., Marotta, R.H. et al, Segmental contractility changes in the indeterminate form of Chagas' disease. Echocardiographic studyArq Bras Cardiol. 1987;49:217–220.
133. Martinelli Filho, M., De Siqueira, S.F., Moreira, H., Fagundes, A., Pedrosa, A., Nishioka, S.D. et al, Probability of occurrence of life-threatening ventricular arrhythmias in Chagas' disease versus non-Chagas' disease. Pacing Clin Electrophysiol. 2000;23:1944–1946.
134. Oliveira-Filho, J., Viana, L.C., Vieira-de-Melo, R.M., Faiçal, F., Torreão, J.A., Villar, F.A. et al, Chagas disease is an independent risk factor for stroke: baseline characteristics of a Chagas Disease cohort. Stroke. 2005;36:2015–2017.
135. Rassi, A., Rassi, S.G., Rassi, A. Sudden death in Chagas' disease. Arq Bras Cardiol. 2001;76:75–96.
136. Bestetti, R.B., Dalbo, C.M., Arruda, C.A., Correia Filho, D., Freitas, O.C. Predictors of sudden cardiac death for patients with Chagas' disease: a hospital-derived cohort study. Cardiology. 1996;87:481–487.
137. Carrasco, H.A., Guerrero, L., Parada, H., Molina, C., Vegas, E., Chuecos, R. Ventricular arrhythmias and left ventricular myocardial function in chronic Chagasic patients. Int J Cardiol. 1990;28:35–41.