Acute Heart Failure in a Young Patient: Cardiac MRI as the Diagnostic Key to Chagas Cardiomyopathy

Presenting Author(s)

• JA

  José Martín Alanís Naranjo, MD

  Cardiovascular Imaging Fellow
  Instituto Nacional de Cardiología Ignacio Chávez
  Mexico City, Mexico City, Mexico

Primary Author(s)

• JA

  José Martín Alanís Naranjo, MD

  Cardiovascular Imaging Fellow
  Instituto Nacional de Cardiología Ignacio Chávez
  Mexico City, Mexico City, Mexico

Co-Author(s)

• DC

  Daniel Campuzano

  médico
  instituto Nacional de Cardiología
  mexico, Mexico
• AR

  Ana Rosas, MD

  CMR and CT consultant
  CT Scanner Lomas Altas
  Mexico city, Distrito Federal, Mexico
• RS

  Rafael Wilse Sanez Reyes, MD

  Cardiovascular Imaging Fellow
  Instituto Nacional de Cardiología Ignacio Chávez, Mexico
• MC

  Miguel Ángel Cruz Marmolejo, MD

  Cardiovascular Imaging Specialist
  Instituto Nacional de Cardiología Ignacio Chávez, Mexico
• SP

  Sergio Alfonso Patron-Chi, MD

  Pediatric Cardiology and Cardiovascular Imaging
  National Institute of Cardiology, Distrito Federal, Mexico
• AM

  Aloha Meave gonzalez, MD

  Chair cardiac magnetic resonance
  Instituto Nacional de Cardiología Ignacio Chávez
  Mexico city, Distrito Federal, Mexico

Description of Clinical Presentation: A 37-year-old man from an urban area in central Mexico presented with progressive dyspnea on minimal exertion and increasing lower limb edema over 4 weeks. Clinical assessment revealed no history of comorbidities, pre-existing cardiovascular disease, or significant family history. On examination, auscultation detected holosystolic murmurs at the mitral and tricuspid areas. Blood tests showed NT-proBNP of 26,706 pg/ml (reference value < 115 pg/ml). ECG demonstrated sinus rhythm, isolated premature ventricular contractions, and signs of left ventricular hypertrophy. Bedside transthoracic echocardiography demonstrated global dilation of all cardiac chambers, severe mitral and tricuspid regurgitation, and a markedly reduced LVEF of 19% (Fig 1A). Initiation of diuretic therapy resulted in clinical improvement. CMR showed severe biventricular systolic dysfunction (Fig 1B-D) accompanied by a diffuse ischemic pattern of LGE involving 46% of the LV mass. Coronary computed tomography angiography ruled out significant coronary artery disease (Fig 1E-F). Serological analysis confirmed infection with Trypanosoma cruzi. Management included implantation of a cardioverter-defibrillator followed by listing for heart transplantation.

Diagnostic Techniques and Their Most Important Findings: Cardiac Magnetic Resonance (Fig 2-3):

• Transmural infarction in the right coronary and circumflex territories; subendocardial infarction in the left anterior descending territory.


• LGE burden: 57 g (46% of LV mass).


• Left ventricular systolic dysfunction: LVEF 17%, global longitudinal strain −5.6%, global circumferential strain −4.1%.


• Right ventricular dilatation with severe systolic dysfunction (RVEF 21%).


• Severe mitral regurgitation; mild tricuspid and pulmonary regurgitation.


• No evidence of intracavitary thrombi.


• Elevated T1 mapping values in the lateral wall across all three segments (1,124 ms) and increased extracellular volume (38%).

Learning Points from this Case:

• CMR stands as the leading imaging modality in the evaluation of biventricular function and myocardial tissue characteristics in cardiomyopathy, while also providing valuable insight into the underlying cause.


• Non-endemic countries and low-prevalence areas report a growing number of Chagas cardiomyopathy cases, raising concerns about limited medical awareness.


• In Chagas cardiomyopathy, CMR enables risk stratification and guides therapeutic decisions. Established techniques such as LGE and myocardial strain yield clinically meaningful information for assessing arrhythmic risk, heart failure severity, and the need for advanced interventions.


• Among young patients presenting with acute heart failure and epidemiological risk factors for Chagas disease, use of CMR enhances diagnostic precision and supports individualized treatment planning.

Figure 1. Initial evaluation. (A) Transthoracic echocardiography showing global cardiac chamber dilatation with severe mitral and tricuspid regurgitation. Cardiac magnetic resonance imaging demonstrating chamber dilatation: (B) Four-chamber cine view in diastole, (C) Four-chamber cine view in systole with severe mitral regurgitation, (D) Short-axis cine view. Cardiac computed tomography angiography ruling out coronary artery disease: (E) Short-axis view with biventricular dilatation, (F) Volume rendering technique 3D reconstruction, (G) Curved multiplanar reformation.
Figure 2. Cardiac magnetic resonance. (A) Balanced steady-state free precession cine short-axis view. (B) Elevated native T1 mapping values in the lateral wall across all three segments (1,124 ms). (C) Post-contrast T1 mapping showing an extracellular volume of 38%. (D) T2 mapping within the normal range. (E) T2* mapping within the normal range. (F) Short-axis first-pass perfusion demonstrating normal myocardial perfusion. Phase-sensitive inversion-recovery sequence showing LGE with transmural enhancement in the anterior, lateral, and inferior walls: (G) Four-chamber view, (H) Short-axis view.
Figure 3. Myocardial strain evaluation with feature tracking technique. (A–B) Circumferential strain. (C–D) Longitudinal strain.