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Dhore-Patil A, Modi V, Gabr EM, Bersali A, Darwish A, Shah D. Cardiac magnetic resonance findings in cardiac amyloidosis. Curr Opin Cardiol 2024; 39:395-406. [PMID: 38963426 DOI: 10.1097/hco.0000000000001166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the increasing importance of cardiac magnetic resonance (CMR) imaging in diagnosing and managing cardiac amyloidosis, especially given the recent advancements in treatment options. RECENT FINDINGS This review emphasizes the crucial role of late gadolinium enhancement (LGE) with phase-sensitive inversion recovery (PSIR) techniques in both diagnosing and predicting patient outcomes in cardiac amyloidosis. The review also explores promising new techniques for diagnosing early-stage disease, such as native T1 mapping and ECV quantification. Additionally, it delves into experimental techniques like diffusion tensor imaging, MR elastography, and spectroscopy. SUMMARY This review underscores CMR as a powerful tool for diagnosing cardiac amyloidosis, assessing risk factors, and monitoring treatment response. While LGE imaging remains the current best practice for diagnosis, emerging techniques such as T1 mapping and ECV quantification offer promise for improved detection, particularly in early stages of the disease. This has significant implications for patient management as newer therapeutic options become available for cardiac amyloidosis.
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Affiliation(s)
- Aneesh Dhore-Patil
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, Houston, Texas, USA
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Albulushi A, Al Hajri R, Hovseth C, Jawa Z, El Hadad MG, Sallam M, Al-Mukhaini M. Advancements and challenges in cardiac amyloidosis imaging: A comprehensive review of novel techniques and clinical applications. Curr Probl Cardiol 2024; 49:102733. [PMID: 38955249 DOI: 10.1016/j.cpcardiol.2024.102733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024]
Abstract
Cardiac amyloidosis, characterized by amyloid fibril deposition in the myocardium, leads to restrictive cardiomyopathy and heart failure. This review explores recent advancements in imaging techniques for diagnosing and managing cardiac amyloidosis, highlighting their clinical applications, strengths, and limitations. Echocardiography remains a primary, non-invasive imaging modality but lacks specificity. Cardiac MRI (CMR), with Late Gadolinium Enhancement (LGE) and T1 mapping, offers superior tissue characterization, though at higher costs and limited availability. Scintigraphy with Tc-99m-PYP reliably diagnoses transthyretin (TTR) amyloidosis but is less effective for light chain (AL) amyloidosis, necessitating complementary diagnostics. Amyloid-specific PET tracers, such as florbetapir and flutemetamol, provide precise imaging and quantitative assessment for both TTR and AL amyloidosis. Challenges include differentiating between TTR and AL amyloidosis, early disease detection, and standardizing imaging protocols. Future research should focus on developing novel tracers, integrating multimodality imaging, and leveraging AI to enhance diagnostic accuracy and personalized treatment. Advancements in imaging have improved cardiac amyloidosis management. A multimodal approach, incorporating echocardiography, CMR, scintigraphy, and PET tracers, offers comprehensive assessment. Continued innovation in tracers and AI applications promises further enhancements in diagnosis, early detection, and patient outcomes.
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Affiliation(s)
- Arif Albulushi
- Department of Adult Cardiology, National Heart Center, The Royal Hospital, Muscat, Oman.
| | - Ruqaya Al Hajri
- Department of Adult Cardiology, National Heart Center, The Royal Hospital, Muscat, Oman
| | - Chad Hovseth
- Division of Cardiovascular Medicine, Nebraska Medicine, Omaha, NE, USA
| | - Zabah Jawa
- Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Mansour Sallam
- Division of Cardiology, Armed Forces Hospital, Muscat, Oman
| | - Mohammed Al-Mukhaini
- Department of Adult Cardiology, National Heart Center, The Royal Hospital, Muscat, Oman
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3
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Westermark P, Merlini G. Successes in translation. Amyloid 2024:1-9. [PMID: 39101820 DOI: 10.1080/13506129.2024.2387163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/11/2024] [Accepted: 07/27/2024] [Indexed: 08/06/2024]
Abstract
Translational research is key in advancing the diagnosis and therapy of systemic amyloidoses. This paper summarises our presentations at the ISA Workshop on Translation in Systemic Amyloidoses held in Athens on September 25-26, 2023. The critical advances made by the pioneers in the field are reviewed, with particular attention to the discoveries and developments of utmost importance to our understanding of what amyloid is and how the substance affects functions. Examples of translational research regarding the mechanisms of cardiac damage in light chain amyloidosis, the role of biomarkers in improving our understanding of the biology of the disease and patients' management, and the molecular mechanisms involved in the cytotoxicity are described. Advances in basic research continue to open new therapeutic avenues.
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Affiliation(s)
- Per Westermark
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Giampaolo Merlini
- Department of Molecular Medicine, Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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Small GR. Myocardial extracellular volume by CT: Assessing the state of the union. J Cardiovasc Comput Tomogr 2024:S1934-5925(24)00402-7. [PMID: 39098511 DOI: 10.1016/j.jcct.2024.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 07/30/2024] [Indexed: 08/06/2024]
Affiliation(s)
- Gary R Small
- Division of Cardiology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Barison A, Gueli IA, Pizzino F, Grigoratos C, Todiere G. Cardiovascular Magnetic Resonance in the Management of Cardiac Amyloidosis: Current and Future Clinical Applications. Heart Fail Clin 2024; 20:295-305. [PMID: 38844300 DOI: 10.1016/j.hfc.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Cardiac magnetic resonance represents the gold standard imaging technique to assess cardiac volumes, wall thickness, mass, and systolic function but also to provide noninvasive myocardial tissue characterization across almost all cardiac diseases. In patients with cardiac amyloidosis, increased wall thickness of all heart chambers, a mildly reduced ejection fraction and occasionally pleural and pericardial effusion are the characteristic morphologic anomalies. The typical pattern after contrast injection is represented by diffuse areas of late gadolinium enhancement, which can be focal and patchy in very early stages, circumferential, and subendocardial in intermediate stages or even diffuse transmural in more advanced stages.
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Affiliation(s)
- Andrea Barison
- Department of Cardiology and Cardiovascular Medicine, Fondazione "Gabriele Monasterio" CNR - Regione Toscana, Via Moruzzi, 1, Pisa 56124, Italy; Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, Pisa 56127, Italy.
| | - Ignazio Alessio Gueli
- Department of Cardiology and Cardiovascular Medicine, Fondazione "Gabriele Monasterio" CNR - Regione Toscana, Via Moruzzi, 1, Pisa 56124, Italy; Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, Pisa 56127, Italy
| | - Fausto Pizzino
- Ospedale del Cuore, Fondazione "Gabriele Monasterio" CNR - Regione Toscana, Via Aurelia Sud, Massa 54100, Italy
| | - Chrysanthos Grigoratos
- Department of Cardiology and Cardiovascular Medicine, Fondazione "Gabriele Monasterio" CNR - Regione Toscana, Via Moruzzi, 1, Pisa 56124, Italy
| | - Giancarlo Todiere
- Department of Cardiology and Cardiovascular Medicine, Fondazione "Gabriele Monasterio" CNR - Regione Toscana, Via Moruzzi, 1, Pisa 56124, Italy
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Tore D, Faletti R, Palmisano A, Salto S, Rocco K, Santonocito A, Gaetani C, Biondo A, Bozzo E, Giorgino F, Landolfi I, Menchini F, Esposito A, Fonio P, Gatti M. Cardiac computed tomography with late contrast enhancement: A review. Heliyon 2024; 10:e32436. [PMID: 38933964 PMCID: PMC11200357 DOI: 10.1016/j.heliyon.2024.e32436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/19/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Cardiac computed tomography (CCT) has assumed an increasingly significant role in the evaluation of coronary artery disease (CAD) during the past few decades, whereas cardiovascular magnetic resonance (CMR) remains the gold standard for myocardial tissue characterization. The discovery of late myocardial enhancement following intravenous contrast administration dates back to the 1970s with ex-vivo CT animal investigations; nevertheless, the clinical application of this phenomenon for cardiac tissue characterization became prevalent for CMR imaging far earlier than for CCT imaging. Recently the technical advances in CT scanners have made it possible to take advantage of late contrast enhancement (LCE) for tissue characterization in CCT exams. Moreover, the introduction of extracellular volume calculation (ECV) on cardiac CT images combined with the possibility of evaluating cardiac function in the same exam is making CCT imaging a multiparametric technique more and more similar to CMR. The aim of our review is to provide a comprehensive overview on the role of CCT with LCE in the evaluation of a wide range of cardiac conditions.
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Affiliation(s)
- Davide Tore
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Anna Palmisano
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Salto
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Katia Rocco
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Ambra Santonocito
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Clara Gaetani
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Andrea Biondo
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Elena Bozzo
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Fabio Giorgino
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Ilenia Landolfi
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesca Menchini
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Fonio
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute e Della Scienza di Torino, University of Turin, Turin, Italy
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Grazzini G, Pradella S, Bani R, Fornaciari C, Cappelli F, Perfetto F, Cozzi D, Giovannelli S, Sica G, Miele V. The Role of T2 Mapping in Cardiac Amyloidosis. Diagnostics (Basel) 2024; 14:1048. [PMID: 38786346 PMCID: PMC11120592 DOI: 10.3390/diagnostics14101048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/14/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy divided into two types: light-chain (LA) and transthyretin (ATTR) CA. Cardiac magnetic resonance (CMR) has emerged as an important diagnostic tool in CA. While late gadolinium enhancement (LGE), T1 mapping and extracellular volume (ECV) have a consolidate role in the assessment of CA, T2 mapping has been less often evaluated. We aimed to test the value of T2 mapping in the evaluation of CA. This study recruited 70 patients with CA (51 ATTR, 19 AL). All the subjects underwent 1.5 T CMR with T1 and T2 mapping and cine and LGE imaging. Their QALE scores were evaluated. The myocardial T2 values were significantly (p < 0.001) increased in both types of CA compared to the controls. In the AL-CA group, increased T2 values were associated with a higher QALE score. The myocardial native T1 values and ECV were significantly (p < 0.001) higher in the CA patients than in the healthy subjects. Left ventricular (LV) mass, QALE score and ECV were higher in ATTR amyloidosis compared with AL amyloidosis, while the LV ejection fraction was lower (p < 0.001). These results support the concept of the presence of myocardial edema in CA. Therefore, a CMR evaluation including not only myocardial T1 imaging but also myocardial T2 imaging allows for more comprehensive tissue characterization in CA.
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Affiliation(s)
- Giulia Grazzini
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Silvia Pradella
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Rossella Bani
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Chiara Fornaciari
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Francesco Cappelli
- Regional Amyloid Center, Azienda Ospedaliero Universitaria Careggi, Largo Piero Palagi 1, 50134 Florence, Italy
| | - Federico Perfetto
- Regional Amyloid Center, Azienda Ospedaliero Universitaria Careggi, Largo Piero Palagi 1, 50134 Florence, Italy
| | - Diletta Cozzi
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Simona Giovannelli
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Giacomo Sica
- Department of Radiology, Monaldi Hospital, Azienda Ospedaliera dei Colli, 80131 Naples, Italy
| | - Vittorio Miele
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
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Maggialetti N, Torrente A, Lorusso G, Villanova I, Ficco M, Gravina M, Ferrari C, Giordano L, Granata V, Rubini D, Lucarelli NM, Stabile Ianora AA, Scardapane A. Role of Cardiovascular Magnetic Resonance in Cardiac Amyloidosis: A Narrative Review. J Pers Med 2024; 14:407. [PMID: 38673034 PMCID: PMC11051560 DOI: 10.3390/jpm14040407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 03/31/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Amyloidosis is a rare infiltrative condition resulting from the extracellular accumulation of amyloid fibrils at the cardiac level. It can be an acquired condition or due to genetic mutations. With the progression of imaging technologies, a non-invasive diagnosis was proposed. In this study, we discuss the role of CMR in cardiac amyloidosis, focusing on the two most common subtypes (AL and ATTR), waiting for evidence-based guidelines to be published.
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Affiliation(s)
- Nicola Maggialetti
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Andrea Torrente
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Giovanni Lorusso
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Ilaria Villanova
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Michele Ficco
- U.O.C. Radiologia, P.O. San Paolo, ASL Bari, 70123 Bari, Italy
| | - Matteo Gravina
- Radiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Cristina Ferrari
- Section of Nuclear Medicine, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Luca Giordano
- U.O.C. Radiodiagnostica, Ospedaliera Vito Fazzi, 73100 Lecce, Italy
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Dino Rubini
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy
| | - Nicola Maria Lucarelli
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Amato Antonio Stabile Ianora
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Arnaldo Scardapane
- Sperimental Medicine Department, University of Salento, 73100 Lecce, Italy
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Pagura L, Porcari A, Cameli M, Biagini E, Canepa M, Crotti L, Imazio M, Forleo C, Pavasini R, Limongelli G, Perlini S, Metra M, Boriani G, Emdin M, Sinagra G, Merlo M. ECG/echo indexes in the diagnostic approach to amyloid cardiomyopathy: A head-to-head comparison from the AC-TIVE study. Eur J Intern Med 2024; 122:68-77. [PMID: 37858441 DOI: 10.1016/j.ejim.2023.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND AND AIMS The discordance between QRS voltages on electrocardiogram (ECG) and left ventricle (LV) wall thickness (LVWT) on echocardiogram (echo) is a recognized red flag (RF) of amyloid cardiomyopathy (AC) and can be measured by specific indexes. No head-to-head comparison of different ECG/echo indexes among subjects with echocardiographic suspicion of AC has yet been undertaken. The study aimed at evaluating the performance and the incremental diagnostic value of different ECG/echo indexes in this subset of patients. METHODS Electrocardiograms of subjects with LV hypertrophy, preserved ejection fraction and ≥ 1 echocardiographic RF of AC participating in the AC-TIVE study, an Italian prospective multicenter study, were independently analyzed by two cardiologists. Low QRS voltages and 8 different ECG/echo indexes were evaluated. Cohort specific cut-offs were computed. RESULTS Among 170 patients, 55 (32 %) were diagnosed with AC. Combination of low QRS voltages with interventricular septum ≥ 1,6 cm was the most specific (specificity 100 %, positive predictive value 100 %) ECG/echo index, while the ratio between the sum of all QRS voltages and LVWT <7,8 was the most sensitive and accurate (sensitivity 94 %, negative predictive value 97 %, accuracy 82 %). When the latter index was added to a model using easily-accessible clinical variables, the diagnostic accuracy for AC greatly increased (AUC from 0,84 to 0,95; p = 0,007). CONCLUSIONS Among patients with non-dilated hypertrophic ventricles with normal ejection fraction and echocardiographic RF of AC, easily-measurable ECG/echo indexes, mainly when added to few clinical variables, can help the physician orient second level investigations. External validation of the results is warranted.
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Affiliation(s)
- Linda Pagura
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Via P. Valdoni 7, Trieste 34100, Italy; Cardiac Surgery, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Via P. Valdoni 7, Trieste 34100, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Elena Biagini
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Canepa
- Department of Internal Medicine, University of Genoa, Genoa, Italy; Cardiovascular Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Lia Crotti
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Massimo Imazio
- Cardiology and Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", ASUFC, Udine and Department of Medicine, University of Udine, Italy; Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza di Torino Hospital, University of Turin, Turin, Italy
| | - Cinzia Forleo
- University Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Polyclinic University Hospital, Bari, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Giuseppe Limongelli
- Department of Translational Medical Sciences, Inherited and Rare Heart Disease, Vanvitelli Cardiology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Stefano Perlini
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Via P. Valdoni 7, Trieste 34100, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Via P. Valdoni 7, Trieste 34100, Italy.
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He X, Wang M, Sun J, Yu Z, Hu X, Liu Y, Lin X. Characterization of Transthyretin Mutation G47V Associated with Hereditary Cardiac Amyloidosis. Cardiology 2024; 149:383-395. [PMID: 38437799 PMCID: PMC11309070 DOI: 10.1159/000538081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/30/2024] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Amyloidosis caused by TTR mutations (ATTRv) is a rare inherited and autosomal dominant disease. More than 150 mutants of TTR have been reported, whereas some of them remain to be investigated. METHODS A 52-year-old male presented with heart failure and clinically diagnosed ATTR cardiac amyloidosis (ATTR-CA) was recruited. Whole-exome sequencing (WES) was performed. Biochemical and biophysical experiments characterized protein stability using urea-mediated tryptophan fluorescence. Drug response was analyzed by fibril formation assay. Finally, tetramer TTR concentration in patient's serum sample was measured by ultra-performance liquid chromatography (UPLC). RESULTS For the proband, WES revealed a mutation (c.200G>T; p.Gly67Val and referred to as G47V) in TTR gene. Biochemical and biophysical kinetics study showed that the thermodynamic stability of G47V-TTR (Cm = 2.4 m) was significantly lower than that of WT-TTR (Cm = 3.4 m) and comparable to that of L55P-TTR (Cm = 2.3 m), an early age-of-onset mutation. G47V:WT-TTR heterozygous tetramer kinetic stability (t1/2 = 1.4 h) was further compromised compared to that of the homozygous G47V-TTR (t1/2 = 3.1 h). Among three small molecule stabilizers, AG10 exhibited the best inhibition of the fibrillation of G47V-TTR homozygous protein. Using a UPLC assay, nearly 40% of TTR in this patient was calculated to be non-tetrameric. CONCLUSION In this work, we reported a patient presented early onset of clinically typical ATTR-CA due to G47V-TTR mutation. Our work for the first time not only characterized the biochemical properties of G47V-TTR mutation, but also provided hints for the pathogenicity of this mutation.
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Affiliation(s)
- Xiaopeng He
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mengdie Wang
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Science, Dalian, China
- Department of Chemistry, University of Chinese Academy of Sciences, Beijing, China
| | - Jialu Sun
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Science, Dalian, China
| | - Zhengyang Yu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu Liu
- CAS Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Science, Dalian, China
| | - Xiaoping Lin
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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11
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Razvi Y, Ioannou A, Patel RK, Chacko L, Karia N, Riefolo M, Porcari A, Rauf MU, Starr N, Ganesananthan S, Blakeney I, Kaza N, Filisetti S, Bolhuis RE, Rowczenio D, Gilbertson J, Hutt D, Mahmood S, Lachmann HJ, Wechalekar AD, Kotecha T, Knight DS, Coghlan JG, Petrie A, Whelan CJ, Venneri L, Martinez-Naharro A, Hawkins P, Fontana M, Gillmore JD. Deep phenotyping of p.(V142I)-associated variant transthyretin amyloid cardiomyopathy: Distinct from wild-type transthyretin amyloidosis? Eur J Heart Fail 2024; 26:383-393. [PMID: 37953725 DOI: 10.1002/ejhf.3088] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/26/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized cause of heart failure. A total of 3-4% of individuals of African descent carry a TTR gene mutation encoding the p.(V142I) variant, a powerful risk factor for development of variant ATTR-CM (ATTRv-CM); this equates to 1.6 million carriers in the United States. We undertook deep phenotyping of p.(V142I)-ATTRv-CM and comparison with wild-type ATTR-CM (ATTRwt-CM). METHODS AND RESULTS A retrospective study of 413 patients with p.(V142I) ATTRv-CM who attended the UK National Amyloidosis Centre (NAC) was conducted. Patients underwent evaluation at time of diagnosis, including clinical, echocardiography, and biomarker analysis; a subgroup had cardiac magnetic resonance (CMR) imaging. A total of 413 patients with ATTRwt-CM, matched for independent predictors of prognosis (age, NAC Stage, decade of first presentation), were used as a comparator group. At time of diagnosis, patients with ATTRv-CM had significant functional impairment by New York Heart Association classification (NHYA class ≥ III; 38%) and 6-min walk test distance (median 276 m). Median 5-year survival in ATTRv-CM patients was 31 versus 59 months in matched patients with ATTRwt-CM (p < 0.001). Patients with ATTRv-CM had significant impairment of functional parameters by echocardiography including biventricular impairment, high burden of regurgitant valvular disease and low cardiac output. Multivariable analysis revealed the prognostic importance of right ventricular dysfunction. CMR and histological analysis revealed myocyte atrophy and widespread myocardial infiltration in ATTRv-CM. CONCLUSION p.(V142I)-ATTRv-CM has an aggressive phenotype characterized by myocyte loss and widespread myocardial infiltration which may account for frequent biventricular failure and poor prognosis in this ATTR-CM genotypic subgroup.
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Affiliation(s)
- Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Rishi K Patel
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Liza Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | - Mattia Riefolo
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Muhammad Umaid Rauf
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Neasa Starr
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | - Iona Blakeney
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | - Stefano Filisetti
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Roos Eline Bolhuis
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Janet Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - David Hutt
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | | | | | - Aviva Petrie
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Carol J Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Phillip Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
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12
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Chacko L, Kotecha T, Ioannou A, Patel N, Martinez-Naharro A, Razvi Y, Patel R, Massa P, Venneri L, Brown J, Porcari A, Knott K, Manisty C, Knight D, Lockie T, Rakhit R, Lachmann H, Wechelakar A, Whelan C, Ponticos M, Moon J, González A, Gilbertson J, Riefolo M, Leone O, Xue H, Hawkins P, Kellman P, Gillmore J, Fontana M. Myocardial perfusion in cardiac amyloidosis. Eur J Heart Fail 2024. [PMID: 38247182 DOI: 10.1002/ejhf.3137] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/07/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
AIMS Cardiac involvement is the main driver of clinical outcomes in systemic amyloidosis and preliminary studies support the hypothesis that myocardial ischaemia contributes to cellular damage. The aims of this study were to assess the presence and mechanisms of myocardial ischaemia using cardiovascular magnetic resonance (CMR) with multiparametric mapping and histopathological assessment. METHODS AND RESULTS Ninety-three patients with cardiac amyloidosis (CA) (light-chain amyloidosis n = 42, transthyretin amyloidosis n = 51) and 97 without CA (three-vessel coronary disease [3VD] n = 47, unobstructed coronary arteries n = 26, healthy volunteers [HV] n = 24) underwent quantitative stress perfusion CMR with myocardial blood flow (MBF) mapping. Twenty-four myocardial biopsies and three explanted hearts with CA were analysed histopathologically. Stress MBF was severely reduced in patients with CA with lower values than patients with 3VD, unobstructed coronary arteries and HV (CA: 1.04 ± 0.51 ml/min/g, 3VD: 1.35 ± 0.50 ml/min/g, unobstructed coronary arteries: 2.92 ± 0.52 ml/min/g, HV: 2.91 ± 0.73 ml/min/g; CA vs. 3VD p = 0.011, CA vs. unobstructed coronary arteries p < 0.001, CA vs. HV p < 0.001). Myocardial perfusion abnormalities correlated with amyloid burden, systolic and diastolic function, structural parameters and blood biomarkers (p < 0.05). Biopsies demonstrated abnormal vascular endothelial growth factor staining in cardiomyocytes and endothelial cells, which may be related to hypoxia conditions. Amyloid infiltration in intramural arteries was associated with severe lumen reduction and severe reduction in capillary density. CONCLUSION Cardiac amyloidosis is associated with severe inducible myocardial ischaemia demonstrable by histology and CMR stress perfusion mapping. Histological evaluation indicates a complex pathophysiology, where in addition to systolic and diastolic dysfunction, amyloid infiltration of the epicardial arteries and disruption and rarefaction of the capillaries play a role in contributing to myocardial ischaemia.
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Affiliation(s)
- Liza Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Tushar Kotecha
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Niket Patel
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Rishi Patel
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Paolo Massa
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola Hospital, Bologna, Italy
| | - Lucia Venneri
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - James Brown
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Kristopher Knott
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, London, UK
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, UK
| | - Daniel Knight
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Tim Lockie
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Roby Rakhit
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Helen Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Carol Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
| | - Markella Ponticos
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - James Moon
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, London, UK
| | - Arantxa González
- Division of Cardiovascular Sciences, University of Navarra, Pamplona, Spain
| | - Janet Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Mattia Riefolo
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Ornella Leone
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Hui Xue
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Philip Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Julian Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Royal Free Hospital NHS Foundation Trust, London, UK
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13
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Kottam A, Hanneman K, Schenone A, Daubert MA, Sidhu GD, Gropler RJ, Garcia MJ. State-of-the-Art Imaging of Infiltrative Cardiomyopathies: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2023; 16:e000081. [PMID: 37916407 DOI: 10.1161/hci.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Infiltrative cardiomyopathies comprise a broad spectrum of inherited or acquired conditions caused by deposition of abnormal substances within the myocardium. Increased wall thickness, inflammation, microvascular dysfunction, and fibrosis are the common pathological processes that lead to abnormal myocardial filling, chamber dilation, and disruption of conduction system. Advanced disease presents as heart failure and cardiac arrhythmias conferring poor prognosis. Infiltrative cardiomyopathies are often diagnosed late or misclassified as other more common conditions, such as hypertrophic cardiomyopathy, hypertensive heart disease, ischemic or other forms of nonischemic cardiomyopathies. Accurate diagnosis is also critical because clinical features, testing methodologies, and approach to treatment vary significantly even within the different types of infiltrative cardiomyopathies on the basis of the type of substance deposited. Substantial advances in noninvasive cardiac imaging have enabled accurate and early diagnosis. thereby eliminating the need for endomyocardial biopsy in most cases. This scientific statement discusses the role of contemporary multimodality imaging of infiltrative cardiomyopathies, including echocardiography, nuclear and cardiac magnetic resonance imaging in the diagnosis, prognostication, and assessment of response to treatment.
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14
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Baghaee M, Mohammadi M, Moradi A, Ghadirzadeh E, Karimi H, Ghorbani P, Rajabnia M, Forootan M. Unusual presentation of transthyretin (ATTR) cardiac amyloidosis: A case report of pruritus as a possible initial symptom and challenging diagnosis. Clin Case Rep 2023; 11:e7883. [PMID: 37675414 PMCID: PMC10477467 DOI: 10.1002/ccr3.7883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/19/2023] [Accepted: 08/25/2023] [Indexed: 09/08/2023] Open
Abstract
Key Clinical Message This case emphasizes the significance of cardiac amyloidosis as a potential diagnosis in individuals manifesting with lesion-free pruritus and normal liver tests. Abstract Amyloidosis is a complex disorder in which misfolded proteins accumulate in various organs of the body. Cardiac amyloidosis (CA) can lead to heart failure, cardiac arrhythmia, sudden cardiac death, and deposition of proteins in coronary arteries. Diagnosing CA can be difficult, as the cardiac manifestations of amyloidosis can be similar to more prevalent etiologies. In addition, the accumulation of proteins in soft tissues, including the skin, can cause pruritus. In this paper, we present a 70-year-old man with generalized pruritus and no skin lesions, later diagnosed as CA after detecting ascites fluid. This case underscores the importance of considering amyloidosis in patients presenting with nonspecific symptoms, particularly those affecting the skin, and highlights the need for increased awareness of this disease among clinicians.
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Affiliation(s)
- Massood Baghaee
- Gastroenterology and Liver Diseases Research CenterResearch Institute for Gastroenterology and Liver Diseases, Guilan University of Medical SciencesRashtIran
| | - Mahsa Mohammadi
- Gastroenterology and Liver Diseases Research CenterResearch Institute for Gastroenterology and Liver Diseases, Guilan University of Medical SciencesRashtIran
| | - Amir Moradi
- Atherosclerosis Research CenterJundishapur University of Medical SciencesAhvazIran
| | - Erfan Ghadirzadeh
- Cardiovascular Research CenterMazandaran University of Medical SciencesSariIran
| | - Hanie Karimi
- School of Medicine, Tehran University of Medical SciencesTehranIran
| | - Parastoo Ghorbani
- Department of Internal Medicine, Faculty of MedicineMazandaran University of Medical SciencesSariIran
| | - Mohsen Rajabnia
- Non‐Communicable Diseases Research Center, Alborz University of Medical SciencesKarajIran
| | - Mojgan Forootan
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical SciencesTehranIran
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15
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Affiliation(s)
- Sarah A M Cuddy
- Cardiac Amyloidosis Program, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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16
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Moody WE, Turvey-Haigh L, Knight D, Coats CJ, Cooper RM, Schofield R, Robinson S, Harkness A, Oxborough DL, Gillmore JD, Whelan C, Augustine DX, Fontana M, Steeds RP. British Society of Echocardiography guideline for the transthoracic echocardiographic assessment of cardiac amyloidosis. Echo Res Pract 2023; 10:13. [PMID: 37653443 PMCID: PMC10468878 DOI: 10.1186/s44156-023-00028-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
These guidelines form an update of the BSE guideline protocol for the assessment of restrictive cardiomyopathy (Knight et al. in Echo Res Prac, 2013). Since the original recommendations were conceived in 2013, there has been an exponential rise in the diagnosis of cardiac amyloidosis fuelled by increased clinician awareness, improvements in cardiovascular imaging as well as the availability of new and effective disease modifying therapies. The initial diagnosis of cardiac amyloidosis can be challenging and is often not clear-cut on the basis of echocardiography, which for most patients presenting with heart failure symptoms remains the first-line imaging test. The role of a specialist echocardiographer will be to raise the suspicion of cardiac amyloidosis when appropriate, but the formal diagnosis of amyloid sub-type invariably requires further downstream testing. This document seeks to provide a focused review of the literature on echocardiography in cardiac amyloidosis highlighting its important role in the diagnosis, prognosis and screening of at risk individuals, before concluding with a suggested minimum data set, for use as an aide memoire when reporting.
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Affiliation(s)
- William E Moody
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK.
- Institute of Cardiovascular Science, College of Medical and Dental Science, University of Birmingham, Birmingham, UK.
| | - Lauren Turvey-Haigh
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK
| | - Daniel Knight
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | | | - Robert M Cooper
- Liverpool Heart and Chest Hospital, Liverpool, UK
- Liverpool John Moores University, Liverpool, UK
| | | | | | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - David L Oxborough
- Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Carol Whelan
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department For Health, University of Bath, Bath, UK
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Richard P Steeds
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK
- Institute of Cardiovascular Science, College of Medical and Dental Science, University of Birmingham, Birmingham, UK
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17
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Tore D, Faletti R, Gaetani C, Bozzo E, Biondo A, Carisio A, Menchini F, Miccolis M, Papa FP, Trovato M, Fonio P, Gatti M. Cardiac magnetic resonance of hypertrophic heart phenotype: A review. Heliyon 2023; 9:e17336. [PMID: 37441401 PMCID: PMC10333467 DOI: 10.1016/j.heliyon.2023.e17336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 06/05/2023] [Accepted: 06/14/2023] [Indexed: 07/15/2023] Open
Abstract
Hypertrophic heart phenotype is characterized by an abnormal left ventricular (LV) thickening. A hypertrophic phenotype can develop as adaptive response in many different conditions such as aortic stenosis, hypertension, athletic training, infiltrative heart muscle diseases, storage disorders and metabolic disorders. Hypertrophic cardiomyopathy (HCM) is the most frequent primary cardiomyopathy (CMP) and a genetical cause of cardiac hypertrophy. It requires the exclusion of any other cause of LV hypertrophy. Cardiac magnetic resonance (CMR) is a comprehensive imaging technique that allows a detailed evaluation of myocardial diseases. It provides reproducible measurements and myocardial tissue characterization. In clinical practice CMR is increasingly used to confirm the presence of ventricular hypertrophy, to detect the underlying cause of the phenotype and more recently as an efficient prognostic tool. This article aims to provide a detailed overview of the applications of CMR in the setting of hypertrophic heart phenotype and its role in the diagnostic workflow of such condition.
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Affiliation(s)
- Davide Tore
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Clara Gaetani
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Elena Bozzo
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Andrea Biondo
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Andrea Carisio
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesca Menchini
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Maria Miccolis
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesco Pio Papa
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Martina Trovato
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Paolo Fonio
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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Meléndez GC, Kavanagh K, Gharraee N, Lacy JL, Goslen KH, Block M, Whitfield J, Widiapradja A, Levick SP. Replacement substance P reduces cardiac fibrosis in monkeys with type 2 diabetes. Biomed Pharmacother 2023; 160:114365. [PMID: 36758315 DOI: 10.1016/j.biopha.2023.114365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM)-associated cardiac fibrosis contributes to heart failure. We previously showed that diabetic mice with cardiomyopathy, including cardiac fibrosis, exhibit low levels of the neuropeptide substance P; exogenous replacement of substance P reversed cardiac fibrosis, independent of body weight, blood glucose and blood pressure. We sought to elucidate the effectiveness and safety of replacement substance P to ameliorate or reverse cardiac fibrosis in type 2 diabetic monkeys. METHODS Four female T2DM African Green monkeys receive substance P (0.5 mg/Kg/day S.Q. injection) for 8 weeks. We obtained cardiac magnetic resonance imaging and blood samples to assess left ventricular function and fibrosis by T1 map-derived extracellular volume as well as circulating procollagen type I C-terminal propeptide. Hematological parameters for toxicities were also assessed in these monkeys and compared with three female T2DM monkeys receiving saline S.Q. as a safety comparison group. RESULTS Diabetic monkeys receiving replacement substance P exhibited a ∼20% decrease in extracellular volume (p = 0.01), concomitant with ∼25% decrease procollagen type I C-terminal propeptide levels (p = 0.008). Left ventricular ejection fraction was unchanged with substance P (p = 0.42); however, circumferential strain was improved (p < 0.01). Complete blood counts, glycosylated hemoglobin A1c, lipids, liver and pancreatic enzymes, and inflammation markers were unchanged (p > 0.05). CONCLUSIONS Replacement substance P reversed cardiac fibrosis in a large preclinical model of type 2 diabetes, independent of glycemic control. No hematological or organ-related toxicity was associated with replacement substance P. These results strongly support a potential application for replacement substance P as safe therapy for diabetic cardiac fibrosis.
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Affiliation(s)
- Giselle C Meléndez
- Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA; Pathology, Section on Comparative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Kylie Kavanagh
- Pathology, Section on Comparative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA; College of Health and Medicine, The University of Tasmania, Hobart, TAS, Australia
| | - Nazli Gharraee
- Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jessica L Lacy
- Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kevin H Goslen
- Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Masha Block
- Pathology, Section on Comparative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jordyn Whitfield
- Pathology, Section on Comparative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alexander Widiapradja
- Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Department of Physiology and Pharmacology, West Virginia University, Morgantown, WV, USA
| | - Scott P Levick
- Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Department of Physiology and Pharmacology, West Virginia University, Morgantown, WV, USA
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19
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Maddipati V, Sankhyan P, Goswami DP, Mahajan A. Pulmonary hypertension in patients with multiple myeloma: A comprehensive review. Pulm Circ 2023; 13:e12210. [PMID: 37063748 PMCID: PMC10098295 DOI: 10.1002/pul2.12210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/02/2023] [Accepted: 03/08/2023] [Indexed: 04/18/2023] Open
Abstract
Multiple myeloma (MM) is a common hematological malignancy resulting from clonal proliferation of plasma cells and is defined by criteria set forth by the international myeloma working group. Pulmonary hypertension (PH) is defined by an elevated mean pulmonary artery pressure >20 mmHg measured during right heart catheterization. Echocardiography-diagnosed PH is relatively common in patients with MM and has been associated with increased mortality, morbidity, and poor stem cell transplant outcomes. PH in patients with MM (PH-MM) is usually multifactorial in origin. MM disease-specific factors, host comorbidities, and treatment-related adverse effects are the key factors for the development of PH-MM. Pragmatically, patients with PH-MM can be grouped into either (i) PH in patients with a new diagnosis of MM or (ii) PH that develops or worsens along the way of MM treatment. In the latter group, drug-induced PH, venous thromboembolism, pulmonary veno occlusive disease, and cardiotoxicity should be considered as possible causes. PH-MM should be evaluated and managed in a multidisciplinary setting. Select individuals with PH-MM could be considered for pulmonary vasodilators at PH-specialized centers.
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Affiliation(s)
- Veeranna Maddipati
- Division of Pulmonary and Critical Care Medicine, Pulmonary Vascular MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Pratyaksha Sankhyan
- Division of Pulmonary and Critical Care MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Durga P. Goswami
- Department of Internal MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
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20
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Tsoi MR, Lin JH, Patel AR. Emerging Therapies for Transthyretin Amyloidosis. Curr Oncol Rep 2023; 25:549-558. [PMID: 36943555 DOI: 10.1007/s11912-023-01397-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE OF REVIEW This review provides an overview of the available therapies for treating neuropathic and/or cardiac manifestations of transthyretin amyloidosis (ATTR), as well as investigational therapeutic agents in ongoing clinical trials. We discuss additional emergent approaches towards thwarting this life-threatening disease that until recently was considered virtually untreatable. RECENT FINDINGS Advances in noninvasive diagnostic methods for detecting ATTR have facilitated easier diagnosis and detection at an earlier stage of disease when therapeutic interventions are likely to be more effective. There are now several ATTR-directed treatments that are clinically available, as well as investigational agents that are being studied in clinical trials. Therapeutic strategies include tetramer stabilization, gene silencing, and fibril disruption. ATTR has been historically underdiagnosed. With advances in diagnostic methods and the advent of disease-modifying treatments, early diagnosis and initiation of treatment is revolutionizing management of this disease.
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Affiliation(s)
- Melissa R Tsoi
- Department of Medicine, Tufts Medical Center, MA, 02111, Boston, USA
| | - Jeffrey H Lin
- Department of Medicine, Tufts Medical Center, MA, 02111, Boston, USA
| | - Ayan R Patel
- Cardiac Amyloidosis Program, Tufts Medical Center, 800 Washington St., MA, 02111, Boston, USA.
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21
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Cersosimo A, Bonelli A, Lombardi CM, Moreo A, Pagnesi M, Tomasoni D, Arabia G, Vizzardi E, Adamo M, Farina D, Metra M, Inciardi RM. Multimodality imaging in the diagnostic management of concomitant aortic stenosis and transthyretin-related wild-type cardiac amyloidosis. Front Cardiovasc Med 2023; 10:1108696. [PMID: 36998972 PMCID: PMC10043370 DOI: 10.3389/fcvm.2023.1108696] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/21/2023] [Indexed: 03/17/2023] Open
Abstract
Severe aortic stenosis (AS) is the most common valvular heart disease with a prevalence rate of more than 4% in 75-year-old people or older. Similarly, cardiac amyloidosis (CA), especially "wild-type transthyretin" (wTTR), has shown a prevalence rate ranging from 22% to 25% in people older than 80 years. The detection of the concomitant presence of CA and AS is challenging primarily because of the similar type of changes in the left ventricle caused by AS and CA, which share some morphological characteristics. The aim of this review is to identify the imaging triggers in order to recognize occult wtATTR-CA in patients with AS, clarifying the crucial step of the diagnostic process. Multimodality imaging methods such as echocardiography, cardiac magnetic resonance, cardiac computed tomography, and DPD scintigraphy will be analyzed as part of the available diagnostic workup to identify wtATTR-CA early in patients with AS.
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Affiliation(s)
- Angelica Cersosimo
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Bonelli
- ASST Grande Ospedale Metropolitano Niguarda, "A. De Gasperis" Department, Cardiology IV, Milan, Italy
| | - Carlo M Lombardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonella Moreo
- ASST Grande Ospedale Metropolitano Niguarda, "A. De Gasperis" Department, Cardiology IV, Milan, Italy
| | - Matteo Pagnesi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Gianmarco Arabia
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Enrico Vizzardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Farina
- ASST Spedali Civili di Brescia, Division of Radiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo M Inciardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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22
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Pudis M, Bastarrika Alemañ G. [Current role of imaging techniques in cardiac amyloidosis]. Med Clin (Barc) 2023; 160:121-128. [PMID: 36543710 DOI: 10.1016/j.medcli.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 12/23/2022]
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed disease and, if left untreated, rapidly fatal. Emerging therapies for CA increase the urgency of developing non-invasive diagnostic methods for its early detection and for monitoring therapeutic response. Classic imaging features on echocardiography and cardiac magnetic resonance, although typical for cardiac amyloidosis, are not specific enough to distinguish light chain amyloidosis from transthyretin. Myocardial bone-avid radiotracer uptake is highly specific for transthyretin cardiac amyloidosis when plasma cell dyscrasia has been excluded; it is now replacing the need for biopsy in many patients. Detection of early cardiac amyloidosis, quantitation of its burden, and assessment of response to therapy are important next steps for imaging to advance the evaluation and management of cardiac amyloidosis.
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Affiliation(s)
- Michal Pudis
- Servicio de Medicina Nuclear-PET (IDI), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
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23
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Umer M, Kalra DK. Cardiac MRI in Fabry disease. Front Cardiovasc Med 2023; 9:1075639. [PMID: 36818911 PMCID: PMC9931723 DOI: 10.3389/fcvm.2022.1075639] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/30/2022] [Indexed: 02/05/2023] Open
Abstract
Fabry disease is a rare, progressive X-linked inherited disorder of glycosphingolipid metabolism due to a deficiency of α-galactosidase A enzyme. It leads to the accumulation of globotriaosylceramide within lysosomes of multiple organs, predominantly the vascular, renal, cardiac, and nervous systems. Fabry cardiomyopathy is characterized by increased left ventricular wall thickness/mass, functional abnormalities, valvular heart disease, arrhythmias, and heart failure. Early diagnosis and treatment are critical to avoid cardiac or renal complications that can significantly reduce life expectancy in untreated FD. This review will focus on the role of cardiovascular magnetic resonance imaging in the diagnosis, clinical decision-making, and monitoring of treatment efficacy.
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24
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Lu J, Zhao P, Qiao J, Yang Z, Tang D, Zhou X, Huang L, Xia L. The major factor of left ventricular systolic dysfunction in patients with cardiac amyloidosis: Amyloid overload or microcirculation impairment? Front Cardiovasc Med 2023; 10:1096130. [PMID: 36776256 PMCID: PMC9909486 DOI: 10.3389/fcvm.2023.1096130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/12/2023] [Indexed: 01/27/2023] Open
Abstract
Purpose Amyloid overload and microcirculation impairment are both detrimental to left ventricular (LV) systolic function, while it is not clear which factor dominates LV functional remodeling in patients with cardiac amyloidosis (CA). The purpose of this study was to investigate the major factor of LV systolic dysfunction using cardiac magnetic resonance imaging. Materials and methods Forty CA patients and 20 healthy controls were included in this study. The CA group was divided into two subgroups by the left ventricular ejection fraction (LVEF): patients with reduced LVEF (LVEF < 50%, rLVEF), and patients with preserved LVEF (LVEF ≥ 50%, pLVEF). The scanning sequences included cine, native and post-contrast T1 mapping, rest first-pass perfusion and late gadolinium enhancement. Perfusion and mapping parameters were compared among the three groups. Correlation analysis was performed to evaluate the relationship between LVEF and mapping parameters, as well as the relationship between LVEF and perfusion parameters. Results Remarkably higher native T1 value was observed in the rLVEF patients than the pLVEF patients (1442.2 ± 85.8 ms vs. 1407.0 ± 93.9 ms, adjusted p = 0.001). The pLVEF patients showed significantly lower slope dividing baseline signal intensity (slope%BL; rLVEF vs. pLVEF, 55.1 ± 31.0 vs. 46.2 ± 22.3, adjusted p = 0.001) and a lower maximal signal intensity subtracting baseline signal intensity (MaxSI-BL; rLVEF vs. pLVEF, 43.5 ± 23.9 vs. 37.0 ± 18.6, adjusted p = 0.003) compared to the rLVEF patients. CA patients required more time to reach the maximal signal intensity than the controls did (all adjusted p < 0.01). There was no significant correlation between LVEF and first-pass perfusion parameters, while significant negative correlation was observed between LVEF and native T1 (r = -0.434, p = 0.005) in CA patients. Conclusion Amyloid overload in the myocardial interstitium may be the major factor of LV systolic dysfunction in CA patients, other than microcirculation impairment.
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Affiliation(s)
- Jianyao Lu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peijun Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,The Department of MRI, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jinhan Qiao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhaoxia Yang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dazhong Tang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyue Zhou
- MR Collaboration, Siemens Healthineers Ltd., Shanghai, China
| | - Lu Huang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,*Correspondence: Lu Huang, ✉
| | - Liming Xia
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Liming Xia, ✉
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25
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Bukhari S, Khan SZ, Bashir Z. Atrial Fibrillation, Thromboembolic Risk, and Anticoagulation in Cardiac Amyloidosis: A Review. J Card Fail 2023; 29:76-86. [PMID: 36122817 DOI: 10.1016/j.cardfail.2022.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 01/17/2023]
Abstract
Cardiac amyloidosis (CA) is caused by extracellular myocardial deposition of amyloid fibrils that are primary derived either from misfolding of transthyretin (ATTR) or light-chain (AL) proteins. CA is associated with atrial fibrillation, potentiated by electromechanical changes as a result of amyloid infiltration in the myocardium. CA also predisposes to thromboembolism and could potentially simultaneously elevate bleeding risk. In this review, we aim to explore and compare the prevalence and pathophysiological mechanisms of atrial fibrillation and thromboembolism in ATTR and AL, examine bleeding risk and factors that promote bleeding, and compare anticoagulation strategies in CA. Finally, we highlight knowledge gaps in the field of thromboembolism in CA to guide future research.
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Affiliation(s)
- Syed Bukhari
- Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania.
| | - Syed Zamrak Khan
- Department of Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Zubair Bashir
- Department of Medicine, Brown University Rhode Island Hospital, Providence, Rhode Island
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26
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A compartment-based myocardial density approach helps to solve the native T1 vs. ECV paradox in cardiac amyloidosis. Sci Rep 2022; 12:21755. [PMID: 36526658 PMCID: PMC9758193 DOI: 10.1038/s41598-022-26216-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) plays an important clinical role for diagnosis and therapy monitoring of cardiac amyloidosis (CA). Previous data suggested a lower native T1 value in spite of a higher LV mass and higher extracellular volume fraction (ECV) value in wild-type transthyretin amyloidosis (ATTRwt) compared to light-chain amyloidosis (AL)-resulting in the still unsolved "native T1 vs. ECV paradox" in CA. The purpose of this study was to address this paradox. The present study comprised N = 90 patients with ATTRwt and N = 30 patients with AL who underwent multi-parametric CMR studies prior to any specific treatment. The CMR protocol comprised cine- and late-gadolinium-enhancement (LGE)-imaging as well as T2-mapping and pre-/post-contrast T1-mapping allowing to measure myocardial ECV. Left ventricular ejection fraction (LV-EF), left ventricular mass index (LVMi) and left ventricular wall thickness (LVWT) were significantly higher in ATTRwt in comparison to AL. Indexed ECV (ECVi) was also higher in ATTRwt (p = 0.041 for global and p = 0.001 for basal septal). In contrast, native T1- [1094 ms (1069-1127 ms) in ATTRwt vs. 1,122 ms (1076-1160 ms) in AL group, p = 0.040] and T2-values [57 ms (55-60 ms) vs. 60 ms (57-64 ms); p = 0.001] were higher in AL. Considering particularities in myocardial density, "total extracellular mass" (TECM) was substantially higher in ATTRwt whereas "total intracellular mass" (TICM) was rather similar between ATTRwt and AL. Consequently, the "ratio TICM/TECM" was lower in ATTRwt compared to AL (0.58 vs. 0.83; p = 0.007). Our data confirm the presence of a "native T1 vs. ECV paradox" with lower native T1 values in spite of higher myocardial mass and ECV in ATTRwt compared to AL. Importantly, this observation can be explained by particularities regarding myocardial density that result in a lower TICM/TECM "ratio" in case of ATTRwt compared to AL-since native T1 is determined by this ratio.
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27
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Rempakos A, Papamichail A, Loritis K, Androulakis E, Lama N, Briasoulis A. Non-LGE Cardiac Magnetic Resonance Imaging in Patients with Cardiac Amyloidosis. Curr Pharm Des 2022; 29:CPD-EPUB-128195. [PMID: 36515044 DOI: 10.2174/1381612829666221212100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/02/2022] [Accepted: 11/12/2022] [Indexed: 12/15/2022]
Abstract
Cardiac involvement is the leading cause of death in patients with cardiac amyloidosis. Early recognition is crucial as it can significantly change the course of the disease. Until now, the imaging modality of choice for diagnosing cardiac amyloidosis has been cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE). LGE-CMR in patients with cardiac amyloidosis reveals characteristic LGE patterns that lead to a diagnosis while also correlating well with disease prognosis. However, LGE-CMR has numerous drawbacks that the newer CMR modality, T1 mapping, aims to improve. T1 mapping can be further subdivided into native T1 mapping, which does not require the use of contrast, and ECV measurement, which requires the use of contrast. Numerous T1 mapping techniques have been developed, each one with its own advantages and disadvantages when it comes to procedure difficulty and image quality. A literature review to identify relevant published articles was performed by two authors. This review aimed to present the value of T1 mapping in diagnosing cardiac amyloidosis, quantifying the amyloid burden, and evaluating the prognosis of patients with amyloidosis with cardiac involvement.
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Affiliation(s)
- Athanasios Rempakos
- Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Adamantia Papamichail
- Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Loritis
- Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Nikki Lama
- Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Briasoulis
- Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa College of Medicine, Iowa City, IA, USA
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28
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Martinez-Naharro A, Patel R, Kotecha T, Karia N, Ioannou A, Petrie A, Chacko LA, Razvi Y, Ravichandran S, Brown J, Law S, Quarta C, Mahmood S, Wisniowski B, Pica S, Sachchithanantham S, Lachmann HJ, Moon JC, Knight DS, Whelan C, Venneri L, Xue H, Kellman P, Gillmore JD, Hawkins PN, Wechalekar AD, Fontana M. Cardiovascular magnetic resonance in light-chain amyloidosis to guide treatment. Eur Heart J 2022; 43:4722-4735. [PMID: 36239754 PMCID: PMC9712028 DOI: 10.1093/eurheartj/ehac363] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 05/26/2022] [Accepted: 06/14/2022] [Indexed: 01/05/2023] Open
Abstract
AIMS To assess the ability of cardiovascular magnetic resonance (CMR) to (i) measure changes in response to chemotherapy; (ii) assess the correlation between haematological response and changes in extracellular volume (ECV); and (iii) assess the association between changes in ECV and prognosis over and above existing predictors. METHODS AND RESULTS In total, 176 patients with cardiac AL amyloidosis were assessed using serial N-terminal pro-B-type natriuretic peptide (NT-proBNP), echocardiography, free light chains and CMR with T1 and ECV mapping at diagnosis and subsequently 6, 12, and 24 months after starting chemotherapy. Haematological response was graded as complete response (CR), very good partial response (VGPR), partial response (PR), or no response (NR). CMR response was graded by changes in ECV as progression (≥0.05 increase), stable (<0.05 change), or regression (≥0.05 decrease). At 6 months, CMR regression was observed in 3% (all CR/VGPR) and CMR progression in 32% (61% in PR/NR; 39% CR/VGPR). After 1 year, 22% had regression (all CR/VGPR), and 22% had progression (63% in PR/NR; 37% CR/VGPR). At 2 years, 38% had regression (all CR/VGPR), and 14% had progression (80% in PR/NR; 20% CR/VGPR). Thirty-six (25%) patients died during follow-up (40 ± 15 months); CMR response at 6 months predicted death (progression hazard ratio 3.82; 95% confidence interval 1.95-7.49; P < 0.001) and remained prognostic after adjusting for haematological response, NT-proBNP and longitudinal strain (P < 0.01). CONCLUSIONS Cardiac amyloid deposits frequently regress following chemotherapy, but only in patients who achieve CR or VGPR. Changes in ECV predict outcome after adjusting for known predictors.
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Affiliation(s)
- Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Rishi Patel
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Tushar Kotecha
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Nina Karia
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | | | - Liza A Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Sriram Ravichandran
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - James Brown
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Steven Law
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Cristina Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Brendan Wisniowski
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Silvia Pica
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, West Smithfield, London, UK
| | - Daniel S Knight
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Carol Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Hui Xue
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Hospital, London, UK
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29
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Donà C, Nitsche C, Anegg O, Poschner T, Koschutnik M, Duca F, Aschauer S, Dannenberg V, Schneider M, Schoenbauer R, Beitzke D, Loewe C, Hengstenberg C, Mascherbauer J, Kammerlander A. Bioimpedance Spectroscopy Reveals Important Association of Fluid Status and T 1 -Mapping by Cardiovascular Magnetic Resonance. J Magn Reson Imaging 2022; 56:1671-1679. [PMID: 35352420 PMCID: PMC9790685 DOI: 10.1002/jmri.28159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Extracellular matrix expansion is a key pathophysiologic feature in heart failure and can be quantified noninvasively by cardiac magnetic resonance T1 -mapping. Free water within the interstitial space of the myocardium, however, may also alter T1 -mapping results. PURPOSE To investigate the association between systemic fluid status and T1 -mapping by cardiac magnetic resonance. STUDY TYPE Prospective, observational single-center study. POPULATION Two-hundred eighty-five consecutive patients (44.4% female, 70.0 ± 14.9 years old) scheduled for cardiac MR due to various cardiac diseases. SEQUENCE AND FIELD STRENGTH 1.5-T scanner (Avanto Fit, Siemens Healthineers, Erlangen, Germany). For T1 -mapping, electrocardiographically triggered modified-Look-Locker inversion (MOLLI) recovery sequence using a 5(3)3 prototype on a short-axis mid-cavity slice and with a four-chamber view was performed. ASSESSMENTS MR parameters including native myocardial T1 -times using MOLLI and extracellular volume (MR-ECV) were assessed, and additionally, we performed bioimpedance analysis (BIA). Furthermore, demographic data and comorbidities were assessed. STATISTICS Wilcoxon's rank-sum test, chi-square tests, and for correlation analysis, Pearson's correlation coefficients were used. Regression analyses were performed to investigate the association between patients' fluid status and T1 -mapping results. A P-value <0.05 was considered statistically significant. RESULTS The mixed cohort presented with a mean overhydration (OH) of +0.2 ± 2.4 liters, as determined by BIA. By MR, native T1 -times were 1038 ± 51 msec and MR-ECV was 31 ± 9%. In the multivariable regression analysis, only OH was significantly associated with MR-ECV (adj. beta: 0.711; 95% CI: 0.28 to 1.14) along with male sex (adj. beta: 2.529; 95% CI: 0.51 to 4.55). In linear as well as multivariable analysis, only OH was significantly associated with native T1 times (adj. beta: 3.750; 95% CI: 1.27 to 6.23). CONCLUSION T1 -times and MR-ECV were significantly associated with the degree of OH on BIA measurement. These effects were independent from age, sex, body mass index, and hematocrit. Patients' volume status may thus be an important factor when T1 -time and MR-ECV values are interpreted. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Carolina Donà
- Division of CardiologyMedical University of ViennaViennaAustria
| | | | - Oliver Anegg
- Division of CardiologyMedical University of ViennaViennaAustria
| | - Thomas Poschner
- Division of CardiologyMedical University of ViennaViennaAustria
| | | | - Franz Duca
- Division of CardiologyMedical University of ViennaViennaAustria
| | - Stefan Aschauer
- Division of CardiologyMedical University of ViennaViennaAustria
| | | | | | | | - Dietrich Beitzke
- Department of Cardiovascular and Interventional RadiologyMedical University of ViennaViennaAustria
| | - Christian Loewe
- Department of Cardiovascular and Interventional RadiologyMedical University of ViennaViennaAustria
| | | | - Julia Mascherbauer
- Division of CardiologyMedical University of ViennaViennaAustria,Karl Landsteiner University of Health Sciences, Department of Internal Medicine 3University Hospital St. PöltenKremsAustria
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30
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Argirò A, Del Franco A, Mazzoni C, Allinovi M, Tomberli A, Tarquini R, Di Mario C, Perfetto F, Cappelli F, Zampieri M. Arrhythmic Burden in Cardiac Amyloidosis: What We Know and What We Do Not. Biomedicines 2022; 10:2888. [PMID: 36359408 PMCID: PMC9687719 DOI: 10.3390/biomedicines10112888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 08/26/2023] Open
Abstract
Cardiac amyloidosis (CA), caused by the deposition of insoluble amyloid fibrils, impairs different cardiac structures, altering not only left ventricle (LV) systo-diastolic function but also atrial function and the conduction system. The consequences of the involvement of the cardiac electrical system deserve more attention, as well as the study of the underlying molecular mechanisms. This is an issue of considerable interest, given the conflicting data on the effectiveness of conventional antiarrhythmic strategies. Therefore, this review aims at summarizing the arrhythmic burden related to CA and the available evidence on antiarrhythmic treatment in this population.
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Affiliation(s)
- Alessia Argirò
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Annamaria Del Franco
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Carlotta Mazzoni
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Marco Allinovi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Alessia Tomberli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Roberto Tarquini
- Department of Internal Medicine I, San Giuseppe Hospital, 50053 Empoli, Italy
| | - Carlo Di Mario
- Structural Interventional Cardiology Department, Careggi University Hospital, 50134 Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
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Wechalekar AD, Fontana M, Quarta CC, Liedtke M. AL Amyloidosis for Cardiologists: Awareness, Diagnosis, and Future Prospects: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:427-441. [PMID: 36444232 PMCID: PMC9700258 DOI: 10.1016/j.jaccao.2022.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022] Open
Abstract
Amyloid light chain (AL) amyloidosis is a rare, debilitating, often fatal disease. Symptoms of cardiomyopathy are common presenting features, and patients often are referred to cardiologists. Cardiac amyloid infiltration is the leading predictor of death. However, the variable presentation and perceived rarity of the disease frequently lead to delay in suspecting amyloidosis as a cause of heart failure, leading to misdiagnoses and a marked delay in diagnosis, with devastating consequences for the patient. A median time from symptom onset to correct diagnosis of about 2 years is often too long when median survival from diagnosis for patients with AL amyloidosis and cardiomyopathy is 4 months to 2 years. The authors highlight the challenges to diagnosis, identify gaps in the current knowledge, and summarize novel treatments on the horizon to raise awareness about the critical need for early recognition of symptoms and diagnosis of AL amyloidosis aimed at accelerating treatment and improving outcomes for patients.
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Key Words
- AL amyloidosis
- AL, amyloid light chain
- ASCT, autologous stem cell transplantation
- ATTR, transthyretin
- CMR, cardiac magnetic resonance imaging
- CR, complete response
- CyBorD, cyclophosphamide-bortezomib-dexamethasone
- FLC, free light chain
- Ig, immunoglobulin
- LGE, late gadolinium enhancement
- NT-proBNP, N-terminal pro–brain natriuretic peptide
- PCD, plasma cell dyscrasia
- QoL, quality of life
- VGPR, very good partial response
- awareness
- diagnosis
- future therapies
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Affiliation(s)
| | - Marianna Fontana
- National Amyloidosis Centre, London, United Kingdom
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - C. Cristina Quarta
- Alexion Pharmaceuticals, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Michaela Liedtke
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
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Guo Y, Li X, Wang Y. State of the Art: Quantitative Cardiac MRI in Cardiac Amyloidosis. J Magn Reson Imaging 2022; 56:1287-1301. [PMID: 35770942 DOI: 10.1002/jmri.28314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 12/15/2022] Open
Abstract
Cardiac amyloidosis (CA) is characterized by amyloid infiltration in the myocardial extracellular space, causing heart failure. Patients with CA are currently underdiagnosed. Cardiac involvement is significantly associated with the prognosis and treatment decision-making for CA. Early identification and accurate stratification are the crucial first step in patient management. Comprehensive cardiac MRI-based evaluation of the cardiac structure, function, and myocardial tissue characterization assesses cardiac involvement by tracing disease processes. Emerging quantitative tissue characterization techniques have introduced new measures that can identify early staged CA and monitor disease progression or response after treatment. Quantitative cardiac MRI is becoming an instrumental tool in understanding CA, which leads to changes in individualized patient care. This review aimed to discuss the quantitative cardiac MRI-based assessment of CA using established and emerging techniques. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Yubo Guo
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiao Li
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yining Wang
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Umer M, Motwani M, Jefferies JL, Kalra DK. Cardiac involvement in Fabry Disease and the Role of Multimodality Imaging in Diagnosis and Disease Monitoring. Curr Probl Cardiol 2022; 48:101439. [DOI: 10.1016/j.cpcardiol.2022.101439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022]
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Targeting Amyloid Fibrils by Passive Immunotherapy in Systemic Amyloidosis. BioDrugs 2022; 36:591-608. [PMID: 36094752 PMCID: PMC9466354 DOI: 10.1007/s40259-022-00550-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 12/03/2022]
Abstract
Systemic amyloidoses are characterized by the unrelenting deposition of autologous proteins as highly ordered fibrils in target organs. The ensuing, potentially fatal organ dysfunction is the result of the combined damage caused by the proteotoxic effect of prefibrillar species and by the cytotoxicity and the structural alterations produced by the amyloid fibrils. Current therapy is focused on eliminating the amyloid protein, thus extinguishing the amyloid cascade at its origin. While this approach may end the cell damage caused by prefibrillar aggregates and prevent further amyloid accumulation, the noxious effects of the amyloid fibrils persist and may hamper the recovery of organ function, which is the ultimate goal of therapy as it is necessary to improve the quality of life and extend survival. Preclinical studies indicate that the clearance of amyloid deposits can be accelerated by specific antibodies targeting amyloid fibrils that activate complement-mediated macrophages and giant cell phagocytosis, possibly promoting the recovery of organ function. Measuring the therapeutic effect of anti-amyloid agents is still a matter of research. In recent years, several monoclonal antibodies targeting amyloid deposits have been tested in clinical trials with mixed outcomes. Recent encouraging results from phase I/II trials, new anti-amyloid agents, and new antibody engineering offer hope that effective amyloid removal will be accomplished in the near future, accelerating organ recovery and improving quality of life and survival.
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Vidula MK, Bravo PE, Chirinos JA. The Role of Multimodality Imaging in the Evaluation of Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:443-457. [DOI: 10.1016/j.ccl.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Velaga J, Liew C, Choo Poh AC, Lee PT, Lath N, Low SC, Bharadwaj P. Multimodality Imaging in the Diagnosis and Assessment of Cardiac Amyloidosis. World J Nucl Med 2022; 21:173-183. [PMID: 36060088 PMCID: PMC9436521 DOI: 10.1055/s-0042-1751057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Amyloidosis is a rare disorder where abnormal protein aggregates are deposited in tissues forming amyloid fibrils, leading to progressive organ failure. Although any organ can be affected, cardiac involvement is the main cause of morbidity and mortality associated with amyloidosis as diagnosis is often delayed due to the indolent nature of the disease in some forms. An early diagnosis of disease and knowledge of the type/subtype of cardiac amyloidosis (CA) are essential for appropriate management and better outcome. Echocardiography is often the first line of investigation for patients suspected of CA and offers superior hemodynamic assessment. Although cardiovascular magnetic resonance (CMR) imaging is not diagnostic of CA, it provides vital clues to diagnosis and has a role in disease quantification and prognostication. Radiolabeled bone seeking tracers are the mainstay of diagnosis of CA and when combined with screening of monoclonal light chains, bone scintigraphy offers high sensitivity in diagnosing transthyretin type of CA. This review aims to describe the noninvasive imaging assessment and approach to diagnosis of patients with suspected CA. Imaging features of echocardiography, nuclear scintigraphy, and CMR are described with a brief mention on computed tomography.
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Affiliation(s)
- Jyothirmayi Velaga
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Charlene Liew
- Department of Radiology, Changi General Hospital, Singapore, Singapore
| | | | | | - Narayan Lath
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Shoen Choon Low
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Pushan Bharadwaj
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
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Porcari A, Fontana M, Gillmore JD. Transthyretin cardiac amyloidosis. Cardiovasc Res 2022; 118:3517-3535. [PMID: 35929637 PMCID: PMC9897687 DOI: 10.1093/cvr/cvac119] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/16/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized cause of heart failure (HF) and mortality worldwide. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have shifted ATTR-CA from a rare and untreatable disease to a relatively prevalent condition that clinicians should consider on a daily basis. Amyloid fibril formation results from age-related failure of homoeostatic mechanisms in wild-type ATTR (ATTRwt) amyloidosis (non-hereditary form) or destabilizing mutations in variant ATTR (ATTRv) amyloidosis (hereditary form). Longitudinal large-scale studies in the United States suggest an incidence of cardiac amyloidosis in the contemporary era of 17 per 100 000, which has increased from a previous estimate of 0.5 per 100 000, which was almost certainly due to misdiagnosis and underestimated. The presence and degree of cardiac involvement is the leading cause of mortality both in ATTRwt and ATTRv amyloidosis, and can be identified in up to 15% of patients hospitalized for HF with preserved ejection fraction. Associated features, such as carpal tunnel syndrome, can preceed by several years the development of symptomatic HF and may serve as early disease markers. Echocardiography and cardiac magnetic resonance raise suspicion of disease and might offer markers of treatment response at a myocardial level, such as extracellular volume quantification. Radionuclide scintigraphy with 'bone' tracers coupled with biochemical tests may differentiate ATTR from light chain amyloidosis. Therapies able to slow or halt ATTR-CA progression and increase survival are now available. In this evolving scenario, early disease recognition is paramount to derive the greatest benefit from treatment.
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Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK,Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Julian D Gillmore
- Corresponding author. Tel: +44 2074332764; fax: +44 2044332817; E-mail:
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Bay K, Gustafsson F, Maiborg M, Bagger‐Bahnsen A, Strand AM, Pilgaard T, Poulsen SH. Suspicion, screening, and diagnosis of wild-type transthyretin amyloid cardiomyopathy: a systematic literature review. ESC Heart Fail 2022; 9:1524-1541. [PMID: 35343098 PMCID: PMC9065854 DOI: 10.1002/ehf2.13884] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 01/15/2023] Open
Abstract
Wild-type transthyretin amyloid cardiomyopathy (ATTRwt CM) is a more common disease than previously thought. Awareness of ATTRwt CM and its diagnosis has been challenged by its unspecific and widely distributed clinical manifestations and traditionally invasive diagnostic tools. Recent advances in echocardiography and cardiac magnetic resonance (CMR), non-invasive diagnosis by bone scintigraphy, and the development of disease-modifying treatments have resulted in an increased interest, reflected in multiple publications especially during the last decade. To get an overview of the scientific knowledge and gaps related to patient entry, suspicion, diagnosis, and systematic screening of ATTRwt CM, we developed a framework to systematically map the available evidence of (i) when to suspect ATTRwt CM in a patient, (ii) how to diagnose the disease, and (iii) which at-risk populations to screen for ATTRwt CM. Articles published between 2010 and August 2021 containing part of or a full diagnostic pathway for ATTRwt CM were included. From these articles, data for patient entry, suspicion, diagnosis, and screening were extracted, as were key study design and results from the original studies referred to. A total of 50 articles met the inclusion criteria. Of these, five were position statements from academic societies, while one was a clinical guideline. Three articles discussed the importance of primary care providers in terms of patient entry, while the remaining articles had the cardiovascular setting as point of departure. The most frequently mentioned suspicion criteria were ventricular wall thickening (44/50), carpal tunnel syndrome (42/50), and late gadolinium enhancement on CMR (43/50). Diagnostic pathways varied slightly, but most included bone scintigraphy, exclusion of light-chain amyloidosis, and the possibility of doing a biopsy. Systematic screening was mentioned in 16 articles, 10 of which suggested specific at-risk populations for screening. The European Society of Cardiology recommends to screen patients with a wall thickness ≥12 mm and heart failure, aortic stenosis, or red flag symptoms, especially if they are >65 years. The underlying evidence was generally good for diagnosis, while significant gaps were identified for the relevance and mutual ranking of the different suspicion criteria and for systematic screening. Conclusively, patient entry was neglected in the reviewed literature. While multiple red flags were described, high-quality prospective studies designed to evaluate their suitability as suspicion criteria were lacking. An upcoming task lies in defining and evaluating at-risk populations for screening. All are steps needed to promote early detection and diagnosis of ATTRwt CM, a prerequisite for timely treatment.
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Affiliation(s)
- Katrine Bay
- Bay WritingCopenhagenDenmark
- Pfizer DenmarkBallerupDenmark
| | - Finn Gustafsson
- The Heart CenterCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Michael Maiborg
- Odense Amyloidosis Center & Department of CardiologyOdense University HospitalOdenseDenmark
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Cha MJ, Kim C, Park CH, Hong YJ, Shin JM, Kim TH, Cha YJ, Park CH. Differential Diagnosis of Thick Myocardium according to Histologic Features Revealed by Multiparametric Cardiac Magnetic Resonance Imaging. Korean J Radiol 2022; 23:581-597. [PMID: 35555885 PMCID: PMC9174501 DOI: 10.3348/kjr.2021.0815] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 11/16/2022] Open
Abstract
Left ventricular (LV) wall thickening, or LV hypertrophy (LVH), is common and occurs in diverse conditions including hypertrophic cardiomyopathy (HCM), hypertensive heart disease, aortic valve stenosis, lysosomal storage disorders, cardiac amyloidosis, mitochondrial cardiomyopathy, sarcoidosis and athlete’s heart. Cardiac magnetic resonance (CMR) imaging provides various tissue contrasts and characteristics that reflect histological changes in the myocardium, such as cellular hypertrophy, cardiomyocyte disarray, interstitial fibrosis, extracellular accumulation of insoluble proteins, intracellular accumulation of fat, and intracellular vacuolar changes. Therefore, CMR imaging may be beneficial in establishing a differential diagnosis of LVH. Although various diseases share LV wall thickening as a common feature, the histologic changes that underscore each disease are distinct. This review focuses on CMR multiparametric myocardial analysis, which may provide clues for the differentiation of thickened myocardium based on the histologic features of HCM and its phenocopies.
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Affiliation(s)
- Min Jae Cha
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Cherry Kim
- Department of Radiology, Korea University Ansan Hospital, Ansan, Korea
| | - Chan Ho Park
- Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Yoo Jin Hong
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Min Shin
- Department of Radiology and Research Institute of Radiological Science, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hoon Kim
- Department of Radiology and Research Institute of Radiological Science, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Jin Cha
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Chul Hwan Park
- Department of Radiology and Research Institute of Radiological Science, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Abstract
Purpose of Review This review will explore the role of cardiac imaging in guiding treatment in the two most commonly encountered subtypes of cardiac amyloidosis (immunoglobulin light-chain amyloidosis [AL] and transthyretin amyloidosis [ATTR]). Recent Findings Advances in multi-parametric cardiac imaging involving a combination of bone scintigraphy, echocardiography and cardiac magnetic resonance imaging have resulted in earlier diagnosis and initiation of treatment, while the evolution of techniques such as longitudinal strain and extracellular volume quantification allow clinicians to track individuals’ response to treatment. Imaging developments have led to a deeper understanding of the disease process and treatment mechanisms, which in combination result in improved patient outcomes. Summary The rapidly expanding treatment regimens for cardiac amyloidosis have led to an even greater reliance on cardiac imaging to help establish an accurate diagnosis, monitor treatment response and aid the adjustment of treatment strategies accordingly.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
| | - Rishi Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
| | - Julian D. Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
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Sozzi FB, Iacuzio L, Belmonte M, Schiavone M, Bursi F, Gherbesi E, Levy F, Canetta C, Carugo S. Early diagnosis of cardiomyopathies by cardiac magnetic resonance. Overview of the main criteria. Monaldi Arch Chest Dis 2022; 92. [PMID: 35416001 DOI: 10.4081/monaldi.2022.2151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/15/2022] [Indexed: 01/05/2023] Open
Abstract
Cardiomyopathies (CMPs) are diseases of the heart muscle. They include a variety of myocardial disorders that manifest with various structural and functional phenotypes and are frequently genetic. Myocardial disease caused by known cardiovascular causes (such as hypertension, ischemic heart disease, or valvular disease) should be distinguished from CMPs for classification and management purposes. Identification of various CMP phenotypes relies primarily upon echocardiographic evaluation. In selected cases, cardiac magnetic resonance imaging (CMR) or computed tomography may be useful to identify and localize fatty infiltration, inflammation, scar/fibrosis, focal hypertrophy, and better visualize the left ventricular apex and right ventricle. CMR imaging has emerged as a comprehensive tool for the diagnosis and follow-up of patients with CMPs. The accuracy and reproducibility in evaluating cardiac structures, the unique ability of non-invasive tissue characterization and the lack of ionizing radiation, make CMR very attractive as a potential "all-in-one technique". Indeed, it provides valuable data to confirm or establish the diagnosis, screen subclinical cases, identify aetiology, establish the prognosis. Additionally, it provides information for setting a risk stratification (based on evaluation of proved independent prognostic factors as ejection fraction, end-systolic-volume, myocardial fibrosis) and follow-up. Last, it helps to monitor the response to the therapy. In this review, the pivotal role of CMR in the comprehensive evaluation of patients with CMP is discussed, highlighting the key features guiding differential diagnosis and the assessment of prognosis.
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Affiliation(s)
- Fabiola B Sozzi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan.
| | | | - Marta Belmonte
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan.
| | | | - Francesca Bursi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan.
| | - Elisa Gherbesi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan.
| | | | - Ciro Canetta
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan.
| | - Stefano Carugo
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan.
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Yilmaz A. Interpretation of CMR-Based Mapping Findings in Cardiac Amyloidosis: Please Act With Caution! JACC Cardiovasc Imaging 2022; 15:604-606. [PMID: 35393064 DOI: 10.1016/j.jcmg.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/24/2021] [Accepted: 12/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ali Yilmaz
- Division of Cardiovascular Imaging, Department of Cardiology I, University Hospital Münster, Münster, Germany.
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43
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Cuddy SAM, Jerosch-Herold M, Falk RH, Kijewski MF, Singh V, Ruberg FL, Sanchorawala V, Landau H, Maurer MS, Yee AJ, Bianchi G, Di Carli MF, Liao R, Kwong RY, Dorbala S. Myocardial Composition in Light-Chain Cardiac Amyloidosis More Than 1 Year After Successful Therapy. JACC Cardiovasc Imaging 2022; 15:594-603. [PMID: 34922860 PMCID: PMC8995332 DOI: 10.1016/j.jcmg.2021.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/09/2021] [Accepted: 09/27/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The goals of this study were to characterize myocardial composition during the active and remission phases of light-chain (AL) cardiac amyloidosis. BACKGROUND Cardiac dysfunction in AL amyloidosis is characterized by dual insults to the myocardium from infiltration and toxicity from light chains during the active phase and by infiltration alone in the remission phase. METHODS Prospectively enrolled subjects with cardiac AL amyloidosis (21 remission AL amyloidosis; age: 63.4 ± 7.3 years; 47.6% male; and 48 active AL amyloidosis; age: 62.5 ± 7.4 years; 60.4% male) underwent contrast-enhanced cardiac magnetic resonance with T1 and T2 mapping and measurement of extracellular volume (ECV). By definition, serum free light-chain levels were normal for at least 1 year following successful AL therapy in the remission group and abnormal in the active group. RESULTS Myocardial ECV was similarly expanded in the remission and active AL amyloidosis groups (0.488 ± 0.082 vs 0.519 ± 0.083, respectively; P = 0.15). However, myocardial T2 relaxation times (47.7 ± 3.2 ms vs 45.5 ± 3.0 ms; P = 0.008) as well as native T1 times (1,368 ms [IQR: 1,290-1,422 ms] vs 1,264 ms [IQR: 1,203-1,380 ms]; P = 0.024) were significantly higher in the remission compared to the active AL amyloidosis group. CONCLUSIONS Myocardial ECV is substantially expanded in the active AL and remission AL cardiac amyloidosis groups, but native T1 values were higher, suggesting a different myocardial composition. There is no evidence of myocardial edema in active AL cardiac amyloidosis. Future phenotyping studies of AL cardiac amyloidosis need to consider complementary myocardial markers that define the interstitial milieu in addition to changes in extracellular volume. (Molecular Imaging of Primary Amyloid Cardiomyopathy; NCT02641145).
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Affiliation(s)
- Sarah A M Cuddy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Jerosch-Herold
- Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marie Foley Kijewski
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vasvi Singh
- Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Vaishali Sanchorawala
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Heather Landau
- Division of Medical Oncology, Memorial Sloan Kettering Medical Center, New York, New York, USA
| | - Matthew S Maurer
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrew J Yee
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Giada Bianchi
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ronglih Liao
- Amyloidosis Program, Stanford University, Stanford, California, USA
| | - Raymond Y Kwong
- Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Bi X, Xu B, Liu J, Wang G, An J, Zhang X, Wang R, Dong W, Guan Z. Diagnostic Value of 11C-PIB PET/MR in Cardiac Amyloidosis. Front Cardiovasc Med 2022; 9:830572. [PMID: 35369284 PMCID: PMC8966842 DOI: 10.3389/fcvm.2022.830572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe thioflavin T derivative, 11C-Pittsburgh-B (PIB), is used for Alzheimer's disease imaging because it specifically binds to β-amyloid protein deposits in the brain. The aim of this study was to estimate the diagnostic value of combined 11C-PIB positron emission tomography/magnetic resonance (PET/MR) in cardiac amyloidosis (CA).MethodsWe enrolled 23 heart failure patients with suspected CA based on echocardiographic and electrocardiograph findings. All patients underwent cardiac 11C-PIB PET/MR and non-cardiac biopsy within one week. We also enrolled eight healthy volunteers that underwent cardiac 11C-PIB PET/MR as a control group. The cardiac magnetic resonance (CMR) protocol included cine imaging, late gadolinium enhancement (LGE), and native and post-contrast T1 mapping. Extracellular volume (ECV) was measured using pre- and post-contrast T1 mapping images. LVEF, IVSD, LVPW, LVmass, LVESV, LVEDV, native T1 value, ECV, and maximum uptake of myocardial tissue-to-blood background ratio (TBR) values were obtained from PET/MR images in all patients and healthy subjects.ResultsThirteen out of twenty-three heart failure patients were clinically diagnosed with CA. The remaining 10 patients were CA-negative (non-CA patient group). Twelve of the thirteen CA patients showed diffuse transmural LGE patterns, whereas LGE was either absent or patchy in the non-CA patients. The diagnostic sensitivity and specificity of TBRmax were 92.3 and 100%, respectively, at a cut-off value of 1.09. Several CMR imaging parameters (LVEF, IVSD, LVmass, LVEDV, LVESV, LVPW, native T1 value and ECV) and TBR showed significant differences between CA patients, non-CA patients, and healthy controls (P < 0.05). Native T1 mapping values positively correlated with TBRmax values in CA and non-CA patients (r = 0.38, P = 0.0004).Conclusions11C-PIB PET/MRI is a valuable tool for the accurate and non-invasive diagnosis of CA because it distinguishes CA patients from non-CA patients and healthy subjects with high specificity and sensitivity. Moreover, native T1 mapping values positively correlated with TBRmax values in CA and non-CA patients. In the future, larger cohort studies are necessary to confirm our findings.
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Affiliation(s)
- Xiao Bi
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Baixuan Xu
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
- Baixuan Xu
| | - Jiajin Liu
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Guanyun Wang
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jing An
- Department of Cardiology, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiaojun Zhang
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Ruimin Wang
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Wei Dong
- Siemens Healthcare Ltd., Guangdong, China
- Wei Dong
| | - Zhiwei Guan
- Department of Nuclear Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
- *Correspondence: Zhiwei Guan
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Multimodal Imaging and Biomarkers in Cardiac Amyloidosis. Diagnostics (Basel) 2022; 12:diagnostics12030627. [PMID: 35328180 PMCID: PMC8946926 DOI: 10.3390/diagnostics12030627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/12/2022] [Accepted: 01/28/2022] [Indexed: 01/15/2023] Open
Abstract
Amyloidosis is a progressive infiltrative disease instigated by the extracellular deposition of amyloid fibrils in various organs such as the heart, kidney, and peripheral nerves. Cardiac amyloid deposits cause restrictive cardiomyopathy, leading to a poor prognosis in systemic amyloidosis. The most common etiologies of cardiac amyloidosis (CA) are immunoglobulin light chain deposits (AL-CA) and misfolded transthyretin deposits (ATTR-CA). In recent years, many developments have been accomplished in the field of diagnosis and treatment of CA. At present, ATTR-CA can be noninvasively diagnosed if the following two conditions are fulfilled in the setting of typical echocardiographic/cardiac MRI findings: (1) grade 2 or 3 myocardial uptake in bone scintigraphy confirmed by SPECT and (2) absence of monoclonal protein confirmed by serum-free light chain assay, and serum/urine protein electrophoresis with immunofixation test. Effective therapies are evolving in both types of CA (tafamidis for ATTR-CA and immunologic treatments for AL-CA). Thus, early suspicion and prompt diagnosis are crucial for achieving better outcomes. In this review, we have summarized the role of multimodal imaging (e.g., echocardiography, cardiac MRI, and bone scintigraphy) and biomarkers (e.g., troponin, BNP) in the diagnosis, risk stratification, and treatment monitoring of CA.
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Suzuki M, Izawa Y, Toba T, Kono AK, Hirata KI. Late Iodine Enhancement and Extracellular Volume Fraction in Cardiac Amyloidosis by Computed Tomography. Circ Rep 2022; 4:145-146. [PMID: 35342840 PMCID: PMC8901246 DOI: 10.1253/circrep.cr-21-0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Masataka Suzuki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Atsushi K Kono
- Department of Radiology, Kobe University Graduate School of Medicine
| | - Ken-ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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Uddin MM, Mir T, Kaur J, Pervaiz E, Babu MA, Sheikh M. ST-elevation myocardial infarction among cardiac amyloidosis patients; a national readmission database study. Heart Fail Rev 2022; 27:1579-1586. [DOI: 10.1007/s10741-021-10210-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/29/2022]
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Razvi Y, Patel RK, Fontana M, Gillmore JD. Cardiac Amyloidosis: A Review of Current Imaging Techniques. Front Cardiovasc Med 2021; 8:751293. [PMID: 34957240 PMCID: PMC8702802 DOI: 10.3389/fcvm.2021.751293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/11/2021] [Indexed: 12/15/2022] Open
Abstract
Systemic amyloidosis is a rare, heterogenous group of diseases characterized by extracellular infiltration and deposition of amyloid fibrils. Cardiac amyloidosis (CA) occurs when these fibrils deposit within the myocardium. Untreated, this inevitably leads to progressive heart failure and fatality. Historically, treatment has remained supportive, however, there are now targeted disease-modifying therapeutics available to patients with CA. Advances in echocardiography, cardiac magnetic resonance (CMR) and repurposed bone scintigraphy have led to a surge in diagnoses of CA and diagnosis at an earlier stage of the disease natural history. CMR has inherent advantages in tissue characterization which has allowed us to better understand the pathological disease process behind CA. Combined with specialist assessment and repurposed bone scintigraphy, diagnosis of CA can be made without the need for invasive histology in a significant proportion of patients. With existing targeted therapeutics, and novel agents being developed, understanding these imaging modalities is crucial to achieving early diagnosis for patients with CA. This will allow for early treatment intervention, accurate monitoring of disease course over time, and thereby improve the length and quality of life of patients with a disease that historically had an extremely poor prognosis. In this review, we discuss key radiological features of CA, focusing on the two most common types; immunoglobulin light chain (AL) and transthyretin (ATTR) CA. We highlight recent advances in imaging techniques particularly in respect of their clinical application and utility in diagnosis of CA as well as for tracking disease change over time.
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Affiliation(s)
- Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Rishi K Patel
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
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Camilli M, La Vecchia G, Lillo R, Iannaccone G, Lamendola P, Montone RA, Hohaus S, Aspromonte N, Massetti M, Lanza GA, Crea F, Graziani F, Lombardo A. Cardiovascular involvement in patients affected by multiple myeloma: a comprehensive review of recent advances. Expert Rev Hematol 2021; 14:1115-1128. [PMID: 34739762 DOI: 10.1080/17474086.2021.2003704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Multiple Myeloma (MM) is hematological neoplasia originating from plasma cells, which accounts for almost 1% of all oncologic malignancies. The median age of patients at diagnosis is about 65 years old and over. In this age group, cardiovascular (CV) diseases often co-exist, increasing the risk of adverse events related to MM treatment. A comprehensive search on the main educational platforms was performed and high-quality original articles and reviews were included. AREAS COVERED Patients affected by MM are at risk for heart failure, uncontrolled systemic hypertension, accelerated ischemic heart disease, arterial/venous thromboembolism, and arrhythmias. These complications may be due to the effects of chemotherapy on the CV system, which may play on preexisting risk factors, and amyloid deposition at cardiac level. EXPERT OPINION This review provides an updated overview of the spectrum of CV diseases that may affect MM patients, highlighting possible treatment strategies according to the latest recommendations. Cooperation between onco-hematologist and cardiologist is crucial in managing this population, in particular for adequate risk assessment, early diagnosis of CV complications, and proper treatment.
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Affiliation(s)
- Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giulia La Vecchia
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Rosa Lillo
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Iannaccone
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Priscilla Lamendola
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefan Hohaus
- Institute of Hematology, Catholic University of Sacred Heart, Rome, Italy.,Dipartimento Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Roma, Italia
| | - Nadia Aspromonte
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gaetano Antonio Lanza
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Graziani
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonella Lombardo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Small GR, Poulin A, Tavoosi A, Small TD, Crean AM, Chow BJW. Cardiac Computed Tomography for Amyloidosis. CURRENT CARDIOVASCULAR IMAGING REPORTS 2021. [DOI: 10.1007/s12410-021-09560-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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