Familial primary amyloidosis with severe amyloid heart disease

Systolic and diastolic ventricular function in cardiac amyloidosis. Studies in six cases diagnosed with endomyocardial biopsy

Five cases of cardiac amyloidosis diagnosed after endomyocardial biopsy are described. Systolic function was normal in three cases as assessed by cardiac index, ejection fraction and maximal velocity of contractile element shortening at zero developed pressure. The diastolic dip and plateau wave form was a characteristic but not an invariable finding. Increased ventricular end-diastolic pressure but normal end-diastolic volume indexes in all cases implied a disorder of diastolic compliance. The diastolic pressure-volume plots suggested a sudden decrease in distensibility after normal early filling of the ventricle. The functional defect did not necessarily differ from that of other diseases of heart muscle. Therefore, hemodynamic data should not be relied upon for diagnostic purposes. Electron microscopy was the most reliable aid in making the diagnosis from the endomyocardial biopsy specimens especially in the presence of fibrosis. It may not be valid to assume a diagnosis of cardiac amyloidosis from the finding of amyloid in other organs.

The conduction system in cardiac amyloidosis. Clinical and pathologic features of 23 patients

Cardiac amyliodosis is frequently associated with major electrocardiographic conduction disturbances; but that these disturbances are due to infiltrative destruction of the conduction system by amyloid is unclear. We studied the conduction systems in 23 autopsy patients with cardiac amyloidosis (group 1) (mild in seven, moderate in five and severe in 11), 21 (91 per cent) of whom had had abnormalities of conduction or rhythm during life. For comparison, we examined the conduction system in 23 control subjects matched in age and heart weight (group 2). Of the 23 patients in group 1, only three had extensive amyloidosis of the conduction system; in all three, electrocardiograms showed first degree atrioventricular block and left anterior hemiblock. A more common morphologic abnormality of the conduction system was severe sinoatrial node fibrosis present in seven (30 per cent) patients, and idiopathic atrophy and fibrosis of the bundle branches present in six (26 per cent) patients. None of the patients in group 2 had severe sinoatrial node fibrosis, but two (9 per cent) had idiopathic atrophy and fibrosis of the left bundle branch. Marked fibrosis of the sinus node was more frequent in patients with severe or moderate amyloid, but fibrosis of the bundle branch did not appear to be related to the amount of amyloid elsewhere in the heart. Varying degrees of atrioventricular and bundle branch block were also present in six patients with no morphologic abnormalities of the conduction system. Thus, conduction and rhythm disturbances are frequent in cardiac amyloidosis, but direct amyloid infiltration of the specialized conduction tissue of the heart does not account for the majority of these disturbances. Whether the increased incidence of fibrosis of the conduction system in group 1 compared to that in group 2 relates to the infiltrative myocardiopathy is uncertain.

Cardiac amyloidosis. Diagnosis by transvenous endomyocardial biopsy

Endomyocardial tissue, obtained from two patients presenting with restrictive cardiomyopathies, demonstrated amyloid infiltration. The percutaneous transvenous cardiac biopsy technic, using a modified Konno-Sakakibara cardiac bioptome, was safe and quick. Physical examination and catheterization data may not provide a definite differential diagnosis between restrictive and constrictive myocardial disease. Confirmation by biopsy of the cardiac amyloidosis assisted in providing optimum diagnostic and therapeutic care for these patients.

Familial renal amyloidosis. Case reports, literature review and classification

Three siblings (two brothers and a sister) of Polish origin, presented in late middle age with the features of the nephrotic syndrome and hypertension. Glomerular deposition of amyloid was found in all on renal biopsy. No amyloid was seen on rectal or gingival biopsy. Their mother and a maternal aunt died in middle age with a clincally similar disease. These cases are compared with other forms of hereditary amyloidosis which are briefly reviewed. The hereditary amyloidoses are classified with particular emphasis on neural and renal involvement.

Type I primary neuropathic amyloidosis (Andrade, portuguese)

The authors present a review of 21 cases with the diagnosis of type I amyloid neuropathy based on epidemiological data, clinical evolution and histopathological findings. They call attention to the possibility of cranial nerves involvement (hyposmia, diplopia, masseterian hypotrophy, peripheral facial paralysis, hypoacusis, dysphonia, laryngeal paralysis, dysphagia, and trapezium muscle hypotrophy), to the severeness of the digestive symptoms, to the precocity of the autonomic disorders, and to the rather high incidence (6 cases) of heart involvement. The electromyography showed anterior horn involvement in 3 cases. The electrocardiography showed repolarization disorders in 11 cases, left ventricular overload in 6 cases and atrioventricular block in 5 cases. The serum proteins electrophoresis showed frequent abnormalities, but no typical curve could be obtained. The barium-contrasted X-rays of the gastrointestinal tract showed no anatomical lesions, but functional abnormalities (hypo or hypermotility) were found in 14 examination. The Schilling test showed impairment of vitamin B12 absorption in 50% of the cases. However, with the concomitant administration of intrinsic factor (3 cases) there was improvement of it absorption. This proves that the gastric mucosa plays an important role in the disease malabsorption. The test with labeled-triolein showed slow absorption in 2 cases and steatorrhea in 3 (6 tests). For the confirmation of the amyloid deposits, the best histopathological procedure was nerve biopsy. In men, when the nerve biopsy was negative, testicular biopsy has shown to be a good option.