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Halwani O, Delgado DH. Cardiac amyloidosis: an approach to diagnosis and management. Expert Rev Cardiovasc Ther 2014; 8:1007-13. [DOI: 10.1586/erc.10.41] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yusuf SW, Solhpour A, Banchs J, Lopez-Mattei JC, Durand JB, Iliescu C, Hassan SA, Qazilbash MH. Cardiac amyloidosis. Expert Rev Cardiovasc Ther 2014; 12:265-77. [DOI: 10.1586/14779072.2014.876363] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Russo C, Green P, Maurer M. The prognostic significance of central hemodynamics in patients with cardiac amyloidosis. Amyloid 2013; 20:199-203. [PMID: 23885891 DOI: 10.3109/13506129.2013.821406] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The diagnosis of cardiac amyloidosis often requires a right heart catheterization with an endomyocardial biopsy. Although the central hemodynamics of the three main types of cardiac amyloidosis (AL, ATTRm, ATTRwt) have previously been described, the prognostic significance of these variables have not been fully explored. OBJECTIVE To compare the right heart catheterization variables between the three sub-groups of AL, ATTRm and ATTRwt, and describe if any of these variables are of prognostic significance. METHODS We conducted a retrospective cohort analysis of patients with biopsy confirmed cardiac amyloidosis between 1997 and 2011. Central hemodynamics as well as baseline clinical and laboratory characteristics were collected at the time of diagnosis. The prognostic significance of the central hemodynamics was evaluated. The internal review board of our institution approved the study. RESULTS Patients with ATTR and AL cardiac amyloidosis had similar central hemodynamic profiles of high filling pressures and low cardiac output with the exception of ATTR having higher pulmonary artery systolic pressure and pulmonary vascular resistance. Right atrial pressure (RAP), pulmonary artery diastolic pressure, pulmonary capillary wedge pressure and pulmonary artery saturation were individual predictors of death or heart transplantation (p < 0.05). However, when each was added to RAP they did not increase the predictive value compared to RAP alone. CONCLUSION The central hemodynamics of ATTR and AL amyloidosis were found to be similar and RAP emerged as the main predictor of transplant-free survival.
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Affiliation(s)
- Christopher Russo
- Center for Advanced Cardiac Care, Division of Cardiology, Department of Medicine, Columbia University Medical Center , New York, NY , USA
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Potena L, Quarta CC, Grigioni F, Rapezzi C. Prognostic stratification and treatment of cardiac light chain amyloidosis: a narrow path in the jungle. J Heart Lung Transplant 2013; 33:136-8. [PMID: 24480447 DOI: 10.1016/j.healun.2013.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/12/2013] [Indexed: 01/04/2023] Open
Affiliation(s)
- Luciano Potena
- Heart Failure and Heart Transplant Program, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy
| | - Candida Cristina Quarta
- Heart Failure and Heart Transplant Program, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy
| | - Francesco Grigioni
- Heart Failure and Heart Transplant Program, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy
| | - Claudio Rapezzi
- Heart Failure and Heart Transplant Program, Department of Experimental Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Italy
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Gray Gilstrap L, Niehaus E, Malhotra R, Ton VK, Watts J, Seldin DC, Madsen JC, Semigran MJ. Predictors of survival to orthotopic heart transplant in patients with light chain amyloidosis. J Heart Lung Transplant 2013; 33:149-56. [PMID: 24200511 DOI: 10.1016/j.healun.2013.09.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 08/23/2013] [Accepted: 09/10/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Orthotopic heart transplant (OHT), followed by myeloablative chemotherapy and autologous stem cell transplant (ASCT), has been successful in the treatment of amyloid light-chain (AL) cardiac amyloidosis. The purpose of this study was to identify predictors of survival to OHT in patients with end-stage heart failure due to AL amyloidosis and compare post-OHT survival of cardiac amyloid patients with survival of other cardiomyopathy patients undergoing OHT. METHODS From January 2000 to June 2011, 31 patients with end-stage heart failure secondary to AL amyloidosis were listed for OHT at Massachusetts General Hospital. Univariate and multivariate regression analyses identified predictors of survival to OHT. Kaplan-Meier analysis compared survival between the Massachusetts General Hospital amyloidosis patients and non-amyloid cardiomyopathy patients from the Scientific Registry of Transplant Recipients (SRTR). RESULTS Low body mass index was the only predictor of survival to OHT in patients with end-stage heart failure caused by cardiac amyloidosis. Survival of cardiac amyloid patients who died before receiving a donor heart was only 63 ± 45 days after listing. Patients who survived to OHT received a donor organ at 53 ± 48 days after listing. Survival of AL amyloidosis patients on the waiting list was less than patients on the waiting list for all other non-amyloid diagnoses. The long-term survival of amyloid patients who underwent OHT was no different than the survival of non-amyloid, restrictive (p = 0.34), non-amyloid dilated (p = 0.34), or all non-amyloid cardiomyopathy patients (p = 0.22) in the SRTR database. CONCLUSIONS Amyloid patients who survive to OHT, followed by ASCT, have a survival rate similar to other cardiomyopathy patients undergoing OHT; however, 35% of the patients died awaiting OHT. The only predictor of survival to OHT in AL amyloidosis patients was a low body mass index, which correlated with a shorter time on the waiting list. To optimize the survival of these patients, access to donor organs must be improved.
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Affiliation(s)
- Lauren Gray Gilstrap
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily Niehaus
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Van-Khue Ton
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutes, Baltimore, Maryland
| | - James Watts
- Cardiology Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - David C Seldin
- Section of Hematology and Oncology, Amyloidosis Center, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Joren C Madsen
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc J Semigran
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Abstract
PURPOSE OF REVIEW Cardiac amyloidosis, an infiltrative restrictive cardiomyopathy once thought to be universally fatal, is now increasingly recognized as less rare than previously thought. This update is intended to provide a review of newer aspects of the presentation, diagnosis and treatment of cardiac amyloidosis. RECENT FINDINGS Amyloid involvement of the heart is increasingly seen, especially in the elderly population. Recent data suggest life expectancy has increased from 6 to 16-20 months in the most common subtype, AL amyloid. The clinical presentation is typically one of heart failure in the setting of normal or low normal ejection fraction, inappropriate ventricular hypertrophy and atrial enlargement with or without atrial fibrillation. Diagnosis is now most often made by cardiac MRI, with 2D echocardiography serving more of a screening role in patients with heart failure or a similar family history. The gold standard diagnostic test is right-ventricular biopsy, which demonstrates positivity for Congo Red staining. Due to a propensity for disease progression, typically low systemic blood pressure, frequent extra-cardiac involvement and autonomic dysfunction, cardiac amyloidosis is difficult to treat due to poor tolerance of most cardiovascular medication and poor outcome for transplantation. Newer therapies such as bortezomib, usually given to patients with multiple myeloma and serum light chains, are promising in controlling amyloidosis. CONCLUSION Recent advances in diagnosis and treatment of amyloid are associated with improved prognosis. Newer therapies offer future benefits.
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Nohria A. Should we avoid heart transplantation in cardiomyopathy due to radiotherapy/chemotherapy or amyloidosis? The devil is in the details. J Heart Lung Transplant 2013. [PMID: 23206982 DOI: 10.1016/j.healun.2012.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Estep JD, Bhimaraj A, Cordero-Reyes AM, Bruckner B, Loebe M, Torre-Amione G. Heart transplantation and end-stage cardiac amyloidosis: a review and approach to evaluation and management. Methodist Debakey Cardiovasc J 2013; 8:8-16. [PMID: 23227279 DOI: 10.14797/mdcj-8-3-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cardiac amyloidosis is one of the most common of the infiltrative cardiomyopathies and is associated with a poor prognosis. The extent of cardiac involvement with amyloid deposition is an important determinant of treatment options and is the major determinant of outcome in patients with amyloidosis. Several small case series with sequential orthotopic heart transplantation and autologous stem cell transplant have demonstrated an improvement in post-transplant outcome and have revived enthusiasm about heart transplantation for patients with end-stage heart failure due to AL amyloidosis. The purpose of this review is to summarize the evaluation and management of cardiac amyloidosis and to provide our single-center experience with end-stage heart failure due to AL amyloidosis treated with heart transplantation followed by an autologous stem cell transplant.
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Affiliation(s)
- Jerry D Estep
- Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
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Left ventricular device implantation for advanced cardiac amyloidosis. J Heart Lung Transplant 2013; 32:563-8. [DOI: 10.1016/j.healun.2013.01.987] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 01/10/2013] [Accepted: 01/14/2013] [Indexed: 11/19/2022] Open
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Esplin BL, Gertz MA. Current Trends in Diagnosis and Management of Cardiac Amyloidosis. Curr Probl Cardiol 2013; 38:53-96. [DOI: 10.1016/j.cpcardiol.2012.11.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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DePasquale EC, Nasir K, Jacoby DL. Outcomes of adults with restrictive cardiomyopathy after heart transplantation. J Heart Lung Transplant 2012; 31:1269-75. [PMID: 23079066 DOI: 10.1016/j.healun.2012.09.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/28/2012] [Accepted: 09/14/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Restrictive cardiomyopathy (RCM) represents a spectrum of disorders with a common physiology but divergent etiologies. RCM commonly leads to progressive heart failure and the need for heart transplantation (HTx). Pediatric RCM is a more homogeneous disorder with post-HTx outcomes comparable to those for non-RCM patients. However, post-HTx outcomes in adult RCM patients have not been studied to date. METHODS Demographic, clinical and survival outcomes of 38,190 adult HTx-only recipients from 1987 to 2010 were acquired from the registry of the United Network of Organ Sharing. The study population included 544 RCM patients (1.4%) and 37,646 non-RCM patients (98.6%). RCM diagnoses included idiopathic (n = 227, 42%), amyloid (n = 142, 26%), sarcoid (n = 81, 15%), radiation/chemotherapy (XRT) (n = 35, 6%) and other (n = 59, 11%). RESULTS Follow-up began at the time of HTx (74±64 months). During the follow-up period, 224 (41%) patients in the RCM group died, whereas 18,791 (50%) in the non-RCM group died. Crude 1-, 5- and 10-year survival for RCM patients was 84%, 66% and 45%, and for non-RCM patients was 85%, 70% and 50%, respectively. The overall unadjusted hazard ratio of RCM vs non-RCM for all-cause mortality was 1.07 (confidence interval [CI] 0.93 to 1.22). Multivariate Cox proportional hazards regression analysis yielded a hazard ratio of 1.06 (CI 0.91 to 1.25). RCM subgroup analysis showed decreased survival at 1, 5 and 10 years in the XRT (71%, 47% and 32%) and amyloid (79%, 47% and 28%) patient groups. The unadjusted hazard ratio for the XRT and amyloid subgroups vs RCM for all-cause mortality was 1.81 (p = 0.002) and 1.85 (p = 0.0004), respectively. CONCLUSIONS Outcomes for RCM patients post-HTx are comparable to those of non-RCM patients. However, RCM subgroup analysis suggests increased mortality for XRT and amyloid subgroups. Further analysis is warranted to understand the contributing factors.
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Affiliation(s)
- Eugene C DePasquale
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles
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Johnson SM, Connelly S, Fearns C, Powers ET, Kelly JW. The transthyretin amyloidoses: from delineating the molecular mechanism of aggregation linked to pathology to a regulatory-agency-approved drug. J Mol Biol 2012; 421:185-203. [PMID: 22244854 PMCID: PMC3350832 DOI: 10.1016/j.jmb.2011.12.060] [Citation(s) in RCA: 244] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 12/22/2011] [Accepted: 12/29/2011] [Indexed: 12/31/2022]
Abstract
Transthyretin (TTR) is one of the many proteins that are known to misfold and aggregate (i.e., undergo amyloidogenesis) in vivo. The process of TTR amyloidogenesis causes nervous system and/or heart pathology. While several of these maladies are associated with mutations that destabilize the native TTR quaternary and/or tertiary structure, wild-type TTR amyloidogenesis also leads to the degeneration of postmitotic tissue. Over the past 20 years, much has been learned about the factors that influence the propensity of TTR to aggregate. This biophysical information led to the development of a therapeutic strategy, termed "kinetic stabilization," to prevent TTR amyloidogenesis. This strategy afforded the drug tafamidis which was recently approved by the European Medicines Agency for the treatment of TTR familial amyloid polyneuropathy, the most common familial TTR amyloid disease. Tafamidis is the first and currently the only medication approved to treat TTR familial amyloid polyneuropathy. Here we review the biophysical basis for the kinetic stabilization strategy and the structure-based drug design effort that led to this first-in-class pharmacologic agent.
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Affiliation(s)
- Steven M. Johnson
- Department of Chemistry and The Skaggs Institute for Chemical Biology, La Jolla, California 92037, USA
| | - Stephen Connelly
- Department of Molecular Biology, La Jolla, California 92037, USA
| | - Colleen Fearns
- Department of Chemistry and The Skaggs Institute for Chemical Biology, La Jolla, California 92037, USA
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California 92037, USA
| | - Evan T. Powers
- Department of Chemistry and The Skaggs Institute for Chemical Biology, La Jolla, California 92037, USA
| | - Jeffery W. Kelly
- Department of Chemistry and The Skaggs Institute for Chemical Biology, La Jolla, California 92037, USA
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California 92037, USA
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Abstract
PURPOSE OF REVIEW We review the clinical and pathological features of the various types of amyloid that involve the heart, the diagnostic utility of endomyocardial biopsy, and the experience of patient survival and disease recurrence following cardiac transplant for amyloidosis. RECENT FINDINGS Patient outcome is dependent on arresting the cause of amyloid as well as controlling the accumulated damage, which may involve multiple organs. As such, the stratification of patient suitability for cardiac transplant must be considered in conjunction with concurrent treatments, which may include autologous stem cell, liver or kidney transplant, and chemotherapy. SUMMARY As the efficacy of these therapies changes, the indications for cardiac transplantation need to be re-evaluated.
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Abstract
Amyloid diseases in man are caused by as many as 23 different pre-cursor proteins already described. Cardiologists predominantly encounter three main types of amyloidosis that affect the heart: light chain (AL) amyloidosis, senile systemic amyloidosis (SSA) and hereditary amyloidosis, most commonly caused by a mutant form of transthyretin. In the third world, secondary amyloid (AA) is more prevalent, due to chronic infections and inadequately treated inflammatory conditions. Much less common, are the non-transthyretin variants, including mutations of fibrinogen, the apolipoproteins apoA1 and apoA2 and gelsolin. These rarer types do not usually cause significant cardiac compromise. Occurring worldwide, later in life and of less clinical significance, isolated atrial amyloid (IAA) also involves the heart. Heart involvement by amyloid often has devastating consequences. Clinical outcome depends on amyloid type, the extent of systemic involvement and the treatment options available. An exact determination of amyloid type is critical to appropriate therapy. In this review we describe the different approaches required to treat this spectrum of amyloid cardiomyopathies.
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Affiliation(s)
- S W Dubrey
- Department of Cardiology, Hillingdon Hospital, Pield Heath Road, Uxbridge, Middlesex, UB8 3NN, UK.
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Ammirati E, Marziliano N, Vittori C, Pedrotti P, Bramerio MA, Motta V, Orsini F, Veronese S, Merlini PA, Martinelli L, Frigerio M. The first Caucasian patient with p.Val122Ile mutated-transthyretin cardiac amyloidosis treated with isolated heart transplantation. Amyloid 2012; 19:113-7. [PMID: 22449240 DOI: 10.3109/13506129.2012.666509] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Effective treatments for mutated transthyretin (TTR)-related cardiac amyloidosis are limited. Heart transplantation or combined liver-heart transplantation are the most successful options, although results rely on underline mechanism and systemic nature of the disease. In this report, we present the first case of a Caucasian patient with the p.Val122Ile mutated TTR-related cardiac amyloidosis treated with heart transplantation due to this gene mutation frequent in Afro-Americans with a prevalent isolated heart involvement. The choice of isolated heart transplantation instead of combined heart and liver transplantations was based on (1) severe and progressive cardiac disease, (2) evidence of a gene mutation generally associated with isolated cardiac disease and (3) absence of relevant extra-cardiac involvement (with the possible exception of mild peripheral neuropathy). In any case, the very short post-transplant observation period of 10 months does not allow any conclusions on the long-term course of the presented strategy. Finally, it is the first European Caucasian family with the p.Val122Ile TTR mutation that has been described. Till now, very few Caucasian cases of p.Val122Ile mutated TTR-related cardiac amyloidosis have been reported. The patient and some members of his family also had mild peripheral neuropathy suggesting a regional phenotypic heterogeneity of European Caucasian TTR p.Val122Ile.
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Affiliation(s)
- Enrico Ammirati
- The Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan, Italy
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Dispenzieri A, Gertz MA, Buadi F. What do I need to know about immunoglobulin light chain (AL) amyloidosis? Blood Rev 2012; 26:137-54. [PMID: 22537397 DOI: 10.1016/j.blre.2012.03.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is the most common acquired systemic amyloidoses. Its presentation is often insidious and progressive, which may delay diagnosis. The interval between first symptoms and actual diagnosis along the intrinsic heterogeneity of tissue tropism create a wide spectrum of presentations, both in terms of scope and depth of symptoms and signs and functional status of patients. In this review, the authors review the pathogenesis, diagnosis and differential diagnosis of AL amyloidosis along with the prognosis and state-of-the-art management for patients with this affliction.
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69
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Affiliation(s)
- Sanjay M Banypersad
- National Amyloidosis Centre, UCL Medical School, UK (S.M.B., C.W., P.N.H., A.D.W.) ; The Heart Hospital, UK (S.M.B., J.C.M.) ; University College London, UK (S.M.B., C.W.)
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Abstract
The cardiac involvement and associated mortality that occur in systemic AL amyloidosis remain among the most challenging aspects of the systemic amyloid-related diseases. Monoclonal immunoglobulin light chains produced by a clone of plasma cells are usually the cause of symptoms and organ dysfunction via both poorly understood toxic effects of misfolded species and accumulation of interstitial amyloid fibrils in key viscera. Treatment is aimed at eliminating the clonal cells in order to eliminate toxic light chain production. Recent advances in therapy have helped many patients with AL achieve complete hematologic responses and significant reversal of organ damage but these benefits do not extend to that 10-15 % who present with advanced cardiac involvement. Even with cardiac transplant followed by effective therapy such as stem cell transplant, outcomes for these patients remain promising at best.
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation "IRCCS Policlinico San Matteo", and Department of Molecular Medicine, University of Pavia, Viale Golgi 19, 27100, Pavia, Italy,
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Leone O, Veinot JP, Angelini A, Baandrup UT, Basso C, Berry G, Bruneval P, Burke M, Butany J, Calabrese F, d'Amati G, Edwards WD, Fallon JT, Fishbein MC, Gallagher PJ, Halushka MK, McManus B, Pucci A, Rodriguez ER, Saffitz JE, Sheppard MN, Steenbergen C, Stone JR, Tan C, Thiene G, van der Wal AC, Winters GL. 2011 consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology. Cardiovasc Pathol 2011; 21:245-74. [PMID: 22137237 DOI: 10.1016/j.carpath.2011.10.001] [Citation(s) in RCA: 361] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/28/2011] [Accepted: 10/07/2011] [Indexed: 01/04/2023] Open
Abstract
The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology have produced this position paper concerning the current role of endomyocardial biopsy (EMB) for the diagnosis of cardiac diseases and its contribution to patient management, focusing on pathological issues, with these aims: • Determining appropriate EMB use in the context of current diagnostic strategies for cardiac diseases and providing recommendations for its rational utilization • Providing standard criteria and guidance for appropriate tissue triage and pathological analysis • Promoting a team approach to EMB use, integrating the competences of pathologists, clinicians, and imagers.
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Affiliation(s)
- Ornella Leone
- U.O. di Anatomia ed Istologia Patologica, Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy.
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Varr BC, Liedtke M, Arai S, Lafayette RA, Schrier SL, Witteles RM. Heart transplantation and cardiac amyloidosis: approach to screening and novel management strategies. J Heart Lung Transplant 2011; 31:325-31. [PMID: 22051505 DOI: 10.1016/j.healun.2011.09.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 09/03/2011] [Accepted: 09/28/2011] [Indexed: 11/17/2022] Open
Abstract
Limited data exist regarding screening methods and outcomes for orthotopic heart transplantation (OHT) in cardiac amyloidosis. As a result, uncertainty exists over the best approach to OHT for cardiac amyloidosis and for the timing of critical post-transplant therapies. This article reviews 6 patients who underwent OHT for cardiac amyloidosis at the Stanford University Amyloid Center from 2008 to present. All patients with light-chain amyloidosis received chemotherapy in the interval between OHT and autologous hematopoietic stem cell transplant. Five patients remain alive up to 25 months after OHT, without evidence of recurrent cardiac amyloid deposition. A novel strategy of OHT, followed by light-chain suppressive chemotherapy before autologous hematopoietic stem cell transplant, is feasible for patients with light-chain amyloidosis.
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Affiliation(s)
- Brandon C Varr
- Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Kapoor P, Thenappan T, Singh E, Kumar S, Greipp PR. Cardiac amyloidosis: a practical approach to diagnosis and management. Am J Med 2011; 124:1006-15. [PMID: 22017778 DOI: 10.1016/j.amjmed.2011.04.013] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/05/2011] [Accepted: 04/06/2011] [Indexed: 10/16/2022]
Abstract
Cardiac amyloidosis, the primary determinant of prognosis in systemic amyloidoses, is characterized by infiltration of myocardium by amyloid protein resulting in cardiomyopathy and conduction disturbances. Cardiac involvement is primarily encountered in immunoglobulin (AL) and transthyretin-associated (hereditary/familial and senile) amyloidoses. Although the latter variants could be indolent, untreated AL amyloidosis with clinical cardiac involvement is a rapidly fatal disease. The management decisions of cardiac amyloidosis are based on the underlying cause. Although treatment of senile systemic amyloidosis is largely supportive, the therapeutic approaches for AL amyloidosis include chemotherapy, autologous stem cell transplantation, and, rarely, cardiac transplantation. The familial variant is potentially curable with a liver ± cardiac transplantation. This narrative review outlines a practical approach to these challenging diagnoses in the face of rapidly evolving management strategies.
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Sohn HR, Song BG, Jeong SY, Hong SM, Jung HG, Jung HJ, Cho WH, Choi SK. A Case of Cardiac Amyloidosis Initially Misdiagnosed as Syndrome X. Cardiol Res 2011; 2:181-184. [PMID: 28352388 PMCID: PMC5358226 DOI: 10.4021/cr67w] [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] [Accepted: 06/30/2011] [Indexed: 11/07/2022] Open
Abstract
Cardiac infiltration of amyloid fibril results in progressive cardiomyopathy with a grave prognosis and results in cardiac diseases such as congestive heart disease, cardiomyopathy, valvular heart disease, and arrhythmias. We present a rare case of cardiac amyloidosis initially misdiagnosed as syndrome X in which recurrent chest pain and progressive heart failure could be managed finally by heart transplantation.
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Affiliation(s)
- Hyung Rae Sohn
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Bong Gun Song
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Seong Yeon Jeong
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Su-Min Hong
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Hyun Gul Jung
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Hye-Jin Jung
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Wook-Hyun Cho
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
| | - Suk-Koo Choi
- Division of Cardiology, Cardiac and Vascular Center, Department of Medicine, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
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Binotto G, Cillo U, Trentin L, Piazza F, Zaninotto M, Semenzato G, Adami F. Double autologous bone marrow transplantation and orthotopic liver transplantation in a patient with primary light chain (AL) amyloidosis. Amyloid 2011; 18 Suppl 1:132-4. [PMID: 21838461 DOI: 10.3109/13506129.2011.574354049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- G Binotto
- Department of Clinical & Experimental Medicine, Hematology & Clinical Immunology Section, Padova University School of Medicine, Padova, Italy
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77
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78
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Kang GH, Ryu DR, Song PS, Song YB, Hahn JY, Choi SH, Gwon HC. A case of a senile systemic amyloidosis patient presenting with angina pectoris and dilated cardiomyopathy. Korean Circ J 2011; 41:209-12. [PMID: 21607172 PMCID: PMC3098414 DOI: 10.4070/kcj.2011.41.4.209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 11/11/2022] Open
Abstract
A 77-year-old man visited our hospital complaining of aggravated exertional chest pain. He was diagnosed with syndrome X 7 years ago and underwent medical treatment in a regional hospital. Coronary angiography and echocardiography did not show any significant abnormalities. On the seventh in-hospital day, cardiogenic shock developed and echocardiography showed a dilated left ventricular (LV) cavity and severe LV systolic dysfunction. We thus inserted an intra-aortic balloon pump for hemodynamic support and were forced to maintain it because of weaning failure several times. Finally, heart transplantation was the decided necessary procedure. After successful heart transplantation, the biopsy specimen revealed a wild-type transthyretin deposition indicating senile systemic amyloidosis in the intramuscular coronary vessels and interstitium. Cardiac biopsy at the 4-year follow-up showed no recurrence of amyloid deposition.
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Affiliation(s)
- Gu Hyun Kang
- Division of Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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79
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Desport E, Moumas E, Abraham J, Delbès S, Lacotte-Thierry L, Touchard G, Fermand JP, Bridoux F, Jaccard A. [Current treatment of AL amyloidosis]. Nephrol Ther 2011; 7:467-73. [PMID: 21497573 DOI: 10.1016/j.nephro.2011.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 02/09/2011] [Indexed: 10/28/2022]
Abstract
Systemic AL amyloidosis is a rare complication of monoclonal gammopathies. Renal manifestations are frequent, mostly characterized by heavy proteinuria, with nephrotic syndrome and renal failure in more than half of the patients at diagnosis. Without treatment, median survival does not exceed 12 months. Amyloid heart disease and diffusion of amyloid deposits are associated with reduced survival. Treatment of systemic AL amyloidosis has been profoundly modified with the introduction of international criteria for the definition of organ involvement and hematologic response, and with the use of sensitive tests for the measurement of serum-free light chain levels. Melphalan plus dexamethasone is now established as the gold standard for first line treatment of systemic AL, with similar efficacy and reduced treatment-related mortality compared to high-dose therapy. Modern chemotherapy regimens, based on the use of novel agents such as bortezomib and lenalidomide, might further improve patient survival.
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Affiliation(s)
- Estelle Desport
- Service de néphrologie et transplantation rénale, hôpital Jean-Bernard, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
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80
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Cardiac transplantation followed by dose-intensive melphalan and autologous stem-cell transplantation for light chain amyloidosis and heart failure. Transplantation 2010; 90:905-11. [PMID: 20733534 DOI: 10.1097/tp.0b013e3181f10edb] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with light chain (AL) amyloidosis who present with severe heart failure due to cardiac involvement rarely survive more than 6 months. Survival after cardiac transplantation is markedly reduced due to the progression of amyloidosis. Autologous stem-cell transplantation (ASCT) has become a common therapy for AL amyloidosis, but there is an exceedingly high treatment-related mortality in patients with heart failure. METHODS We developed a treatment strategy of cardiac transplant followed by ASCT. Twenty-six patients were evaluated, and of 18 eligible patients, nine patients underwent cardiac transplantation. Eight of these patients subsequently received an ASCT. RESULTS Six of seven evaluable patients achieved a complete hematologic remission, and one achieved a partial remission. At a median follow-up of 56 months from cardiac transplant, five of seven patients are alive without recurrent amyloidosis. Their survival is comparable with 17,389 patients who received heart transplants for nonamyloid heart disease: 64% in nonamyloid vs. 60% in amyloid patients at 7 years (P=0.83). Seven of eight transplanted patients have had no evidence of amyloid in their cardiac allograft. CONCLUSIONS This demonstrates that cardiac transplantation followed by ASCT is feasible in selected patients with AL amyloidosis and heart failure, and that such a strategy may lead to improved overall survival.
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Abstract
Endomyocardial biopsy is a commonly performed useful procedure utilized for the evaluation of cardiac tissue. Biopsy may be used to monitor transplant rejection, but it has many other applications including the evaluation of myocarditis, cardiomyopathy, chest pain, arrhythmia, and secondary involvement by systemic diseases. Drug toxicity may be evaluated and neoplasms may be biopsied. Recent developments include advances in myocardial and viral molecular biology and advances in image or electrophysiology guided biopsy. The utility of endomyocardial biopsy is reviewed with consideration of these advances.
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Affiliation(s)
- John P Veinot
- Division of Anatomical Pathology, University of Ottawa Heart Institute, Department of Pathology and Laboratory Medicine at the Ottawa Hospital,Civic Campus and the University of Ottawa, Ottawa, Ontario, Canada.
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82
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Luo JM, Chou NK, Chi NH, Chen YS, Yu HY, Wang CH, Ko WJ, Tsao CI, Sun CD, Wang SS. Heart transplantation in patients with amyloidosis. Transplant Proc 2010; 42:927-9. [PMID: 20430206 DOI: 10.1016/j.transproceed.2010.02.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cardiac transplantation is currently the only established surgical approach to the treatment of refractory heart failure. Heart transplantation because of amyloid cardiomyopathy continues to generate controversy because of donor shortage and concerns about disease recurrence in the allograft. We reviewed the medical records for all patients who underwent heart transplantation at our institution from 1987 to 2007, and found that 4 patients were diagnosed as having amyloid cardiomyopathy after pathologic examination of the excised hearts. No operative mortality was noted; however, all of the patients died of sepsis after transplantation. Because of the poor results, we do not recommended performing transplantation in patients with amyloidosis. Preoperative surveys and evaluation for amyloidosis must be emphasized in patients with hypertrophic cardiomyopathy.
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Affiliation(s)
- J-M Luo
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan
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83
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84
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Luk A, Ahn E, Lee A, Ross HJ, Butany J. Recurrent cardiac amyloidosis following previous heart transplantation. Cardiovasc Pathol 2010; 19:e129-33. [DOI: 10.1016/j.carpath.2009.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 05/31/2009] [Accepted: 06/25/2009] [Indexed: 10/20/2022] Open
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85
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Abstract
Involvement of the heart is a common finding in amyloidosis. The heart is usually infiltrated by amyloid fibrils in primary amyloidosis and age-related forms of amyloidosis, less commonly in transthyretin familial amyloidosis, and rarely in secondary amyloidosis. The most common clinical presentation is restrictive cardiomyopathy with right-sided heart failure. The second most frequent presentation is congestive heart failure due to systolic dysfunction, followed by arrhythmias and orthostatic hypotension. The diagnosis of amyloidosis requires tissue sample confirmation; at present, Congo red staining in polarized light is the diagnostic method of choice. The characterization of protein fibril type by immunohistochemistry or biochemistry is essential for patient prognosis and treatment. The therapeutic approach consists of specific treatment of amyloidosis and supportive treatment for cardiac-related symptoms. The treatment depends on the type of amyloidosis and the stage of disease. The mainstay of supportive treatment of cardiac failure is diuretic therapy. Primary amyloidosis treatment protocol includes melphalan and prednisone chemotherapy. Heart transplantation is only a palliative treatment. Stem cell transplantation is an emerging treatment alternative. Combination therapy of melphalan and stem cell transplantation has been shown to be a promising treatment strategy. Secondary amyloidosis requires aggressive treatment of the associated inflammatory and neoplastic process. Age-related (senile) amyloidosis benefits from supportive cardiac treatment when applicable. Transthyretin amyloidosis, the most common cardiac hereditary amyloidosis, is treated by liver or combined liver-heart transplantation. New therapies based on chemical and immunologic reaction with amyloid or its precursor are under intensive development.
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Affiliation(s)
- Ivana Kholová
- Institute of Clinical Medicine, Pathology and Forensic Medicine, University of Kuopio, P.O. Box 1627, FIN-70211 Kuopio, Finland.
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86
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Abstract
A nonhereditary form of systemic amyloidosis associated with wild-type transthyretin causes heart involvement predominantly in elderly men (systemic senile amyloidosis, or SSA). However, hereditary transthyretin-related amyloidosis (ATTR) is the most frequent form of familial systemic amyloidosis, a group of severe diseases with variable neurological and organ involvement. ATTR remains a challenging and widely underdiagnosed condition, owing to its extreme phenotypic variability: the clinical spectrum of the disease ranges from an almost exclusive neurologic involvement to a strictly cardiac presentation. Such heterogeneity principally results from differential effects of the various reported transthyretin mutations, the geographic region the patient is from and, in the case of the most common mutation, Val30Met, whether or not large foci of cases occur (endemic versus nonendemic aggregation). Genetic or environmental factors (such as age, sex, and amyloid fibril composition) also contribute to the heterogeneity of ATTR, albeit to a lesser extent. The existence of exclusively or predominantly cardiac phenotypes should lead clinicians to consider the possibility of ATTR in all patients who present with an unexplained increase in left ventricular wall thickness at echocardiography. Assessment of such patients should include an active search for possible red flags that can point to the correct final diagnosis.
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87
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Dubrey SW, Lodge F. Old men and thickened hearts. BMJ Case Rep 2010; 2010:2010/may06_1/bcr0820092212. [PMID: 22736726 DOI: 10.1136/bcr.08.2009.2212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The case of a patient with confirmed amyloid, initially believed to be light chain (AL) type, whose diagnosis was clouded by an atypical gastrointestinal tract system presentation and a concomitant haematological condition, is presented. Duodenal biopsy samples subsequently stained positive for transthyretin and the diagnosis was revised to senile systemic amyloidosis. The patient was managed medically and remains alive more than 2 years after the diagnosis was formally established. Differentiating the systemic amyloidoses from one another can be challenging as the features often overlap and the most sensitive tests usually require a tertiary referral. Ultimately, cases usually require histological verification from tissue biopsies. Helpful pointers can be obtained with a careful history and examination in combination with some routinely available diagnostic tests.
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88
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Mueller II, Gawaz M, Linke RP, Zuern C, Steiner D, Altland K, Von Beckerath N, Weig HJ. Restrictive cardiomyopathy in inherited ATTR amyloidosis (TTR-Ser23Asn) in a patient of German-Italian extraction. BMJ Case Rep 2010; 2010:bcr06.2009.2032. [PMID: 22400056 DOI: 10.1136/bcr.06.2009.2032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Amyloidosis occurs when certain soluble proteins are transformed into amyloid fibrils in the extracellular space. Most common are the light-chain amyloidoses; less common is the AA-amyloidosis, which follows chronic inflammatory diseases, and the amyloidoses of transthyretin (TTR) origin. We report on a women of Italian-German origin with the mutation TTR (Ser23Asn). Whole body scintigraphy using TC99m-DPD showed end stage hereditary amyloidosis caused by ATTR with predominant tracer retention in the myocardium. Myocardial biopsies revealed the presence of amyloid by Congo red staining. Further immunohistochemical analysis showed ATTR amyloidosis. DNA sequencing revealed a point mutation of the transthyretin gene leading to a single amino acid substitution. The only effective treatment in patients with manifest cardiac ATTR amyloidosis is combined heart and liver transplantation. Our patient was placed on a list for this procedure, but unfortunately she died during the standby procedure due to urosepsis.
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Affiliation(s)
- Iris I Mueller
- Medizinische Klinik Universitaetsklinikum Tuebingen, Kardiologie, Otfried-Mueller-Str. 10, Tuebingen, 72076, Germany
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89
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Abstract
Amyloidosis is a clinical disorder caused by the extracellular deposition of misfolded, insoluble aggregated protein with a characteristic ss pleated sheet configuration that produces apple-green birefringence under polarized light when stained with Congo red dye. The spectrum of organ involvement can include the kidneys, heart, blood vessels, central and peripheral nervous systems, liver, intestines, lungs, eyes, skin, and bones. Cardiovascular amyloidosis can be primary, a part of systemic amyloidosis, or the result of chronic systemic disease elsewhere in the body. The most common presentations are congestive heart failure because of restrictive cardiomyopathy and conduction abnormalities. Recent developments in imaging techniques and extracardiac tissue sampling have minimized the need for invasive endomyocardial biopsy for amyloidosis. Cardiac amyloidosis management will vary depending on the subtype but consists of supportive treatment of cardiac related symptoms and reducing the amyloid fibrils formation attacking the underlying disease. Despite advances in treatment, the prognosis for patients with amyloidosis is still poor and depends on the underlying disease type. Early diagnosis of cardiac amyloidosis may improve outcomes but requires heightened suspicion and a systematic clinical approach to evaluation. Delays in diagnosis, uncertainties about the relative merits of available therapies, and difficulties in mounting large-scale clinical trials in rare disorders combine to keep cardiac amyloidosis a challenging problem. This review outlines current approaches to diagnosis, assessment of disease severity, and treatment of cardiac amyloidosis.
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90
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91
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Affiliation(s)
- Simon W Dubrey
- Department of Cardiology, Hillingdon Hospital, Uxbridge Middlesex, UB8 3NN
| | - Rodney H Falk
- Brigham and Women's Hospital Cardiac Amyloidosis Program, Harvard Vanguard Medical Associates, Boston, MA, USA
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92
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Kristen AV, Sack FU, Schonland SO, Hegenbart U, Helmke BM, Koch A, Schnabel PA, Röcken C, Hardt S, Remppis A, Goldschmidt H, Karck M, Ho AD, Katus HA, Dengler TJ. Staged heart transplantation and chemotherapy as a treatment option in patients with severe cardiac light-chain amyloidosis. Eur J Heart Fail 2010; 11:1014-20. [PMID: 19789405 DOI: 10.1093/eurjhf/hfp121] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS The prognosis of advanced cardiac light-chain amyloidosis is poor. Heart transplantation might enable causative therapy and ultimately improve prognosis. METHODS AND RESULTS Nineteen patients with cardiac amyloidosis but no obvious involvement of other organs were scheduled for heart transplantation. Four to 6 months later, high-dose melphalan chemotherapy and autologous stem cell transplantation (HDM-ASCT) was planned in patients not in complete remission. Seven of nineteen patients died while waiting for heart transplantation. The remaining 12 patients (complete remission, n = 4) underwent surgery. Chemotherapy in patients not in complete remission consisted of HDM-ASCT (n = 5/12; subsequent complete remission, n = 2; partial remission, n = 3) or melphalan-prednisolone (partial remission, n = 1). Two of twelve patients were ineligible for any chemotherapy. Three of twelve patients died [423.5 (105-2131) days] from progressive disease, relapse, or sepsis. The 1- and 3-year survival rates were 83 and 83%, respectively, similar to those of patients undergoing heart transplantation for standard indications. Corresponding survival rates stratified by haematological response were 100 and 100% for complete remission (partial remission, 100 and 100%; progressive disease, 0 and 0%). CONCLUSION Heart transplantation in advanced cardiac amyloidosis is a promising approach to interrupting the vicious circle of ineligibility for potential curative chemotherapeutic treatment and extremely poor prognosis of cardiac amyloidosis without chemotherapy. Highly urgent heart transplantation combined with subsequent HDM-ASCT appears to offer a successful treatment option to improve the poor outcome of cardiac amyloidosis. However, it should be restricted to highly selected patients in specialized centres.
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Affiliation(s)
- Arnt V Kristen
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 410, Heidelberg D-69120, Germany.
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93
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94
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Gómez-Bueno M, Segovia J, García-Pavía P, Barceló JM, Krsnik I, Sánchez-Turrión V, Salas C, Alonso-Pulpón L. Cardiac amyloidosis: the importance of a multidisciplinary approach. Rev Esp Cardiol 2009; 62:698-702. [PMID: 19480768 DOI: 10.1016/s1885-5857(09)72236-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cardiac amyloidosis is associated with the interstitial deposition of abnormal protein in the myocardium, which can lead to a form of restrictive cardiomyopathy with a poor prognosis. This protein can have a number of different origins, which give rise to various subtypes of amyloidosis that have different prognoses and that require different therapeutic approaches. Drugs commonly used in heart failure have little effect in amyloidosis and the use of heart transplantation is controversial because amyloidosis is a multi-organ disease and because there is a possibility of disease recurrence in the graft. The use of new techniques to identify the specific amyloidosis subtype, the emergence of novel ways of preventing or decreasing amyloid production, the ability to monitor responses to therapy and, above all, the introduction of multidisciplinary teams that can implement a combination of therapies, including multiple organ transplantation, have contributed to a substantial improvement in the prognosis of this disease.
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Affiliation(s)
- Manuel Gómez-Bueno
- Unidad de Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, España.
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95
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Gómez-Bueno M, Segovia J, García-Pavía P, Barceló JM, Krsnik I, Sánchez-Turrión V, Salas C, Alonso-Pulpón L. Amiloidosis cardiaca: la importancia del manejo multidisciplinario. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)71339-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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96
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Roig E, Almenar L, González-Vílchez F, Rábago G, Delgado J, Gómez-Bueno M, Crespo-Leiro MG, Arizón JM, de la Fuente L, Manito N. Outcomes of heart transplantation for cardiac amyloidosis: subanalysis of the spanish registry for heart transplantation. Am J Transplant 2009; 9:1414-9. [PMID: 19459811 DOI: 10.1111/j.1600-6143.2009.02643.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Amyloidosis (Am), a systemic disease, has poor prognosis because of organ damage produced by protein deposition in the extracellular space. Although heart transplantation (HTx) is possible, donor availability concerns and high mortality make this approach controversial. The Spanish Registry for Heart Transplantation includes 25 Am patients (54 +/- 9 years): 13 with AL type, 2 with AA and 10 with TTR mutation. Fifteen patients (60%) died during follow-up (4.9 +/- 1.3 years): 9 AL-Am patients, both AA-Am patients and 4 with TTR-Am. HTx survival for Am patients was similar to patients without Am at 1 month but significantly worse at 5 years: 46% versus 78% (p < 0.02). Of 10 AL-Am patients undergoing successful HTx, 4 died of systemic Am. Stem cell transplantation was performed in 3 (1 died of acute rejection). Five of 10 patients with TTR-Am underwent liver transplant; 4 remained alive at the last follow-up. Findings include poor outcome for AL-Am patients despite HTx and better survival for TTR-Am patients if HTx is associated with liver transplantation. Given the shortage of donors and poor outcome for Am patients, we would recommend that HTx be reserved for patients without or with mild systemic Am and be supplemented by additional therapies as indicated.
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Affiliation(s)
- E Roig
- Hospital Clínic, Barcelona, Spain.
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97
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Feng D, Syed IS, Martinez M, Oh JK, Jaffe AS, Grogan M, Edwards WD, Gertz MA, Klarich KW. Intracardiac Thrombosis and Anticoagulation Therapy in Cardiac Amyloidosis. Circulation 2009; 119:2490-7. [DOI: 10.1161/circulationaha.108.785014] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background—
Primary amyloidosis has a poor prognosis as a result of frequent cardiac involvement. We recently reported a high prevalence of intracardiac thrombus in cardiac amyloid patients at autopsy. However, neither the prevalence nor the effect of anticoagulation on intracardiac thrombus has been evaluated antemortem.
Methods and Results—
We studied all transthoracic and transesophageal echocardiograms of cardiac amyloid patients at the Mayo Clinic. The prevalence of intracardiac thrombosis, clinical and transthoracic/transesophageal echocardiographic risks for intracardiac thrombosis, and effect of anticoagulation were investigated. We identified 156 patients with cardiac amyloidosis who underwent transesophageal echocardiograms. Amyloidosis was the primary type (AL) in 80; other types occurred in 76 patients, including 56 with the wild transthyretin type, 17 with the mutant transthyretin type, and 3 with the secondary type. Fifth-eight intracardiac thrombi were identified in 42 patients (27%). AL amyloid had more frequent intracardiac thrombus than the other types (35% versus 18%;
P
=0.02), although the AL patients were younger and had less atrial fibrillation. Multivariate analysis showed that atrial fibrillation, poor left ventricular diastolic function, and lower left atrial appendage emptying velocity were independently associated with increased risk for intracardiac thrombosis, whereas anticoagulation was associated with a significantly decreased risk (odds ratio, 0.09; 95% CI, 0.01 to 0.51;
P
<0.006).
Conclusions—
Intracardiac thrombosis occurs frequently in cardiac amyloid patients, especially in the AL type and in those with atrial fibrillation. Risk for thrombosis increased if left ventricular diastolic dysfunction and atrial mechanical dysfunction were present. Anticoagulation therapy appears protective. Timely screening in high-risk patients may allow early detection of intracardiac thrombus. Anticoagulation should be carefully considered.
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Affiliation(s)
- DaLi Feng
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Imran S. Syed
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Matthew Martinez
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Jae K. Oh
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Allan S. Jaffe
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Martha Grogan
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - William D. Edwards
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Morie A. Gertz
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
| | - Kyle W. Klarich
- From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn
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Audard V, Matignon M, Weiss L, Remy P, Pardon A, Haioun C, Belhadj K, Salomon L, Hillon ML, Sahali D, Vermes E, Lang P, Grimbert P. Successful long-term outcome of the first combined heart and kidney transplant in a patient with systemic Al amyloidosis. Am J Transplant 2009; 9:236-40. [PMID: 19067666 PMCID: PMC2810314 DOI: 10.1111/j.1600-6143.2008.02469.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Simultaneous cardiac and renal involvement is associated with a particularly poor prognosis in patients with AL amyloidosis (AL-A). We report the first case of a successful long-term outcome of combined heart and kidney transplantation not followed by autologous stem cell transplantation in a patient with systemic AL-A. The recipient was a 46-year-old man with end-stage renal failure associated with serious cardiac involvement in the context of AL-A. Before transplantation, two courses of oral melphalan plus prednisone induced partial hematologic remission, as shown by the decrease in circulating free light chain with no improvement of renal or heart function. The patient underwent combined heart and kidney transplantation as a rescue treatment. During the follow-up period (36 months), plasma cell dyscrasia remains in complete remission, with normal free lambda light chain levels and no recurrence of amyloid deposition on heart and kidney grafts. This case report demonstrates that combined heart and kidney transplantation not systematically associated with stem cell transplantation may be considered an additional therapeutic option in AL-A patients with severe organ dysfunction and partial hematologic remission.
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Affiliation(s)
- Vincent Audard
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR,* Correspondence should be adressed to: Vincent Audard
| | - Marie Matignon
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Lise Weiss
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Philippe Remy
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Agathe Pardon
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Corinne Haioun
- Service d'Hématologie Biologique
AP-HPHôpital Henri MondorUniversité Paris XIICréteil,FR
| | - Karim Belhadj
- Service d'Hématologie Biologique
AP-HPHôpital Henri MondorUniversité Paris XIICréteil,FR
| | - Laurent Salomon
- Service d'urologie
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, Créteil,FR
| | - Marie Line Hillon
- Service de chirurgie thoracique et cardio-vasculaire
AP-HPHôpital Henri MondorUniversité Paris XII Val de MarneCréteil,FR
| | - Dil Sahali
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Emanuelle Vermes
- Service de chirurgie thoracique et cardio-vasculaire
AP-HPHôpital Henri MondorUniversité Paris XII Val de MarneCréteil,FR
| | - Philippe Lang
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
| | - Philippe Grimbert
- Service de néphrologie et transplantation
AP-HPHôpital Henri MondorUniversité Paris XII Val de Marne51, av du Maréchal de Tassigny, 94010 Créteil,FR
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Mignot A, Varnous S, Redonnet M, Jaccard A, Epailly E, Vermes E, Boissonnat P, Gandjbakhch I, Herpin D, Touchard G, Bridoux F. Heart transplantation in systemic (AL) amyloidosis: a retrospective study of eight French patients. Arch Cardiovasc Dis 2008; 101:523-32. [PMID: 19041836 DOI: 10.1016/j.acvd.2008.06.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 06/16/2008] [Accepted: 06/19/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Immunoglobulinic (AL) amyloidosis is a complication of plasma cell dyscrasia, characterized by widespread deposition of amyloid fibrils derived from monoclonal light chains. Cardiac amyloid is the main prognostic factor, with a median survival of six months. Cardiac transplantation in AL amyloidosis is associated with high mortality, due to disease recurrence in the allograft and systemic progression. Suppression of light chain (LC) production with chemotherapy by melphalan plus dexamethasone (MD) or high dose melphalan followed by autologous stem cell transplantation (HDM/ASCT) improves survival. However, both the indications and results of chemotherapy in patients transplanted for cardiac AL amyloidosis remain unclear. AIMS To assess the outcome of cardiac transplantation and haematological therapy in patients with cardiac AL amyloidosis. METHODS Eight French patients, who underwent heart transplantation for cardiac AL amyloidosis between 2001 and 2006 were studied retrospectively. RESULTS Before transplantation, six patients received MD (n=5) or HDM/ASCT (n=1). Haematological remission was obtained in three patients treated with MD. In the three remaining patients, postoperative HDM/ASCT (n=2) or allogeneic bone marrow transplantation (n=1) resulted in haematological remission in one patient. In 2 patients not treated before transplantation, post-operative treatment with MD resulted in complete hematological remission in one. After a median follow-up of 26 months from cardiac transplantation, six patients were alive and four had sustained haematological remission, as indicated by normal serum free LC levels. CONCLUSION Appropriate haematological therapy, including MD, may result in a survival benefit in AL amyloidosis patients with advanced heart failure requiring transplantation.
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Affiliation(s)
- Aude Mignot
- Department of Cardiology, CHU of Poitiers, University of Poitiers, Poitiers, France
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