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Argiro' A, Zampieri M, Mazzoni C, Catalucci T, Biondo B, Tomberli A, Gabriele M, Di Mario C, Perfetto F, Cappelli F. Red flags for the diagnosis of cardiac amyloidosis: simple suggestions to raise suspicion and achieve earlier diagnosis. J Cardiovasc Med (Hagerstown) 2022; 23:493-504. [PMID: 35904994 DOI: 10.2459/jcm.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac amyloidosis is an infiltrative disease characterized by extracellular deposition of insoluble amyloid fibrils in the heart leading to organ dysfunction. Despite recent diagnostic advances, the diagnosis of cardiac amyloidosis is often delayed or even missed. Furthermore, a long diagnostic delay is associated with adverse outcomes, with the early diagnosed patients showing the longest survival. In this narrative review we aimed to summarize the 'red flags' that may facilitate the correct diagnosis. The red flags may be classified as clinical, biohumoral, electrocardiographic, echocardiographic, and cardiac magnetic resonance features and should promptly raise the suspicion of cardiac amyloidosis in order to start a correct diagnostic pathway and targeted treatment strategies that may improve patients' outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Carlo Di Mario
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre
- IV Internal Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department
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Nitsche C. Echocardiographic tracking of ATTR Cardiomyopathy: which parameters matter the most? Eur J Heart Fail 2022; 24:1713-1715. [PMID: 35906799 DOI: 10.1002/ejhf.2639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Christian Nitsche
- Medical University of Vienna, Division of Cardiology, Waehringerguertel 18-20, 1090, Vienna, Austria
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103
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Temporal Trends and Outcomes of Transcatheter and Surgical Aortic Valve Replacement in Patients With Cardiac Amyloidosis and Severe Aortic Stenosis. Am J Cardiol 2022; 179:118-122. [PMID: 35879152 DOI: 10.1016/j.amjcard.2022.06.026] [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: 05/19/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022]
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104
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Reduction in Afterload Reveals the Apical Sparing Phenotype. Circ Cardiovasc Imaging 2022; 15:e014549. [DOI: 10.1161/circimaging.122.014549] [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: 11/16/2022]
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105
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Aortic stenosis and cardiac amyloidosis: PARTNERs in crime? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 43:26-27. [DOI: 10.1016/j.carrev.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 11/20/2022]
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Nitsche C, Koschutnik M, Donà C, Radun R, Mascherbauer K, Kammerlander A, Heitzinger G, Dannenberg V, Spinka G, Halavina K, Winter MP, Calabretta R, Hacker M, Agis H, Rosenhek R, Bartko P, Hengstenberg C, Treibel T, Mascherbauer J, Goliasch G. Reverse Remodeling Following Valve Replacement in Coexisting Aortic Stenosis and Transthyretin Cardiac Amyloidosis. Circ Cardiovasc Imaging 2022; 15:e014115. [PMID: 35861981 DOI: 10.1161/circimaging.122.014115] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dual pathology of severe aortic stenosis (AS) and transthyretin cardiac amyloidosis (ATTR) is increasingly recognized. Evolution of symptoms, biomarkers, and myocardial mechanics in AS-ATTR following valve replacement is unknown. We aimed to characterize reverse remodeling in AS-ATTR and compared with lone AS. METHODS Consecutive patients referred for transcatheter aortic valve replacement (TAVR) underwent ATTR screening by blinded 99mTc-DPD bone scintigraphy (Perugini Grade-0 negative, 1-3 increasingly positive) before intervention. ATTR was diagnosed by DPD and absence of monoclonal protein. Reverse remodeling was assessed by comprehensive evaluation before TAVR and at 1 year. RESULTS One hundred twenty patients (81.8±6.3 years, 51.7% male, 95 lone AS, 25 AS-ATTR) with complete follow-up were studied. At 12 months (interquartile range, 7-17) after TAVR, both groups experienced significant symptomatic improvement by New York Heart Association functional class (both P<0.001). Yet, AS-ATTR remained more symptomatic (New York Heart Association ≥III: 36.0% versus 13.8; P=0.01) with higher residual NT-proBNP (N-terminal pro-brain natriuretic peptide) levels (P<0.001). Remodeling by echocardiography showed left ventricular mass regression only for lone AS (P=0.002) but not AS-ATTR (P=0.5). Global longitudinal strains improved similarly in both groups. Conversely, improvement of regional longitudinal strain showed a base-to-apex gradient in AS-ATTR, whereas all but apical segments improved in lone AS. This led to the development of an apical sparing pattern in AS-ATTR only after TAVR. CONCLUSIONS Patterns of reverse remodeling differ from lone AS to AS-ATTR, with both groups experiencing symptomatic improvement by TAVR. After AS treatment, AS-ATTR transfers into a lone ATTR cardiomyopathy phenotype.
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Affiliation(s)
- Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Carolina Donà
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Richard Radun
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Katharina Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Andreas Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Gregor Heitzinger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Varius Dannenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Georg Spinka
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Kseniya Halavina
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Max-Paul Winter
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | | | - Marcus Hacker
- Division of Nuclear Medicine (R.C., M.H.), Medical University of Vienna
| | - Hermine Agis
- Division of Hematology (H.A.), Medical University of Vienna
| | - Raphael Rosenhek
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Philipp Bartko
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
| | - Thomas Treibel
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom (T.T.)
| | - Julia Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
- Karl Landsteiner University of Health Sciences, Department of Internal Medicine III, University Hospital St. Pölten, Krems, Austria (J.M.)
| | - Georg Goliasch
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (C.N., M.K., C.D., R. Radun, K.M., A.K., G.H., V.D., G.S., K.H., M.-P.W., R. Rosenhek, P.B., C.H., J.M., G.G.)
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Rossi M, Varrà GG, Porcari A, Saro R, Pagura L, Lalario A, Dore F, Bussani R, Sinagra G, Merlo M. Re-Definition of the Epidemiology of Cardiac Amyloidosis. Biomedicines 2022; 10:biomedicines10071566. [PMID: 35884871 PMCID: PMC9313045 DOI: 10.3390/biomedicines10071566] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/09/2022] [Accepted: 06/20/2022] [Indexed: 11/29/2022] Open
Abstract
The epidemiology of cardiac amyloidosis (CA), traditionally considered a rare and incurable disease, has changed drastically over the last ten years, particularly due to the advances in diagnostic methods and therapeutic options in the field of transthyretin CA (ATTR-CA). On the one hand, the possibility of employing cardiac scintigraphy with bone tracers to diagnose ATTR-CA without a biopsy has unveiled the real prevalence of the disease; on the other, the emergence of effective treatments, such as tafamidis, has rendered an early and accurate diagnosis critical. Interestingly, the following subgroups of patients have been found to have a higher prevalence of CA: elderly subjects > 75 years, patients with cardiac hypertrophy hospitalized for heart failure with preserved ejection fraction, subjects operated on for bilateral carpal tunnel syndrome, patients with cardiac hypertrophy not explained by concomitant factors and individuals with aortic valve stenosis. Many studies investigating the prevalence of CA in these particular populations have contributed to rewriting the epidemiology of the disease, increasing the awareness of the medical community for a previously underappreciated condition. In this review, we summarized the latest evidence on the epidemiology of CA according to the different clinical settings typically associated with the disease.
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Affiliation(s)
- Maddalena Rossi
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Guerino Giuseppe Varrà
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Linda Pagura
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Andrea Lalario
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Franca Dore
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy;
| | - Rossana Bussani
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiothoracic Department, Institute of Pathological Anatomy and Histology, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, 34149 Trieste, Italy;
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, 34149 Trieste, Italy; (M.R.); (G.G.V.); (A.P.); (R.S.); (L.P.); (A.L.); (G.S.)
- Correspondence:
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108
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Cannata F, Chiarito M, Pinto G, Villaschi A, Sanz-Sánchez J, Fazzari F, Regazzoli D, Mangieri A, Bragato RM, Colombo A, Reimers B, Condorelli G, Stefanini GG. Transcatheter aortic valve replacement in aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis. ESC Heart Fail 2022; 9:3188-3197. [PMID: 35770333 DOI: 10.1002/ehf2.13876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 12/03/2021] [Accepted: 02/24/2022] [Indexed: 01/15/2023] Open
Abstract
AIMS Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical diseases of the elderly. Up to 16% of older adults with severe AS referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. CA-AS population suffers from reduced functional capacity and worse prognosis than AS patients. As the prognostic impact of TAVR in patients with CA-AS has been historically questioned and in light of recently published evidence, we aim to provide a comprehensive synthesis of the efficacy and safety of TAVR in CA-AS patients. METHODS AND RESULTS We performed a systematic review and meta-analysis of studies: (i) evaluating mortality with TAVR as compared with medical therapy in CA-AS patients and (ii) reporting complications and clinical outcomes of TAVR in CA-AS patients as compared with patients with AS alone. A total of seven observational studies were identified: four reported mortality with TAVR, and four reported complications and clinical outcomes after TAVR of patients with CA-AS compared with AS alone patients. In patients with CA-AS, the risk of mortality was lower with TAVR (n = 44) as compared with medical therapy (n = 36) [odds ratio (OR) 0.23, 95% confidence interval (CI) 0.07-0.73, I2 = 0%, P = 0.001, number needed to treat = 3]. The safety profile of TAVR seems to be similar in patients with CA-AS (n = 75) as compared with those with AS alone (n = 536), with comparable risks of stroke, vascular complications, life-threatening bleeding, acute kidney injury, and 30 day mortality, although CA-AS was associated with a trend towards an increased risk of permanent pacemaker implantation (OR 1.76, 95% CI 0.91-4.09, I2 = 0%, P = 0.085). CA is associated with a numerically higher rate of long-term mortality and rehospitalizations following TAVR in patients with CA-AS as compared with those with AS alone. CONCLUSIONS TAVR is an effective and safe procedure in CA-AS patients, with a substantial survival benefit as compared with medical therapy, and a safety profile comparable with patients with AS alone except for a trend towards higher risk of permanent pacemaker implantation.
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Affiliation(s)
- Francesco Cannata
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Giuseppe Pinto
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Alessandro Villaschi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Jorge Sanz-Sánchez
- Hospital Universitario y Politecnico La Fe, Valencia, Spain.,Centro de Investigación Biomedica en Red (CIBERCV), Madrid, Spain
| | - Fabio Fazzari
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | | | | | | | | | | | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele-Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
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Antonopoulos AS, Panagiotopoulos I, Kouroutzoglou A, Koutsis G, Toskas P, Lazaros G, Toutouzas K, Tousoulis D, Tsioufis K, Vlachopoulos C. Prevalence and Clinical Outcomes of Transthyretin Amyloidosis: A Systematic Review and Meta-analysis. Eur J Heart Fail 2022; 24:1677-1696. [PMID: 35730461 DOI: 10.1002/ejhf.2589] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: a) the prevalence of cardiac amyloidosis in various patient subgroups, b) survival estimates for ATTR subtypes and c) the effects of novel therapeutics on the natural course of disease. METHODS A systematic review of literature published in Medline before 31/12/2021 was performed for the prevalence of cardiac amyloidosis & all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2 and 5-years. Subgroup analyses were performed for ATTR subtype i.e., wild type ATTR (wtATTR) vs. hereditary ATTR (htATTR), htATTR genotypes and treatment subgroups. RESULTS We identified a total of 62 studies (n=277,882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, HFpEF, and elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n=18,238 ATTR patients). Patients with wtATTR were older (p=7x10-10 ) and more frequently male (p=5x10-20 ) vs. htATTR. The 2-year survival of ATTR was 73.3% (95%CI 71.6-76.2); for non-subtyped ATTR 70.4% (95%CI 66.9-73.9), for wtATTR (76.0%, 95%CI: 73.0-78.9) and for htATTR (77.2%, 95%CI: 74.0-80.4); in meta-regression analysis wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and htATTR genotypes (p=10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95%CI: 74.4-85.3 vs. 72.4%, 95%CI 69.8-74.9, p<0.05). CONCLUSIONS We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Ioannis Panagiotopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Alexandrina Kouroutzoglou
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Pantelis Toskas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Lazaros
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
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Mergen V, Sartoretti T, Klotz E, Schmidt B, Jungblut L, Higashigaito K, Manka R, Euler A, Kasel M, Eberhard M, Alkadhi H. Extracellular Volume Quantification With Cardiac Late Enhancement Scanning Using Dual-Source Photon-Counting Detector CT. Invest Radiol 2022; 57:406-411. [PMID: 35066531 PMCID: PMC9390230 DOI: 10.1097/rli.0000000000000851] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/12/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the feasibility and accuracy of cardiac late enhancement (LE) scanning for extracellular volume (ECV) quantification with dual-source photon-counting detector computed tomography (PCD-CT). MATERIALS AND METHODS In this institutional review board-approved study, 30 patients (mean age, 79 years; 12 women; mean body mass index, 28 kg/m2) with severe aortic stenosis undergoing PCD-CT as part of their preprocedural workup for transcatheter aortic valve replacement were included. The scan protocol consisted of a nonenhanced calcium-scoring scan, coronary CT angiography (CTA) followed by CTA of the thoracoabdominal aorta, and a low-dose LE scan 5 minutes after the administration of 100 mL contrast media (all scans electrocardiogram-gated). Virtual monoenergetic (65 keV) and dual-energy (DE) iodine images were reconstructed from the LE scan. Extracellular volume was calculated using the iodine ratios of myocardium and blood-pool of the LE scan, and additionally based on single-energy (SE) subtraction of the nonenhanced scan from the LE scan. Three-dimensional analysis was performed automatically for the whole-heart myocardial volume by matching a heart model generated from the respective coronary CTA data. Bland-Altman and correlation analysis were used to compare the ECV values determined by both methods. RESULTS The median dose length product for the LE scan was 84 mGy·cm (interquartile range, 69; 125 mGy·cm). Extracellular volume quantification was feasible in all patients. The median ECV value was 30.5% (interquartile range, 28.4%-33.6%). Two focal ECV elevations matched known prior myocardial infarction. The DE- and SE-based ECV quantification correlated well (r = 0.87, P < 0.001). Bland-Altman analysis showed small mean errors between DE- and SE-based ECV quantification (0.9%; 95% confidence interval, 0.1%-1.6%) with narrow limits of agreement (-3.3% to 5.0%). CONCLUSIONS Dual-source PCD-CT enables accurate ECV quantification using an LE cardiac DE scan at low radiation dose. Extracellular volume calculation from iodine ratios of the LE scan obviates the need for acquisition of a true nonenhanced scan and is not affected by potential misregistration between 2 separate scans.
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Affiliation(s)
- Victor Mergen
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Thomas Sartoretti
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | | | | | - Lisa Jungblut
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Kai Higashigaito
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Robert Manka
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - André Euler
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Markus Kasel
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Eberhard
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Hatem Alkadhi
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
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111
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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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112
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Gallone G, Bruno F, Trenkwalder T, D'Ascenzo F, Islas F, Leone PP, Nicol P, Pellegrini C, Incaminato E, Jimenez-Quevedo P, Alvarez-Covarrubias HA, Bragato R, Andreis A, Salizzoni S, Rinaldi M, Kastrati A, Conrotto F, Joner M, Stefanini G, Nombela-Franco L, Xhepa E, Escaned J, De Ferrari GM. Prognostic implications of impaired longitudinal left ventricular systolic function assessed by tissue Doppler imaging prior to transcatheter aortic valve implantation for severe aortic stenosis. Int J Cardiovasc Imaging 2022; 38:1317-1328. [PMID: 35006473 PMCID: PMC11142981 DOI: 10.1007/s10554-021-02519-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/30/2021] [Indexed: 11/05/2022]
Abstract
Change in longitudinal left ventricular (LV) systolic function serves as an early marker of the deleterious effect of aortic stenosis (AS) and other cardiac comorbidities on cardiac function. We explored the prognostic value of tissue Doppler imaging (TDI)-derived longitudinal LV systolic function, defined by the peak systolic average of lateral and septal mitral annular velocities (average S') among symptomatic patients with severe AS undergoing transcatheter aortic valve implantation (TAVI). 297 consecutive patients with severe AS undergoing TAVI at three european centers with available average S' at preprocedural echocardiography were retrospectively included. The primary endpoint was the Kaplan Meier estimate of all-cause mortality. After a median 18 months (IQR 12-18) follow-up, 36 (12.1%) patients had died. Average S' was associated with all-cause mortality (per 1 cm/sec decrease: HR 1.29, 95%CI 1.03-1.60, p = 0.025), the cut-off of 6.5 cm/sec being the most accurate. Patients with average S' < 6.5 cm/sec (55.2%) presented characteristics of more advanced LV remodeling and functional impairment along with higher burden of cardiac comorbidities, and experienced higher all-cause mortality (17.6% vs. 7.5%, p = 0.007), also when adjusted for in-study outcome predictors (adj-HR: 2.69, 95%CI 1.22-5.93, p = 0.014). Results were consistent among patients with preserved ejection fraction, normal-flow AS, high-gradient AS and in those without LV hypertrophy. Longitudinal LV systolic function assessed by average S' is independently associated with long-term all-cause mortality among TAVI patients. An average S' below 6.5 cm/sec best defines clinically meaningful reduced longitudinal systolic function and may aid clinical risk stratification in these patients.
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Affiliation(s)
- Guglielmo Gallone
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy.
| | - Francesco Bruno
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy
| | | | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy
| | - Fabian Islas
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | | | | | | | - Enrico Incaminato
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy
| | - Pilar Jimenez-Quevedo
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | | | - Renato Bragato
- Humanitas Clinical and Research Center IRCCS, Rozzano-Milan, Italy
| | - Alessandro Andreis
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy
| | - Stefano Salizzoni
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy
| | - Mauro Rinaldi
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy
| | | | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy
| | | | - Giulio Stefanini
- Humanitas Clinical and Research Center IRCCS, Rozzano-Milan, Italy
| | - Luis Nombela-Franco
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Erion Xhepa
- Deutsches Herzzentrum München, Munich, Germany
| | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Gaetano M De Ferrari
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Corso Bramante 88/90, 10126, Turin, Italy
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113
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Nishi M, Takashio S, Morioka M, Fujiyama A, Nakashima N, Hirakawa K, Hanatani S, Usuku H, Yamamoto E, Kidoh M, Oda S, Gushima R, Matsushita K, Fukushima S, Ueda M, Tsujita K. Extracardiac Biopsy Sensitivity in Transthyretin Amyloidosis Cardiomyopathy Patients With Positive <sup>99 m</sup>Tc-Labeled Pyrophosphate Scintigraphy Findings. Circ J 2022; 86:1113-1120. [DOI: 10.1253/circj.cj-22-0118] [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: 11/09/2022]
Affiliation(s)
- Masato Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Mami Morioka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Akira Fujiyama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Naoya Nakashima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Kyoko Hirakawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Masafumi Kidoh
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University
| | - Seitaro Oda
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University
| | - Kenichi Matsushita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Satoshi Fukushima
- Department of Dermatology and Plastic Surgery, Graduate School of Medical Sciences, Kumamoto University
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
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114
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Irabor B, McMillan JM, Fine NM. Assessment and Management of Older Patients With Transthyretin Amyloidosis Cardiomyopathy: Geriatric Cardiology, Frailty Assessment and Beyond. Front Cardiovasc Med 2022; 9:863179. [PMID: 35656395 PMCID: PMC9152087 DOI: 10.3389/fcvm.2022.863179] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022] Open
Abstract
Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is commonly diagnosed in older adults, in particular the wild-type (ATTRwt), which is regarded as an age-related disease. With an aging population and improved diagnostic techniques, the prevalence and incidence of ATTR-CM will continue to increase. With increased availability of mortality reducing ATTR-CM therapies, patients are living longer. The predominant clinical manifestation of ATTR-CM is heart failure, while other cardiovascular manifestations include arrhythmia and aortic stenosis. Given their older age at diagnosis, patients often present with multiple age-related comorbidities, some of which can be exacerbated by ATTR, including neurologic, musculoskeletal, and gastrointestinal problems. Considerations related to older patient care, such as frailty, cognitive decline, polypharmacy, falls/mobility, functional capacity, caregiver support, living environment, quality of life and establishing goals of care are particularly important for many patients with ATTR-CM. Furthermore, the high cost ATTR treatments has increased interest in establishing improved predictors of response to therapy, with assessment of frailty emerging as a potentially important determinant. Multidisciplinary care inclusive of collaboration with geriatric and elder care medicine specialists, and others such as neurology, orthopedic surgery, electrophysiology and transcatheter aortic valve replacement clinics, is now an important component of ATTR-CM management. This review will examine current aspects of the management of older ATTR-CM patients, including shared care with multiple medical specialists, the emerging importance of frailty assessment and other considerations for using ATTR therapies.
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Affiliation(s)
| | - Jacqueline M. McMillan
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Geriatrics, Departments of Medicine and Community Health Sciences, Calgary, AB, Canada
| | - Nowell M. Fine
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Cardiology, Departments of Cardiac Sciences, Medicine and Community Health Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada
- *Correspondence: Nowell M. Fine
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115
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Généreux P, Pibarot P, Redfors B, Bax JJ, Zhao Y, Makkar RR, Kapadia S, Thourani VH, Mack MJ, Nazif TM, Lindman BR, Babaliaros V, Vincent F, Russo M, McCabe JM, Gillam LD, Alu MC, Hahn RT, Webb JG, Leon MB, Cohen DJ. Evolution and Prognostic Impact of Cardiac Damage After Aortic Valve Replacement. J Am Coll Cardiol 2022; 80:783-800. [PMID: 35595203 DOI: 10.1016/j.jacc.2022.05.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The impact of aortic valve replacement (AVR) on progression/regression of extra-valvular cardiac damage and its association with subsequent prognosis is unknown. OBJECTIVES To describe evolution of cardiac damage post-AVR and its association with outcomes. METHODS Patients undergoing transcatheter or surgical AVR from the PARTNER 2 and 3 trials were pooled and classified by cardiac damage stage at baseline and 1-year (Stage 0, no damage; Stage 1, left ventricular damage; Stage 2, left atrial or mitral valve damage; Stage 3, pulmonary vasculature or tricuspid valve damage; Stage 4, right ventricular damage). Proportional hazards models determined association between change in cardiac damage post-AVR and 2-year outcomes. RESULTS Among 1974 patients, 121 (6.1%) were Stage 0, 287 (14.5%) Stage 1, 1014 (51.4%) Stage 2, 412 (20.9%) Stage 3, and 140 (7.1%) Stage 4 pre-AVR. Two-year mortality was associated with extent of cardiac damage at baseline and 1-year. Compared with baseline, cardiac damage improved in ∼15%, remained unchanged in ∼60%, and worsened in ∼25% of patients at 1-year. One-year change in cardiac damage stage was independently associated with mortality (adjHR for improvement=0.49; no change=1.0; worsening=1.95; p=0.023) and composite of death or heart failure hospitalization (adjHR for improvement=0.60; no change=1.0; worsening=2.25; p<0.001) at 2 years. CONCLUSION In patients undergoing AVR, extent of extravalvular cardiac damage at baseline and its change at 1-year have important prognostic implications. These findings suggest that earlier detection of AS and intervention prior to development of irreversible cardiac damage may improve global cardiac function and prognosis.
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Affiliation(s)
- Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA.
| | - Philippe Pibarot
- Department of Medicine, Laval University, Quebec, Quebec, Canada
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Columbia University Irving Medical Center, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Yanglu Zhao
- Edwards Lifesciences, Irvine, California, USA
| | - Raj R Makkar
- Cedars Sinai Medical Center, Los Angeles, California, USA
| | | | | | - Michael J Mack
- Baylor Scott and White Research Institute, Plano, Texas, USA
| | - Tamim M Nazif
- Columbia University Irving Medical Center, New York, New York, USA
| | - Brian R Lindman
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Flavien Vincent
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Lille University Hospital, Lille, France
| | - Mark Russo
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Linda D Gillam
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Maria C Alu
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Columbia University Irving Medical Center, New York, New York, USA
| | - Rebecca T Hahn
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Columbia University Irving Medical Center, New York, New York, USA
| | - John G Webb
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Martin B Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Columbia University Irving Medical Center, New York, New York, USA
| | - David J Cohen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; St. Francis Hospital and Heart Center, Roslyn, New York, USA
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116
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Khan MZ, Brailovsky Y, Vishnevsky O(A, Baqi A, Patel K, Alvarez RJ. Clinical outcome of TAVR vs SAVR in patients with cardiac amyloidosis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 43:20-25. [DOI: 10.1016/j.carrev.2022.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/16/2022]
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117
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Rafael Sádaba J, Tribouilloy C, Wojakowski W. Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.023] [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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118
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New Advanced Imaging Parameters and Biomarkers—A Step Forward in the Diagnosis and Prognosis of TTR Cardiomyopathy. J Clin Med 2022; 11:jcm11092360. [PMID: 35566485 PMCID: PMC9101617 DOI: 10.3390/jcm11092360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative disorder characterized by extracellular myocardial deposits of amyloid fibrils, with poor outcome, leading to heart failure and death, with significant treatment expenditure. In the era of a novel therapeutic arsenal of disease-modifying agents that target a myriad of pathophysiological mechanisms, timely and accurate diagnosis of ATTR-CM is crucial. Recent advances in therapeutic strategies shown to be most beneficial in the early stages of the disease have determined a paradigm shift in the screening, diagnostic algorithm, and risk classification of patients with ATTR-CM. The aim of this review is to explore the utility of novel specific non-invasive imaging parameters and biomarkers from screening to diagnosis, prognosis, risk stratification, and monitoring of the response to therapy. We will summarize the knowledge of the most recent advances in diagnostic, prognostic, and treatment tailoring parameters for early recognition, prediction of outcome, and better selection of therapeutic candidates in ATTR-CM. Moreover, we will provide input from different potential pathways involved in the pathophysiology of ATTR-CM, on top of the amyloid deposition, such as inflammation, endothelial dysfunction, reduced nitric oxide bioavailability, oxidative stress, and myocardial fibrosis, and their diagnostic, prognostic, and therapeutic implications.
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119
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de Campos D, Saleiro C, Botelho A, Costa M, Gonçalves L, Teixeira R. Aortic valve intervention for aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis. Future Cardiol 2022; 18:477-486. [PMID: 35420047 DOI: 10.2217/fca-2021-0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aortic stenosis with cardiac amyloidosis (CA-AS) is common in the elderly. We provide an overview and a meta-analysis of outcomes after aortic valve (AV) intervention. The primary end point was all-cause mortality. Weighted pooled analysis showed a non-significant higher risk of death in CA-AS patients following surgical or transcatheter AV replacement. After transcatheter AV replacement, the risk of death in CA-AS patients was comparable to that associated with aortic stenosis alone (risk ratio: 1.23; 95% CI: 0.77-1.96; p = 0.39; I2 = 0%). An AV intervention is possibly not futile in CA-AS and should not be denied to patients with this condition.
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Affiliation(s)
- Diana de Campos
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, Coimbra, 3041-801, Portugal
| | - Carolina Saleiro
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, Coimbra, 3041-801, Portugal
| | - Ana Botelho
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, Coimbra, 3041-801, Portugal
| | - Marco Costa
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, Coimbra, 3041-801, Portugal
| | - Lino Gonçalves
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, Coimbra, 3041-801, Portugal.,Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, Coimbra, 3000-370, Portugal.,Coimbra Institute for Clinical & Biomedical Research (iCBR), Azinhaga Santa Comba, Celas, Coimbra, 3000-548, Portugal
| | - Rogério Teixeira
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, Coimbra, 3041-801, Portugal.,Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, Coimbra, 3000-370, Portugal
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120
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Rapezzi C, Vergaro G, Emdin M, Fabbri G, Cantone A, Sanguettoli F, Aimo A. The revolution of ATTR amyloidosis in cardiology: certainties, gray zones and perspectives. Minerva Cardiol Angiol 2022; 70:248-257. [PMID: 35412035 DOI: 10.23736/s2724-5683.21.05926-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Transthyretin (TTR) is a tetrameric protein synthesized mostly by the liver. As a result of gene mutations or as an ageing-related phenomenon, TTR molecules may misfold and deposit in the heart and in other organs as amyloid fibrils. Amyloid transthyretin cardiac amyloidosis (ATTR-CA) manifests typically as left ventricular pseudohypertrophy and/or heart failure with preserved ejection fraction and is an underdiagnosed disorder affecting quality of life and prognosis. This justifies the current search for novel tools for early diagnosis and accurate risk prediction, as well as for safe and effective therapies. In this review we will provide an overview of the main unsolved issues and the most promising research lines on ATTR-CA, ranging from the mechanisms of amyloid formation to therapies.
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Affiliation(s)
- Claudio Rapezzi
- Cardiologic Center, University of Ferrara, Ferrara, Italy - .,GVM Care & Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy -
| | - Giuseppe Vergaro
- Sant'Anna High School, Institute of Life Sciences, Pisa, Italy.,Division of Cardiology, Toscana Gabriele Monasterio Foundation, Pisa, Italy
| | - Michele Emdin
- Sant'Anna High School, Institute of Life Sciences, Pisa, Italy.,Division of Cardiology, Toscana Gabriele Monasterio Foundation, Pisa, Italy
| | - Gioele Fabbri
- Cardiologic Center, University of Ferrara, Ferrara, Italy
| | - Anna Cantone
- Cardiologic Center, University of Ferrara, Ferrara, Italy
| | | | - Alberto Aimo
- Sant'Anna High School, Institute of Life Sciences, Pisa, Italy.,Division of Cardiology, Toscana Gabriele Monasterio Foundation, Pisa, Italy
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121
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The Role of Cardiac Magnetic Resonance in Aortic Stenosis and Regurgitation. J Cardiovasc Dev Dis 2022; 9:jcdd9040108. [PMID: 35448084 PMCID: PMC9030119 DOI: 10.3390/jcdd9040108] [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: 03/06/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiac magnetic resonance (CMR) imaging is a well-set diagnostic technique for assessment of valvular heart diseases and is gaining ground in current clinical practice. It provides high-quality images without the administration of ionizing radiation and occasionally without the need of contrast agents. It offers the unique possibility of a comprehensive stand-alone assessment of the heart including biventricular function, left ventricle remodeling, myocardial fibrosis, and associated valvulopathies. CMR is the recognized reference for the quantification of ventricular volumes, mass, and function. A particular strength is the ability to quantify flow, especially with new techniques which allow accurate measurement of stenosis and regurgitation. Furthermore, tissue mapping enables the visualization and quantification of structural changes in the myocardium. In this way, CMR has the potential to yield important prognostic information predicting those patients who will progress to surgery and impact outcomes. In this review, the fundamentals of CMR in assessment of aortic valve diseases (AVD) are described, together with its strengths and weaknesses. This state-of-the-art review provides an updated overview of CMR potentials in all AVD issues, including valve anatomy, flow quantification, ventricular volumes and function, and tissue characterization.
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122
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Management of Cardiac Symptoms in Amyloidosis. Am J Med 2022; 135 Suppl 1:S9-S12. [PMID: 35235819 DOI: 10.1016/j.amjmed.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 11/22/2022]
Abstract
Cardiac amyloidosis (CA) results in symptoms of heart failure, atrial and ventricular arrhythmias, conduction disturbances, and profound autonomic dysfunction. These symptoms present unique management challenges as compared with patients without CA, and can be very debilitating. Thus, management of the cardiovascular symptoms of these patients plays a central role in their care. This review presents an overview of the typical cardiovascular manifestations encountered in patients with CA and highlights the key management considerations for each.
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123
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Definition and diagnosis of paradoxical aortic stenosis: A call for reappraisal. Arch Cardiovasc Dis 2022; 115:243-248. [DOI: 10.1016/j.acvd.2022.01.006] [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: 12/28/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/20/2022]
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124
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Nitsche C, Mascherbauer K, Wollenweber T, Koschutnik M, Donà C, Dannenberg V, Hofer F, Halavina K, Kammerlander AA, Traub-Weidinger T, Goliasch G, Hengstenberg C, Hacker M, Mascherbauer J. The Complexity of Subtle Cardiac Tracer Uptake on Bone Scintigraphy. JACC: CARDIOVASCULAR IMAGING 2022; 15:1516-1518. [DOI: 10.1016/j.jcmg.2022.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 12/20/2022]
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125
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Myasoedova VA, Conte M, Valerio V, Moschetta D, Massaiu I, Petraglia L, Leosco D, Poggio P, Parisi V. Red Flags, Prognostic Impact, and Management of Patients With Cardiac Amyloidosis and Aortic Valve Stenosis: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:858281. [PMID: 35355593 PMCID: PMC8959832 DOI: 10.3389/fmed.2022.858281] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Cardiac amyloidosis (CA) has been recently recognized as a condition frequently associated with aortic stenosis (AS). The aim of this study was to evaluate: the main characteristics of patients with AS with and without CA, the impact of CA on patients with AS mortality, and the effect of different treatment strategies on outcomes of patients with AS with concomitant CA. Materials and Methods A detailed search related to CA in patients with AS and outcomes was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventeen studies enrolling 1,988 subjects (1,658 AS alone and 330 AS with CA) were included in the qualitative and quantitative analysis of main patients with AS characteristics with and without CA, difference in mortality, and treatment strategy. Results The prevalence of CA resulted in a mean of 15.4% and it was even higher in patients with AS over 80 years old (18.2%). Patients with the dual diagnosis were more often males, had lower body mass index (BMI), were more prone to have low flow, low gradient with reduced left ventricular ejection fraction AS phenotype, had higher E/A and E/e', and greater interventricular septum hypertrophy. Lower Sokolow–Lyon index, higher QRS duration, higher prevalence of right bundle branch block, higher levels of N-terminal pro-brain natriuretic peptide, and high-sensitivity troponin T were significantly associated with CA in patients with AS. Higher overall mortality in the 178 patients with AS + CA in comparison to 1,220 patients with AS alone was observed [odds ratio (OR) 2.25, p = 0.004]. Meta-regression analysis showed that younger age and diabetes were associated with overall mortality in patients with CS with CA (Z-value −3.0, p = 0.003 and Z-value 2.5, p = 0.013, respectively). Finally, patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) had a similar overall mortality risk, but lower than medication-treated only patients. Conclusion Results from our meta-analysis suggest that several specific clinical, electrocardiographic, and echocardiographic features can be considered “red flags” of CA in patients with AS. CA negatively affects the outcome of patients with AS. Patients with concomitant CA and AS benefit from SAVR or TAVI.
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Affiliation(s)
- Veronika A Myasoedova
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Maddalena Conte
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, Naples, Italy.,Casa di Cura San Michele, Maddaloni, Italy
| | - Vincenza Valerio
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Donato Moschetta
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Dipartimento di Scienze farmacologiche e biomolecolari, Università degli Studi di Milano, Milano, Italy
| | - Ilaria Massaiu
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Developmental Biology of the Immune System, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Laura Petraglia
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Dario Leosco
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Poggio
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Valentina Parisi
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, Naples, Italy
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126
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Gill SS, Fellin E, Stampke L, Zhao Y, Masri A. Clinical Clues and Diagnostic Workup of Cardiac Amyloidosis. Methodist Debakey Cardiovasc J 2022; 18:36-46. [PMID: 35414856 PMCID: PMC8932349 DOI: 10.14797/mdcvj.1061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/10/2022] [Indexed: 11/18/2022] Open
Abstract
Cardiac amyloidosis is increasingly recognized as an underlying cause of left ventricular wall thickening, heart failure, and arrhythmia with variable clinical presentation. Due to the subtle cardiac findings in early transthyretin cardiac amyloidosis and the availability of therapies that can modify but not reverse the disease progression, early recognition is vital. In light chain amyloidosis, timely diagnosis and treatment can significantly improve survival. In this manuscript, we review the clinical, imaging, and electrocardiographic clues that should raise suspicion for cardiac amyloidosis and provide a simplified diagnostic workup algorithm that ensures an accurate diagnosis. The evolution of the noninvasive diagnosis of cardiac amyloidosis has significantly influenced our understanding of disease prevalence, presentations, and outcomes. However, clinical recognition of clues and red flags remains the most important factor in advancing the care of patients with cardiac amyloidosis.
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Affiliation(s)
- Sajan S. Gill
- Knight Cardiovascular Institute, Oregon Health & Science University School of Medicine, Portland, Oregon, US
| | - Eric Fellin
- Oregon Health & Science University School of Medicine, Portland, Oregon, US
| | - Lisa Stampke
- Oregon Health & Science University School of Medicine, Portland, Oregon, US
| | - Yunazi Zhao
- Knight Cardiovascular Institute, Oregon Health & Science University School of Medicine, Portland, Oregon, US
| | - Ahmad Masri
- Knight Cardiovascular Institute, Oregon Health & Science University School of Medicine, Portland, Oregon, US
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127
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Stern LK, Patel J. Cardiac Amyloidosis Treatment. Methodist Debakey Cardiovasc J 2022; 18:59-72. [PMID: 35414852 PMCID: PMC8932359 DOI: 10.14797/mdcvj.1050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/07/2021] [Indexed: 01/17/2023] Open
Abstract
Cardiac amyloidosis (CA) is a restrictive cardiomyopathy with a traditionally poor prognosis. Until recently, CA treatment options were limited and consisted predominantly of managing symptoms and disease-related complications. However, the last decade has seen significant advances in disease-modifying therapies, increased awareness of CA, and improved diagnostic methods resulting in earlier diagnoses. In this review, we provide an overview of current and experimental treatments for the predominant types of CA: transthyretin cardiac amyloidosis (ATTR-CA) and immunoglobulin light chain (AL)-mediated CA (AL-CA). The mainstay of AL-CA treatment is proteasome inhibitor-based chemotherapy with daratumumab and, when feasible, autologous stem cell transplantation. For ATTR-CA, the stabilizer tafamidis is the only US Food and Drug Administration (FDA)-approved treatment. However, promising novel therapies on the horizon target various points in the ATTR-CA amyloidogenic cascade. These include transthyretin gene (TTR) silencing agents to prevent TTR formation, TTR tetramer stabilization and inhibition of oligomer aggregation to prevent fibril formation, anti-TTR fiber antibodies, and amyloid degradation. For end-stage CA, advanced interventions may need to be considered, including heart, heart-kidney, and, for hereditary ATTR-CA, heart-liver transplantation. Despite the evolution of treatment options, CA management remains complex due to patient frailty and therapeutic side effects or intolerance with advanced cardiac disease. This is particularly relevant for those with AL-CA, when active teamwork between the hematologist-oncologist and the cardiologist is critical for treatment success. Often, referral to an expert center is necessary for timely diagnosis, initiation of treatment, and participation in clinical trials.
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Affiliation(s)
- Lily K. Stern
- Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, US
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, US
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128
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Akras D, Bullinger K, Kondapaneni M, Siraj A, Akhrass R, Aneja A. Transfemoral aortic valve replacement in a nonagenarian with aortic stenosis and cardiac amyloidosis: case report. J Cardiothorac Surg 2022; 17:32. [PMID: 35260184 PMCID: PMC8905911 DOI: 10.1186/s13019-022-01776-z] [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] [Received: 09/13/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac amyloidosis (CA) is diagnosed with increasing frequency in the elderly population with severe aortic stenosis (AS), especially with the low-flow, low- gradient phenotype. Prognosis is poor with no treatment. CASE PRESENTATION The patient is a 94-year-old active male who presented with a stroke that fully resolved. He was found to have low-flow, low-gradient severe AS, along with concomitant CA. Gradients across the aortic valve worsened with the dobutamine challenge test. He underwent successful transfemoral aortic valve replacement (TAVR) and did well postoperatively, where he remained in the hospital for only one day. Treatment of his CA with Tafamidis was recommended; however, the patient declined due to its cost and personal preference. CONCLUSION To our knowledge, we report on one of the oldest patients to undergo TAVR for low-flow, low-gradient AS with concurrent CA (AS-CA). It might be prudent to screen elderly patients with AS for CA, as prognosis is worse with medical management alone. TAVR has overall improved survival in patients with AS-CA and is considered the procedure of choice, as these patients are typically older and at higher risk for surgical intervention.
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Affiliation(s)
- Deena Akras
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Keith Bullinger
- Department of Cardiology, Heart and Vascular Institute, MetroHealth Medical Center, Cleveland, OH, USA
| | - Meera Kondapaneni
- Department of Cardiology, Heart and Vascular Institute, MetroHealth Medical Center, Cleveland, OH, USA
| | - Aisha Siraj
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Department of Cardiology, Heart and Vascular Institute, MetroHealth Medical Center, Cleveland, OH, USA
| | - Rami Akhrass
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. .,Department of Cardiology, Heart and Vascular Institute, MetroHealth Medical Center, Cleveland, OH, USA.
| | - Ashish Aneja
- Department of Cardiology, Heart and Vascular Institute, MetroHealth Medical Center, Cleveland, OH, USA
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129
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Ueda M. Transthyretin: Its function and amyloid formation. Neurochem Int 2022; 155:105313. [PMID: 35218869 DOI: 10.1016/j.neuint.2022.105313] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/20/2022] [Accepted: 02/20/2022] [Indexed: 10/19/2022]
Abstract
Transthyretin (TTR), which is one of the major amyloidogenic proteins in systemic amyloidosis, forms extracellular amyloid deposits in the systemic organs such as nerves, ligaments, heart, and arterioles, and causes two kinds of systemic amyloidosis, hereditary ATTR (ATTRv) amyloidosis induced by variant TTR and aging-related wild-type ATTR (ATTRwt) amyloidosis. More than 150 different mutations, most of which are amyloidogenic, have been reported in the TTR gene. Since most disease-associated mutations affect TTR tetramer dissociation rates, destabilization of TTR tetramers is widely believed to be a critical step in TTR amyloid formation. Recently, effective disease-modifying therapies such as TTR tetramer stabilizers and TTR gene silencing therapies have been developed for ATTR amyloidosis. This study reviews the clinical phenotypes of ATTR amyloidosis, TTR features, and recent progress in promising therapies for ATTR amyloidosis.
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Affiliation(s)
- Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan.
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130
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Fuster V. Editor-in-Chief's Top Picks From 2021. J Am Coll Cardiol 2022; 79:695-753. [PMID: 35177199 DOI: 10.1016/j.jacc.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16M+), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (both Original Investigations and Review Articles) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations and podcasts. The highlights comprise the following sections: Artificial Intelligence & Machine Learning (NEW section), Basic & Translational Research, Biomarkers (NEW section), Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Cardiovascular Disease in Women, Coronary Disease & Interventions, Congenital Heart Disease, Coronavirus, Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, Vascular Medicine, and Valvular Heart Disease.1-100.
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131
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 106] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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132
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Nicol M, Siguret V, Vergaro G, Aimo A, Emdin M, Dillinger JG, Baudet M, Cohen‐Solal A, Villesuzanne C, Harel S, Royer B, Arnulf B, Logeart D. Thromboembolism and bleeding in systemic amyloidosis: a review. ESC Heart Fail 2022; 9:11-20. [PMID: 34784656 PMCID: PMC8787981 DOI: 10.1002/ehf2.13701] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/18/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
The assessment of both thromboembolic and haemorrhagic risks and their management in systemic amyloidosis have been poorly emphasized so far. This narrative review summarizes main evidence from literature with clinical perspective. The rate of thromboembolic events is as high as 5-10% amyloidosis patients, at least in patients with cardiac involvement, with deleterious impact on prognosis. The most known pro-thrombotic factors are heart failure, atrial fibrillation, and atrial myopathy. Atrial fibrillation could occur in 20% to 75% of systemic amyloidosis patients. Cardiac thrombi are frequently observed in patients, particularly in immunoglobulin light chains (AL) amyloidosis, up to 30%, and it is advised to look for them systematically before cardioversion. In AL amyloidosis, nephrotic syndrome and the use of immunomodulatory drugs also favour thrombosis. On the other hand, the bleeding risk increases because of frequent amyloid digestive involvement as well as factor X deficiency, renal failure, and increased risk of dysautonomia-related fall.
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Affiliation(s)
- Martin Nicol
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
- Université de ParisParisFrance
| | - Virginie Siguret
- Université de ParisParisFrance
- INSERM UMR‐S‐1140 University of ParisParisFrance
- Laboratory of HematologyLariboisière Hospital, APHPParisFrance
| | - Giuseppe Vergaro
- Division of Cardiology and Cardiovascular MedicineFondazione Toscana Gabriele MonasterioPisaItaly
| | - Alberto Aimo
- Division of Cardiology and Cardiovascular MedicineFondazione Toscana Gabriele MonasterioPisaItaly
| | - Michele Emdin
- Division of Cardiology and Cardiovascular MedicineFondazione Toscana Gabriele MonasterioPisaItaly
| | - Jean Guillaume Dillinger
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
- Université de ParisParisFrance
| | - Mathilde Baudet
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
| | - Alain Cohen‐Solal
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
- Université de ParisParisFrance
| | | | - Stephanie Harel
- Immuno‐hematology DepartmentSaint Louis Hospital, APHPParisFrance
| | - Bruno Royer
- Immuno‐hematology DepartmentSaint Louis Hospital, APHPParisFrance
| | - Bertrand Arnulf
- Université de ParisParisFrance
- Immuno‐hematology DepartmentSaint Louis Hospital, APHPParisFrance
| | - Damien Logeart
- Cardiology departmentLariboisière Hospital, APHP2 rue Ambroise ParéParisFrance
- Université de ParisParisFrance
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133
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Gonska B, Buckert D, Mörike J, Scharnbeck D, Kersten J, Cuspidi C, Rottbauer W, Tadic M. Imaging Challenges in Patients with Severe Aortic Stenosis and Heart Failure: Did We Find a Way Out of the Labyrinth? J Clin Med 2022; 11:jcm11020317. [PMID: 35054012 PMCID: PMC8777924 DOI: 10.3390/jcm11020317] [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: 11/30/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022] Open
Abstract
Aortic stenosis (AS) is the most frequent degenerative valvular disease in developed countries. Its incidence has been constantly rising due to population aging. The diagnosis of AS was considered straightforward for a very long time. High gradients and reduced aortic valve area were considered as "sine qua non" in diagnosis of AS until a growing body of evidence showed that patients with low gradients could also have severe AS with the same or even worse outcome. This completely changed the paradigm of AS diagnosis and involved large numbers of parameters that had never been used in the evaluation of AS severity. Low gradient AS patients may present with heart failure (HF) with preserved or reduced left ventricular ejection fraction (LVEF), associated with changes in cardiac output and flow across the aortic valve. These patients with low-flow low-gradient or paradoxical low-flow low-gradient AS are particularly challenging to diagnose, and cardiac output and flow across the aortic valve have become the most relevant parameters in evaluation of AS, besides gradients and aortic valve area. The introduction of other imaging modalities in the diagnosis of AS significantly improved our knowledge about cardiac mechanics, tissue characterization of myocardium, calcium and inflammation burden of the aortic valve, and their impact on severity, progression and prognosis of AS, not only in symptomatic but also in asymptomatic patients. However, a variety of novel parameters also brought uncertainty regarding the clinical relevance of these indices, as well as the necessity for their validation in everyday practice. The aim of this review is to summarize the prevalence of HF in patients with severe AS and elaborate on the diagnostic challenges and advantages of comprehensive multimodality cardiac imaging to identify the patients that may benefit from surgical or transcatheter aortic valve replacement, as well as parameters that may help during follow-up.
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Affiliation(s)
- Birgid Gonska
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Dominik Buckert
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Johannes Mörike
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Dominik Scharnbeck
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Johannes Kersten
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Cesare Cuspidi
- Department for Internal Medicine, University of Milan-Bicocca, 20126 Milan, Italy;
| | - Wolfang Rottbauer
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Marijana Tadic
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
- Correspondence: ; Tel.: +49-176-3236-0011
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134
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Martyn T, Rubio AC, Estep JD, Hanna M. Opportunities for Earlier Diagnosis and Treatment of Cardiac Amyloidosis. Methodist Debakey Cardiovasc J 2022; 18:27-39. [PMID: 36561083 PMCID: PMC9733170 DOI: 10.14797/mdcvj.1163] [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: 09/19/2022] [Accepted: 10/07/2022] [Indexed: 12/12/2022] Open
Abstract
Despite the rapid expansion of noninvasive (nonbiopsy) diagnosis, contemporary patients with cardiac amyloidosis too often present with advanced features of disease, such as diminished quality of life, elevated natriuretic peptides, and advanced heart failure. Therapeutics for transthyretin cardiomyopathy (ATTR-CM) are most effective when administered before significant symptoms of cardiac dysfunction manifest, making early identification of affected individuals of paramount importance. Community engagement and ensuring that a broad range of clinicians have working knowledge of how to screen for ATTR-CM in everyday practice will be an important step in moving disease identification further upstream. However, reliance on the appropriate and timely diagnosis by individual clinicians may continue to underperform. This review highlights how targeted screening of special populations may facilitate earlier diagnosis. Systems of care that operationalize screening of high-risk subpopulations and prospective validation of novel approaches to ATTR-CM identification are needed.
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Affiliation(s)
- Trejeeve Martyn
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio, US,Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, US
| | - Andres Carmona Rubio
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio, US,Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, US
| | - Jerry D. Estep
- Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, US,Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston, Florida, US
| | - Mazen Hanna
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio, US,Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio, US
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135
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Patel KP, Scully PR, Nitsche C, Kammerlander AA, Joy G, Thornton G, Hughes R, Williams S, Tillin T, Captur G, Chacko L, Kelion A, Sabharwal N, Newton JD, Kennon S, Ozkor M, Mullen M, Hawkins PN, Gillmore JD, Menezes L, Pugliese F, Hughes AD, Fontana M, Lloyd G, Treibel TA, Mascherbauer J, Moon JC. Impact of afterload and infiltration on coexisting aortic stenosis and transthyretin amyloidosis. Heart 2022; 108:67-72. [PMID: 34497140 DOI: 10.1136/heartjnl-2021-319922] [Citation(s) in RCA: 8] [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: 07/05/2021] [Accepted: 08/23/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The coexistence of wild-type transthyretin cardiac amyloidosis (ATTR) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). However, the impact of ATTR and AS on the resultant AS-ATTR is unclear and poses diagnostic and management challenges. We therefore used a multicohort approach to evaluate myocardial structure, function, stress and damage by assessing age-related, afterload-related and amyloid-related remodelling on the resultant AS-ATTR phenotype. METHODS We compared four samples (n=583): 359 patients with AS, 107 with ATTR (97% Perugini grade 2), 36 with AS-ATTR (92% Perugini grade 2) and 81 age-matched and ethnicity-matched controls. 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy was used to diagnose amyloidosis (Perugini grade 1 was excluded). The primary end-point was NT-pro Brain Natriuretic Peptide (BNP) and secondary end-points related to myocardial structure, function and damage. RESULTS Compared with older age controls, the three disease cohorts had greater cardiac remodelling, worse function and elevated NT-proBNP/high-sensitivity Troponin-T (hsTnT). NT-proBNP was higher in AS-ATTR (2844 (1745, 4635) ng/dL) compared with AS (1294 (1077, 1554)ng/dL; p=0.002) and not significantly different to ATTR (3272 (2552, 4197) ng/dL; p=0.63). Diastology, hsTnT and prevalence of carpal tunnel syndrome were statistically similar between AS-ATTR and ATTR and higher than AS. The left ventricular mass indexed in AS-ATTR was lower than ATTR (139 (112, 167) vs 180 (167, 194) g; p=0.013) and non-significantly different to AS (120 (109, 130) g; p=0.179). CONCLUSIONS The AS-ATTR phenotype likely reflects an early stage of amyloid infiltration, but the combined insult resembles ATTR. Even after treatment of AS, ATTR-specific therapy is therefore likely to be beneficial.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Paul Richard Scully
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Christian Nitsche
- Department of Internal Medicine, Medical University of Vienna, Wien, Austria
| | | | - George Joy
- Cardiac Imaging Department, Barts Heart Centre, London, UK
| | - George Thornton
- Institute of Cardiovascular Science, University College London, London, UK
- Cardiac Imaging Department, Barts Heart Centre, London, UK
| | - Rebecca Hughes
- Institute of Cardiovascular Science, University College London, London, UK
- Cardiac Imaging Department, Barts Heart Centre, London, UK
| | | | | | - Gabriella Captur
- Institute of Cardiovascular Science, University College London, London, UK
- MRC Unit for Lifelong Health and Ageing, London, UK
| | | | - Andrew Kelion
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nikant Sabharwal
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James D Newton
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon Kennon
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Mick Ozkor
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Michael Mullen
- Department of Cardiology, Barts Heart Centre, London, UK
| | | | | | - Leon Menezes
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, London, UK
- Advanced Cardiovascular Imaging, William Harvey Research Institute, The London Chest Hospital, London, UK
| | | | | | - Guy Lloyd
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Barts Heart Centre, London, UK
| | | | - James C Moon
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Barts Heart Centre, London, UK
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136
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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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137
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Scully PR, Patel KP, Klotz E, Augusto JB, Thornton GD, Saberwal B, Haberland U, Kennon S, Ozkor M, Mullen M, Lloyd G, Kelion A, Menezes LJ, Hawkins PN, Moon JC, Pugliese F, Treibel TA. Myocardial Fibrosis Quantified by Cardiac CT Predicts Outcome in Severe Aortic Stenosis After Transcatheter Intervention. JACC Cardiovasc Imaging 2021; 15:542-544. [PMID: 34922871 PMCID: PMC8901438 DOI: 10.1016/j.jcmg.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 11/05/2022]
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138
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Ruberg FL. Phenotype Mapping in Cardiac Amyloidosis. J Am Coll Cardiol 2021; 78:2193-2195. [PMID: 34823662 DOI: 10.1016/j.jacc.2021.09.857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 01/07/2023]
Affiliation(s)
- Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, and Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.
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139
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Sin-Ying Ho J, Kor Q, Kong WK, Lim YC, Yan-Yee Chan M, Syn NL, Ngiam JN, Chew NW, Yeo TC, Chai P, Poh KK, Wong RC, Lin W, Sia CH. Prevalence and outcomes of concomitant cardiac amyloidosis and aortic stenosis: A systematic review and meta-analysis. Hellenic J Cardiol 2021; 64:67-76. [PMID: 34856378 DOI: 10.1016/j.hjc.2021.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/29/2021] [Accepted: 11/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Cardiac amyloidosis (CA) is an increasingly recognised condition in patients with aortic stenosis (AS). However, there is large variation in the reported prevalence figures, due to differences in populations and diagnostic methods. We aimed to investigate the prevalence, risk factors and outcomes of concomitant CA and AS. METHODS We performed a systematic review and meta-analysis of the literature searched on Medline, EMBASE, Scopus and CENTRAL. We analysed the prevalence of CA in AS grouped according to diagnostic techniques, and the risk factors and outcomes of concomitant CA and AS was analysed in AS patients referred for surgical or transcatheter aortic valve replacement (AVR). RESULTS A total of 21 studies were included, involving 4,243 patients. The pooled prevalence of CA in patients with AS was 14.4%, with substantial heterogeneity. The pooled prevalence of AS in CA was 8.7%, with substantial heterogeneity. Patients with both AS and CA had higher all-cause mortality than those with AS or CA alone. In AS patients requiring AVR, CA was associated with increasing age, male sex, higher NT-proBNP levels, increased interventricular septal end diastole thickness and lower left ventricular ejection fraction. Concomitant AS and CA was associated with increased all-cause mortality and pacemaker implantation post-procedure. Study limitations included the heterogeneity of results and the fair to good quality of studies published. CONCLUSION Overall, a substantial proportion of patients with AS may have CA, and they have poorer prognosis. A high degree of clinical suspicion is needed to identify "red flags" and perform appropriate diagnostic imaging.
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Affiliation(s)
- Jamie Sin-Ying Ho
- Academic Foundation Programme, North Middlesex University Hospital NHS Trust, United Kingdom
| | - Qianyi Kor
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William Kf Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Yoke Ching Lim
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Nicholas Lx Syn
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jinghao Nicholas Ngiam
- Internal Medicine Residency, University Medicine Cluster, National University Health System, Singapore
| | - Nicholas Ws Chew
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Raymond Cc Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Weiqin Lin
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
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140
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MUW researcher of the month. Wien Klin Wochenschr 2021; 133:1233-1234. [PMID: 34787708 DOI: 10.1007/s00508-021-01984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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141
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Snir AD, Ng MK, Strange G, Playford D, Stewart S, Celermajer DS. Prevalence and Outcomes of Low-Gradient Severe Aortic Stenosis-From the National Echo Database of Australia. J Am Heart Assoc 2021; 10:e021126. [PMID: 34719256 PMCID: PMC8751961 DOI: 10.1161/jaha.121.021126] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The prevalence and outcomes of the different subtypes of severe low‐gradient aortic stenosis (AS) in routine clinical cardiology practice have not been well characterized. Methods and Results Data were derived from the National Echocardiography Database of Australia. Of 192 060 adults (aged 62.8±17.8 [mean±SD] years) with native aortic valve profiling between 2000 and 2019, 12 013 (6.3%) had severe AS. Of these, 5601 patients (47%) had high‐gradient and 6412 patients (53%) had low‐gradient severe AS. The stroke volume index was documented in 2741 (42.7%) patients with low gradient; 1750 patients (64%) with low flow, low gradient (LFLG); and 991 patients with normal flow, low gradient. Of the patients with LFLG, 1570 (89.7%) had left ventricular ejection fraction recorded; 959 (61%) had paradoxical LFLG (preserved left ventricular ejection fraction), and 611 (39%) had classical LFLG (reduced left ventricular ejection fraction). All‐cause and cardiovascular‐related mortality were assessed in the 8162 patients with classifiable severe AS subtype during a mean±SD follow‐up of 88±45 months. Actual 1‐year and 5‐year all‐cause mortality rates varied across these groups and were 15.8% and 49.2% among patients with high‐gradient severe AS, 11.6% and 53.6% in patients with normal‐flow, low‐gradient severe AS, 16.9% and 58.8% in patients with paradoxical LFLG severe AS, and 30.5% and 72.9% in patients with classical LFLG severe AS. Compared with patients with high‐gradient severe AS, the 5‐year age‐adjusted and sex‐adjusted mortality risk hazard ratios were 0.94 (95% CI, 0.85–1.03) in patients with normal‐flow, low‐gradient severe AS; 1.01 (95% CI, 0.92–1.12) in patients with paradoxical LFLG severe AS; and 1.65 (95% CI, 1.48–1.84) in patients with classical LFLG severe AS. Conclusions Approximately half of those patients with echocardiographic features of severe AS in routine clinical practice have low‐gradient hemodynamics, which is associated with long‐term mortality comparable with or worse than high‐gradient severe AS. The poorest survival was associated with classical LFLG severe AS.
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Affiliation(s)
- Afik D Snir
- Faculty of Medicine and Health University of Sydney Australia
| | - Martin K Ng
- Faculty of Medicine and Health University of Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Camperdown Australia
| | - Geoff Strange
- Heart Research Institute Newtown Australia.,School of Medicine University of Notre Dame Fremantle Australia
| | - David Playford
- School of Medicine University of Notre Dame Fremantle Australia
| | - Simon Stewart
- Torrens University Australia Adelaide Australia.,University of Glasgow Scotland
| | - David S Celermajer
- Faculty of Medicine and Health University of Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Camperdown Australia.,Heart Research Institute Newtown Australia
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142
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Guo X, Song R, Chen Y. Severe aortic regurgitation and heart failure. Heart 2021; 107:1874-1924. [PMID: 34764203 DOI: 10.1136/heartjnl-2021-319612] [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] [Indexed: 11/04/2022] Open
Affiliation(s)
- Xinli Guo
- Department of Cardiology, Sichuan University, Chengdu, China
| | - Rizhen Song
- Department of Cardiology, Sichuan University, Chengdu, China
| | - Yucheng Chen
- Department of Cardiology, Sichuan University, Chengdu, China
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143
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Ruan D, Sun L. Diagnostic efficacy of bone scintigraphy in transthyretin cardiac amyloidosis: an updated systematic review and Bayesian bivariate meta-analysis. Clin Transl Imaging 2021. [DOI: 10.1007/s40336-021-00471-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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144
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Griffin JM, Rosenthal JL, Grodin JL, Maurer MS, Grogan M, Cheng RK. ATTR Amyloidosis: Current and Emerging Management Strategies: JACC: CardioOncology State-of-the-Art Review. JACC: CARDIOONCOLOGY 2021; 3:488-505. [PMID: 34729521 PMCID: PMC8543085 DOI: 10.1016/j.jaccao.2021.06.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is increasingly diagnosed owing to the emergence of noninvasive imaging and improved awareness. Clinical penetrance of pathogenic alleles is not complete and therefore there is a large cohort of asymptomatic transthyretin variant carriers. Screening strategies, monitoring, and treatment of subclinical ATTR-CA requires further study. Perhaps the most important translational triumph has been the development of effective therapies that have emerged from a biological understanding of ATTR-CA pathophysiology. These include recently proven strategies of transthyretin protein stabilization and silencing of transthyretin production. Data on neurohormonal blockade in ATTR-CA are limited, with the primary focus of medical therapy on judicious fluid management. Atrial fibrillation is common and requires anticoagulation owing to the propensity for thrombus formation. Although conduction disease and ventricular arrhythmias frequently occur, little is known regarding optimal management. Finally, aortic stenosis and ATTR-CA frequently coexist, and transcatheter valve replacement is the preferred treatment approach.
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Key Words
- 6MWT, 6-minute walk test
- AF, atrial fibrillation
- AL, light chain amyloid
- AS, aortic stenosis
- ASO, antisense oligonucleotide
- ATTR-CA, transthyretin cardiac amyloidosis
- ATTRv, variant transthyretin cardiac amyloidosis
- ATTRwt, wild-type transthyretin cardiac amyloidosis
- CMR, cardiac magnetic resonance
- DCCV, direct current cardioversion
- HF, heart failure
- LVEF, left ventricular ejection fraction
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- SAP, serum amyloid P component
- TAVR, transcatheter aortic valve replacement
- amyloidosis
- cardiomyopathy
- heart failure
- siRNA, small interfering RNA
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Affiliation(s)
- Jan M Griffin
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mathew S Maurer
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Richard K Cheng
- University of Washington Medical Center, Seattle, Washington, USA
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145
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Sex-related differences in the clinical characteristics of wild-type transthyretin amyloidosis cardiomyopathy. J Cardiol 2021; 79:50-57. [PMID: 34756766 DOI: 10.1016/j.jjcc.2021.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND A significant male predominance has been reported in wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM). Hence, female cases of ATTRwt-CM are overlooked, and sex-related differences in ATTRwt-CM remain unclear. This study aimed to examine sex-related differences in clinical characteristics and diagnostic approaches in ATTRwt-CM. METHODS We retrospectively analyzed 199 consecutive patients who were diagnosed with ATTRwt-CM and evaluated sex-related differences in clinical characteristics, imaging parameters, biomarkers, and diagnostic approaches. RESULTS Twenty-nine patients (15%) were female. These female patients were significantly older at diagnosis (77.1 ± 6.5 years vs. 82.9 ± 4.8 years; p<0.001) and had a more advanced New York Health Association functional class (2.2 ± 0.7 vs. 2.6 ± 0.8; p = 0.006) than their male counterparts. The median B-type natriuretic peptide levels were significantly higher (236 pg/mL vs. 394 pg/mL; p = 0.017) in female patients. Echocardiography revealed that the mean interventricular septum diameter was thinner (15.7 ± 2.6 mm vs. 14.1 ± 2.5 mm; p = 0.004) and left ventricular ejection fraction (LVEF) was preserved (51.2 ± 10.2% vs. 57.2 ± 9.1%; p = 0.003) in female patients. The mean heart-to-contralateral ratio obtained using 99mTc-labeled pyrophosphate (99mTc-PYP) was significantly lower (1.89 ± 0.33 vs. 1.63 ± 0.20; p < 0.001), moderate to severe aortic stenosis was more frequently observed (5% vs. 45%; p < 0.001), and the frequency of histological diagnosis was significantly lower (77% vs. 59%; p = 0.036) in female patients. CONCLUSIONS Female patients with ATTRwt-CM were predominantly octogenarians and less hypertrophic and had preserved LVEF and weaker cardiac uptake of the 99mTc-PYP tracer compared with male patients. These characteristics contribute to the underdiagnosis of ATTRwt-CM in female patients.
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146
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Shimoni S, Zikri M, Haberman D, Livschitz S, Tshori S, Fabricant Y, Meledin V, Gandelman G, Goland S, George J. Transthyretin cardiac amyloidosis in patients after TAVR: clinical and echocardiographic findings and long term survival. ESC Heart Fail 2021; 8:4549-4561. [PMID: 34704399 PMCID: PMC8712785 DOI: 10.1002/ehf2.13667] [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: 07/01/2021] [Revised: 08/27/2021] [Accepted: 09/27/2021] [Indexed: 01/15/2023] Open
Abstract
Aims The aim of this study was to examine the prevalence of amyloid transthyretin (ATTR) cardiac amyloidosis in patients 1–2 years after trans‐catheter aortic valve replacement (TAVR) and to assess their clinical and echocardiographic outcome and long‐term survival. Methods and results We enrolled 88 patients, mean age 81 years, 534 (390–711) days after TAVR. Patients underwent a Tc99m‐PYP scintigraphy for the diagnosis of ATTR cardiac amyloidosis. Eleven (12.5%) participants were diagnosed with ATTR cardiac amyloidosis. Eighty eight per cent of patients without amyloidosis were in New York Heart Association Classes 1–2 after TAVR, compared with 64% patients with ATTR cardiac amyloidosis (P = 0.022). There were no differences in left ventricular (LV) ejection fraction (P = 0.69) between patients with and without ATTR cardiac amyloidosis at enrolment. The LV mass index and pulmonary artery pressure were significantly higher in patients with ATTR cardiac amyloidosis (P = 0.046 and P = 0.002, respectively). Global longitudinal strain and myocardial work efficiency were significantly lower in patients with ATTR cardiac amyloidosis (P = 0.031 and P = 0.048, respectively). We assessed changes in echocardiographic data, from the time of TAVR to enrolment, and as expected, there was a significant decrease in aortic valve gradient in both groups. There was a significant reduction in LV mass and LV mass index and improvement in basal segment LV strain in the ATTR cardiac amyloidosis negative group (P = 0.045, P = 0.046 and 0.023, respectively). However, in the ATTR cardiac amyloidosis group the change in LV mass and LV mass index and LV basal strain values was not significant (P = 0.24, P = 0.13 and P = 0.35, respectively). The were no significant changes in other echocardiographic parameters in both groups. The patients were followed for 1150 (1086–1221) days after enrolment. Twenty seven patients had at least one cardiac hospitalization during of follow up, of them seven were with ATTR cardiac amyloidosis and 20 patients without amyloidosis (P = 0.017). Eighteen patients (20%) died during follow up; 12 (14%) patients died due to cardiac causes. There was no difference in all‐cause and cardiac mortality between patients with and without ATTR cardiac amyloidosis (P = 0.6 and P = 0.53, respectively). Conclusions The long‐term survival after TAVR is not significantly affected by the presence of ATTR cardiac amyloidosis. However, the clinical course of these patients and the LV hemodynamic improvement is less favourable. This hypothesis‐generating study suggests screening for ATTR cardiac amyloidosis in patients who underwent TAVR and have limited clinical or echocardiographic improvement, because they may potentially improve with new therapies for ATTR cardiac amyolidosis.
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Affiliation(s)
- Sara Shimoni
- The Heart Center, Kaplan Medical Center, Rehovot, Israel.,Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Meital Zikri
- The Heart Center, Kaplan Medical Center, Rehovot, Israel
| | - Dan Haberman
- The Heart Center, Kaplan Medical Center, Rehovot, Israel
| | - Shay Livschitz
- The Heart Center, Kaplan Medical Center, Rehovot, Israel
| | - Sagi Tshori
- The Heart Center, Kaplan Medical Center, Rehovot, Israel.,Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | | | - Valery Meledin
- The Heart Center, Kaplan Medical Center, Rehovot, Israel
| | - Gera Gandelman
- The Heart Center, Kaplan Medical Center, Rehovot, Israel
| | - Sorel Goland
- The Heart Center, Kaplan Medical Center, Rehovot, Israel.,Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Jacob George
- The Heart Center, Kaplan Medical Center, Rehovot, Israel.,Hadassah Medical School, Hebrew University, Jerusalem, Israel
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147
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2021; 60:727-800. [PMID: 34453161 DOI: 10.1093/ejcts/ezab389] [Citation(s) in RCA: 298] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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148
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Fabbri G, Serenelli M, Cantone A, Sanguettoli F, Rapezzi C. Transthyretin amyloidosis in aortic stenosis: clinical and therapeutic implications. Eur Heart J Suppl 2021; 23:E128-E132. [PMID: 34650371 PMCID: PMC8503413 DOI: 10.1093/eurheartj/suab107] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
About one in seven elderly patients with severe calcific aortic stenosis (AS) also have ATTR amyloid cardiomyopathy (AC-TTR). The reasons for this close association are not fully known, but the two entities are not only related by common epidemiology. For example, it is possible to hypothesize that an amyloidotic infiltration of the aortic valve, even partial, can act as a trigger for the development of endothelial damage and subsequent calcification. Another hypothesis is the increased myocardial strain induced by AS may locally favour the process of amyloidogenesis and tissue infiltration. In a patient with AS, the coexistence of AC-TTR can be suspected by careful analysis of the echocardiogram and the ECG, especially if a clinical history of carpal tunnel syndrome coexists. Bone tracer scintigraphy allows a diagnosis of certainty. Recently, several studies have evaluated the prognostic implications of the coexistence of the two entities in candidates for percutaneous aortic valve replacement, showing how amyloidosis would not significantly impact the results of the procedure, but would only be associated with a greater risk of distant heart failure. In patients with AS associated with AC-TTR, valve replacement should not be ruled out in the presence of the usual clinical-haemodynamic indications.
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Affiliation(s)
- Gioele Fabbri
- Centro Cardiologico, Università di Ferrara, via Aldo Moro 8, Cona, 44124 Ferrara, Italy
| | - Matteo Serenelli
- Centro Cardiologico, Università di Ferrara, via Aldo Moro 8, Cona, 44124 Ferrara, Italy
| | - Anna Cantone
- Centro Cardiologico, Università di Ferrara, via Aldo Moro 8, Cona, 44124 Ferrara, Italy
| | - Federico Sanguettoli
- Centro Cardiologico, Università di Ferrara, via Aldo Moro 8, Cona, 44124 Ferrara, Italy
| | - Claudio Rapezzi
- Centro Cardiologico, Università di Ferrara, via Aldo Moro 8, Cona, 44124 Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
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149
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Affiliation(s)
- Richard Cheng
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Jan Griffin
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
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150
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Singal AK, Bansal R, Singh A, Dorbala S, Sharma G, Gupta K, Saxena A, Bhargava B, Karthikeyan G, Ramakrishnan S, Bisoi AK, Hote MP, Rajashekar P, Chowdhury UK, Devagourou V, Patel C, Ray R, Arawa SK, Mishra S. Concomitant Transthyretin Amyloidosis and Severe Aortic Stenosis in Elderly Indian Population: A Pilot Study. JACC CardioOncol 2021; 3:565-576. [PMID: 34746852 PMCID: PMC8551518 DOI: 10.1016/j.jaccao.2021.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Prevalence of both degenerative severe aortic stenosis (AS) and transthyretin cardiac amyloidosis (ATTR-CA) increases with age. Dual disease (AS+myocardial ATTR-CA) occurs in significant proportion of patients undergoing surgical aortic valve replacement (SAVR). OBJECTIVES This study aimed to determine the prevalence of ATTR-CA in severe AS in the Indian population, identify noninvasive predictors of its diagnosis, and understand its impact on prognosis. METHODS Symptomatic severe AS patients aged ≥65 years undergoing SAVR were enrolled. ATTR-CA diagnosis was based on preoperative 99m-technetium pyrophosphate (PYP) scan and intraoperatively obtained basal interventricular septum biopsy for myocardial ATTR-CA, and excised native aortic valve for isolated valvular ATTR-CA. Primary amyloidosis was excluded by serum/urine protein electrophoresis with serum immunofixation. RESULTS SAVR was performed in 46 AS patients (age 70 ± 5 years, 70% men). PYP scan was performed for 32 patients, with significant PYP uptake in 3 (n = 3 of 32, 9.4%), suggestive of myocardial ATTR-CA. On histopathological examination, none of the interventricular septum biopsy specimens had amyloid deposits, whereas 33 (71.7%) native aortic valves showed amyloid deposits, of which 19 (57.6%) had transthyretin deposition suggestive of isolated valvular amyloidosis. Noninvasive markers of dual disease included low myocardial contraction fraction (median [interquartile range], 28.8% [23.8% to 39.1%] vs 15.3% [9.3% to 16.1%]; P = 0.006), deceleration time (215 [144 to 236] ms vs 88 [60 to 106] ms; P = 0.009) and global longitudinal strain (-18.7% [-21.1% to -16.9%] vs -14.2% [-17.0% to -9.7%]; P = 0.030). At 1-year follow-up, 2 patients died (4.3%); 1 each in myocardial ATTR-CA negative and positive groups (3.4% vs 33.3%; P = 0.477). CONCLUSIONS Dual disease is not uncommon in India. Isolated valvular amyloidosis in severe AS is much more common.
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Key Words
- 99m-technetium pyrophosphate scan
- 99mTc-PYP, 99m-technetium pyrophosphate
- AL-CA, light chain cardiac amyloidosis
- AS, aortic stenosis
- ATTR-CA, transthyretin cardiac amyloidosis
- EMB, endomyocardial biopsy
- GLS, global longitudinal strain
- IHC, immunohistochemistry
- LfLg AS, low-flow, low-gradient aortic stenosis
- SAVR, surgical aortic valve replacement
- TAVR, transcatheter aortic valve replacement
- TTR, transthyretin
- dual aortic stenosis transthyretin cardiac amyloidosis
- severe aortic stenosis
- transthyretin cardiac amyloidosis
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Affiliation(s)
| | | | - Avinainder Singh
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sharmila Dorbala
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Kartik Gupta
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Anita Saxena
- Department of Cardiology, AIIMS, New Delhi, India
| | - Balram Bhargava
- Department of Cardiology, AIIMS, New Delhi, India
- Indian Council of Medical Research, New Delhi, India, and Department of Health Research (Ministry of Health and Family Welfare), Government of India, New Delhi, India
| | | | | | | | | | | | | | | | - Chetan Patel
- Department of Nuclear Medicine, AIIMS, New Delhi, India
| | - Ruma Ray
- Department of Pathology, AIIMS, New Delhi, India
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