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Sidorova TN, Mace LC, Wells KS, Yermalitskaya LV, Su PF, Shyr Y, Atkinson JB, Fogo AB, Prinsen JK, Byrne JG, Petracek MR, Greelish JP, Hoff SJ, Ball SK, Glabe CG, Brown NJ, Barnett JV, Murray KT. Hypertension is associated with preamyloid oligomers in human atrium: a missing link in atrial pathophysiology? J Am Heart Assoc 2014; 3:e001384. [PMID: 25468655 PMCID: PMC4338732 DOI: 10.1161/jaha.114.001384] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Increasing evidence indicates that proteotoxicity plays a pathophysiologic role in experimental and human cardiomyopathy. In organ‐specific amyloidoses, soluble protein oligomers are the primary cytotoxic species in the process of protein aggregation. While isolated atrial amyloidosis can develop with aging, the presence of preamyloid oligomers (PAOs) in atrial tissue has not been previously investigated. Methods and Results Atrial samples were collected during elective cardiac surgery in patients without a history of atrial arrhythmias, congestive heart failure, cardiomyopathy, or amyloidosis. Immunohistochemistry was performed for PAOs using a conformation‐specific antibody, as well as for candidate proteins identified previously in isolated atrial amyloidosis. Using a myocardium‐specific marker, the fraction of myocardium colocalizing with PAOs (PAO burden) was quantified (green/red ratio). Atrial samples were obtained from 92 patients, with a mean age of 61.7±13.8 years. Most patients (62%) were male, 23% had diabetes, 72% had hypertension, and 42% had coronary artery disease. A majority (n=62) underwent aortic valve replacement, with fewer undergoing coronary artery bypass grafting (n=34) or mitral valve replacement/repair (n=24). Immunostaining detected intracellular PAOs in a majority of atrial samples, with a heterogeneous distribution throughout the myocardium. Mean green/red ratio value for the samples was 0.11±0.1 (range 0.03 to 0.77), with a value ≥0.05 in 74 patients. Atrial natriuretic peptide colocalized with PAOs in myocardium, whereas transthyretin was located in the interstitium. Adjusting for multiple covariates, PAO burden was independently associated with the presence of hypertension. Conclusion PAOs are frequently detected in human atrium, where their presence is associated with clinical hypertension.
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Affiliation(s)
- Tatiana N Sidorova
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN (T.N.S., L.C.M., L.V.Y., J.K.P., N.J.B., J.V.B., K.T.M.)
| | - Lisa C Mace
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN (T.N.S., L.C.M., L.V.Y., J.K.P., N.J.B., J.V.B., K.T.M.)
| | - K Sam Wells
- Departments of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN (S.W.)
| | - Liudmila V Yermalitskaya
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN (T.N.S., L.C.M., L.V.Y., J.K.P., N.J.B., J.V.B., K.T.M.)
| | - Pei-Fang Su
- Center for Quantitative Sciences, Vanderbilt University School of Medicine, Nashville, TN (P.F.S., Y.S.)
| | - Yu Shyr
- Center for Quantitative Sciences, Vanderbilt University School of Medicine, Nashville, TN (P.F.S., Y.S.)
| | - James B Atkinson
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN (J.B.A., A.B.F.)
| | - Agnes B Fogo
- Departments of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN (J.B.A., A.B.F.)
| | - Joseph K Prinsen
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN (T.N.S., L.C.M., L.V.Y., J.K.P., N.J.B., J.V.B., K.T.M.)
| | - John G Byrne
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN (J.G.B., M.R.P., J.P.G., S.J.H., S.K.B.)
| | - Michael R Petracek
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN (J.G.B., M.R.P., J.P.G., S.J.H., S.K.B.)
| | - James P Greelish
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN (J.G.B., M.R.P., J.P.G., S.J.H., S.K.B.)
| | - Steven J Hoff
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN (J.G.B., M.R.P., J.P.G., S.J.H., S.K.B.)
| | - Stephen K Ball
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN (J.G.B., M.R.P., J.P.G., S.J.H., S.K.B.)
| | | | - Nancy J Brown
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN (T.N.S., L.C.M., L.V.Y., J.K.P., N.J.B., J.V.B., K.T.M.)
| | - Joey V Barnett
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN (T.N.S., L.C.M., L.V.Y., J.K.P., N.J.B., J.V.B., K.T.M.)
| | - Katherine T Murray
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN (T.N.S., L.C.M., L.V.Y., J.K.P., N.J.B., J.V.B., K.T.M.)
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Bauer R, Dikow N, Brauer A, Kreuter M, Buss S, Evers C, Röcken C, Schnabel PA, Hinderhofer K, Ehlermann P, Katus HA, Kristen AV. The "Wagshurst study": p.Val40Ile transthyretin gene variant causes late-onset cardiomyopathy. Amyloid 2014; 21:267-75. [PMID: 25291558 DOI: 10.3109/13506129.2014.967846] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Transthyretin-related amyloidosis (ATTR) is characterized by a wide heterogeneity of genotypes and predominantly neurological and cardiac phenotypes. This study aims to characterize a cohort of patients with the rare transthyretin (TTR) Val20Ile (p.TTRVal40Ile) variant. METHODS AND RESULTS This study comprises a single-center cohort of 59 individuals subsequently evaluated for TTRVal20Ile variant due to clinical (n = 13) or predictive (n = 46) reasons. All patients were mainly related to Wagshurst, a small village in the South of Germany. Clinical assessment was performed by neurological evaluation, echocardiography, electrocardiography, cardiac biomarkers, cardiac MRI (n = 13), and (99m)Tc-DPD scintigraphy (n = 16). The rare TTRVal20Ile variant was found in 41 patients; evidence of cardiac amyloidosis was present in 22 patients. Evidence of pulmonary involvement was obtained by (99m)Tc-DPD scintigraphy in eight patients. No further organ involvement was observed in any of the patients carrying TTRVal20Ile variant. Correlation of inter-ventricular septum thickness as well as decrease of left ventricular longitudinal contractility with age was observed. Moreover, thickness of inter-ventricular septum correlated with NT-proBNP plasma levels and decrease in mitral annular plane systolic excursion. Cardiac manifestation started during the early sixth life decade indicated by higher left ventricular septum thickness and NT-proBNP plasma levels as compared to patients in fifth decade of life. All patients of the seventh and eighth life decade (n = 10) presented with cardiac amyloidosis. During median follow-up of 26 (0-108) months, eight patients underwent heart transplantation with 1-year mortality rate of 25%. CONCLUSIONS This large cohort of individuals carrying the TTRVal20Ile mutation reveals a predominantly cardiac phenotype with high penetrance and late onset of symptoms. Cardiac manifestation progressed to end-stage heart failure within a few years, finally requiring heart transplantation with promising long-term survival rates.
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Affiliation(s)
- Ralf Bauer
- Department of Cardiology, Angiology, and Respiratory Medicine, University Hospital Heidelberg , Heidelberg , Germany
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Abstract
Amyloid cardiomyopathy should be suspected in any patient who presents with heart failure and preserved ejection fraction. In patients with echocardiographic evidence of ventricular thickening and without a clear history of hypertension, infiltrative cardiomyopathy should be considered. If imaging suggests the presence of amyloid deposits, confirmation by biopsy is required, although endomyocardial biopsy is generally not necessary. Assessment of aspirated subcutaneous fat and bone-marrow biopsy samples verifies the diagnosis in 40-80% of patients, dependent on the type of amyloidosis. Mass spectroscopy can be used to determine the protein subunit and classify the disease as immunoglobulin light-chain amyloidosis or transthyretin-related amyloidosis associated with mutant or wild-type TTR (formerly known as familial amyloid cardiomyopathy and senile cardiac amyloidosis, respectively). In this Review, we discuss the characteristics of cardiac amyloidosis, and present a structured approach to both the assessment of patients and treatment with emerging therapies and organ transplantation.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Angela Dispenzieri
- Division of Clinical Biochemistry and Immunology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Taimur Sher
- Division of Hematology/Oncology, Cancer Center, and Breast Clinic, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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