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Lopez J, Duarte G, Mark JD, Vergara Sanchez C, De Camps Martinez ER, Black AL, Perez A, Zachariah A, Elshazly M, Colombo RA, Losiniecki F, Chait R, Jimenez M, Baez-Escudero J. Impact of cardiac conduction disease in patients with cardiac amyloidosis: A national retrospective cohort study. Int J Cardiol 2024; 417:132468. [PMID: 39242034 DOI: 10.1016/j.ijcard.2024.132468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 08/04/2024] [Accepted: 08/16/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND There is a paucity of data regarding the impact of cardiac conduction disease (CD) on clinical outcomes in patients with cardiac amyloidosis (CA). METHODS The National Inpatient Sample (NIS) was queried to identify all CA admissions and those with CD using ICD-10 codes from 2016 to 2019. We explored baseline characteristics and used multivariate logistic regression to assess the association between CD and several clinical outcomes during index admission; a p-value of <0.05 was significant. Propensity score matching (PSM) was performed to validate our results. RESULTS A total of 12,185 patients with CA were identified. Of these, 920 (7.6 %) had CD. The median age of the sample was 72 years (IQR: 64-80). After multivariate adjustment and PSM, the presence of CD in CA was associated with higher odds of ventricular arrhythmias (VA) (aOR = 2.97, 95 % CI 1.78-4.96, p < 0.001), syncope (aOR = 3.44, 95 % CI 1.51-7.83, p = 0.003), and cardiovascular implantable electronic device (CIED) implantation (aOR = 12.86, 95 % CI 5.50-30.04, p < 0.001) but not with sudden cardiac arrest (p = 0.092), acute heart failure (p = 0.060), all-cause in-hospital mortality (p = 0.384), and non-routine discharge in patients admitted for CA (p = 0.271). CONCLUSIONS Although CD was not associated with all-cause in-hospital mortality, there was a significant association with VAs and syncope. Syncope is associated with worse survival in patients with CA. Further studies that prospectively follow patients are needed to determine the true effect of cardiac CD on mortality in patients with CA.
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Affiliation(s)
- Jose Lopez
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, JFK Medical Center, Atlantis, FL, United States
| | - Gustavo Duarte
- Division of Cardiology, Cleveland Clinic's Heart, Vascular & Thoracic Institute (HVTI), Cleveland Clinic Florida, Weston, FL, United States.
| | - Justin D Mark
- Department of Internal Medicine, University of Miami Miller School of Medicine, Holy Cross Health, Fort Lauderdale, FL, United States
| | - Carlos Vergara Sanchez
- Division of Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, United States
| | | | - Ann Lowery Black
- Department of Internal Medicine, HCA Florida Kendall Hospital, Miami, FL, United States
| | - Arturo Perez
- Section of Clinical Cardiac Electrophysiology, University of Miami Miller School of Medicine, JFK Medical Center, Atlantis, FL, United States
| | - Ashvin Zachariah
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, JFK Medical Center, Atlantis, FL, United States
| | - Mohamed Elshazly
- Section of Clinical Cardiac Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, FL, United States
| | - Rosario A Colombo
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, Jackson Health System, Miami, FL, United States
| | - Fergie Losiniecki
- Section of Clinical Cardiac Electrophysiology, Medical University of South Carolina, Charleston, SC, United States
| | - Robert Chait
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, JFK Medical Center, Atlantis, FL, United States
| | - Marcello Jimenez
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, JFK Medical Center, Atlantis, FL, United States; Section of Clinical Cardiac Electrophysiology, University of Miami Miller School of Medicine, JFK Medical Center, Atlantis, FL, United States
| | - Jose Baez-Escudero
- Division of Cardiology, Cleveland Clinic's Heart, Vascular & Thoracic Institute (HVTI), Cleveland Clinic Florida, Weston, FL, United States
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Martini N, Sinigiani G, De Michieli L, Mussinelli R, Perazzolo Marra M, Iliceto S, Zorzi A, Perlini S, Corrado D, Cipriani A. Electrocardiographic features and rhythm disorders in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:257-264. [PMID: 36841466 DOI: 10.1016/j.tcm.2023.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/27/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by extracellular deposition of amyloid fibrils, mainly derived from transthyretin, either wild-type or hereditary variants, or immunoglobulin light chains misfolding. It is characterized by an increased left ventricular (LV) mass and diastolic dysfunction, which can lead to heart failure with preserved ejection fraction and/or conduction disturbances. The diagnosis is based on invasive pathology demonstration of amyloid deposits, or non-invasive criteria using advanced cardiovascular imaging techniques. Nevertheless, 12-lead electrocardiogram (ECG) remains of crucial importance in the assessment of patients with CA, since they can manifest peculiar features such as low QRS voltages, in discordance with the LV hypertrophy, but also pseudo-infarction patterns, sinus node dysfunction, atrioventricular blocks, premature supraventricular and ventricular beats, which support the presence of a myocardial disease. Great awareness of these common ECG characteristics of CA is needed to increase diagnostic performance and improve patient's outcome. In the present review, we discuss the current role of the ECG in the diagnosis and management of CA, focusing on the most common ECG abnormalities and rhythm disorders.
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Affiliation(s)
- Nicolò Martini
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Giulio Sinigiani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Laura De Michieli
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Martina Perazzolo Marra
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Sabino Iliceto
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alessandro Zorzi
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Stefano Perlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy; Emergency Medicine, Vascular and Metabolic Disease Unit, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Domenico Corrado
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alberto Cipriani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy.
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Bukhari S, Khan SZ, Ghoweba M, Khan B, Bashir Z. Arrhythmias and Device Therapies in Cardiac Amyloidosis. J Clin Med 2024; 13:1300. [PMID: 38592132 PMCID: PMC10932014 DOI: 10.3390/jcm13051300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Cardiac amyloidosis is caused by amyloid fibrils that deposit in the myocardial interstitium, causing restrictive cardiomyopathy and eventually death. The electromechanical, inflammatory, and autonomic changes due to amyloid deposition result in arrhythmias. Atrial fibrillation is by far the most common arrhythmia. The rate control strategy is generally poorly tolerated due to restrictive filling physiology and heart rate dependance, favoring adoption of the rhythm control strategy. Anticoagulation for stroke prophylaxis is warranted, irrespective of CHA2DS2-VASc score in patients with a favorable bleeding profile; data on left appendage closure devices are still insufficient. Ventricular arrhythmias are also not uncommon, and the role of implantable cardioverter-defibrillator in cardiac amyloidosis is controversial. There is no evidence of improvement in outcomes when used for primary prevention in these patients. Bradyarrhythmia is most commonly associated with sudden cardiac death in cardiac amyloidosis. Pacemaker implantation can help provide symptomatic relief but does not confer mortality benefit.
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Affiliation(s)
- Syed Bukhari
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Syed Zamrak Khan
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Mohamed Ghoweba
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Bilal Khan
- Department of Hospital Medicine, Temple University-Jeanes Campus, Philadelphia, PA 19111, USA;
| | - Zubair Bashir
- Department of Hospital Medicine, Alpert Medical School of Brown University, Providence, RI 02903, USA;
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4
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Laptseva N, Rossi VA, Sudano I, Schwotzer R, Ruschitzka F, Flammer AJ, Duru F. Arrhythmic Manifestations of Cardiac Amyloidosis: Challenges in Risk Stratification and Clinical Management. J Clin Med 2023; 12:jcm12072581. [PMID: 37048664 PMCID: PMC10095126 DOI: 10.3390/jcm12072581] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Amylodiosis is a systemic disease characterized by extracellular deposits of insoluble amyloid in various tissues and organs. Cardiac amyloidosis is a frequent feature of the disease, causing a progressive, restrictive type of cardiomyopathy, and is associated with adverse clinical outcomes and increased mortality. The typical clinical presentation in patients with cardiac amyloidosis is heart failure (HF) with preserved ejection fraction. Most patients present with typical symptoms and signs of HF, such as exertional dyspnea, pretibial edema, pleural effusions and angina pectoris due to microcirculatory dysfunction. However, patients may also frequently encounter various arrhythmias, such as atrioventricular nodal block, atrial fibrillation and ventricular tachyarrhythmias. The management of arrhythmias in cardiac amyloidosis patients with drugs and devices is often a clinical challenge. Moreover, predictors of life-threatening arrhythmic events are not well defined. This review intends to give a deepened insight into the arrhythmic features of cardiac amyloidosis by discussing the pathogenesis of these arrhythmias, addressing the challenges in risk stratification and strategies for management in these patients.
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Hassan R, Miller RJH, Howlett JG, White JA, Fine NM. Prevalence, incidence and clinical outcomes of epicardial coronary artery disease among transthyretin amyloidosis cardiomyopathy patients. BMC Cardiovasc Disord 2023; 23:124. [PMID: 36890444 PMCID: PMC9996970 DOI: 10.1186/s12872-023-03140-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 02/21/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Transthyretin amyloidosis cardiomyopathy (ATTR-CM) patients are often older and may be at risk for obstructive epicardial coronary artery disease (oeCAD). While ATTR-CM may cause small vessel coronary disease, the prevalence and clinical significance of oeCAD is not well described. METHODS AND RESULTS The prevalence and incidence of oeCAD and its association with all-cause mortality and hospitalization among 133 ATTR-CM patients with ≥ 1-year follow-up was evaluated. The mean age was 78 ± 9 years, 119 (89%) were male, 116 (87%) had wild-type and 17 (13%) had hereditary subtypes. Seventy-two (54%) patients underwent oeCAD investigations, with 30 (42%) receiving a positive diagnosis. Among patients with a positive oeCAD diagnosis, 23 (77%) were diagnosed prior to ATTR-CM diagnosis, 6 (20%) at the time of ATTR-CM diagnosis, and 1 (3%) after ATTR-CM diagnosis. Baseline characteristics between patients with and without oeCAD were similar. Among patients with oeCAD, only 2 (7%) required additional investigations, intervention or hospitalization after ATTR-CM diagnosis. After a median follow-up of 27 months there were 37 (28%) deaths in the study population, including 5 patients with oeCAD (17%). Fifty-six (42%) patients in the study population required hospitalization, including 10 patients with oeCAD (33%). There was no significant difference in the rates of death or hospitalization among ATTR-CM patients with and without oeCAD, and oeCAD was not significantly associated with either outcome by univariable regression analysis. CONCLUSIONS While oeCAD is prevalent in ATTR-CM patients, this diagnosis is frequently known at time of ATTR-CM diagnosis and characteristics are similar to patients without oeCAD.
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Affiliation(s)
- Rana Hassan
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada
| | - Robert J H Miller
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada
| | - Jonathan G Howlett
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada
| | - James A White
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada
| | - Nowell M Fine
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada.
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Bukhari S, Khan B. Prevalence of ventricular arrhythmias and role of implantable cardioverter-defibrillator in cardiac amyloidosis. J Cardiol 2023; 81:429-433. [PMID: 36894119 DOI: 10.1016/j.jjcc.2023.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
Cardiac amyloidosis is an underdiagnosed disease that is caused by myocardial deposition of misfolded light chain (AL) or transthyretin (ATTR) amyloid fibrils, leading to restrictive cardiomyopathy and eventually death if untreated. Ventricular arrhythmias are common in cardiac amyloidosis, and the prevalence is higher in AL than ATTR. There are multiple suspected pathogenic mechanisms for ventricular arrhythmia including activation of inflammatory cascade from direct amyloid deposition, and electro-mechanical as well as autonomic dysfunction due to systemic amyloid deposition. Cardiac amyloidosis is associated with an increased risk of sudden cardiac death, and the risk is higher in AL than ATTR. Finally, the role of implantable cardioverter-defibrillators in cardiac amyloidosis is controversial, and while successful termination of life-threatening ventricular arrhythmias has been reported in few studies, there has been no evidence of improvement in outcomes when used for primary prevention in patients with cardiac amyloidosis.
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Affiliation(s)
- Syed Bukhari
- Department of Medicine, Temple University Hospital-Jeanes Campus, Philadelphia, PA, USA.
| | - Bilal Khan
- Department of Medicine, Temple University Hospital-Jeanes Campus, Philadelphia, PA, USA
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7
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Lu J, Zhao P, Qiao J, Yang Z, Tang D, Zhou X, Huang L, Xia L. The major factor of left ventricular systolic dysfunction in patients with cardiac amyloidosis: Amyloid overload or microcirculation impairment? Front Cardiovasc Med 2023; 10:1096130. [PMID: 36776256 PMCID: PMC9909486 DOI: 10.3389/fcvm.2023.1096130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/12/2023] [Indexed: 01/27/2023] Open
Abstract
Purpose Amyloid overload and microcirculation impairment are both detrimental to left ventricular (LV) systolic function, while it is not clear which factor dominates LV functional remodeling in patients with cardiac amyloidosis (CA). The purpose of this study was to investigate the major factor of LV systolic dysfunction using cardiac magnetic resonance imaging. Materials and methods Forty CA patients and 20 healthy controls were included in this study. The CA group was divided into two subgroups by the left ventricular ejection fraction (LVEF): patients with reduced LVEF (LVEF < 50%, rLVEF), and patients with preserved LVEF (LVEF ≥ 50%, pLVEF). The scanning sequences included cine, native and post-contrast T1 mapping, rest first-pass perfusion and late gadolinium enhancement. Perfusion and mapping parameters were compared among the three groups. Correlation analysis was performed to evaluate the relationship between LVEF and mapping parameters, as well as the relationship between LVEF and perfusion parameters. Results Remarkably higher native T1 value was observed in the rLVEF patients than the pLVEF patients (1442.2 ± 85.8 ms vs. 1407.0 ± 93.9 ms, adjusted p = 0.001). The pLVEF patients showed significantly lower slope dividing baseline signal intensity (slope%BL; rLVEF vs. pLVEF, 55.1 ± 31.0 vs. 46.2 ± 22.3, adjusted p = 0.001) and a lower maximal signal intensity subtracting baseline signal intensity (MaxSI-BL; rLVEF vs. pLVEF, 43.5 ± 23.9 vs. 37.0 ± 18.6, adjusted p = 0.003) compared to the rLVEF patients. CA patients required more time to reach the maximal signal intensity than the controls did (all adjusted p < 0.01). There was no significant correlation between LVEF and first-pass perfusion parameters, while significant negative correlation was observed between LVEF and native T1 (r = -0.434, p = 0.005) in CA patients. Conclusion Amyloid overload in the myocardial interstitium may be the major factor of LV systolic dysfunction in CA patients, other than microcirculation impairment.
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Affiliation(s)
- Jianyao Lu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peijun Zhao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,The Department of MRI, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jinhan Qiao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhaoxia Yang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dazhong Tang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyue Zhou
- MR Collaboration, Siemens Healthineers Ltd., Shanghai, China
| | - Lu Huang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,*Correspondence: Lu Huang, ✉
| | - Liming Xia
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Liming Xia, ✉
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8
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Pour-Ghaz I, Bath A, Kayali S, Alkhatib D, Yedlapati N, Rhea I, Khouzam RN, Jefferies JL, Nayyar M. A Review of Cardiac amyloidosis: Presentation, Diagnosis, and Treatment. Curr Probl Cardiol 2022; 47:101366. [PMID: 35995246 DOI: 10.1016/j.cpcardiol.2022.101366] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022]
Abstract
Amyloidosis is a group of disorders that can affect almost any organ due to the misfolding of proteins with their subsequent deposition in various tissues, leading to various disease manifestations based on the location. When the heart is involved, amyloidosis can manifest with a multitude of presentations such as heart failure, arrhythmias, orthostatic hypotension, syncope, and pre-syncope. Diagnosis of cardiac amyloidosis can be difficult due to the non-specific nature of symptoms and the relative rarity of the disease. Amyloidosis can remain undiagnosed for years, leading to its high morbidity and mortality due to this delay in diagnosis. Newer imaging modalities, such as cardiac magnetic resonance imaging, advanced echocardiography, and biomarkers, make a timely cardiac amyloidosis diagnosis more feasible. Many treatment options are available, which have provided new hope for this patient population. This manuscript will review the pathology, diagnosis, and treatment options available for cardiac amyloidosis and provide a comprehensive overview of this complicated disease process.
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Affiliation(s)
- Issa Pour-Ghaz
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN.
| | - Anandbir Bath
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Sharif Kayali
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Deya Alkhatib
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | | | - Isaac Rhea
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Rami N Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - John L Jefferies
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Mannu Nayyar
- Department of Cardiology, Regional One Health, Memphis, TN
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Butt EJ, Boyars MC. An Unusual Case of Heart Failure: Sometimes When You Hear Hoof Beats You Should Think of Zebras. Cureus 2021; 13:e20801. [PMID: 35141062 PMCID: PMC8796951 DOI: 10.7759/cureus.20801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 11/07/2022] Open
Abstract
This case describes a 74-year-old male who was hospitalized with hyponatremia and worsening systolic and new diastolic heart failure. Workup showed low voltage QRS complexes on electrocardiogram and new diastolic dysfunction on echocardiogram. Because of this clinical scenario amyloidosis was suspected. ATTR amyloidosis was confirmed without doing an invasive endocardial biopsy by the use of immunofixation studies and Technetium 99 PYPm scan, and abdominal fat pad biopsy. The types and manifestations of amyloidosis in general and cardiac amyloidosis, in particular, are reviewed as well as the diagnostic test available to the clinician to confirm this diagnosis.
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Affiliation(s)
- Edward J Butt
- Internal Medicine, University of Texas Medical Branch, Galveston, USA
| | - Michael C Boyars
- Internal Medicine, University of Texas Medical Branch, Galveston, USA
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Electrophysiological Manifestations of Cardiac Amyloidosis: JACC: CardioOncology State-of-the-Art Review. JACC: CARDIOONCOLOGY 2021; 3:506-515. [PMID: 34729522 PMCID: PMC8543134 DOI: 10.1016/j.jaccao.2021.07.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 01/15/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by the extracellular deposition of amyloid fibrils in the myocardium. Although cardiac amyloidosis patients primarily present with heart failure symptoms, arrhythmias and conduction system disease are frequently encountered. Atrial fibrillation (AF) is observed in up to 70% of patients at the time of diagnosis, and patients typically have controlled ventricular rates caused by concomitant conduction system disease. Thromboembolic risk is particularly high in patients with CA and AF, and left atrial thrombi have been observed even in the absence of clinically diagnosed AF. Atrioventricular nodal and infra-Hisian disease are common, and permanent pacemakers are frequently required. The use of implantable cardioverter-defibrillators in this population is controversial. This review summarizes the published data and therapeutic strategies surrounding arrhythmias and conduction system disease with the goal of aiding clinicians managing the clinical complexities of CA.
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Pucci A, Aimo A, Musetti V, Barison A, Vergaro G, Genovesi D, Giorgetti A, Masotti S, Arzilli C, Prontera C, Pastormerlo LE, Coceani MA, Ciardetti M, Martini N, Palmieri C, Passino C, Rapezzi C, Emdin M. Amyloid Deposits and Fibrosis on Left Ventricular Endomyocardial Biopsy Correlate With Extracellular Volume in Cardiac Amyloidosis. J Am Heart Assoc 2021; 10:e020358. [PMID: 34622675 PMCID: PMC8751897 DOI: 10.1161/jaha.120.020358] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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 relative contribution of amyloid and fibrosis to extracellular volume expansion in cardiac amyloidosis (CA) has never been defined. Methods and Results We included all patients diagnosed with amyloid light-chain (AL) or transthyretin cardiac amyloidosis at a tertiary referral center between 2014 to 2020 and undergoing a left ventricular endomyocardial biopsy. Patients (n=37) were more often men (92%), with a median age of 72 years (interquartile range, 68-81). Lambda-positive AL was found in 14 of 19 AL cases (38%) and kappa-positive AL in 5 of 19 (14%), while transthyretin was detected in the other 18 cases (48%). Amyloid deposits accounted for 15% of tissue sample area (10%-30%), without significant differences between AL and transthyretin amyloidosis. All patients displayed myocardial fibrosis, with a median extent of 15% of tissue samples (10%-23%; range, 5%-60%), in the absence of spatial overlap with amyloid deposits. Interstitial fibrosis was often associated with mild and focal subendocardial fibrosis. The extent of fibrosis or the combination of amyloidosis and fibrosis did not differ significantly between transthyretin amyloidosis and AL subgroups. In 20 patients with myocardial T1 mapping at cardiac magnetic resonance, the combined amyloid and fibrosis extent displayed a modest correlation with extracellular volume (r=0.661, P=0.001). The combined amyloid and fibrosis extent correlated with high-sensitivity troponin T (P=0.035) and N-terminal pro-B-type natriuretic peptide (P=0.002) serum levels. Conclusions Extracellular spaces in cardiac amyloidosis are enlarged to a similar extent by amyloid deposits and fibrotic tissue. Their combination can better explain the increased extracellular volume at cardiac magnetic resonance and circulating biomarkers than amyloid extent alone.
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Affiliation(s)
| | - Alberto Aimo
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Veronica Musetti
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Andrea Barison
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Giuseppe Vergaro
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Fondazione Toscana Gabriele Monasterio Pisa Italy
| | | | | | - Silvia Masotti
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | | | | | | | | | | | | | - Cataldo Palmieri
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Claudio Passino
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Claudio Rapezzi
- Centro Cardiologico Universitario di Ferrara University of Ferrara Italy.,Maria Cecilia Hospital GVM Care & Research Cotignola Italy
| | - Michele Emdin
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Fondazione Toscana Gabriele Monasterio Pisa Italy
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Jakaitė R, Pečeliūnas V, Aidietienė S, Bertašiūtė A, Bileišienė N, Mickevičiūtė O, Barysienė J. Electrocardiographic left ventricular strain pattern, ST-segment depression and atrial fibrillation at the time of diagnosis of systemic light chain amyloidosis: Incidence and clinical significance. J Electrocardiol 2021; 68:157-163. [PMID: 34455115 DOI: 10.1016/j.jelectrocard.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 07/31/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND ST/T abnormalities recognized as electrocardiographic (ECG) left ventricular (LV) strain pattern are known as a marker of myocyte death and reduced survival. The purpose of this study was to determine whether ECG LV strain pattern, its components and atrial fibrillation (AF) predict lower survival at the time of diagnosis of systemic light chain (AL) amyloidosis. METHODS 12‑lead surface electrocardiogram (ECG), standard two-dimensional echocardiography, laboratory analyses were retrospectively evaluated within 2 months of diagnosis in 87 patients with biopsy-proven systemic AL amyloidosis from 2009 to 2017 in a single center. ECG strain pattern was defined as coexistence of ST-segment horizontal or downward sloping depression ≥0.05 mV at its most horizontal section and negative asymmetrical T-wave deeper than 0.1 mV in at least 1 of leads I,aVL,V1-V6. Patients with QRS >120 ms (BBB or major IVCD) were excluded from the analysis. RESULTS Kaplan-Meier survival analysis revealed a 1.8-fold shorter overall survival (OS) at 2 years in the ECG strain (21% of participants) group (p = 0.0078), 2.0-fold shorter OS in the ST-segment depression (STd) (isolated and strain related as one group) (34% of participants) group (p < 0.0001), and 3.9-fold shorter OS in AF (23% of participants) group (p < 0.0001) compared with those without. Median survival of patients with STd and AF were and 13.0 (range 1-74) and 9.5 (range 1-74) months respectively. In univariate analysis STd and AF were stronger predictors of inferior OS than relative wall thickness, average E/e' ratio, and LV ejection fraction, but weaker predictors of OS than B-type natriuretic peptide. In multivariate analysis STd and AF lost significance after adjustment for age, gender, number of organs involved and BNP. CONCLUSIONS ST-segment depression and AF were not significantly associated with reduced survival in AL amyloidosis at diagnosis.
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Affiliation(s)
- Rusnė Jakaitė
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania.
| | - Valdas Pečeliūnas
- Center of Haematology, Oncology and Transfusion Medicine, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Čiurlionio 21/27, LT-03101 Vilnius, Lithuania
| | - Sigita Aidietienė
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Čiurlionio 21/27, LT-03101 Vilnius, Lithuania
| | - Agnė Bertašiūtė
- Center of Haematology, Oncology and Transfusion Medicine, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania
| | - Neringa Bileišienė
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania
| | - Orinta Mickevičiūtė
- Center of Haematology, Oncology and Transfusion Medicine, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania
| | - Jūratė Barysienė
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Čiurlionio 21/27, LT-03101 Vilnius, Lithuania
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13
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Awaya T, Minamimoto R, Iwama K, Kubota S, Hotta M, Hirai R, Yamamoto M, Okazaki O, Hara H, Hiroi Y, Hiroe M, Moroi M. Performance of 99mTc-aprotinin scintigraphy for diagnosing light chain (AL) cardiac amyloidosis confirmed by endomyocardial biopsy. J Nucl Cardiol 2020; 27:1145-1153. [PMID: 31591695 DOI: 10.1007/s12350-019-01868-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 08/06/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Light chain (AL) cardiac amyloidosis is associated with a poor prognosis. Diagnosing at an early stage is critical for treatment and the management of cardiac complication. PURPOSE We aimed to evaluate the diagnostic performance of 99mTc-aprotinin images in patients with AL cardiac amyloidosis. METHODS AND RESULTS 99mTc-aprotinin scintigraphy and endomyocardial biopsy were performed in 10 patients with suspected amyloidosis. Endomyocardial biopsy showed amyloid deposits in 5 of 10 patients. 99mTc-aprotinin (planer image) was positive in 4 of 5 patients who had amyloid deposits in endomyocardial biopsy. On the other hand, all 5 patients without amyloid deposits were negative in planer image. 99mTc-aprotinin (SPECT/CT image) was positive in all 5 patients who had amyloid deposits. CONCLUSIONS 99mTc-aprotinin scintigraphy is valuable for the non-invasive diagnosis of AL cardiac amyloidosis.
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Affiliation(s)
- Toru Awaya
- Department of Cardiovascular Medicine, National Center for Global Health and Medicine, Tokyo, Japan.
- Division of Cardiovascular Medicine, Toho University Medical Center Ohashi Hospital, Tokyo, Japan.
| | - Ryogo Minamimoto
- Division of Nuclear Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kentaro Iwama
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuji Kubota
- Department of Cardiovascular Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masatoshi Hotta
- Division of Nuclear Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Risen Hirai
- Department of Hematology, Internal medicine Tokyo-Kita Medical Center, Tokyo, Japan
| | - Masaya Yamamoto
- Department of Cardiovascular Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Osamu Okazaki
- Department of Cardiovascular Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hisao Hara
- Department of Cardiovascular Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yukio Hiroi
- Department of Cardiovascular Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Michiaki Hiroe
- Department of Cardiovascular Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masao Moroi
- Division of Cardiovascular Medicine, Toho University Medical Center Ohashi Hospital, Tokyo, Japan
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14
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Saba SG, Gannon MP, Majure DT, Rahmani N, Shah AB, Palestro CJ, Shah RD. Cardiac amyloidosis CT sign. Clin Res Cardiol 2020; 110:1841-1846. [PMID: 32661673 DOI: 10.1007/s00392-020-01693-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Shahryar G Saba
- Department of Cardiology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA. .,Department of Radiology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA. .,Multimodality Cardiovascular Imaging Laboratory, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA.
| | - Michael P Gannon
- Department of Medicine, Section of Cardiology, Lewis Katz School of Medicine, Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - David T Majure
- Department of Cardiology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Navid Rahmani
- Department of Radiology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA.,Multimodality Cardiovascular Imaging Laboratory, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Amar B Shah
- Department of Radiology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA.,Multimodality Cardiovascular Imaging Laboratory, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Christopher J Palestro
- Department of Radiology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA.,Multimodality Cardiovascular Imaging Laboratory, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Rakesh D Shah
- Department of Radiology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, 11030, USA.,Multimodality Cardiovascular Imaging Laboratory, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, 11030, USA
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15
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Oda S, Kidoh M, Nagayama Y, Takashio S, Usuku H, Ueda M, Yamashita T, Ando Y, Tsujita K, Yamashita Y. Trends in Diagnostic Imaging of Cardiac Amyloidosis: Emerging Knowledge and Concepts. Radiographics 2020; 40:961-981. [DOI: 10.1148/rg.2020190069] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Seitaro Oda
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Masafumi Kidoh
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Yasunori Nagayama
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Seiji Takashio
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Hiroki Usuku
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Mitsuharu Ueda
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Taro Yamashita
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Yukio Ando
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Kenichi Tsujita
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Yasuyuki Yamashita
- From the Departments of Diagnostic Radiology (S.O., M.K., Y.N., Y.Y.), Cardiovascular Medicine (S.T., H.U., K.T.), Molecular Laboratory Medicine (H.U.), and Neurology (M.U., T.Y., Y.A.), Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
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16
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Halawa A, Woldu HG, Kacey KG, Alpert MA. Effect of ICD implantation on cardiovascular outcomes in patients with cardiac amyloidosis: A systematic review and meta-anaylsis. J Cardiovasc Electrophysiol 2020; 31:1749-1758. [PMID: 32391952 DOI: 10.1111/jce.14541] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/26/2020] [Accepted: 04/24/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Cardiac amyloidosis is associated with a high rate of sudden cardiac death (SCD). Whether implantable cardioverter-defibrillator (ICD) use in such patients prevents SCD is uncertain. This study assesses outcomes of ICD use in patients with cardiac amyloidosis. METHODS A systematic review and meta-analysis of data were performed after searching multiple databases and scientific sites pertaining to ICD use and cardiac amyloidosis. Of 8260 citations identified, six studies comprising 194 patients met inclusion criteria. RESULTS Mean values and frequencies of patient characteristics were as follows: mean NT-proBNP: 6867.9 pg/mL, mean left ventricular ejection fraction: 48.1%, heart failure: 67%, nonsustained ventricular tachycardia: 51%, syncope: 21%, and secondary prevention: 33%. During the mean follow-up period of 18.21 months, 18% of patients received appropriate ICD treatment and 5% received inappropriate ICD treatment. The mortality rate was 31%. Two studies assessed the difference between patients with appropriate ICD treatment and patients with absence of appropriate ICD treatment. There was no difference between the two groups when stratified on multiple selected third variables except for two subgroups. Male gender was associated with a higher rate of appropriate ICD treatment, whereas New York Heart Association class III or IV heart failure patients was associated with a lower rate of appropriate ICD treatment. CONCLUSION The frequency of appropriate ICD treatment in cardiac amyloidosis is low and is not predicted by nonsustained ventricular tachycardia. Male gender is associated with appropriate ICD treatment. New York Heart Association class III or IV heart failure is associated with lower rate of appropriate ICD treatment.
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Affiliation(s)
- Ahmad Halawa
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Henok G Woldu
- Biostatistics Design Unit, University of Missouri School of Medicine, Columbia, Missouri
| | - Kristina Gifft Kacey
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Martin A Alpert
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri
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17
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Zhang KW, Stockerl-Goldstein KE, Lenihan DJ. Emerging Therapeutics for the Treatment of Light Chain and Transthyretin Amyloidosis. JACC Basic Transl Sci 2019; 4:438-448. [PMID: 31312767 PMCID: PMC6609907 DOI: 10.1016/j.jacbts.2019.02.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/16/2019] [Accepted: 02/19/2019] [Indexed: 02/08/2023]
Abstract
Cardiac amyloidosis is a restrictive cardiomyopathy that results from the deposition of misfolded light chain or transthyretin proteins, most commonly, in cardiac tissue. Traditionally, treatment options for light chain (AL) and transthyretin (ATTR) amyloidosis have been limited. However, there are now multiple novel therapeutics in development and several therapeutics recently approved that promise to revolutionize clinical management of AL and ATTR. Most of these agents disrupt specific stages of amyloidogenesis such as light chain or transthyretin protein production, formation of amyloidogenic intermediates, or amyloid fibril aggregation. Others aim to remove existing amyloid tissue deposits using monoclonal antibody technology. Although these advances represent an important step forward in the care of cardiac amyloidosis patients, additional studies are needed to define the optimal treatment paradigms for AL and ATTR and to validate clinical, imaging, or serum biomarker strategies that may confirm a cardiac response to therapy.
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Key Words
- AL, light chain amyloidosis
- ASCT, autologous stem cell transplantation
- ATTR, transthyretin amyloidosis
- CA, cardiac amyloidosis
- GLS, global longitudinal strain
- MGUS, monoclonal gammopathy of undetermined significance
- MM, multiple myeloma
- MMP, matrix metalloproteinase
- NT-proBNP, N-terminal prohormone of brain natriuretic peptide
- SAP, serum amyloid P
- cardiac amyloidosis
- clinical trials
- therapeutics
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Affiliation(s)
- Kathleen W. Zhang
- Division of Cardiology, Cardio-Oncology Center of Excellence, Washington University in St. Louis School of Medicine, Saint Louis, Missouri
| | | | - Daniel J. Lenihan
- Division of Cardiology, Cardio-Oncology Center of Excellence, Washington University in St. Louis School of Medicine, Saint Louis, Missouri
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18
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Ishida M, Shinagawa H, Yamada Y, Mizutani T, Hara A, Ako J, Inomata T. Intramural Coronary Amyloidosis Mimicking Effort Angina Pectoris Preceding Fatal Heart Failure. Circ J 2019; 83:837. [PMID: 30197408 DOI: 10.1253/circj.cj-18-0180] [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)
- Miwa Ishida
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
| | - Hisahito Shinagawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Yoko Yamada
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
| | - Tomohiro Mizutani
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
| | - Atsuko Hara
- Department of Pathology, Kitasato University Kitasato Institute Hospital
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
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19
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Wan K, Sun J, Han Y, Luo Y, Liu H, Yang D, Cheng W, Zhang Q, Zeng Z, Chen Y. Right ventricular involvement evaluated by cardiac magnetic resonance imaging predicts mortality in patients with light chain amyloidosis. Heart Vessels 2018; 33:170-179. [PMID: 28840397 DOI: 10.1007/s00380-017-1043-y3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 08/18/2017] [Indexed: 05/25/2023]
Abstract
Few studies have focused on right ventricular (RV) involvement in cardiac amyloidosis (CA). We investigated the prognostic value of RV assessment by cardiovascular magnetic resonance (CMR) in CA. In 2011-2014, consecutive patients with suspected CA referred for CMR were retrospectively evaluated. Demographic and baseline clinical characteristics were collected. Healthy volunteers were matched for sex and age and served as controls. All subjects underwent a contrast-enhanced CMR examination. RV size, function, and late gadolinium enhancement (LGE) were analyzed. All deaths during follow-up were recorded. Sixty-one patients [37 males (60.7%), age 60 ± 11 years] were included; CA was diagnosed in 47 (77.0%) patients. CA patients displayed decreased biventricular ejection fraction, elevated left ventricular mass index, and increased biventricular end-systolic volume index (ESVi) compared with controls. A total of 27 deaths (57.4%) occurred in the CA group at 21-month median follow-up. Multivariable analysis demonstrated that RVESVi (HR 1.033, 95% CI 1.004-1.063, P = 0.026) and RV-LGE (HR 2.814, 95% CI 1.063-7.450, P = 0.037) were independent predictors of mortality in CA. For all amyloid patients, log NT-proBNP (HR 3.412; 95% CI 1.484-7.845; P = 0.004) and RV-LGE (HR 4.149; 95% CI 1.623-10.607; P = 0.003) were identified as independent predictors. RVESVi and RV-LGE are independent predictors of survival and evaluation of RV by CMR enables risk stratification in patients with CA.
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Affiliation(s)
- Ke Wan
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jiayu Sun
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yuchi Han
- Cardiovascular Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yong Luo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Hong Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Dan Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Wei Cheng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Zhi Zeng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
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20
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Ochs MM, Fritz T, Arenja N, Riffel J, Andre F, Mereles D, Siepen FAD, Hegenbart U, Schönland S, Katus HA, Friedrich MGW, Buss SJ. Regional differences in prognostic value of cardiac valve plane displacement in systemic light-chain amyloidosis. J Cardiovasc Magn Reson 2017; 19:87. [PMID: 29121956 PMCID: PMC5680757 DOI: 10.1186/s12968-017-0402-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 10/16/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND To compare the prognostic value of cardiac valve plane displacement (CVPD) on various locations in cardiac light chain (AL) amyloidosis. METHODS Consecutive patients with biopsy-proven cardiac involvement in AL amyloidosis who had undergone cardiovascular magnetic resonance (CMR) between 2005 and 2014 in our institution, were retrospectively identified and data analyzed. The primary combined endpoint was all-cause mortality or heart transplantation. Systolic CVPD were obtained from standard cine bSSFP in 2-, 3- and 4-chamber views at anterior aortic plane systolic excursion (AAPSE); anterior, anterolateral, inferolateral, inferior, inferoseptal mitral (MAPSE); and lateral tricuspid (TAPSE) annular segments. RESULTS We identified 68 patients (58 ± 10 years; 59% male). Median follow-up period was 1.2 years (IQR, 0.3-4.1). Significant differences in CVPD between patients who reached a primary endpoint (n = 44) and transplant-free survivors were found only for AAPSE (6.1 mm (IQR, 4.6-9.4) vs. 8.8 mm (IQR, 6.9-10.4); p = 0.02) and MAPSEanterolateral (7.3 mm (IQR, 5.4-11.7) vs. 10.5 mm (IQR, 8.1-13.4); p = 0.03). AAPSE (χ2 = 15.6; p = 0.0002) provided the best predictive value for transplant-free survival compared to all other valvular plane locations. A high-risk cutoff (AAPSE ≤ 7.6 mm) was calculated by ROC analysis to predict all-cause death or heart transplantation within 6 months from index examination (AUC = 0.80; CI: 0.68 to 0.89; p < 0.0001). AAPSE added incremental prognostic power to an imaging prediction model of late gadolinium enhancement and global longitudinal strain (GLS) (∆χ2 = 5.8, p = 0.02) as well as to a clinical model including Karnofsky index and NT-proBNP (∆χ2 = 6.2, p = 0.01). CONCLUSION In patients with cardiac involvement in AL amyloidosis, systolic CVPD obtained from standard long axis cine views appear to indicate outcome better, when obtained in the anterior aortic plane (AAPSE) and provide incremental prognostic value to LGE and strain measurements.
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Affiliation(s)
- Marco M. Ochs
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Thomas Fritz
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Nisha Arenja
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Johannes Riffel
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Florian Andre
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Derliz Mereles
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Fabian aus dem Siepen
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Ute Hegenbart
- Department of Hematooncology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Stefan Schönland
- Department of Hematooncology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | - Hugo A. Katus
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
| | | | - Sebastian J. Buss
- Department of Cardiology, University of Heidelberg, INF 410, 69120 Heidelberg, Germany
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21
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Right ventricular involvement evaluated by cardiac magnetic resonance imaging predicts mortality in patients with light chain amyloidosis. Heart Vessels 2017; 33:170-179. [PMID: 28840397 PMCID: PMC5766713 DOI: 10.1007/s00380-017-1043-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 08/18/2017] [Indexed: 02/05/2023]
Abstract
Few studies have focused on right ventricular (RV) involvement in cardiac amyloidosis (CA). We investigated the prognostic value of RV assessment by cardiovascular magnetic resonance (CMR) in CA. In 2011–2014, consecutive patients with suspected CA referred for CMR were retrospectively evaluated. Demographic and baseline clinical characteristics were collected. Healthy volunteers were matched for sex and age and served as controls. All subjects underwent a contrast-enhanced CMR examination. RV size, function, and late gadolinium enhancement (LGE) were analyzed. All deaths during follow-up were recorded. Sixty-one patients [37 males (60.7%), age 60 ± 11 years] were included; CA was diagnosed in 47 (77.0%) patients. CA patients displayed decreased biventricular ejection fraction, elevated left ventricular mass index, and increased biventricular end-systolic volume index (ESVi) compared with controls. A total of 27 deaths (57.4%) occurred in the CA group at 21-month median follow-up. Multivariable analysis demonstrated that RVESVi (HR 1.033, 95% CI 1.004–1.063, P = 0.026) and RV-LGE (HR 2.814, 95% CI 1.063–7.450, P = 0.037) were independent predictors of mortality in CA. For all amyloid patients, log NT-proBNP (HR 3.412; 95% CI 1.484–7.845; P = 0.004) and RV-LGE (HR 4.149; 95% CI 1.623–10.607; P = 0.003) were identified as independent predictors. RVESVi and RV-LGE are independent predictors of survival and evaluation of RV by CMR enables risk stratification in patients with CA.
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Hashimura H, Kimura F, Ishibashi-Ueda H, Morita Y, Higashi M, Nakano S, Iguchi A, Uotani K, Sugimura K, Naito H. Radiologic-Pathologic Correlation of Primary and Secondary Cardiomyopathies: MR Imaging and Histopathologic Findings in Hearts from Autopsy and Transplantation. Radiographics 2017; 37:719-736. [PMID: 28129067 DOI: 10.1148/rg.2017160082] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
RSNA, 2017.
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Affiliation(s)
- Hiromi Hashimura
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Fumiko Kimura
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Hatsue Ishibashi-Ueda
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Yoshiaki Morita
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Masahiro Higashi
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Shintaro Nakano
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Atsushi Iguchi
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Kensuke Uotani
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Kazuro Sugimura
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
| | - Hiroaki Naito
- From the Departments of Radiology (H.H., Y.M., M.H., H.N.) and Pathology (H.H., H.I.U.), National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan; Departments of Diagnostic Radiology (F.K.), Cardiology (S.N.), and Cardiovascular Surgery (A.I.), Saitama Medical University International Medical Center, Hidaka, Japan; Department of Radiology, Tenri Hospital, Tenri, Japan (K.U.); and Department of Radiology, Kobe University, Kobe, Japan (K.S.)
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Ishibashi-Ueda H, Matsuyama TA, Ohta-Ogo K, Ikeda Y. Significance and Value of Endomyocardial Biopsy Based on Our Own Experience. Circ J 2017; 81:417-426. [DOI: 10.1253/circj.cj-16-0927] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Keiko Ohta-Ogo
- Department of Pathology, National Cerebral and Cardiovascular Center
| | - Yoshihiko Ikeda
- Department of Pathology, National Cerebral and Cardiovascular Center
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Reduced trans-mitral A-wave velocity predicts the presence of wild-type transthyretin amyloidosis in elderly patients with left ventricular hypertrophy. Heart Vessels 2016; 32:708-713. [PMID: 27882404 DOI: 10.1007/s00380-016-0925-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
Abstract
Wild-type transthyretin amyloidosis (ATTRwt) is often overlooked in elderly patients with left ventricular hypertrophy (LVH). Impaired atrial function, in addition to ventricular diastolic dysfunction, is one of the hallmarks of cardiac amyloidosis. Here, we assessed the hypothesis that atrial function evaluated by A-velocity in pulse Doppler echocardiography is useful to differentiate ATTRwt in elderly patients with LVH. We analyzed 133 consecutive patients who underwent tissue biopsy to rule out infiltrative cardiomyopathy in our institute. We excluded patients younger than 50 years, without LVH (LV thickness was less than 12 mm), with other types of cardiac amyloidosis and patients with chronic atrial fibrillation, and analyzed remaining 51 patients (ATTRwt: 16, non-ATTRwt: 35). ATTRwt patients were significantly older and had advanced heart failure compared with non-ATTRwt group. In echocardiography, E/A, E/e', and relative wall thickness was significantly higher in ATTRwt group than non-ATTRwt group. A-velocity was significantly decreased in ATTRWT group compared with non-ATTRwt group (40.8 ± 20.8 vs. 78.7 ± 28.2 cm/s, p = 0.0001). Multivariate logistic analysis using eight forced inclusion models identified trans-mitral Doppler A-wave velocity was more significant factor of cardiac amyloidosis in ATTRwt. In receiver operating characteristic (ROC) analysis, the area under the curve (AUC) for A-wave velocity in discrimination between ATTRwt and non-ATTRwt were 0.86 (CI 0.76-0.96, p < 0.001). The cut-off value was 62.5 cm/s, and it yielded the best combination of sensitivity (69.7%) and specificity (87.5%) for prediction of amyloidosis. We concluded that reduced A-velocity predicts the presence of ATTRwt in elderly patients with LVH in sinus rhythm.
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Muchtar E, Buadi FK, Dispenzieri A, Gertz MA. Immunoglobulin Light-Chain Amyloidosis: From Basics to New Developments in Diagnosis, Prognosis and Therapy. Acta Haematol 2016; 135:172-90. [PMID: 26771835 DOI: 10.1159/000443200] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/03/2015] [Indexed: 11/19/2022]
Abstract
Immunoglobulin amyloid light-chain (AL) amyloidosis is the most common form of systemic amyloidosis, where the culprit amyloidogenic protein is immunoglobulin light chains produced by marrow clonal plasma cells. AL amyloidosis is an infrequent disease, and since presentation is variable and often nonspecific, diagnosis is often delayed. This results in cumulative organ damage and has a negative prognostic effect. AL amyloidosis can also be challenging on the diagnostic level, especially when demonstration of Congo red-positive tissue is not readily obtained. Since as many as 31 known amyloidogenic proteins have been identified to date, determination of the amyloid type is required. While several typing methods are available, mass spectrometry has become the gold standard for amyloid typing. Upon confirming the diagnosis of amyloidosis, a pursuit for organ involvement is essential, with a focus on heart involvement, even in the absence of suggestive symptoms for involvement, as this has both prognostic and treatment implications. Details regarding initial treatment options, including stem cell transplantation, are provided in this review. AL amyloidosis management requires a multidisciplinary approach with careful patient monitoring, as organ impairment has a major effect on morbidity and treatment tolerability until a response to treatment is achieved and recovery emerges.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minn., USA
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