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Razvi Y, Porcari A, Di Nora C, Patel RK, Ioannou A, Rauf MU, Masi A, Law S, Chacko L, Rezk T, Ravichandran S, Gilbertson J, Rowczenio D, Blakeney IJ, Kaza N, Hutt DF, Lachmann H, Wechalekar A, Moody W, Lim S, Chue C, Whelan C, Venneri L, Martinez-Naharro A, Merlo M, Sinagra G, Livi U, Hawkins P, Fontana M, Gillmore JD. Cardiac transplantation in transthyretin amyloid cardiomyopathy: Outcomes from three decades of tertiary center experience. Front Cardiovasc Med 2023; 9:1075806. [PMID: 36741843 PMCID: PMC9894650 DOI: 10.3389/fcvm.2022.1075806] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023] Open
Abstract
Aims Transthyretin cardiac amyloidosis (ATTR-CM) is a progressive and fatal cardiomyopathy. Treatment options in patients with advanced ATTR-CM are limited to cardiac transplantation (CT). Despite case series demonstrating comparable outcomes with CT between patients with ATTR-CM and non-amyloid cardiomyopathies, ATTR-CM is considered to be a contraindication to CT in some centers, partly due to a perceived risk of amyloid recurrence in the allograft. We report long-term outcomes of CT in ATTR-CM at two tertiary centers. Materials and methods and Results We retrospectively evaluated ATTR-CM patients across two tertiary centers who underwent transplantation between 1990 and 2020. Pre-transplantation characteristics were determined and outcomes were compared with a cohort of non-transplanted ATTR-CM patients. Fourteen (12 male, 2 female) patients with ATTR-CM underwent CT including 11 with wild-type ATTR-CM and 3 with variant ATTR-CM (ATTRv). Median age at CT was 62 years and median follow up post-CT was 66 months. One, three, and five-year survival was 100, 92, and 90%, respectively and the longest surviving patient was Censored > 19 years post CT. No patients had recurrence of amyloid in the cardiac allograft. Four patients died, including one with ATTRv-CM from complications of leptomeningeal amyloidosis. Survival among the cohort of patients who underwent CT was significantly prolonged compared to UK patients with ATTR-CM generally (p < 0.001) including those diagnosed under age 65 years (p = 0.008) or with early stage cardiomyopathy (p < 0.001). Conclusion CT is well-tolerated, restores functional capacity and improves prognosis in ATTR-CM. The risk of amyloid recurrence in the cardiac allograft appears to be low.
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Affiliation(s)
- Yousuf Razvi
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Aldostefano Porcari
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Rishi K. Patel
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Adam Ioannou
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Muhammad U. Rauf
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ambra Masi
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Steven Law
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Liza Chacko
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Tamer Rezk
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Sriram Ravichandran
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Janet Gilbertson
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Dorota Rowczenio
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Iona J. Blakeney
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | | | - David F. Hutt
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Helen Lachmann
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ashutosh Wechalekar
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - William Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Sern Lim
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Colin Chue
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Carol Whelan
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Lucia Venneri
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ana Martinez-Naharro
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Marco Merlo
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Ugolino Livi
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Philip Hawkins
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Julian D. Gillmore
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
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Kraus MJ, Smits JM, Meyer AL, Strelniece A, van Kins A, Boeken U, Reinecke A, Provaznik Z, Van Caenegem O, Ancion A, Berchtold-Herz M, Van Cleemput JJA, Haverich A, Laufer G, Gummert J, Karck M, Warnecke G, Raake PW, Frey N, Kreusser MM. Outcomes in patients with cardiac amyloidosis undergoing heart transplantation: the eurotransplant experience. J Heart Lung Transplant 2023; 42:778-785. [PMID: 36710093 DOI: 10.1016/j.healun.2023.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/14/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND When advanced heart failure occurs in cardiac amyloidosis, prognosis is poor. In this setting heart transplantation (HTX) is a treatment option for selected patients. We here present the results of post-transplantation outcomes in cardiac amyloidosis within the Eurotransplant area, investigating possible predictors of survival. METHODS Of 115 patients undergoing HTX due to cardiac amyloidosis in the Eurotransplant region between November 1987 and May 2020, detailed assessment prior to transplantation was available in 85 patients. The present study was conducted in a retrospective approach. Primary endpoint was mortality after HTX. Baseline variables were entered in a Cox proportional hazards model with the primary endpoint as a dependent variable. RESULTS Median overall survival following HTX was 6.3 years in the overall collective and the subgroup. Univariate Cox proportional hazards model revealed a significant relationship between overall survival and the transplantation period (2008 to 2020 vs 1987 to 2007; median survival 9.7 years vs 1.8 years, hazard ratio 0.45, p = 0.01). Further predictors were albumin concentration (hazard ratio 0.92, p < 0.001), and systolic blood pressure (hazard ratio 0.96, p < 0.001). The transplant period as well as albumin concentration remained significant independent predictors in the AL sub cohort in a multivariate Cox proportional hazards model. CONCLUSIONS HTX is a viable treatment option for patients at an advanced stage of cardiac amyloidosis as overall survival after transplantation has improved in the modern age. Patients at a very advanced stage of the disease, indicated by low serum albumin and blood pressure, show worse outcomes following HTX. Optimal timing and careful patient selection may therefore be particularly important to further improve post-HTX survival in amyloidosis patients.
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Affiliation(s)
- Martin J Kraus
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany.
| | | | - Anna L Meyer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | | | | | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Alexander Reinecke
- Department of Cardiology, Angiology and Intensive Care, University of Kiel, Kiel, Germany
| | - Zdenek Provaznik
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Oliver Van Caenegem
- Cardiovascular Department, Intensive Care Unit, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium (deceased)
| | - Arnaud Ancion
- Cardiology, Centre Hospitalier Universitaire Sart-Tilman, Liège, Belgium
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany; Department of Medicine, University Heart Center Freiburg, Freiburg, Germany
| | | | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Guenther Laufer
- Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Jan Gummert
- Heart and Diabetes Center Nord-Rhein-Westfalen, Ruhr University Bochum, Bochum, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Philip W Raake
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany; Department of Cardiology, University Hospital of Augsburg, Augsburg Germany
| | - Norbert Frey
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
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de Marneffe N, Dulgheru R, Ancion A, Moonen M, Lancellotti P. Cardiac amyloidosis: a review of the literature. Acta Cardiol 2022; 77:683-692. [PMID: 35852493 DOI: 10.1080/00015385.2021.1992990] [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: 12/24/2022]
Abstract
Cardiac amyloidosis is a rare disease associated with severe morbidity and mortality. There are three main types of amyloidosis associated with cardiac involvement: light chain (AL), familial or senile (ATTR) and secondary amyloidosis (AA). Cardiac amyloidosis often results in heart failure with preserved left ventricular ejection fraction, may display echocardiographic features of restrictive cardiomyopathy associated with left ventricular hypertrophy or mimic hypertrophic obstructive cardiomyopathy. However, left ventricular systolic dysfunction and normal wall thickness can sometimes be encountered. Imaging studies (echocardiography, bone scintigraphy, cardiac magnetic resonance) and blood and urine analysis are usually the main tools for the diagnosis. Sometimes, a tissue biopsy may be necessary. Treatment, which is constantly improving, will be carried out on two fronts: treatment of the symptoms and complications that the disease already caused and prevention of additional amyloid deposits while managing the concomitant complications. The purpose of this article is to review the management of cardiac amyloidosis.
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Affiliation(s)
- Nils de Marneffe
- Department of Cardiology, University Hospital of Liege, Liege, Belgium
| | - R Dulgheru
- Head of Clinic, Department of Cardiology, University Hospital of Liege, Liege, Belgium
| | - A Ancion
- Head of Clinic, Department of Cardiology, University Hospital of Liege, Liege, Belgium
| | - M Moonen
- Head of Clinic, Department of Cardiology, University Hospital of Liege, Liege, Belgium
| | - P Lancellotti
- Professor at the University of Liege, Head of the Cardiology Department, Director of the Cardiovascular GIGA, University Hospital of Liege
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Heart Transplantation, Either Alone or Combined With Liver and Kidney, a Viable Treatment Option for Selected Patients With Severe Cardiac Amyloidosis. Transplant Direct 2022; 8:e1323. [PMID: 35747521 PMCID: PMC9208885 DOI: 10.1097/txd.0000000000001323] [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: 01/27/2022] [Accepted: 02/22/2022] [Indexed: 11/25/2022] Open
Abstract
Heart transplantation in cardiac amyloidosis (CA) patients is possible and generally considered for transplantation if other organs are not affected. In this study, we aimed to describe and assess outcome in patients following heart transplantations at our CA referral center. Methods We assessed all CA patients that had heart transplantations at our center between 2005 and 2018. Patients with New York Heart Association status 3 out of 4, with poor short-term prognosis due to heart failure, despite treatment, and without multiple myeloma, systemic disease, severe neuropathic/digestive comorbidities, cancer, or worsening infections were eligible for transplantation. Hearts were transplanted by bicaval technique. Standard induction and immunosuppressive therapies were used. Survival outcome of CA patients after transplantation was compared with recipients with nonamyloid pathologies in France. Results Between 2005 and 2018, 23 CA patients had heart transplants: 17 (74%) had light chain (light chain amyloidosis [AL]) and 6 (26%) had hereditary transthyretin (hereditary transthyretin amyloidosis [ATTRv]) CA. Also, 13 (57%) were male, and the mean age at diagnosis was 56.5 y (range, 47.7-62.8). Among AL patients, 13 had heart-only and 5 had heart-kidney transplantations. Among ATTRv patients, 1 had heart-only and 5 had heart-liver transplantations. The 1-y survival rate after transplantation was 78%, 70% with AL, and 100% with ATTRv. At 2 y, 74% were alive: 65% with AL and 100% with ATTRv. Conclusion After heart transplantation, French CA and nonamyloid patients have similar survival outcomes. Among CA patients, ATTRv patients have better prognosis than those with AL, possibly due to the combined heart-liver transplantation. Selected CA patients should be considered for heart transplantations.
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Ross JC, Hutt DF, Burniston M, Grigore SF, Fontana M, Page J, Hawkins PN, Gilbertson JA, Rowczenio D, Gillmore JD. The role of serial 99mTc-DPD scintigraphy in monitoring cardiac transthyretin amyloidosis. Amyloid 2022; 29:38-49. [PMID: 34704883 DOI: 10.1080/13506129.2021.1991302] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE Cardiac transthyretin amyloidosis is a usually fatal form of restrictive cardiomyopathy for which clinical trials of treatments are ongoing. It is anticipated that quantitative nuclear medicine scintigraphy, which is experiencing growing interest, will soon be used to evaluate treatment efficacy. We investigated its utility for monitoring changes in disease load over a significant time period. METHODS Sixty-two treatment-naive patients underwent 99mTc-labelled 3,3-diphosphono-1,2propanodicarboxylic acid (99mTc-DPD) scintigraphy two to four times each over a five-year period. Quantitation of cardiac 99mTc-DPD retention was performed according to two established methods: measurement of heart-to-contralateral ratio (H/CL) in the anterior view (planar) and percentage of administered activity in the myocardium (SPECT). RESULTS In total 170 datasets were analysed. Increased myocardial retention of 99mTc-DPD was demonstrable as early as 12 months from baseline. Year-on-year progression across the cohort was observed using SPECT-based quantitation, though on 30 occasions (27.8%) the change in our estimate was negative. CONCLUSIONS The spread of our results was notably high compared to the year-on-year increases. If left unaccounted for, variance may draw fallacious conclusions about changes in disease load. We therefore urge caution in drawing conclusions solely from nuclear medicine scintigraphy on a patient-by-patient basis, particularly across a short time period.
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Affiliation(s)
- James C Ross
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK.,Department of Nuclear Medicine, Barts Health NHS Trust, London, UK
| | - David F Hutt
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Maria Burniston
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK.,Department of Nuclear Medicine, Barts Health NHS Trust, London, UK
| | - Simona F Grigore
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Marianna Fontana
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Joanne Page
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK.,Department of Nuclear Medicine, Royal Free London, NHS Foundation Trust, London, UK
| | - Philip N Hawkins
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Janet A Gilbertson
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Dorota Rowczenio
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Julian D Gillmore
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
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[Cardiac amyloidosis and aortic valve stenosis]. Herz 2021; 46:485-496. [PMID: 34487196 DOI: 10.1007/s00059-021-05054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Aortic valve stenosis in old age has become a topic of interest for cardiology and cardiac surgery after the development of transvascular and transluminal minimally invasive techniques for aortic valve implantation. The observation of amyloid deposits in surgically excised valvular material led to the diagnostics of amyloidosis of the myocardium, which was discovered in up to 20% of the patients who underwent valve implantation. Clinical signs of cardiac amyloidosis, such as carpal tunnel syndrome and ruptured distal biceps tendon should be taken into account. In addition to the electrocardiogram (ECG), echocardiogram and magnetic resonance imaging, 99mtechnetium bone scintigraphy plays a key diagnostic role. The simultaneous occurrence of severe aortic valve stenosis and amyloidosis explains the special hemodynamic situation of a low gradient with low blood flow in high-grade valve stenosis. The interventional or surgical valve implantation improves the prognosis for these patients, similarly to aortic valve stenosis alone, followed by a specific pharmaceutical treatment depending on the type of amyloidosis.
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Singh BM, Bohara N, Gautam K, Basnet M, Kc S, Kc B, Raut A, Phudong A, Gautam J. A Systematic Review of Tafamidis in Patients With Transthyretin Amyloid Cardiomyopathy. Cureus 2021; 13:e18221. [PMID: 34703707 PMCID: PMC8541744 DOI: 10.7759/cureus.18221] [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: 09/23/2021] [Indexed: 11/11/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy disease burden is increasing daily due to advancements in diagnostic and imaging modalities in the modern world. Tafamidis is one of many therapeutic options. The main objective of this review is to study the role of Tafamidis in slowing the progression of transthyretin cardiomyopathy (TTR-CM) by analyzing randomized controlled trials (RCTs) and non-RCTs of Tafamidis. We searched for published papers of Tafamidis in the English language in electronic databases like Google Scholar, PubMed, Cochrane Library, and PubMed Central. We imported the resulting articles from our search to Mendeley software. Four reviewers removed the duplicates and performed title and abstract screening of the articles. The same reviewers obtained the full-text of relevant articles and did full-text screening based on eligibility criteria. Finally, five reviewers performed a quality assessment of RCTs using the Cochrane risk of bias assessment and of non-RCTs by a checklist prepared by Downs and Black. Any disagreements about any process were resolved by a discussion with other authors. One RCT and five non-RCTs of Tafamidis were included in this systematic review. From the non-RCTs, stability was observed in different parameters like echocardiographic findings, cardiac biomarkers, and ECG in patients with transthyretin cardiomyopathy during the study duration with Tafamidis. ATTR-ACT (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial) trial demonstrated reduction of cardiovascular events and all-cause mortality in the Tafamidis group in comparison to placebo. In both RCT and non-RCTs, Tafamidis was established as a safe and tolerable drug for patients with TTR-CM. Our study proved the role of Tafamidis in reducing cardiovascular events, all-cause mortality, and the progression of cardiac disease in TTR-CM patients. In addition to five non-RCTs, current evidence is based on the findings of only one RCT of Tafamidis. Hence, evidence from additional RCTs is required to strongly support the stability of parameters like echocardiographic findings, cardiac biomarkers, and ECG with Tafamidis use.
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Affiliation(s)
- Bishnu Mohan Singh
- Division of Clinical and Translational Research, Larkin Community Hospital, Miami, USA
- Emergency and General Medicine, Patan Academy of Health Sciences, Lalitpur, NPL
| | - Narayan Bohara
- Cardiology, Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, NPL
| | - Kamal Gautam
- Internal Medicine, Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, NPL
| | - Madan Basnet
- Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, NPL
| | - Sistu Kc
- Internal Medicine, Patan Academy of Health Sciences, Lalitpur, NPL
| | - Binod Kc
- Internal Medicine, Upstate University Hospital, New York, USA
| | - Anuradha Raut
- Internal Medicine, Nepal Medical College and Teaching Hospital, Kathmandu, NPL
| | - Abisha Phudong
- Emergency Department, Care and Cure Multispeciality Hospital, Lalitpur, NPL
| | - Jeevan Gautam
- Internal Medicine, Tribhuvan University Teaching Hospital, Kathmandu, NPL
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McGoldrick MT, Etchill EW, Giuliano K, Barbur I, Yenokyan G, Whitman G, Kilic A. Improving contemporary outcomes following heart transplantation for cardiac amyloidosis. J Card Surg 2021; 36:3509-3518. [PMID: 34254364 DOI: 10.1111/jocs.15796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The incidence of systemic amyloidosis is rising, and there is a concomitant rise in heart transplant for an indication of cardiac amyloidosis. METHODS We utilized the Organ Procurement and Transplantation Network (OPTN) database to retrospectively assess survival and outcomes in adult patients undergoing heart transplant for cardiac amyloidosis from 1999 to 2019. We also compared survival among four distinct time periods: 1999-2001, 2002-2008, 2008-2015, 2016-2019. RESULTS Of 41,103 patients, 425 (1.03%) were transplanted for an indication of restrictive cardiomyopathy due to cardiac amyloidosis (RCM-Amyloidosis). The percent of all transplants occurring for RCM-Amyloidosis increased from 0.25% in the 1999-2001 era to 1.74% in the 2015-2019 era (p < .001). Across eras, Kaplan-Meier survival functions were comparable between RCM-Amyloidosis and non-RCM patients at 1 year (88% vs. 89%, p = .56) and at 5 years (72% vs. 77%, p = .092), but worse for RCM-Amyloidosis patients at 10 years (44% vs. 59%, p = .002). With adjustment for other clinical variables in multivariable Cox regression model, RCM-Amyloidosis was not associated with increased risk of death at 1 year (hazard ratio [HR] = 1.11, p = .56) or at 5 years (HR = 1.20, p = .18), but it was associated with increased risk of death at 10 years (HR = 1.35, p = .01). Cardiac amyloidosis was not associated with any morbidity outcomes following transplant, including graft failure, acute rejection, or hospitalization for infection or rejection. CONCLUSIONS Our data suggest a trend of improving survival among RCM-Amyloidosis patients compared with non-RCM patients across transplant eras, with current similarities in 1- and 5-year survival but a persistent, increased risk of mortality at 10 years.
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Affiliation(s)
- Matthew T McGoldrick
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eric W Etchill
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Katherine Giuliano
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Iulia Barbur
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Gayane Yenokyan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Glenn Whitman
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ahmet Kilic
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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9
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Kim EJ, Holmes BB, Huang S, Lugo R, Al Aboud A, Goodman S, Hung RR, Slosky D, Stevenson WG, Michaud GF, John RM. Outcomes in patients with cardiac amyloidosis and implantable cardioverter-defibrillator. Europace 2021; 22:1216-1223. [PMID: 32514579 DOI: 10.1093/europace/euaa094] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/26/2019] [Accepted: 04/03/2020] [Indexed: 12/21/2022] Open
Abstract
AIMS Cardiac amyloidosis (CA) is associated with increased mortality due to arrhythmias, heart failure, and electromechanical dissociation. However, the role of an implantable cardioverter-defibrillator (ICD) remains unclear. We conducted case-control study to assess survival in CA patients with and without a primary prevention ICD and compared outcomes to an age, sex, and device implant year-matched non-CA group with primary prevention ICD. METHODS AND RESULTS There were 91 subjects with CA [mean age= 71.2 ± 10.2, female 22.0%, 49 AL with Mayo Stage 2.9 ± 1.0, 41 transthyretin amyloidosis (ATTR), 1 other] followed by Vanderbilt Amyloidosis centre. Patients with ICD (n = 23) were compared with those without (n = 68) and a non-amyloid group with ICD (n = 46). All subjects with ICD had implantation for primary prevention. Mean left ventricular ejection fraction was 36.2% ± 14.4% in CA with ICD, 41.0% ± 10.6% in CA without ICD, and 33.5% ± 14.4% in non-CA patients. Over 3.5 ± 3.1 years, 6 (26.1%) CA, and 12 (26.1%) non-CA subjects received ICD therapies (P = 0.71). Patients with CA had a significantly higher mortality (43.9% vs. 17.4%, P = 0.002) compared with the non-CA group. Mean time from device implantation to death was 21.8 months in AL and 22.8 months in ATTR patients. There was no significant difference in mortality between CA patients who did and did not receive an ICD (39.0% vs. 46.0%, P = 0.59). CONCLUSIONS Despite comparable event rates patients with CA had a significantly higher mortality and ICDs were not associated with longer survival. With the emergence of effective therapy for AL amyloidosis, further study of ICD is needed in this group.
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Affiliation(s)
- Eun-Jeong Kim
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA 94143, USA
| | - Benjamin B Holmes
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Ricardo Lugo
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Asad Al Aboud
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Stacey Goodman
- Division of Hematology and Oncology, Department of MedicineVanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rebecca R Hung
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - David Slosky
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - William G Stevenson
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Gregory F Michaud
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Roy M John
- Cardiac Arrhythmia Service, Northshore University Medical Center, Cohen 1, 300 Community Drive, Manhasset, NY 11030, USA
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10
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Smith A, Balmforth D, Treibel TA, Lall K, Oo A, Ambekar S. Cardiac amyloidosis in non-transplant cardiac surgery. J Card Surg 2021; 36:2901-2910. [PMID: 33993535 DOI: 10.1111/jocs.15629] [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: 12/05/2020] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 11/30/2022]
Abstract
Cardiac amyloidosis is a rare infiltrative cardiomyopathy that portends a poor prognosis. There is a growing recognition of co-existent aortic valve stenosis and transthyretin cardiac amyloidosis, with some studies suggesting that dual pathology may be associated increased risk of complication and mortality during surgical intervention. This review aims to evaluate the available literature on non-transplant cardiac surgical interventions in patients with cardiac amyloidosis, with particular focus on diagnosis, high surgical risk and areas of uncertainty that require further research.
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Affiliation(s)
- Alex Smith
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK.,Queen Mary University of London, London, UK
| | - D Balmforth
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - T A Treibel
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK.,Institute for Cardiovascular Sciences, University College London, London, UK
| | - Kulvinder Lall
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Aung Oo
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Shirish Ambekar
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
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11
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Hasib Sidiqi M, Gertz MA. Immunoglobulin light chain amyloidosis diagnosis and treatment algorithm 2021. Blood Cancer J 2021; 11:90. [PMID: 33993188 PMCID: PMC8124067 DOI: 10.1038/s41408-021-00483-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/11/2021] [Accepted: 04/28/2021] [Indexed: 12/29/2022] Open
Abstract
Immunoglobulin light chain amyloidosis (AL) commonly presents with nephrotic range proteinuria, heart failure with preserved ejection fraction, nondiabetic peripheral neuropathy, unexplained hepatomegaly or diarrhea, and should be considered in patients presenting with these symptoms. More importantly, patients being monitored for smoldering multiple myeloma and a monoclonal gammopathy of undetermined significance (MGUS) are at risk for developing AL amyloidosis. MGUS and myeloma patients that have atypical features, including unexplained weight loss; lower extremity edema, early satiety, and dyspnea on exertion should be considered at risk for light chain amyloidosis. Overlooking the diagnosis of light chain amyloidosis leading to therapy delay is common, and it represents an error of diagnostic consideration. Herein we provide a review of established and investigational treatments for patients with AL amyloidosis and provide algorithms for workup and management of these patients.
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Affiliation(s)
- M Hasib Sidiqi
- Haematology Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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12
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Abstract
Amyloidosis is a disorder characterized by misfolded precursor proteins that form depositions of fibrillar aggregates with an abnormal cross-beta-sheet conformation, known as amyloid, in the extracellular space of several tissues. Although there are more than 30 known amyloidogenic proteins, both hereditary and non-hereditary, cardiac amyloidosis (CA) typically arises from either misfolded transthyretin (ATTR amyloidosis) or immunoglobulin light-chain aggregation (AL amyloidosis). Its prevalence is more common than previously thought, especially among patients with heart failure and preserved ejection fraction (HFpEF) and aortic stenosis. If there is a clinical suspicion of CA, focused echocardiography, laboratory screening for the presence of a monoclonal protein (serum and urinary electrophoresis with immunofixation and serum free light-chain ratio), and cardiac scintigraphy with 99mtechnetium-labeled bone-tracers are sensitive and specific initial diagnostic tests. In some cases, more advanced/invasive techniques are necessary and, in the last several years, treatment options for both AL CA and ATTR CA have rapidly expanded. It is important to note that the aims of therapy are different. Systemic AL amyloidosis requires treatment targeted against the abnormal plasma cell clone, whereas therapy for ATTR CA must be targeted to the production and stabilization of the TTR molecule. It is likely that a multistep treatment approach will be optimal for both AL CA and ATTR CA. Additionally, treatment of CA includes the management of restrictive cardiomyopathy with preserved or reduced ejection fraction in addition to treating the amyloid deposition. Future studies are necessary to define optimal management strategies for AL CA and ATTR CA and confirm cardiac response to therapy.
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Affiliation(s)
- Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - WH Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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13
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Burton A, Castaño A, Bruno M, Riley S, Schumacher J, Sultan MB, See Tai S, Judge DP, Patel JK, Kelly JW. Drug Discovery and Development in Rare Diseases: Taking a Closer Look at the Tafamidis Story. Drug Des Devel Ther 2021; 15:1225-1243. [PMID: 33776421 PMCID: PMC7987260 DOI: 10.2147/dddt.s289772] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/20/2021] [Indexed: 12/25/2022] Open
Abstract
Rare diseases are increasingly recognized as a global public health priority. Governments worldwide currently provide important incentives to stimulate the discovery and development of orphan drugs for the treatment of these conditions, but substantial scientific, clinical, and regulatory challenges remain. Tafamidis is a first-in-class, disease-modifying transthyretin (TTR) kinetic stabilizer that represents a major breakthrough in the treatment of transthyretin amyloidosis (ATTR amyloidosis). ATTR amyloidosis is a rare, progressive, and fatal systemic disorder caused by aggregation of misfolded TTR and extracellular deposition of amyloid fibrils in various tissues and organs, including the heart and nervous systems. In this review, we present the successful development of tafamidis spanning 3 decades, marked by meticulous laboratory research into disease mechanisms and natural history, and innovative clinical study design and implementation. These efforts established the safety and efficacy profile of tafamidis, leading to its regulatory approval, and enabled post-approval initiatives that further support patients with ATTR amyloidosis.
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Affiliation(s)
| | | | | | - Steve Riley
- Clinical Pharmacology, Pfizer Inc, Groton, CT, USA
| | | | - Marla B Sultan
- Global Product Development, Pfizer Inc, New York, NY, USA
| | - Sandi See Tai
- Global Product Development, Pfizer Inc, Collegeville, PA, USA
| | - Daniel P Judge
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Jeffery W Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
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14
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Cruz Rodriguez JB, Tallaj JA. Narrative review of pharmacotherapy for transthyretin cardiac amyloid. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:519. [PMID: 33850916 PMCID: PMC8039703 DOI: 10.21037/atm-20-4636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Treatment of cardiac amyloidosis is determined by the amyloid type and degree of involvement. Two types of amyloid commonly infiltrate the heart: immunoglobulin light-chain amyloid (AL), and transthyretin amyloid (ATTR), that encompasses other two forms, a hereditary form (hATTR), and a sporadic, age-related wild-type (wtATTR). The prevalence is expected to increase with aging population. The natural history of ATTR cardiomyopathy includes progressive heart failure (HF), complicated by arrhythmias and conduction system disease. New therapies options have been approved or are under investigation. We performed a narrative literature review, manually-searched the reference lists of included articles and relevant reviews. Treatment for cardiac ATTR should be directed towards alleviation of HF symptoms and to slow or stop progressive amyloid deposition. Conventional HF medications are poorly tolerated and may not alter the disease progression or symptoms, except perhaps with the administration of diuretics. There are three approaches of therapy for ATTR cardiomyopathy: tetramer stabilizers, inhibition of ATTR protein synthesis and clearance of deposited fibrils. Tafamidis diminishes the progression of cardiomyopathy, functional parameters, improves overall outcome in patients with early disease stages, irrespective of ATTR status and is well tolerated. Diflunisal has shown promising results in early studies, but at the expense of significant side effects. Two new agents, antisense oligonucleotides, patisiran and inotersen are under investigation in cardiac amyloidosis. Patisiran appears to be the most effective treatment for hATTR, although evidence is limited, with a relatively small cardiac subpopulation. Therapies considering clearance of amyloid fibrils from tissue remain experimental. In conclusion, tafamidis is the only approved agent for the treatment of ATTR cardiomyopathy although multiple other agents have shown promising early results and are undergoing clinical trials. Careful consideration of the type of ATTR, comorbidities and disease stage will be key in deciding the optimal therapy for ATTR patients.
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Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Diseases, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Jose A Tallaj
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Medicine, Birmingham VA Medical Center, Birmingham, AL, USA
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15
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Chiou A, Aman E, Kesarwani M. A case report of an infiltrative cardiomyopathy in everyday practice: a specific cause that cannot be missed in the elderly. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 33442642 PMCID: PMC7793182 DOI: 10.1093/ehjcr/ytaa382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/25/2020] [Accepted: 09/16/2020] [Indexed: 01/15/2023]
Abstract
Background Transthyretin amyloid cardiomyopathy (ATTR-CM) is a commonly misdiagnosed cardiac condition due to low disease awareness and perceived rarity, which frequently results in incorrect management and poor outcomes. Early and prompt diagnosis has become critical with emerging therapies that improve patient survival. Case summary A 68-year-old woman presented to a tertiary care centre with acute decompensated heart failure following recurrent hospitalizations for the same issue over the past several months. Transthoracic echocardiography revealed severe concentric left ventricular hypertrophy with grade III diastolic dysfunction. However, QRS voltage by 12-lead electrocardiogram (ECG) was discordant with the degree of left ventricular hypertrophy seen by echocardiography, and the patient had recurrent non-sustained ventricular tachycardia that necessitated implantable cardioverter-defibrillator implantation a few months prior. After aggressive diuresis, the patient completed cardiac magnetic resonance imaging that raised concern for cardiac amyloidosis. Subsequent serum and urine protein electrophoresis with associated immunofixation were within normal limits. Finally, ATTR-CM was confirmed by technetium-99m pyrophosphate scintigraphy with plans to initiate tafamidis after genetic testing. Discussion Patients >60 years of age with diastolic heart failure phenotypically similar to hypertrophic cardiomyopathy and/or hypertensive heart disease should always be evaluated for ATTR-CM. Features that increase suspicion include discordance between left ventricular wall thickness and ECG voltage, and signs/symptoms of a primary peripheral and autonomic neuropathy. Useful non-invasive diagnostic testing has also made the diagnosis of ATTR-CM inexpensive and possible without the need for an endomyocardial biopsy. Unfortunately, this patient's diagnosis of ATTR-CM came late in her disease course, which delayed the onset of definitive therapy.
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Affiliation(s)
- Andrew Chiou
- Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Edris Aman
- Division of Cardiovascular Medicine, Department of Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Manoj Kesarwani
- Division of Cardiovascular Medicine, Department of Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
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16
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Chih S, McDonald M, Dipchand A, Kim D, Ducharme A, Kaan A, Abbey S, Toma M, Anderson K, Davey R, Mielniczuk L, Campbell P, Zieroth S, Bourgault C, Badiwala M, Clarke B, Belanger E, Carrier M, Conway J, Doucette K, Giannetti N, Isaac D, MacArthur R, Senechal M. Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care. Can J Cardiol 2020; 36:335-356. [PMID: 32145863 DOI: 10.1016/j.cjca.2019.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022] Open
Abstract
Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.
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Affiliation(s)
- Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kim
- University of Alberta, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Susan Abbey
- Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Mustafa Toma
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Halifax Infirmary, Department of Medicine-Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ryan Davey
- University of Western Ontario, London, Ontario, Canada
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Christine Bourgault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Debra Isaac
- University of Calgary, Calgary, Alberta, Canada
| | | | - Mario Senechal
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Université Laval, Laval, Québec, Canada
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17
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Alatassi EU, Mohamed A, Habib S, Alabdul Razzak I, Mahmoud A. Suspecting Cardiac Amyloidosis in Congestive Heart Failure. Cureus 2020; 12:e11046. [PMID: 33224643 PMCID: PMC7676447 DOI: 10.7759/cureus.11046] [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: 10/19/2020] [Indexed: 11/28/2022] Open
Abstract
Amyloidosis is a rare multisystem disease due to deposition of abnormal protein fragments, and cardiac amyloidosis is progressive and difficult to diagnose due to its subtle and non-specific symptoms unless the physician maintains a high degree of suspicion. This case report focuses on amyloid deposition in the heart of an 84-year-old woman who presented with symptoms of uncompensated heart failure.
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Affiliation(s)
| | - Alaa Mohamed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Memorial Hermann-Texas Medical Center, Houston, USA
| | - Salim Habib
- Internal Medicine, University of Damascus, Damascus, SYR
| | | | - Anas Mahmoud
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens General Hospital, New York, USA
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18
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Benson MD, Dasgupta NR, Rao R. Diagnosis and Screening of Patients with Hereditary Transthyretin Amyloidosis (hATTR): Current Strategies and Guidelines. Ther Clin Risk Manag 2020; 16:749-758. [PMID: 32884276 PMCID: PMC7434568 DOI: 10.2147/tcrm.s185677] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/12/2020] [Indexed: 11/23/2022] Open
Abstract
The outlook for transthyretin amyloidosis (ATTR) is changing with the availability of new and emerging treatments. ATTR now appears to be more common than previously thought and is no longer viewed as an obscure diagnosis with a grim prognosis. Now more than ever, there is growing emphasis on the need for early diagnosis because the treatments appear to be most effective if started in earlier stages of the disease. Diagnosing ATTR is a challenge as it may initially present with nonspecific symptoms and it is often thought of as a diagnosis of exclusion. Increased awareness is imperative as new treatments offer hope and have the potential to change the disease trajectory. ATTR commonly presents with neurological and cardiac features. Transthyretin (TTR) is a protein produced in the liver which misfolds either due to genetic mutations or due to aging and results in deposition of amyloid fibrils in organs and tissues. Apart from the traditional imaging modalities, newer techniques including echocardiographic strain imaging, magnetic resonance imaging (MRI), and nuclear scintigraphy, as well as the increased availability of genetic testing are aiding in making a timely diagnosis. In this review, we present the current understanding of the ATTR disease process, diagnostic and surveillance approaches, newer treatment modalities, and the future directions.
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Affiliation(s)
- M D Benson
- Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - N R Dasgupta
- Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN46040, USA
| | - R Rao
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN46040, USA
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19
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Barrett CD, Alexander KM, Zhao H, Haddad F, Cheng P, Liao R, Wheeler MT, Liedtke M, Schrier S, Arai S, Weisshaar D, Witteles RM. Outcomes in Patients With Cardiac Amyloidosis Undergoing Heart Transplantation. JACC-HEART FAILURE 2020; 8:461-468. [DOI: 10.1016/j.jchf.2019.12.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 01/01/2023]
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20
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Itzhaki Ben Zadok O, Kornowski R. Cardiac Care of Patients with Cardiac Amyloidosis. Acta Haematol 2020; 143:343-351. [PMID: 32408301 DOI: 10.1159/000506919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 02/28/2020] [Indexed: 12/20/2022]
Abstract
Cardiac amyloidosis, the majority of cases of which are due to immunoglobulin light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR), affects different aspects of the heart and cardiovascular system. Amyloid-induced cardiomyopathy, clinically manifesting with heart failure and electrophysiological abnormalities, has distinct characteristics compared to non-amyloid cardiomyopathies. Accordingly, specific management strategies are required. This paper will review the cardiovascular manifestations of patients with cardiac amyloidosis and their suggested treatment strategies, emphasizing the importance of multidisciplinary care.
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Affiliation(s)
- Osnat Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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21
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Macedo AVS, Schwartzmann PV, de Gusmão BM, Melo MDTD, Coelho-Filho OR. Advances in the Treatment of Cardiac Amyloidosis. Curr Treat Options Oncol 2020; 21:36. [PMID: 32328845 PMCID: PMC7181421 DOI: 10.1007/s11864-020-00738-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OPINION STATEMENT Cardiac amyloidosis is associated with a high mortality rate, a long delay between the first signs and the diagnosis but a short interval between diagnosis and death. This scenario has changed recently due to improved disease awareness among doctors and significant progress in diagnosis thanks to multimodal imaging and a multidisciplinary approach. Therefore, during the last few years, we have had access to specific therapies for those patients. Those therapies are quite different depending on the type of amyloidosis, but there has been real progress. Systemic light chain amyloidosis (AL) with cardiac involvement is the most common form of cardiac amyloidosis. The severity of heart disease dictates the prognosis in AL amyloidosis. Advances in chemotherapy and immunotherapy that suppress light chain production have improved the outcomes. These recent improvements in survival rates have enabled therapies such as implanted cardiac defibrillators and heart transplantation that were usually not indicated for patients with advanced light chain amyloid cardiomyopathy to now be applied in selected patients. For transthyretin amyloidosis (ATTR), the second most common form of amyloidosis with cardiac involvement, there is also significant progress in treatment. Until recently, we had no specific therapy for ATTR cardiomyopathy (ATTR-CM), though now disease-modifying therapies are available. Therapies that stabilize transthyretin, such as tafamidis, have been shown to improve outcomes for patients with ATTR-CM. Modern treatments that stop the synthesis of TTR through gene silencing, such as patisiran and inotersen, have shown positive results for patients with TTR amyloidosis. Significant progress has been made in the treatment of amyloid cardiomyopathy, and hopefully, we will see even more progress with the spread of those treatments. We now can be optimistic about patients with this disease.
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Affiliation(s)
| | | | | | | | - Otávio Rizzi Coelho-Filho
- Department of Internal Medicine, Discipline of Cardiology, Faculty of Medical Science, State University of Campinas, Campinas, Brazil
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22
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Ruberg FL, Grogan M, Hanna M, Kelly JW, Maurer MS. Transthyretin Amyloid Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 73:2872-2891. [PMID: 31171094 DOI: 10.1016/j.jacc.2019.04.003] [Citation(s) in RCA: 529] [Impact Index Per Article: 132.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/03/2019] [Accepted: 04/09/2019] [Indexed: 12/16/2022]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an under-recognized cause of heart failure (HF) in older adults, resulting from myocardial deposition of misfolded transthyretin (TTR) or pre-albumin. Characteristic patterns of echocardiography and cardiac magnetic resonance can strongly suggest the disease but are not diagnostic. The diagnosis can be made with noninvasive nuclear imaging when there is no evidence of a monoclonal protein. Amyloid fibril formation results from a destabilizing mutation in hereditary ATTR amyloidosis (hATTR) or from an aging-linked process in wild-type ATTR amyloidosis (wtATTR). Recent studies have suggested that up to 10% to 15% of older adults with HF may have unrecognized wtATTR. Associated features, including carpal tunnel syndrome and lumbar spinal stenosis, raise suspicion and may afford a means for early diagnosis. Previously treatable only by organ transplantation, pharmaceutical therapy that slows or halts ATTR-CM progression and favorably affects clinical outcomes is now available. Early recognition remains essential to afford the best treatment efficacy.
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Affiliation(s)
- Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jeffery W Kelly
- Departments of Chemistry and Molecular Medicine, Scripps Research Institute, La Jolla, California
| | - Mathew S Maurer
- Division of Cardiology, Department of Medicine, Center for Advanced Cardiac Care, Columbia University Medical Center, New York, New York.
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23
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Abstract
PURPOSE OF REVIEW Heart failure represents a major growing health problem in developed world. This article aims to review recent heart failure trials that have significantly impacted the management of heart failure. RECENT FINDINGS Despite advances in heart failure, mortality and morbidity remains elevated amongst patients. Recent clinical trials demonstrate promising treatment strategies that likely impact clinical practice; including heart failure prevention with the use of SGLT2-inhibitors in patients with diabetes and cardiovascular risk, new treatments that may abrogate disease progression in cardiac amyloidosis, intravenous iron therapy in iron deficiency anemia in chronic systolic heart failure, predischarge treatment with angiotensin receptor blocker with neprilysin inhibition (ARNi) in patients hospitalized for acute decompensated heart failure, and newer continuous flow left ventricular assist device with increased durability and efficacy in patients with Stage D heart failure. SUMMARY Recent clinical trials with SGLT2 inhibitors, therapies targeting transthyretin cardiac amyloidosis, iron, angiotensin receptor blocker with neprilysin inhibition and newer mechanical circulatory support devices are very promising as practice changing new treatment strategies in prevention and treatment of heart failure. This article presents a summary of important trials and should be of practical value to both clinicians and researchers.
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24
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Guglin M, Zucker MJ, Borlaug BA, Breen E, Cleveland J, Johnson MR, Panjrath GS, Patel JK, Starling RC, Bozkurt B. Evaluation for Heart Transplantation and LVAD Implantation. J Am Coll Cardiol 2020; 75:1471-1487. [DOI: 10.1016/j.jacc.2020.01.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
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25
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Kreusser MM, Volz MJ, Knop B, Ehlermann P, Schmack B, Ruhparwar A, Hegenbart U, Schönland SO, Katus HA, Raake PW. A novel risk score to predict survival in advanced heart failure due to cardiac amyloidosis. Clin Res Cardiol 2019; 109:700-713. [PMID: 31630214 DOI: 10.1007/s00392-019-01559-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 09/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiac amyloidosis, caused by deposition of immunoglobulin light chains (AL) or transthyretin (ATTR), carries a poor prognosis. Established risk scores for amyloidosis may not predict outcomes in those patients who develop advanced heart failure and who are potential candidates for heart transplantation. Here, we aimed to identify predictive parameters for patients with severe heart failure due to amyloidosis. METHODS Out of > 1000 patients with cardiac amyloidosis (AL or ATTR) admitted to our centre between September 1998 and January 2016, a cohort of 120 patients with a complete cardiac assessment at diagnosis, including right heart catheterization, echocardiography and biomarkers, was analysed retrospectively in this study. Primary endpoint was all-cause mortality. We performed univariate and multivariate Cox regression analysis, generated risk scores to predict outcomes in AL and ATTR amyloidosis and compared those to established risk models for amyloidosis. RESULTS In the Cox multivariate model, high-sensitivity troponin T (hsTnT; hazard ratio (HR) 1.003; confidence interval (CI) 1.001-1.005; p = 0.009) and mean pulmonary artery pressure (HR 1.061; CI 1.024-1.100; p = 0.001) were found to significantly and independently predict outcomes for AL amyloidosis, whereas QRS duration (HR 1.021; CI 1.004-1.039; p = 0.013), hsTnT (HR 1.021; CI 1.006-1.036; p = 0.006) and N-terminal pro-brain natriuretic peptide (HR 1.0003; CI 1.0001-1.0004; p = 0.002) were the best predictors for ATTR amyloidosis. A simple risk score ("HeiRisk") including these parameters for AL and ATTR allowed a more precise risk stratification in our patient population compared to established risk models. CONCLUSIONS Risk stratification for cardiac amyloidosis with the newly developed "HeiRisk" score may be superior to other staging systems for patients with advanced heart failure due to amyloid cardiomyopathy.
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Affiliation(s)
- Michael M Kreusser
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany.
| | - Martin J Volz
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Benjamin Knop
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Philipp Ehlermann
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ute Hegenbart
- Division of Hematology and Oncology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Stefan O Schönland
- Division of Hematology and Oncology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philip W Raake
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
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Di Giovanni B, Gustafson D, Delgado DH. Amyloid transthyretin cardiac amyloidosis: diagnosis and management. Expert Rev Cardiovasc Ther 2019; 17:673-681. [DOI: 10.1080/14779072.2019.1662723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Bennett Di Giovanni
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Dakota Gustafson
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Division of Advanced Diagnostics, Toronto General Hospital Research Institute, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Diego Hernan Delgado
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Panhwar MS, AL-KINDI SADEERG, TOFOVIC DAVID, OLIVEIRA GUILHERMEH, GINWALLA MAHAZARIN. Waitlist Mortality of Patients With Amyloid Cardiomyopathy who Are Listed for Heart Transplantation and Implications for Organ Allocation. J Card Fail 2019; 25:767-771. [DOI: 10.1016/j.cardfail.2019.04.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/09/2019] [Accepted: 04/18/2019] [Indexed: 11/30/2022]
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Manolis AS, Manolis AA, Manolis TA, Melita H. Cardiac amyloidosis: An underdiagnosed/underappreciated disease. Eur J Intern Med 2019; 67:1-13. [PMID: 31375251 DOI: 10.1016/j.ejim.2019.07.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/15/2019] [Accepted: 07/23/2019] [Indexed: 12/14/2022]
Abstract
Cardiac amyloidosis or amyloid cardiomyopathy (ACM), commonly resulting from extracellular deposition of amyloid fibrils consisted of misfolded immunoglobulin light chain (AL) or transthyretin (TTR) protein, is an underestimated cause of heart failure and cardiac arrhythmias. Among the three types of cardiac amyloidosis (wild-type or familial TTR and light-chain), the wild-type (Wt) TTR-related amyloidosis (ATTR) is an increasingly recognized cause of heart failure with preserved ejection fraction (HFpEF), and amyloidosis should be considered in the differential diagnosis of this heart failure group of patients. Recent advances in the diagnosis and drug treatment of ACM have ushered in a new era in early disease detection and better management of these patients. Certain clues in cardiac and extracardiac manifestations of ACM may heighten clinical suspicion and guide further confirmatory testing. Newer noninvasive imaging methods (strain echocardiography, cardiac magnetic resonance and bone scintigraphy) may obviate the need for endomyocardial biopsy in ATTR patients, while newer targeted therapies may alter the adverse prognosis in these patients. Early recognition of ACM is crucial in halting the disease process before irreversible organ damage occurs. Chemotherapy and stem-cell transplantation combined with immunomodulatory therapy may also favorably affect the course and prognosis of light chain ACM. Finally, in select patients with end-stage disease, heart transplantation may render results comparable to non-ACM patients. All these issues are herein reviewed.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece.
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Bitan G. Disease-modifying therapy for proteinopathies: Can the exception become the rule? PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2019; 168:277-287. [PMID: 31699321 DOI: 10.1016/bs.pmbts.2019.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Disease-modifying therapies for proteinopathies are urgently needed yet clinical trials for the major neurodegenerative diseases, Alzheimer's and Parkinson's, have been failing at an alarming rate leaving patients and caregivers scrambling for any sign of hope. At the same time, for one family of proteinopathies, the rare TTR amyloidoses, disease-modifying therapy has existed for almost 3 decades and two new types of disease-modifying therapy have become available more recently. In this chapter, I discuss those therapies, examine to what extent they can be generalized for other diseases, and consider what we may learn from their relative success.
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Affiliation(s)
- Gal Bitan
- Department of Neurology, David Geffen School of Medicine, Brain Research Institute, and Molecular Biology Institute, University of California, Los Angeles, CA, United States.
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30
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Kittleson MM, Cole RM, Patel J, Ramzy D, Passano E, Chang DH, Geft DR, Czer L, Vescio R, Chung J, Kobashigawa JA, Arabia F, Esmailian F, Moriguchi JD. Mechanical circulatory support for cardiac amyloidosis. Clin Transplant 2019; 33:e13663. [DOI: 10.1111/ctr.13663] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/25/2019] [Accepted: 07/06/2019] [Indexed: 12/01/2022]
Affiliation(s)
| | - Robert M. Cole
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Jignesh Patel
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Danny Ramzy
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Elizabeth Passano
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - David H. Chang
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Dael R. Geft
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Lawrence Czer
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Robert Vescio
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Joshua Chung
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Jon A. Kobashigawa
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Francisco Arabia
- Banner-University of Arizona Medical Center Phoenix Phoenix Arizona
| | - Fardad Esmailian
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
| | - Jaime D. Moriguchi
- Cedars‐Sinai Medical Center Smidt Heart Institute Los Angeles California
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31
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Affiliation(s)
- Christopher Strouse
- Department of Internal Medicine, Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa, Iowa City, IA, USA
| | - Alexandros Briasoulis
- Cardiomyopathy Section, Cardiology Division, University of Iowa, Iowa City, Iowa, USA
| | - Rafael Fonseca
- Bone Marrow Transplant Program, Mayo Clinic, Phoenix, Arizona, USA
| | - Yogesh Jethava
- Department of Internal Medicine, Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa, Iowa City, IA, USA
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Hereditary transthyretin amyloidosis: a model of medical progress for a fatal disease. Nat Rev Neurol 2019; 15:387-404. [PMID: 31209302 DOI: 10.1038/s41582-019-0210-4] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2019] [Indexed: 02/06/2023]
Abstract
Hereditary amyloidogenic transthyretin (ATTRv) amyloidosis with polyneuropathy (also known as familial amyloid polyneuropathy) is a condition with adult onset caused by mutation of transthyretin (TTR) and characterized by extracellular deposition of amyloid and destruction of the somatic and autonomic PNS, leading to loss of autonomy and death. This disease represents a model of the scientific and medical progress of the past 30 years. ATTRv amyloidosis is a worldwide disease with broad genetic and phenotypic heterogeneity that presents a diagnostic challenge for neurologists. The pathophysiology of the neuropathy is increasingly understood and includes instability and proteolysis of mutant TTR leading to deposition of amyloid with variable lengths of fibrils, microangiopathy and involvement of Schwann cells. Wild-type TTR is amyloidogenic in older individuals. The main symptoms are neuropathic, but the disease is systemic; neurologists should be aware of cardiac, eye and kidney involvement that justify a multidisciplinary approach to management. Infiltrative cardiomyopathy is usually latent but present in half of patients. Disease-modifying therapeutics that have been developed include liver transplantation and TTR stabilizers, both of which can slow progression of the disease and increase survival in the early stages. Most recently, gene-silencing drugs have been used to control disease in the more advanced stages and produce some degree of improvement.
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Taiwo AA, Alapati L, Movahed A. Cardiac amyloidosis: A case report and review of literature. World J Clin Cases 2019; 7:742-752. [PMID: 30968039 PMCID: PMC6448069 DOI: 10.12998/wjcc.v7.i6.742] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cardiac amyloidosis, a disease caused by the precipitation of amyloid proteins in the myocardial extracellular matrix has been historically difficult to diagnose due to lack of specific clinical manifestations and necessity of biopsy to demonstrate amyloid deposition. However, advances in cardiovascular imaging techniques have facilitated earlier recognition of this disease. In addition, while once thought of as incurable, treatment strategies are emerging for cardiac amyloidosis, making early diagnosis essential.
CASE SUMMARY We outline the case of a 73 years old African American female who was admitted with sudden onset shortness of breath and found to be in cardiogenic shock. Cardiac amyloidosis was suspected due to discordance between electrocardiogram and echocardiogram findings and this was subsequently confirmed with the aid of scintigraphy and an endomyocardial biopsy.
CONCLUSION Our objective is to highlight the diagnostic evaluation and clinical implications of cardiac amyloidosis.
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Affiliation(s)
- Adeyemi Adedamola Taiwo
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Lavanya Alapati
- Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, NC 27834, United States
| | - Assad Movahed
- Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, NC 27834, United States
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34
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Gertz MA. Immunoglobulin light chain amyloidosis diagnosis and treatment algorithm 2018. Blood Cancer J 2018; 8:44. [PMID: 29795248 PMCID: PMC5966459 DOI: 10.1038/s41408-018-0080-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/13/2018] [Accepted: 03/29/2018] [Indexed: 12/18/2022] Open
Abstract
Immunoglobulin light chain amyloidosis (AL) should be considered in any patient that presents to a cancer care provider with nephrotic range proteinuria, heart failure with preserved ejection fraction, non-diabetic peripheral neuropathy, unexplained hepatomegaly or diarrhea. More importantly, patients being monitored for smoldering multiple myeloma and a monoclonal gammopathy of undetermined significance (MGUS) are at risk for developing AL amyloidosis. MGUS and myeloma patients that have atypical features, including unexplained weight loss; lower extremity edema, early satiety, and dyspnea on exertion should be considered at risk for light chain amyloidosis. Overlooking the diagnosis of light chain amyloidosis leading to therapy delay is common, and it represents an error of diagnostic consideration. Algorithms will be provided on how to evaluate patients with suspected AL amyloid as well as how to manage patients referred from other medical specialties with biopsy-proven amyloid. An organized stepwise approach to the treatment of patients with light chain amyloidosis, including established and investigational therapies, will be reviewed.
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Affiliation(s)
- Morie A Gertz
- Mayo Clinic, SW Division of Hematology, 200 First Street, Rochester, MN, 55905, USA.
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35
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Kristen AV, Kreusser MM, Blum P, Schönland SO, Frankenstein L, Dösch AO, Knop B, Helmschrott M, Schmack B, Ruhparwar A, Hegenbart U, Katus HA, Raake PW. Improved outcomes after heart transplantation for cardiac amyloidosis in the modern era. J Heart Lung Transplant 2018; 37:611-618. [DOI: 10.1016/j.healun.2017.11.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 11/09/2017] [Accepted: 11/10/2017] [Indexed: 01/01/2023] Open
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Halatchev IG, Zheng J, Ou J. Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA), previously known as senile cardiac amyloidosis: clinical presentation, diagnosis, management and emerging therapies. J Thorac Dis 2018; 10:2034-2045. [PMID: 29707360 DOI: 10.21037/jtd.2018.03.134] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cardiac amyloidosis is thought to be a rare group of diseases caused by extracellular deposition of misfolded proteins in the extracellular cardiac matrix resulting in heart failure with preserved ejection fraction (HFpEF). This review focuses on the similarities and differences between the pathophysiology, clinical presentation and diagnostic tests of wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) compared to immunoglobulin light chain amyloidosis and hereditary cardiac amyloidosis. We address some obstacles to timely diagnosis and opportunities for management of the clinical symptoms as well as possibility of future novel disease modifying therapies.
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Affiliation(s)
- Ilia G Halatchev
- Division of Cardiology, John Cochran Veterans Affairs Medical Center, St. Louis, USA.,Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jingsheng Zheng
- Department of Cardiology, AtlantiCare Regional Medical Center, Pomona, NJ, USA
| | - Jiafu Ou
- Division of Cardiology, John Cochran Veterans Affairs Medical Center, St. Louis, USA.,Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
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37
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Milani P, Palladini G, Merlini G. New concepts in the treatment and diagnosis of amyloidosis. Expert Rev Hematol 2018; 11:117-127. [DOI: 10.1080/17474086.2018.1424534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
- PhD program in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
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38
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Arai K, Murata D, Verissimo AR, Mukae Y, Itoh M, Nakamura A, Morita S, Nakayama K. Fabrication of scaffold-free tubular cardiac constructs using a Bio-3D printer. PLoS One 2018; 13:e0209162. [PMID: 30557409 PMCID: PMC6296519 DOI: 10.1371/journal.pone.0209162] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 12/02/2018] [Indexed: 12/18/2022] Open
Abstract
A major challenge in cardiac tissue engineering is the host's immune response to artificial materials. To overcome this problem, we established a scaffold-free system for assembling cell constructs using an automated Bio-3D printer. This printer has previously been used to fabricate other three-dimensional (3D) constructs, including liver, blood vessels, and cartilage. In the present study, we tested the function in vivo of scaffold-free cardiac tubular construct fabricated using this system. Cardiomyocytes derived from induced pluripotent stem cells (iCells), endothelial cells, and fibroblasts were combined to make the spheroids. Subsequently, tubular cardiac constructs were fabricated by Bio-3D printer placing the spheroids on a needle array. Notably, the spheroid fusion and beat rate in the constructs were observed while still on the needle array. After removal from the needle array, electrical stimulation was used to test responsiveness of the constructs. An increased beat rate was observed during stimulation. Importantly, the constructs returned to their initial beat rate after stimulation was stopped. In addition, histological analysis shows cellular reorganization occurring in the cardiac constructs, which may mimic that observed during organ transplantation. Taken together, our results indicate that these engineered cardiac tubular constructs, which address both the limited supply of donor tissues as well as the immune-induced transplant rejection, has potential to be used for both clinical and drug testing applications. To our knowledge, this is the first time that cardiac tubular constructs have been produced using optimized Bio-3D printing technique and subsequently tested for their use as cardiac pumps.
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Affiliation(s)
- Kenichi Arai
- Department of Regenerative Medicine and Biomedical Engineering, Faculty of Medicine, Saga University, Saga, Japan
| | - Daiki Murata
- Department of Regenerative Medicine and Biomedical Engineering, Faculty of Medicine, Saga University, Saga, Japan
| | - Ana Raquel Verissimo
- Department of Regenerative Medicine and Biomedical Engineering, Faculty of Medicine, Saga University, Saga, Japan
| | - Yosuke Mukae
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Manabu Itoh
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Anna Nakamura
- Department of Regenerative Medicine and Biomedical Engineering, Faculty of Medicine, Saga University, Saga, Japan
| | - Shigeki Morita
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Koichi Nakayama
- Department of Regenerative Medicine and Biomedical Engineering, Faculty of Medicine, Saga University, Saga, Japan
- * E-mail:
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Panhwar MS, Al-Kindi S, Oliveira GH, Ginwalla M. Successful use of palliative inotrope therapy in end-stage cardiac ATTR amyloidosis. Amyloid 2017; 24:217-218. [PMID: 28868918 DOI: 10.1080/13506129.2017.1372412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Muhammad S Panhwar
- a Harrington Heart and Vascular Institute, Division of Cardiovascular Medicine , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Sadeer Al-Kindi
- a Harrington Heart and Vascular Institute, Division of Cardiovascular Medicine , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Guilherme H Oliveira
- a Harrington Heart and Vascular Institute, Division of Cardiovascular Medicine , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
| | - Mahazarin Ginwalla
- a Harrington Heart and Vascular Institute, Division of Cardiovascular Medicine , University Hospitals Cleveland Medical Center , Cleveland , OH , USA
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