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Brito D, Albrecht FC, de Arenaza DP, Bart N, Better N, Carvajal-Juarez I, Conceição I, Damy T, Dorbala S, Fidalgo JC, Garcia-Pavia P, Ge J, Gillmore JD, Grzybowski J, Obici L, Piñero D, Rapezzi C, Ueda M, Pinto FJ. World Heart Federation Consensus on Transthyretin Amyloidosis Cardiomyopathy (ATTR-CM). Glob Heart 2023; 18:59. [PMID: 37901600 PMCID: PMC10607607 DOI: 10.5334/gh.1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 10/31/2023] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive and fatal condition that requires early diagnosis, management, and specific treatment. The availability of new disease-modifying therapies has made successful treatment a reality. Transthyretin amyloid cardiomyopathy can be either age-related (wild-type form) or caused by mutations in the TTR gene (genetic, hereditary forms). It is a systemic disease, and while the genetic forms may exhibit a variety of symptoms, a predominant cardiac phenotype is often present. This document aims to provide an overview of ATTR-CM amyloidosis focusing on cardiac involvement, which is the most critical factor for prognosis. It will discuss the available tools for early diagnosis and patient management, given that specific treatments are more effective in the early stages of the disease, and will highlight the importance of a multidisciplinary approach and of specialized amyloidosis centres. To accomplish these goals, the World Heart Federation assembled a panel of 18 expert clinicians specialized in TTR amyloidosis from 13 countries, along with a representative from the Amyloidosis Alliance, a patient advocacy group. This document is based on a review of published literature, expert opinions, registries data, patients' perspectives, treatment options, and ongoing developments, as well as the progress made possible via the existence of centres of excellence. From the patients' perspective, increasing disease awareness is crucial to achieving an early and accurate diagnosis. Patients also seek to receive care at specialized amyloidosis centres and be fully informed about their treatment and prognosis.
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Affiliation(s)
- Dulce Brito
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Fabiano Castro Albrecht
- Dante Pazzanese Institute of Cardiology – Cardiac Amyloidosis Center Dante Pazzanese Institute, São Paulo, Brazil
| | | | - Nicole Bart
- St Vincent’s Hospital, Victor Chang Cardiac Research Institute, University of New South Wales, Sydney, Australia
| | - Nathan Better
- Cabrini Health, Malvern, Royal Melbourne Hospital, Parkville, Monash University and University of Melbourne, Victoria, Australia
| | | | - Isabel Conceição
- Department of Neurosciences and Mental Health, CHULN – Hospital de Santa Maria, Portugal
- Centro de Estudos Egas Moniz Faculdade de Medicina da Universidade de Lisboa Portugal, Portugal
| | - Thibaud Damy
- Department of Cardiology, DHU A-TVB, CHU Henri Mondor, AP-HP, INSERM U955 and UPEC, Créteil, France
- Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Reseau amylose, Créteil, France. Filière CARDIOGEN
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Cardiac Amyloidosis Program, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Julian D. Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom
| | - Jacek Grzybowski
- Department of Cardiomyopathy, National Institute of Cardiology, Warsaw, Poland
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Claudio Rapezzi
- Cardiovascular Institute, University of Ferrara, Ferrara, Italy
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Fausto J. Pinto
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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Raval M, Siddiq S, Sharma K, Sanghvi L, Jain A, Patel S, Trivedi J, Uttam Chandani K, Patel D, Desai R. A review of recent advances in the diagnosis of cardiac amyloidosis, treatment of its cardiac complications, and disease-modifying therapies. F1000Res 2023; 12:192. [PMID: 36911240 PMCID: PMC9995736 DOI: 10.12688/f1000research.130285.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
Cardiac amyloidosis (CA), a significant condition resulting in infiltrative cardiomyopathy and heart failure with preserved ejection fraction (HFpEF), is caused by extracellular deposition of amyloid fibrils in the heart. Even though this has been known for an extended period, its prevalence in elderly patients with heart failure is increasingly being recognized. Recent advances in diagnosis with non-invasive methods like technetium pyrophosphate-labeled cardiac scintigraphy (i.e., Tc-PYP scan) and treatment options with tafamidis have played a pivotal role in awareness of the burden of this disease. Management of cardiac complications like heart failure, atrial arrhythmias, conduction block, ventricular arrhythmias, coronary artery disease, and aortic stenosis is now more critical than ever. We aim to review and outline the recent advances in diagnoses of CA. We also review management strategies for cardiac complications of CA with a brief summary of disease-modifying therapies.
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Affiliation(s)
- Maharshi Raval
- Department of Internal Medicine, New York Medical College, Valhalla, New York, USA.,Department of Internal Medicine, Landmark Medical Center, Woonsocket, Rhode Island, USA
| | - Sajid Siddiq
- Department of Cardiology, New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Landmark Medical Center, Woonsocket, Rhode Island, USA
| | - Kamal Sharma
- Department of Cardiology, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India
| | - Labdhi Sanghvi
- Department of Pediatrics, Ahmedabad Municipal Corporation Medical Education Trust Medical College, Ahmedabad, Gujarat, India
| | - Akhil Jain
- Department of Internal Medicine, Mercy Fitzgerald Hospital, Darby, Pennsylvania, USA
| | - Sagar Patel
- Department of Internal Medicine, New York Medical College, Valhalla, New York, USA.,Department of Internal Medicine, Landmark Medical Center, Woonsocket, Rhode Island, USA
| | - Jaahnavee Trivedi
- Department of Internal Medicine, New York Medical College, Valhalla, New York, USA.,Department of Internal Medicine, Landmark Medical Center, Woonsocket, Rhode Island, USA
| | - Kanishka Uttam Chandani
- Department of Internal Medicine, New York Medical College, Valhalla, New York, USA.,Department of Internal Medicine, Landmark Medical Center, Woonsocket, Rhode Island, USA
| | - Dhriti Patel
- Department of Medicine, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, USA
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Alreshq R, Tugal D, Siddiqi O, Ruberg F. Conduction abnormalities and role of cardiac pacing in cardiac amyloidosis: A systematic review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:2092-2099. [PMID: 34632598 DOI: 10.1111/pace.14375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 01/05/2023]
Abstract
Cardiac amyloidosis (CA) is an increasingly recognized cause of heart failure, characterized by extracellular deposition of insoluble protein fibrils leading to progressive myocardial dysfunction. The most common types of cardiac amyloidosis are immunoglobin light-chain (AL) and transthyretin (ATTR). Conduction abnormalities are commonly encountered among patients with cardiac amyloidosis and are an important cause of morbidity and mortality. Abnormalities range from infra-Hisian intraventricular conduction delay and bundle branch block to complete atrioventricular block. Pacemaker placement in CA patients follows established guidelines, similar to those for patients without CA, with generally good efficacy. The role and appropriate timing of pacemakers for primary prevention of brady-arrhythmias in CA remains uncertain. While biventricular (BiV) pacing has been shown to improve clinical outcomes in patients with systolic heart failure without CA, there are few data examining the utility of BiV pacing in patients with CA. With the advent of effective treatments for AL and ATTR, appropriate application of pacing is important to support patients with CA and conduction disease through therapeutic trials. This systematic review summarizes the current literature examining the utility of pacing in CA.
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Affiliation(s)
- Rabah Alreshq
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Derin Tugal
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Omar Siddiqi
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Frederick Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Department of Radiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Cha S, Kim J, Choi SJ, Kim GS. Domino living donor liver transplantation of familial amyloid polyneuropathy patient - A case report. Anesth Pain Med (Seoul) 2020; 15:472-477. [PMID: 33329851 PMCID: PMC7724126 DOI: 10.17085/apm.20059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/28/2020] [Accepted: 09/21/2020] [Indexed: 11/17/2022] Open
Abstract
Background Familial amyloid polyneuropathy (FAP) is caused by mutation in a gene transcribing transport protein produced mainly by the liver. Liver transplantation is required to stop FAP progression, but the pathology causes anesthetic management challenges. Case We report a case of domino living donor liver transplantation in an FAP patient. No intraoperative events occurred; however, during postoperative day 1 in the intensive care unit (ICU), the FAP patient underwent multiple cardiopulmonary resuscitation (CPR) sessions due to pulseless electrical activity following a sudden drop in blood pressure and ventricular tachycardia. Despite ICU management, the patient died after the third CPR session. Conclusions Various anesthetic management techniques should be considered for FAP patients. Anesthetic management was carefully assessed with the use of isoflurane, isoproterenol, and an external patch. The cause of deterioration in the ICU is unclear, but further investigation is needed to prevent and better manage postoperative morbidity and mortality.
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Affiliation(s)
- Sungrok Cha
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, Korea
| | - Jiwon Kim
- Department of Nursing, Samsung Medical Center, Seoul, Korea
| | - Soo Joo Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, Korea
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Abstract
PURPOSE OF REVIEW The review's main focus centers on the genetics of hereditary cardiac amyloidosis, highlighting the opportunities and challenges posed by the widespread availability of genetic screening and diagnostic cardiac imaging. RECENT FINDINGS Advancements in cardiac imaging, heightened awareness of the ATTR amyloidosis diagnosis, and greater access to genetic testing have all led to an increased appreciation of the prevalence of ATTR cardiac amyloidosis. Elucidation of the TTR molecular structure and effect of mutations on TTR function have allowed for novel TTR therapy development leading to clinical implementation of transthyretin stabilizers and transthyretin gene silencers. The transthyretin amyloidoses are a diverse group of protein misfolding disorders with cardiac and peripheral/autonomic nervous system manifestations due to protein deposition. Genetic screening allows for the early identification of asymptomatic TTR mutation carriers. With the advent of TTR-specific therapeutics, clinical guidance is necessary for the management of individuals with mutations in the TTR gene without evidence of disease.
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Aimo A, Rapezzi C, Vergaro G, Giannoni A, Spini V, Passino C, Emdin M. Management of complications of cardiac amyloidosis: 10 questions and answers. Eur J Prev Cardiol 2020; 28:1000-1005. [PMID: 32299232 DOI: 10.1177/2047487320920756] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 01/15/2023]
Abstract
Amyloidosis is a systemic disorder characterized by extracellular deposition of insoluble fibrils. The most common forms are amyloid light chain and amyloid transthyretin (ATTR) amyloidoses. Cardiac involvement may be found in both these forms, and is an important cause of morbidity and mortality. The clinical presentation of cardiac amyloidosis (CA) may be represented by congestive heart failure (HF), possibly progressing to end-stage HF, as well as atrial fibrillation with possible thromboembolic events, and also conduction disturbances related to amyloid infiltration of conduction fibres. Beyond therapies targeting the blood dyscrasia or the ATTR amyloidogenic cascade, a careful choice of drug therapies, need for device implantation, and possibly treatments for advanced HF is then warranted. In the present review, we try to provide a useful guide to clinicians treating patients with CA by enucleating 10 main questions and answering them based on the evidence available as well as expert opinion and our clinical experience.
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Affiliation(s)
- Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | | | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | | | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy.,Fondazione Toscana Gabriele Monasterio, Italy
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Yamamoto H, Yokochi T. Transthyretin cardiac amyloidosis: an update on diagnosis and treatment. ESC Heart Fail 2019; 6:1128-1139. [PMID: 31553132 PMCID: PMC6989279 DOI: 10.1002/ehf2.12518] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/19/2019] [Accepted: 08/25/2019] [Indexed: 12/14/2022] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR‐CA) demonstrates progressive, potentially fatal, and infiltrative cardiomyopathy caused by extracellular deposition of transthyretin‐derived insoluble amyloid fibrils in the myocardium. Two distinct types of transthyretin (wild type or variant) become unstable, and misfolding forms aggregate, resulting in amyloid fibrils. ATTR‐CA, which has previously been underrecognized and considered to be rare, has been increasingly recognized as a cause of heart failure with preserved ejection fraction among elderly persons. With the advanced technology, the diagnostic tools have been improving for cardiac amyloidosis. Recently, the efficacy of several disease‐modifying agents focusing on the amyloidogenic process has been demonstrated. ATTR‐CA has been changing from incurable to treatable. Nevertheless, there are still no prognostic improvements due to diagnostic delay or misdiagnosis because of phenotypic heterogeneity and co‐morbidities. Thus, it is crucial for clinicians to be aware of this clinical entity for early diagnosis and proper treatment. In this mini‐review, we focus on recent advances in diagnosis and treatment of ATTR‐CA.
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Affiliation(s)
- Hiroyuki Yamamoto
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, 1-1-1 Hiyoshidai, Tomisato, Chiba, 286-0201, Japan
| | - Tomoki Yokochi
- Department of Clinical Research, Chiba Tokushukai Hospital, Chiba, Japan
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